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Beyond sacral slope: a new quantitative paradigm for Roussouly classification.

Domenico Compagnone1, Andrea Pezzi2, Francesca Barile1

  • 1IRCCS Ospedale Galeazzi-Sant'Ambrogio, Milan, Italy.

European Spine Journal : Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society
|April 11, 2026
PubMed
Summary
This summary is machine-generated.

Pelvic incidence alone doesn't define sagittal alignment. Combining distal lordosis and thoracolumbar morphology enhances Roussouly morphotype classification for better surgical planning in asymptomatic spines.

Keywords:
Adult spine deformityLumbar lordosisRoussouly classificationSagittal balanceSpinopelvic alignmentSurgical planning

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Area of Science:

  • Spine biomechanics and sagittal alignment analysis.
  • Radiographic assessment of spinal morphology.
  • Surgical planning optimization in orthopedics.

Background:

  • Roussouly morphotypes classify asymptomatic spinal sagittal alignment.
  • Pelvic incidence (PI) is a key parameter in spinal alignment.
  • Current classification methods may have limitations in differentiating subtypes.

Purpose of the Study:

  • To propose a new pelvic incidence-based asymptomatic spine classification.
  • To quantitatively define differences among Roussouly morphotypes.
  • To develop a morphotype-oriented algorithm for surgical planning.

Main Methods:

  • Retrospective analysis of 102 asymptomatic adults with full-spine EOS radiographs.
  • Classification according to Roussouly criteria and measurement of spinopelvic parameters.
  • Receiver operating characteristic (ROC) curve analysis to assess discriminative capacity of sagittal variables.

Main Results:

  • Pelvic incidence showed overlap among Roussouly Types 1-3.
  • L5-S1 lordosis (cutoff 19°) best differentiated Type 1 from Type 2 (AUC 0.92).
  • Thoracolumbar junction morphology varied: kyphotic in Type 1, neutral in Type 2, and neutral-to-lordotic in Type 3.

Conclusions:

  • Pelvic incidence alone is insufficient for defining sagittal alignment.
  • Integrating L5-S1 lordosis and thoracolumbar morphology improves morphotype differentiation.
  • This refined classification may enhance precision in surgical planning for spinal alignment.