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Importance of the sagittal profile in spinal deformity surgery

The Spine is an integral part of the human body that protects our spinal cord and supports our body weight. A healthy spine is made up of multiple small bones called vertebrae that are stacked on top of each other with fibrous discs placed in between them.

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Importance of the sagittal profile in spinal deformity surgery

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  1. The importance of the sagittal profile inspinal deformitysurgery Jwalant S.Mehta FRCS (Orth), MCh (Orth), D (Orth), MS(Orth) Consultant Spine DeformitySurgeon The Royal Orthopaedic Hospital, Birmingham Childrens’Hospital BMIHealthcare SpireHealthcare Jwalant S.Mehta www.mehtaspine.com

  2. Outline • Understanding & measuring the sagittalprofile • Pathological changes in sagittalprofile • Surgical reconstruction options • Clinical evidence /cases Jwalant S.Mehta www.mehtaspine.com

  3. Sagittal plane: divides into right & lefthalves t S.Mehta Jwalan www.mehta spine.com

  4. Balance: Head overheels! Jwalant S.Mehta www.mehtaspine.com

  5. The spinal‘fingerprint’ Jwalant S.Mehta www.mehtaspine.com

  6. Cone ofeconomy J.Dubousset Jwalant S.Mehta www.mehtaspine.com

  7. Sagittal PlaneAlignment… … More Than Just theSpine Thoracickyphosis Lumbarlordosis Pelvicmorphology/ version Global Alignment Lowerextremity Jwalant S.Mehta www.mehtaspine.com Biospace /LBM

  8. Sagittal verticalaxis Jwalant S.Mehta www.mehtaspine.com June2014

  9. Jwalant S.Mehta www.mehtaspine.com June2014

  10. Radiographicmeasures Jwalant S.Mehta www.mehtaspine.com

  11. Thoracic kyphosis: 38° ±18 Lumbar lordosis: 48° ±18 Jwalant S.Mehta www.mehtaspine.com

  12. TLJunction T10 L2 Jwalant S.Mehta www.mehtaspine.com June2014

  13. Pelvicmeasures • Sacral slope(SS) • Pelvic tilt(PT) • Pelvic incidence(PI) Jwalant S.Mehta www.mehtaspine.com June2014

  14. Sacralslope • Horizontal & cranial sacral end platetangent • 41°±8.4° (Vialle JBJS2005) Jwalant S.Mehta www.mehtaspine.com

  15. Pelvictilt • Verticalline between • middle of cranial sacralend plate • centre of the bicoxo-femoral • axis • 13° ± 6° (Vialle JBJS2005) Jwalant S.Mehta www.mehtaspine.com

  16. Significance of pelvictilt • Centre of gravity overLL • Maintains sacral plate posterior to the hip • Increases withage Jwalant S.Mehta www.mehtaspine.com

  17. Pelvicincidence • Keyparameter • Perpendicularto: • the middle of the sacralend • plate • mid-point of femoral heads • 55° ± 10.6° (Vialle JBJS2005) Jwalant S.Mehta www.mehtaspine.com

  18. Spino-pelviccompensation • PI regulatesPT • HigherPI Bettercompensation Jwalant S.Mehta www.mehtaspine.com June2014

  19. Jwalant S.Mehta www.mehtaspine.com June2014

  20. PI=PT+SS Jwalant S.Mehta www.mehtaspine.com June2014

  21. Curvetypes Schwab et al. SPINE2011 Modifiers Jwalant S.Mehta www.mehtaspine.com June2014

  22. The sagittal planedeformity Jwalant S.Mehta www.mehtaspine.com June2014

  23. The coronal planedeformity Jwalant S.Mehta www.mehtaspine.com June2014

  24. Spino-pelvic pathologypatterns Progressivekyphosis Gravity line drifts forwards Pelvis rotates backwards Sacral slopedecreases Kneeflexion JwalantS.Mehta www.mehtaspine.com

  25. Type1:Non-harmoniousspine Thoraco lumbardisc Junctionallisthesis Eurospine2007 Bruxelles .Mehta ine.com JwalantS www.mehtasp Ju

  26. Type 2: Harmonious but FlatBack Early discdegeneration lant S.Me htaspine.c Jwa www.me hta om

  27. Type 3:The mostharmonious (“probably a goodback”) Jwalant S.Mehta www.mehtaspine.com

  28. Type 4: Harmonious buthyper-curved. • When young: verystrong • HighPI • Goodlordosis • Withaging • will loselordosis • pelvic tilt increases to compensate foranterior imbalance Lumbarstenosis+spondylolisJwtahlanetSs.Mieshta www.mehtaspine.com

  29. Jwalant S.Mehta www.mehtaspine.com

  30. Discdegeneration Jwalant S.Mehta www.mehtaspine.com

  31. Jwalant S.Mehta www.mehtaspine.com June2014

  32. JwalantS.Mehta www.mehtaspine.com

  33. Facet jointchanges Jointcapsule Inferior articularprocess Superior articularprocess Increased axial rotation indisc Jwalant S.Mehta www.mehtaspine.com degeneration

  34. Facet jointchanges Jointcapsule Inferior articularprocess Superior articularprocess Increased axial rotation in disc degeneration results in shear ofthe enthesis and direct pressure upon the capJswaulalnetS. Mehta

  35. Facet jointchanges Inferior articularprocess Superior articular process Encompassing joint formation develops through directcontact ofenthesophytes in advanceddegeneJwraalatnitoS. nMehta www.mehtaspine.com

  36. Facet jointchanges In contrast to other joints, reactions of the joint capsule / enthesis are seen before permanent cartilagedamage Early restoration of disc biomechanics may prevent progression to stage of permanentdamage Vernon-Roberts & Pirie RheumatolRehabil 1977 Fujiwara et al. Eur Spine J1999

  37. Facet jointdegeneration • Jointwidth • Articularerosions • Sub-chondralsclerosis • Osteophytes Jwalant S.Mehta www.mehtaspine.com June2014

  38. Facet jointchanges JwalantS.Mehta ww.mehtaspine.com w

  39. Two views of a typical facet joint contact space object (for a normalspine) Volume(mm3) 309.50 SuJwralfaantcS.eMehatarea(mm2) Jun4e200144.25 www.mehtaspine.com 48

  40. Surface area of the facet joint contact space (mean ±stdev) 1400 1200 1000 Surface area(mm2) 800 600 400 200 0 L1-2-R L1-2-L L2-3-R L2-3-L L3-4-R L3-4-L L4-5-R L4-5-L L5-S1-R L5-S1-L Jwalant S.Mehta www.mehtaspine.com

  41. Volume of the facet joint contact space (mean ±stdev) 1400 1200 1000 Volume(mm3) 800 600 400 200 0 L1-2-R L1-2-L L2-3-R L2-3-L L3-4-R L3-4-L L4-5-R L4-5-L L5-S1-R L5-S1-L

  42. JwalantS.Mehta ww.mehtaspine.com w

  43. Clinical effects of plumb-lineshifts Glassman, Bridwell et al. Spine2005 Jwalant S.Mehta www.mehtaspine.com June2014

  44. deformity Jwalant S.Mehta www.mehtaspine.com June2014

  45. Hyperextlat Standinglat Jwalant S.Mehta www.mehtaspine.com June2014

  46. Aim1:achievefusion • Good pain relief; 69 – 87% • Kostuik Clin Orthop1973 Swank JBJS Am1981 • Improvement in the lumbarlordosis • Anterior column load sharing Jwalant S.Mehta www.mehtaspine.com

  47. Aim 2: adaptation oflordosis • Excise facetjoints • ‘Open’ degenerate discspaces • LL=PI ±90 • Measure the PI, and build in thelordosis Jwalant S.Mehta www.mehtaspine.com

  48. Adult Deformity: Surgicalgoals • Normalize & balancecontours • Fuse the least number ofsegments • Neuraldecompression • Obtain solid biologicalfusion Jwalant S.Mehta www.mehtaspine.com

  49. Adult Deformity: principles ofsurgery • Traction + erect full spinefilms • Measureparameters • Levels toinstrument • Levels todecompress • Anterior columnmanagement Jwalant S.Mehta www.mehtaspine.com June2014

  50. MM 86Y Jwalant S.Mehta www.mehtaspine.com June2014

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