Sagittal Balance, Reconstructive Surgery, and Structural Chiropractic

This is a summary of a 2015 paper published in the International Orthopaedic Journal about the importance of sagittal balance analysis and spinopelvis angulation of the individual patient before undergoing reconstructive surgery of the spine.  At Structural Chiropractic we use the same concepts with the same goal of correcting structure, except without surgery.

During the past two decades reconstructive surgeons of the spine have realized the importance of SAGITTAL BALANCE analysis and spinopelvic angulation(images below).  It used to be that surgeons would perform vertebral fusions without considering sagittal balance.  In turn, the locked position of fused vertebra resulted in many patients with loss of lumbar curve and permanent sagittal imbalance.  It is also common for this patient to have a flexed forward trunk due to the sagittal imbalance (Spine C, image below).  Postoperative pain is related to alterations of sagittal balance and spinopelvic angulation.  With the increasing use of vertebral fusion and all the reports of unfavorable effects of surgery on sagittal balance, the surgeons are left with no choice but to perform studies in order to improve their analysis and surgical technique for the sake of their patient.

If you are faced with the decision to choose a reconstructive surgeon, we urge you to find a surgeon who is up to date with his methods.  Search for a sagittal balance surgeon.  If you would like to see if a non-surgical solution to structural correction is for you, we are here.

The figure below can help you understand what sagittal balance is. Spine A is one of normal sagittal balance.  Spine B has a loss of lumbar curve and in order for the body to stay in sagittal balance, the pelvis compensates by rocking backwards while you use neuromuscular effort to pull your trunk back.  Spine C shows a loss of lumbar curve, the rocking back of the pelvis and the lack of neuromuscular control isn’t sufficient to compensate for sagittal imbalance so the knees bend.


Here is an image of a spine with the Normal Structure.  Take a look at the curves of the spine.  When the curves become straightened, issues are bound to develop.  Sagittal imbalance presents itself and compensations occur.

The images below shows the spinopelvic angulation measurements that both surgeons and chiropractors who focus on structural correction use to predict how much correction is possible for the patient.  Not everyone is built to have the same curve angulation.

The image below shows a patient with a loss of lumbar curve, the pelvis has rocked backwards, the trunk is leaning forward, notice the bent knees(left).  On the right, the patient underwent reconstructive surgery.  The lumbar lordosis and thoracis kyphosis is restored, and notice the knees are not bent and are now below the hips.

As you can see, the field is ever changing and evolving.  It’s important to stay current and be responsible for the patients sake.  Some other interesting things that were found:

  • more than 70% of the total lumbar curve is located between the L4-L5 and S1 vertebrae.  It is very interesting because L4-L5 and S1 levels are the most frequent targets for surgery.  This is mostly due to an engineering concept called snap through buckling.  All the weight is supported at these levels.
  • Lumbar degenerative disc disease always showed loss of lumbar curve which resulted in low back pain and consequences of global balance.  This confirms that sagittal imbalance is a source of pain.
  • Degenerative Spondylolisthesis is a major factor of imbalance and degenerative scoliosis associated with compensated balance.  The last two examples suggest that correcting sagittal balance could improve back pain.
  • An increased Pelvic Tilt angle was correlated with persistent pain after fusion.  This is when the pelvis is rocked back.
  • Patients who had an abnormal C7 plumb line or abnormal Sacral Slope had a higher rate of adjacent segment deterioration.  This means that when you are sagitally imbalanced, your spine and body with experience a higher rate of degeneration.
  • Surgical restoration of Lumbar curve was associated with an improvement in the thoracic kyphosis.  This means that correcting a lumbar curve can have a global effect on the spine.
  • Sacral Slope and lumbar curve were decreased in degenerative pathologies.

In conclusion, it is now routine to measure spinopelvic angles and sagittal balance for many interventions for spinal disease.

At Structural Chiropractic in Glen Cove, we have one of the few practices in the country with the knowledge and equipment to offer structural correction of the spine without surgery.  We are fully equipped including high-frequency, low-dose, laser guided x ray in order to give you the best films for analysis.  We also make it a point to stay current with research.

If you would like to schedule a Complimentary Consultation to talk or to schedule a Complete Structural Chiropractic Examination, feel free to contact us.

tel: 516 888 6139

2015 Jan;39(1):87-95. doi: 10.1007/s00264-014-2516-6. Epub 2014 Sep 6.

Evidence showing the relationship between sagittal balance and clinical outcomes in surgical treatment of degenerative spinal diseases: a literature review.


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