Spine deformities recognition and evaluation

Spine Deformities
Recognition and Evaluation
Dr. Bahaa Ali Kornah
Prof.. Of Orthopedic
Al-Azhar University
Cairo - Egypt
bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT

Dr. Bahaa Ali Kornah
Prof.. Of Orthopedic
Al-Azhar University
Cairo - Egypt
‫وبركاته‬ ‫هللا‬ ‫ورحمة‬ ‫عليكم‬ ‫السالم‬

Deformities
• Types
• Static
• Progressive

Deformities
• Site at
Bone short bone
Bending
Mal - Alignments
Joints defect articular surface
ligaments laxity
osteoligamentous structures

Deformities
• Postural deformities
Deformity correct by voluntary effort
• Structural deformity
Deformity can not correct by voluntary effort
due to anatomical structures changes
+ progressive
• Fixed deformity
Joint is deformed and immobile
• bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT

Adult Spinal Deformity
Quality of Life Affected
Functional limitations
Increased pain
Use of analgesics
Baldus et al. Spine 2008

Adult Spinal Deformity
Psychological Effect
Social Stigma
Depression
Anxiety
Beven et al. Spine, 2003

Spinal Deformity
• Coronal plan
• Sagittal plane
• Axilla plane

• Ideal spinal alignment allows a standing posture with minimal
muscular energy expenditure.
• This is accomplished through a complex relationship between
the
1. physiologic curvatures of the spine,
2. the morphology of the pelvis, and
3. the musculature of the axial and appendicular skeleton.
(Schwab F, et al. Spine2010)
(Bhalla A, et al. Seminars in Spine Surgery 2015)

NORMAL SPINE ALLIGNMENT
 FRONTAL PLANE
=CORONAL
STRAIGHT
 LATERAL PLANE=
SAGITTAL
– Cervical lordosis (≈30°)
– Thoracic kyphosis (10°-40°)
– Lumbar lordosis (40°-60°)

• C7 – Prom.
Spinous Process
 T3- Level with
Medial Scapular
Spine
 T7 – Inferior angle
of scapula
 L2 – Lowest Rib
 L4 – Iliac Crestbahaa Kornah- Al-Azhar UN.- Cairo-EGYPT

Gravity line of
human body
AND
the plumb
line,

Postural
Alignment
• 2 naturally occurring curves
– LORDOTIC (in lumbar region)
– KYPHOTIC (in upper thoracic
lower cervical regions)
– Abnormalities -- accentuated
vertebral curves

CSVL= central sacral vertical line

Spinal Deformity
 Sagittal plane deformity
 Coronal plane deformity
 Axial plane deformity
 Spinopelvic balance
• Uniplanar + in one direction
• Two planer deformity
• Rotational deformity
• Combined

Spinal Deformity
 Scoliosis
 3-dimensional deformity affecting
all 3 planes
 Can be difficult to visualize with
2-dimensional radiographs
 Kyphosis
 Deformity affecting the sagittal
plane
 Neuromuscular
 Results from neurologic or
muscular diseases, such as
cerebral palsy, muscular
dystrophy, or polio

Types of Deformity
 Congenital
 Idiopathic (80%)
 Infantile (0-2 y)
 Juvenile (3-9 y)
 Adolescent (10-17 y)
 Adult (>18 yo)
 Neuromuscular (CP, DMD, SMA etc..)
 Degenerative
 Traumatic / infectious
 Iatrogenic
 Syndromic (ED, Marfans, PW, Down S etc.)

• Adult spinal deformity (ASD) resulting in
coronal and/or sagittal plane
decompensation.
– idiopathic scoliosis
– de novo or degenerative curves (Savage JW, et al. Global Spine J 2014)

SPINAL DEFORMITY IN ADULTS
• CLINICAL PRESENTATION
 PAIN
 COSMETIC DEFORMITY
 NEUROLOGIC SYMPTOMS
 PULMONARY COMPROMISE
 PROGRESSION

DEFORMITY
Clinical
Radiology

Evaluation of patient with ASD
Clinical examination of spine

Cervical
(Lordosis)
Thoracic
(Kyphosis)
Lumbar
(Lordosis)
Front Side

A. Physical:
• Posture:
» Splinting
» Body language
• Gait:
» Antalgia
» Heel / Toe pattern
» Trendelenburg
• Musculoskeletal:
» ROM
» Leg length
» Vascular
» Atrophy

• Back:
» Inspection
» Palpation
» ROM
» Scoliosis
• Neurological:
» Sensation
» Motor
» DTRs
• Abdomen:
» Presence of masses
• Rectal if indicated:
» Evaluation of sphincter tone

Gait

Inspection
Standing
(a) Look from the side
i. normal spine
> cervical lordosis
> thoracic kyphosis
> lumbar lordosis

• Kyphos and kyphosis
• A Kyphosis is a
posterior convexity of
the spinal column
• Smooth = round back
• Or
• Angular

•Smooth = round back
 senile kyphosis (with
osteoporosis, osteomalacia
or pathological fracture)
 Scheuermann’s disease
(osteochondritis
involving one or more of the
vertebrae)
 ankylosing spondylitis

Kyphosis

Angular
Gibbus (angular kyphosis)
 fracture
 tuberculosis of the
spine
 congenital abnormality

Thoracic
Kyphosis
• exaggerated thoracic curve
• occurs more frequently than
lordosis
• mechanism -- vertebra
becomes wedge shaped
• causes a person to “hunch
over”

Kyphosis
• aka “Swimmer’s Back”
• develops in children
swimmers who train with an
excessive amount of butterfly
• also seen in elderly women
suffering from osteoporosis

• Lordosis
• A lordosis is a posterior
concavity of the spinal
column, often in the
lumbar region.
• Spondylolisthesis.
• Pregnancy
• Compensatory lordosis
may be necessary to
maintain balance.

. Lumbar curvature
>flattening or reversal of lumbar lordosis :
prolapsed intervertebral disc
osteoarthritis of the spine
infection of vertebral bodies
ankylosing spondylitis
>increase in lumbar lordosis
may be normal (esp. in pregnant women)
spondylolisthesis
secondary to increased thoracic
curvature or to flexion deformity of the
hips

Lumbar
Lordosis
• exaggeration of the lumbar
curve
• associated w/weakened
abdominals (relative to
extensors)
• characterized by low back
pain
• prevalent in gymnasts, figure
skaters, swimmers (flyers)

Look from behind = posterior
i.listing of trunk (due to muscle spasm)
ii.Scoliosis (lateral curvature of spine)
- postural : scoliosis disappears with
forward flexion of the spine
- structural : scoliosis persists with
forward flexion of the spine and a rib
hump presents
iii.Shoulder tilt
iv.Pelvic tilt

v. Skin changes over the spine
- hair tuft (spina bifida)
- sinus
- color changes or pigmentation (neurofibroma)
- scar
vi.Swelling
vii.Prominent crease of the trunk
viii.Wasting of paraspinal muscles, glutei,
hamstrings and calf muscles

Scoliosis
.

Scoliosis
• lateral deviation of the spinal
column
• can be a ‘C’ or ‘S’ shape
• involves the thoracic and/or
lumbar regions
• associated w/disease, leg
length abnormalities,
muscular imbalances

Scoliosis
• more prevalent in females
• cases range from mild to
severe
– small deviations may result
from repeated unilateral
loading (e.g. carrying books
on one shoulder)

Saggital Imbalance

• Feel= Palpation
• In the midline and laterally.
• The vertebral spinous processes
• Interspinal ligaments
• The muscles on each side of the
spine should also be palpated for
spasm.

Palpation

3.SWELLING-
Spina bifida-meningocele in the
sacral or occipital region
Congenital sacrococcygeal
teratoma in sacrococcygeal
region

MEASUREME
NTS1. Linear measurements
a.From external occipital
protrubence to tip of
coccyx
b. Iliocostal distance ( tip
off last rib to iliac cest)
c.Segmental
measurement
d. Acromiooccipital
distance
e.Schober`s test
f. Otto test
2. Chest expansion
3. Limb length discrepancybahaa Kornah- Al-Azhar UN.- Cairo-EGYPT

 Thoracic and lumbar spine
 Forward flexion (Schober’s test)
Normal : 90 degrees
 Extension
Normal : 30 degrees
 Lateral flexion to left and right
Normal : 30 to 45 degrees
 Rotation to left and right
Normal : 45 degrees

• NEUROLOGICAL EXAMINATION

Cone of economy:
• Increasing positive sagittal imbalance causes
– a position toward the periphery of the cone
– increased muscular effort and energy expenditure
– causing pain, fatigue, and disability
• If the body is shifted beyond the periphery of the cone, external
supports are needed:
– a cane, crutch, or walker
The Dubousset cone of economy
concept is important in
maintaining upright posture
minimized energy expenditure with
standing and walking

Concept of cone of economy
• Management of spinal deformity includes
the recognition and treatment of scoliotic,
kyphotic, and spondylolisthetic conditions.
• Several radiographic measures have been
defined for the assessment of
spinal alignment, including coronal, sagittal,
and pelvic measures.

Deviation in coronal direction
Scoliosis
Def.
Lat. deviation of
the spine from
midline with
rotation

Deviation in sagittal direction
• Lordosis
• kyphosis

Radiographic Evaluation
• In the radiographic assessment we need
– a standard full-length (36-inch) posterior-anterior and lateral spine x-
rays
– the hips and the knees fully extended
• For the lateral radiographs
– elbows and wrists should be fully flexed
– hands in a fist
– the proximal interphalangeal joints placed into the supraclavicular
fossa
– With no external supports
• In Hyperextension films
– a bolster placed at the apex of the deformity
– prone and supine images
(Horton WC, et al. Spine 2005)

Sagittal plane analysis:
Full length AP and lateral views:
• Hips and knees are fully extended.
• Elbows and wrists are fully flexed.
• Hands in the supra clavicular fossa.
• . New system radiography EOS X-ray
system (Nobel prize-winning) allowing 2D
to 3D reconstructions from biplanar X-ray
images (EOS Imaging, Paris, France)

Regional Parameters
A. Thoracic Kyphosis
B. Thoraco-Lumbar
C. Lumbar Lordosis
Radiographic Evaluation
A B
C7 T1
Regional Parameters Global Alignment
Pelvic Parameters
A
C
B
T1
C
Global Alignment
A. SVA (Sagittal vertical axis)
B. T1-SPI (T1 & T9 sagittal
tilt)
C. TPA (T1 pelvic angle)
D. Proximal thoracic slope
Pelvic Parameters
A. Pelvic Incidence
B. Sacral Slope
C. Pelvic Tilt

Regional Parameters
Sagittal balance
• Sagittal balance: is the balance
between the normal sagittal curves
of the spine to center the head on
the pelvis with the least energy
expenditure.
• Regional sagittal alignment is assessed by;
Cervical lordosis (≈30°)
Thoracic kyphosis (10°-40°)
Lumbar lordosis (40°-60°)
These curves should balance the
occiput over the sacropelvic axis.
• Hips and Knees share spine and
pelvis in sagittal balance control.

Global Sagittal Alignment
Radiological Evaluation:
A) Sagittal vertical axis (plumb
line):
• From center of C7 downwards.
• Normally within 0.5 cm from
the postero-superior aspect of
S1.
• Offset >2.5-4 cm ant. Or post is
abnormal.

B) T1-SPI (T1 & T9 sagittal tilt)
T1 spinopelvic inclination

• T1 spinopelvic inclination (T1-SPI)
– T1 or T9 sagittal tilt is the angle subtended by a vertical plumb line
from the center of the T1 or T9 vertebral body and a line drawn to
the bicoxofemoral axis.
• There is a correlation between T1-SPI and patient self reported
function
– with SRS, ODI, and SF-12 assessments of HRQOL
• T1-SPI is superior to the SVA
– does not differentiate between compensated offset of the upper
thoracic spine and deformity with pelvic retroversion.
• T9-SPI can be used, with the added benefit of greater visibility
on radiographs as compared to T1
(Lafage V, et al. Spine 2009)
(Lafage, V, et al. Spine 2008)
(Schwab F, et al. Spine 2009)

C) TPA (T1 pelvic angle)
• T1 pelvic angle (TPA) is a novel parameter showing both trunk
inclination and pelvic retroversion.
– TPA is the angle between the line from the femoral head axis to the centroid of
T1 and the line from the femoral head axis to the middle of the S1 endplate.
• Increasing values of TPA have been correlated with worse health
outcome measures.
• TPA can be measured intraoperatively with the patient in the
prone position.
• The severe deformity threshold for TPA was determined to be 20°
(ODI > 40)
– 4.1° (ODI change = 15)
(Ryan DJ, et al. Spine 2014)

D)Proximal thoracic slope
25 DEGREE

Pelvic Parameters
Sacropelvic parameters:
• Pelvic incidence: (50°-60°)
non positional parameter.
morphological parameter.
line perpendicular to sacral plate at
its midpoint and a line to axis of rotation of
femoral head.
• Sacral slope : (40°-50°)
positional parameter.
compensatory parameter.
superior end plate of S1 and a horizontal line.
• Pelvic tilt angle : (10°-20°)
positional parameter.
compensatory parameter.
mid point of sacral plate to femoral rotational
axis and a vertical line.
The pelvic incidence is equal to the arithmetic sum of the sacral
slope and the pelvic tilt (PI = PT + SS).
Legaye J, et al. Eur Spine J 1998)

Pelvic Parameters
Sacropelvic parameters:
• Position of pelvis plays an important role in
upright sitting and standing postures.
• Pelvic incidence is constant and
specific to each individual, and is
independent of the spatial orientation of
the pelvis.
– (PI = PT + SS)
– LL = PI +/- 9 °
• PT and SS are dynamic pelvic
parameters.
• PT is correlated with increased pain and
disability.
(Lafage, V, et al. Spine 2008)
(Le Huec JC, et al. International Orthopedics 2015)
(PI = 52° ±
10°)
(PT = 15° ± 7°) (SS = 30° ± 9°)
(Lafage V, et al. Spine 2009)
(D. Deinlein et al. Spine Deformity 2013)
(Labelle H, et al. Spine 2005)

Pelvic Parameters
Sacropelvic parameters
• Compared changes between SVA and PT
– Negative SVA (<0); PT = 10°
– Neutral SVA (0-5 cm); PT = 16°
– Positive SVA (> 5 cm); PT = 21°
• SVA increases result in compensatory
increase in PT
• As PT increases, the SS decreases and PI
remains constant.
– PI = PT + SS
• The degree of pelvic retroversion is essential in
understanding the severity of sagittal plane
imbalance and plays a key role in determining
the amount of surgical correction.
Increasing SVA  increase in PT  greater energy
expenditure and greater disability
Increasing PT to maintain neutral
(A) No pelvic retroversion and high sagittal vertical axis (SVA).
(B) Moderate pelvic retroversion and SVA.
(C) High pelvic retroversion and no SVA.
A B C

Importance of Spinopelvic
parameter's
• A high PI/ PT are a predisposing factor for facet
joint degeneration at the lower lumbar spine.
• Increased PT values reflected pelvic retroversion
and correlated with worsening Health-related
quality of life (HRQOL) scores.
• T1SPI was more accurately correlated with
HRQOL scores than did sagittal vertical axis (SVA).
Pourtaheri S et al. Pelvic retroversion: a compensatory mechanism for lumbar stenosis. J Neurosurg Spine
27:137–144, 2017
Lafage V, et al: Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults
with spinal deformity. Spine (Phila Pa 1976) 34:599–606, 2009

The SRS-Schwab adult spinal deformity
classification :
• this one correlated radiographic deformity
with patient-reported outcomes,

SRS-Schwab Classification
• A classification system can reliably describe
a deformity, and establish a basis for
treatment.
• The SRS-Schwab ASD classification includes
a curve type descriptor, and a three sagittal
spinopelvic modifiers:
– PI-LL mismatch, SVA, and PT
• The most important components are:
– PI - LL within 10 degrees (normal)
– SVA (quantifies global malalignment)
– PT (measures the degree of pelvic retroversion)
• Each classified as
– Non- pathological (0)
– Moderate deformity (+)
– Marked deformity (+ +)
SRS-Schwab Classification for ASD

SRS-Schwab Classification
• These parameters are associated
with HRQOL outcomes
• They were established on the basis
of patient-reported outcome data.
• SRS –Schwab classification has
– clinical relevance and applicable
– surgical goals using the spinopelvic
modifiers
SRS-Schwab Classification for ASD
(Terran JS, et al. Neurosurgery 2013)

sagittal balance
• Positive sagittal balance
• occurs when the C7 plumb line
falls anterior to the posterior-
superior corner of the S1
endplate.
• Negative sagittal balance
• occurs when the C7 plumb line
falls posterior to the posterior-
superior corner of the S1
endplate.

Negative sagittal balance
• occurs when the C7 plumb line falls posterior
• either fixed or flexible.
• the imbalance can be
either compensated or decompensated.
“Compensated” either
a) local (a few vertebra causing significant tilt),
b) regional (many vertebra causing a slow forward
bend), or
c) a mix of the two

Regional Sagittal malalignment
kyphosis (T10-L1)
• Regional deformity is characterized by
sagittal malalignment within the
• cervical,
• thoracic or
• lumbosacral regions of the spine.
– Hypo kyphotic < 20°,
– Hyperkyphotic > 60°
– Hypo lordotic < 30°
(Berthonnaud E, et al. J Spinal Disord Tech 2005)

Sagittal imbalance cascade:
• Loss of lumbar lordosis.
• Pelvic retroversion.
• Hip extension.
• Knee flexion.
• Loss balance .
• External support.

Compensation mechanisms for
anterior segment imbalance.

Causes of Sagittal imbalance:
• Primary spine causes:
- All causes of kyphosis (congenital, Ankylosing spondyliotis,
Scheurman, Neuromuscular,…….).
- Destructive lesions( Tumors, infections).
- Traumatic lesions (fractures).
- Degenerative lesions (multilevel disc disease, high grade
spondylolisthesis).
• Secondary spine causes:
- Iatrogenic flat back.
- Post laminectomy kyphosis.
- Adjacent segment disease.
• Extra spinal causes:
- Hips and knees contractures.

Coronal imbalance:
Coronal offset:
• The distance between c7 plumb
line and CSVL.
• More than 4 cm has been correlated
with poor function
and increased disability.
IT is defined the amount of
coronal plane
decompensation in
centimeters.

Coronal plane deformity
correction
• Deviation
• To left is negative,
• To right is positive

• Coronal deformity can be broken down into
idiopathic (residual) ASD
– the result of untreated adolescent idiopathic scoliosis in
the adult
• degenerative (de novo) ASD
– defined as a progressive deformity in the adult caused by
• degenerative changes
• iatrogenic
• paralytic
• posttraumatic

Pelvic Obliquity

CLASSIFICATIONS of PO.
I- Mayer (1936) :
1- Functional / non-structural PO :
- Present only when pt. stands with knees straight & no lift under foot & disappear on
sitting & on recumbency w legs parallel to midline of body
- due to LLD.
2- Structural / fixed PO :
-persists in all positions & cannot be passively corrected.
-Etiology:
a- infrapelvic (hips)
b- pelvic
c-suprapelvic ( spine)
d- combined

SUPRA-PELVIC FIXED PO.:
- in cong. or neuromuscular scoliosis
- not in idiopathic scoliosis ( curve not
extend to pelvis )
INFRA-PELVIC FIXED PO.
A- Congenital hip contracture:
1- cong. Abductor contracture
2- cong. Adduction contracture
B- neuromuscular hip contractures :
Abd, add or both.

pelvic obliquity
• Pelvic obliquity and associated etiology should be
considered in the coronal plane correction strategy.
• Pelvic obliquity is quantified by measuring the angle
formed between a horizontal reference line and a pelvic
coronal reference line.

Treatment of patients with scoliosis, coronal
misalignment and pelvic obliquity
• All patients should be
evaluated for a leg length
discrepancy
• Patients with a flexible
curve due to pelvic
obliquity as a result of a
leg length discrepancy
may respond well to the
addition of a shoe lift only
or surgical treatment of
the leg length discrepancy.

Summary
• Several radiographic parameters have been shown to correlate with patient quality
of life and normative thresholds have been established.
• Studies have shown that sagittal balance is the most important and reliable
radiographic predictor of clinical health status in adult patients with spinal
deformity.
• Current radiographic goals include:
– SVA within 5 cm
– PI and LL mismatch less than 10°
– PT less than 20°
– T1SPi less than 1°
• Restoration of these normal sagittal parameters has become a primary objective in
ASD surgery.
(Bhalla A, et al. Seminars in Spine Surgery, 2015), (Schwab FJ, et al. Spine 2013),
(Lafage V, et al. Spine 2009), (Turner JD, et al. Eur Spine J 2015)

TH-TH-TH-THAT’S ALL FOLKS!

‫ا‬.‫د‬.‫قرنة‬ ‫بهاء‬
Prof. Dr. Bahaa Kornah
•.

Spine deformities recognition and evaluation

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