Sagittal balance parameters influence indications for lumbar disc arthroplasty or ALIF

Chronic lower back pain is a potentially incapacitating condition associated with disc degeneration. Although therapy is primarily pharmaceutical, surgery comprising arthrodesis constitutes an alternative. Anterior intersomatic lumbar arthrodesis (ALIF, anterior interbody lumbar fusion) is the reference approach, although total disc arthroplasty may also be undertaken. Analysis of pelvic and spinal parameters provides the best indication of sagittal balance.

This was a prospective study in a continuous series of 99 patients presenting chronic lower back pain due to disc disease. Pelvic incidence, sacral slope, pelvic tilt, spino-sacral angle (SSA) and the four back types in the Roussouly classification were studied in radiographs of the whole spine under load using an EOS imaging system.

The pre-operative SSA value for the study population was 126.09° ± 8.45° and the mean spine tilt angle was 90° compared with 95° in healthy subjects. Following surgery, the SSA was considerably increased in the discal arthroplasty, resulting in a significantly more balanced spinal position. In the group of patients undergoing arthrodesis using the ALIF technique, no such significant improvement was found despite the use of a lordosis cage. We showed that in cases of low pelvic incidence, it was necessary to maintain a Roussouly type 1 or 2 back without increasing lordosis. The results demonstrated the value of L4-L5 disc prostheses in these subjects. L5-S1 arthrodesis seemed a more suitable approach for treating patients with elevated sacral slope (back type 3 or 4). This new type of analysis of sagittal parameters should be performed prior to all surgical procedures involving lumbar prostheses.