Relationship between sagittal balance and adjacent segment disease in surgical treatment of degenerative lumbar spine disease: meta-analysis and implications for choice of fusion technique

Kevin Phan, Alexander Nazareth, Awais K. Hussain, Adam A. Dmytriw, Mithun Nambiar, Damian Nguyen, Jack Kerferd, Steven Phan, Chet Sutterlin, Samuel K. Cho, Ralph J. Mobbs

Research output: Contribution to journalReview ArticleResearchpeer-review

66 Citations (Scopus)


Study design: Meta-analysis. Objective: To conduct a meta-analysis investigating the relationship between spinopelvic alignment parameters and development of adjacent level disease (ALD) following lumbar fusion for degenerative disease. Summary of background data: ALD is a degenerative pathology that develops at mobile segments above or below fused spinal segments. Patient outcomes are worse, and the likelihood of requiring revision surgery is higher in ALD compared to patients without ALD. Spinopelvic sagittal alignment has been found to have a significant effect on outcomes post-fusion; however, studies investigating the relationship between spinopelvic sagittal alignment parameters and ALD in degenerative lumbar disease are limited. Methods: Six e-databases were searched. Predefined endpoints were extracted and meta-analyzed from the identified studies. Results: There was a significantly larger pre-operative PT in the ALD cohort versus control (WMD 3.99, CI 1.97–6.00, p = 0.0001), a smaller pre-operative SS (WMD − 2.74; CI − 5.14 to 0.34, p = 0.03), and a smaller pre-operative LL (WMD − 4.76; CI − 7.66 to 1.86, p = 0.001). There was a significantly larger pre-operative PI-LL in the ALD cohort (WMD 8.74; CI 3.12–14.37, p = 0.002). There was a significantly larger postoperative PI in the ALD cohort (WMD 2.08; CI 0.26–3.90, p = 0.03) and a larger postoperative PT (WMD 5.23; CI 3.18–7.27, p < 0.00001). Conclusion: The sagittal parameters: PT, SS, PI-LL, and LL may predict development of ALD in patients’ post-lumbar fusion for degenerative disease. Decision-making aimed at correcting these parameters may decrease risk of developing ALD in this cohort. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.].

Original languageEnglish
Pages (from-to)1981-1991
Number of pages11
JournalEuropean Spine Journal
Issue number8
Publication statusPublished - 1 Aug 2018
Externally publishedYes


  • Adjacent segment disease
  • Deformity
  • Lumbar degeneration
  • Lumbar lordosis
  • Pelvic incidence
  • Sagittal alignment
  • Sagittal compensate
  • Spinopelvic parameters

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