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The T4-L1-Hip Axis: Defining a Normal Sagittal Spinal Alignment.

Jeffrey Hills1, Lawrence G Lenke2, Zeeshan M Sardar2

  • 1University of Texas, San Antonio, TX.

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This study defines normal sagittal balance in healthy adults, finding that pelvic incidence and L1 pelvic angle accurately predict lumbar lordosis. These parameters, along with thoracic alignment, can guide surgical goals for spinal alignment.

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Area of Science:

  • Spine biomechanics
  • Radiographic assessment
  • Orthopedic surgery

Background:

  • Current targets for sagittal alignment are based on spinal deformity patients, not healthy populations.
  • This leads to poor accounting for normal variations in spinal alignment.

Purpose of the Study:

  • To describe sagittal plane alignment and balance in a multinational cohort of nondegenerated, asymptomatic adults.
  • To establish normative values for spinal alignment in a healthy population.

Main Methods:

  • Cross-sectional cohort study of 320 healthy adults from 4 continents.
  • Sagittal balance and spinopelvic alignment measured using vertebral body tilt and pelvic angles (C2-L5).
  • Linear regression used to assess associations with pelvic incidence (PI) and define normal L1-S1 lordosis and T4 pelvic angle.

Main Results:

  • Pelvic incidence (PI) alone poorly predicted lumbar lordosis (L1-S1).
  • Lumbar lordosis was well-explained (R2=0.74) by a function of PI and L1 pelvic angle (L1PA).
  • Thoracic alignment (T4 pelvic angle) strongly correlated with L1PA (r=0.9).

Conclusions:

  • Defined normal sagittal balance and spinopelvic alignment in a disease-free cohort.
  • Four parameters (PI, L1PA, L1-S1 lordosis, T4 pelvic angle) can define normal thoracic and lumbar alignment.
  • These parameters are surgically relevant for achieving optimal spinal alignment.