Thoracolumbar Realignment Surgery Results in Simultaneous Reciprocal Changes in Lower Extremities and Cervical Spine

Louis M. Day, Subaraman Ramchandran, Cyrus M. Jalai, Bassel G. Diebo, Barthelemy Liabaud, Renaud Lafage, Themistocles Protopsaltis, Peter G. Passias, Frank J. Schwab, Shay Bess, Thomas J. Errico, Virginie Lafage, Aaron J. Buckland

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Study Design. A retrospective, clinical, and radiographic single-center study. Objective. The aim of this study was to assess simultaneous cervical spine and lower extremity compensatory changes with changes in thoracolumbar spinal alignment. Summary of Background Data. Full-body stereoradiographic imaging allows better understanding of reciprocal changes in cervical and lower extremity alignment in the setting of thoracolumbar malalignment. Few studies describe the simultaneous effect of alignment correction on these mechanisms. Methods. Patients aged ≥18 years undergoing instrumented thoracolumbar fusion without previous cervical spine fusion, hip, knee, or ankle arthroplasty were included. Spinopelvic, lower extremity, and cervical alignment were assessed from full-body standing stereoradiographs using validated software. Patients were matched for pelvic incidence and stratified on the basis of baseline T1-pelvic angle (TPA) as: TPA-Low <14°, TPA-Moderate = 14° to 22°, and TPA-High >22°. Perioperative changes between baseline and first postoperative visit <6 months in lower extremity alignment (pelvic shift: P Shift, sacrofemoral angle: SFA, knee angle: KA, ankle angle: AA, global sagittal axis: GSA) and cervical alignment (C0-C2 angle, C2-slope, C2-C7 lordosis and C2-C7 SVA:cSVA) were correlated with change in magnitude of TPA and sagittal vertical axis (SVA) correction. Results. After matching, 87 patients were assessed. Increasing baseline TPA severity was associated with a progressive increase in all regional spinopelvic parameters except thoracic kyphosis, in addition to increased SFA, P Shift, KA, GSA, and C2-C7 lordosis. As TPA correction increased, there was a reciprocal reduction in SFA, KA, P Shift, GSA, and C2-C7 lordosis. Change in SVA correlated most with change in GSA (r = 0.886), P Shift (r = 0.601), KA (r = 0.534), and C2-C7 lordosis (r = 0.467). Change in TPA correlated with change in SFA (r = 0.372), while SVA did not. Conclusion. Patients with thoracolumbar malalignment exhibit compensatory changes in cervical spine and lower extremity simultaneously in the form of cervical hyperlordosis, pelvic shift, knee flexion, and pelvic retroversion. These compensatory mechanisms resolve reciprocally in a linear fashion following optimal surgical correction.

Original languageEnglish
Pages (from-to)799-807
Number of pages9
Issue number11
Publication statusPublished - 1 Jun 2017
Externally publishedYes


  • adult spinal deformity
  • alignment correction
  • cervical spine
  • compensatory mechanisms
  • lower extremity
  • sagittal spinal deformity
  • sagittal vertical axis
  • scoliosis
  • T1 pelvic angle
  • thoracolumbar surgery

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