European Spine Journal

, Volume 28, Issue 1, pp 161–169 | Cite as

Possible factors associated with sagittal malalignment recurrence after pedicle subtraction osteotomy

  • David Eichler
  • Yann Philippe CharlesEmail author
  • Florent Baldairon
  • Yves Ntilikina
  • Erik André Sauleau
  • Jean-Paul Steib
Original Article



This retrospective study investigates sagittal alignment after pedicle subtraction osteotomy (PSO). The purpose was to investigate factors associated with malalignment recurrence.


Full spine radiographs were analyzed in 66 patients (average age 54.5 years, follow-up 3.8 years). Measurements were taken preoperatively, 3 months postoperatively, at follow-up: SVA C2 and C7, C2–C7 lordosis, T4–T12 kyphosis, L1–S1 lordosis, PSO lordosis, pelvic incidence, pelvic tilt, sacral slope. Follow-up CTs were screened for pseudarthrosis and gas in sacroiliac joints.


PSO lordosis increased from 11.8° to 40.8° (p < 0.0001) and kept stable. Lumbar lordosis increased from 28.6° to 57.7° (p < 0.0001) and decreased to 49.7° (p = 0.0008). Pelvic tilt decreased from 29.2° to 16.5° (p < 0.0001) and increased to 22.5° (p < 0.0001). SVA C7 decreased from 105.1 to 35.5 mm (p < 0.0001) and increased to 64.8 mm (p = 0.0005). Twenty-eight patients (42%) had an SVA C7 increase of more than 70 mm in the postoperative course: recurrence group. These patients were older: 62.8 years versus 52.3 years (p = 0.0031). Loss of lordosis was 11.9° (recurrence group) versus 5.0° (non-recurrence group). Eleven patients (17%) had pseudarthrosis. Pelvic incidence increased by 9.3° (recurrence group) versus 3.8° (non-recurrence group). In 23 patients (35%), pelvic incidence increased > 10°. Gas was evidenced in sacroiliac joints in 22 patients (33%).


Postoperative anterior malalignment recurrence may occur after PSO. Elderly patients were at risk of recurrence. Loss of lumbar lordosis linked to pseudarthrosis represented another factor. With malalignment recurrence, anterior trunk rotation and pelvic retroversion might additionally have augmented moments across sacroiliac joints with subsequent ligament laxity and pelvic incidence increase.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.


Sagittal balance Thoracolumbar alignment Pedicle subtraction osteotomy Malalignment recurrence Lumbar pseudarthrosis Loss of reduction Sacroiliac joint laxity 


Compliance with ethical standards

Conflict of interest

None of the authors has any conflict of interest related to this study.

Supplementary material

586_2018_5767_MOESM1_ESM.pptx (440 kb)
Supplementary material 1 (PPTX 440 kb)


  1. 1.
    Smith JS, Klineberg E, Schwab F, Shaffrey CI, Moal B, Ames CP, Hostin R, Fu KM, Burton D, Akbarnia B, Gupta M, Hart R, Bess S, Lafage V, International Spine Study Group (2013) Change in classification grade by the SRS-Schwab adult spinal deformity classification predicts impact on health-related quality of life measures. Spine (Phila Pa 1976) 38:1663–1671CrossRefGoogle Scholar
  2. 2.
    Schwab F, Blondel B, Bess S, Hostin R, Shaffrey CI, Smith JS, Boachie-Adjei O, Burton DC, Akbarnia BA, Mundis GM, Ames CP, Kabaish K, Hart R, Farcy JP, Lafage V, International Spine Study Group (ISSG) (2013) Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity. A prospective multicenter analysis. Spine (Phila Pa 1976) 38:E803–E812CrossRefGoogle Scholar
  3. 3.
    Terran J, Schwab F, Shaffrey CI, Smith JS, Devos P, Ames CP, Fu KM, Burton D, Hostin R, Klineberg E, Gupta M, Deviren V, Mundis G, Hart R, Bess S, Lafage V, International Spine Study Group (2013) The SRS-Schwab adult spinal deformity classification: assessment and clinical correlations based on a prospective operative and nonoperative cohort. Neurosurgery 73:559–568CrossRefGoogle Scholar
  4. 4.
    Enercan M, Ozturk C, Kahraman S, Sarier M, Hamzaoglu A, Alanay A (2013) Osteotomies/spinal column resections in adult deformity. Eur Spine J 22(Suppl 2):S254–S264CrossRefGoogle Scholar
  5. 5.
    Berjano P, Aebi M (2015) Pedicle subtraction osteotomies (PSO) in the lumbar spine for sagittal deformities. Eur Spine J 24(Suppl 1):S49–S57CrossRefGoogle Scholar
  6. 6.
    Yang BP, Ondra SL, Chen LA, Jung HS, Koski TR, Salehi SA (2006) Clinical and radiographic outcomes of thoracic and lumbar pedicle subtraction osteotomy for fixed sagittal imbalance. J Neurosurg Spine 5(1):9–17CrossRefGoogle Scholar
  7. 7.
    Lee SH, Kim KT, Suk KS, Lee JH, Seo EM, Huh DS (2011) Sagittal decompensation after corrective osteotomy for lumbar degenerative kyphosis: classification and risk factors. Spine (Phila Pa 1976) 36(8):E538–E544CrossRefGoogle Scholar
  8. 8.
    Schwab FJ, Patel A, Shaffrey CI, Smith JS, Farcy JP, Boachie-Adjei O, Hostin RA, Hart RA, Akbarnia BA, Burton DC, Bess S, Lafage V (2012) Sagittal realignment failures following pedicle subtraction osteotomy surgery: are we doing enough? Clinical article. J Neurosurg Spine 16(6):539–546CrossRefGoogle Scholar
  9. 9.
    Chiffolot X, Lemaire JP, Bogorin I, Steib JP (2006) Pedicle closing-wedge osteotomy for the treatment of fixed sagittal imbalance. Rev Chir Orthop Reparatrice Appar Mot 92(3):257–265 [French] CrossRefGoogle Scholar
  10. 10.
    Nicholls FH, Bae J, Theologis AA, Eksi MS, Ames CP, Berven SH, Burch S, Tay BK, Deviren V (2017) Factors associated with the development of and revision for proximal junctional kyphosis in 440 consecutive adult spinal deformity patients. Spine (Phila Pa 1976) 42(22):1693–1698CrossRefGoogle Scholar
  11. 11.
    Liu FY, Wang T, Yang SD, Wang H, Dl Yang, Ding WY (2016) Incidence and risk factors for proximal junctional kyphosis: a meta-analysis. Eur Spine J 25(8):2376–2383CrossRefGoogle Scholar
  12. 12.
    Roussouly P, Gollogly S, Berthonnaud E, Dimnet J (2005) Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine (Phila Pa 1976) 30(3):346–353CrossRefGoogle Scholar
  13. 13.
    Sebaaly A, Riouallon G, Obeid I, Grobost P, Rizkallah M, Laouissat F, Charles YP, Roussouly P (2018) Proximal junctional kyphosis in adult scoliosis: comparison of four radiological predictor models. Eur Spine J 27(3):613–621CrossRefGoogle Scholar
  14. 14.
    Dickson D, Lenke L, Bridwell K, Koester L (2014) Risk factors for and assessment of symptomatic pseudarthrosis after lumbar pedicle subtraction osteotomy in adult spinal deformity. Spine 15:1190–1195CrossRefGoogle Scholar
  15. 15.
    Theologis AA, Safaee M, Scheer JK, Lafage V, Hostin R, Hart RA, Klineberg EO, Protopsaltis TS, Deviren V, Burton DC, Sciubba DM, Kebaish K, Bess S, Shaffrey CI, Schwab F, Smith JS, Ames CP, International Spine Study Group (ISSG) (2017) Magnitude, location, and factors related to regional and global sagittal alignment change in long adult deformity constructs: report of 183 patients with 2-year follow-up. Clin Spine Surg 30:E948–E953CrossRefGoogle Scholar
  16. 16.
    Banno T, Hasegawa T, Yamato Y, Kobayashi S, Togawa D, Oe S, Mihara Y, Matsuyama Y (2017) The prevalence and risk factors of iliac screw loosening after adult spinal deformity surgery. Spine (Phila Pa 1976) 42(17):E1024–E1030CrossRefGoogle Scholar
  17. 17.
    Ohtori S, Inoue G, Orita S, Yamauchi K, Eguchi Y, Ochiai N, Kishida S, Kuniyoshi K, Aoki Y, Nakamura J, Ishikawa T, Miyagi M, Kamoda H, Suzuki M, Kubota G, Sakuma Y, Oikawa Y, Inage K, Sainoh T, Takaso M, Toyone T, Takahashi K (2013) Comparison of teriparatide and bisphosphonate treatment to reduce pedicle screw loosening after lumbar spinal fusion surgery in postmenopausal women with osteoporosis from a bone quality perspective. Spine (Phila Pa 1976) 38(8):E487–E492CrossRefGoogle Scholar
  18. 18.
    Legaye J, Duval-Beaupere G, Hecquet J, Marty C (1998) Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine J 7(2):99–103CrossRefGoogle Scholar
  19. 19.
    Mac-Thiong JM, Roussouly P, Berthonnaud E, Guigui P (2011) Age- and sex-related variations in sagittal sacropelvic morphology and balance in asymptomatic adults. Eur Spine J 20(Suppl 5):572–577CrossRefGoogle Scholar
  20. 20.
    Legaye J (2014) Influence of age and sagittal balance of the spine on the value of the pelvic incidence. Eur Spine J 23(7):1394–1399CrossRefGoogle Scholar
  21. 21.
    Charles YP, Yu B, Steib JP (2016) Sacroiliac joint luxation after pedicle subtraction osteotomy: report of two cases and analysis of failure mechanism. Eur Spine J 25(Suppl 1):63–74CrossRefGoogle Scholar
  22. 22.
    Vialle R, Ilharreborde B, Dauzac C, Guigui P (2006) Intra and inter-observer reliability of determining degree of pelvic incidence in high-grade spondylolisthesis using a computer assisted method. Eur Spine J 15(10):1449–1453CrossRefGoogle Scholar
  23. 23.
    Kim YJ, Bridwell KH, Lenke LG, Cheh G, Baldus C (2007) Results of lumbar pedicle subtraction osteotomies for fixed sagittal imbalance: a minimum 5-year follow-up study. Spine 32(20):2189–2197CrossRefGoogle Scholar
  24. 24.
    Rose PS, Bridwell KH, Lenke LG, Cronen GA, Mulconrey DS, Buchowski JM, Kim YJ (2009) Role of pelvic incidence, thoracic kyphosis, and patient factors on sagittal plane correction following pedicle subtraction osteotomy. Spine (Phila Pa 1976) 34(8):785–791CrossRefGoogle Scholar
  25. 25.
    Yagi M, King AB, Cunningham ME, Boachie-Adjei O (2013) Long-term clinical and radiographic outcomes of pedicle subtraction osteotomy for fixed sagittal imbalance: does level of proximal fusion affect the outcome? Minimum 5-year follow-up. Spine Deform 1(2):123–131CrossRefGoogle Scholar
  26. 26.
    Merrill RK, Kim JS, Leven DM, Kim JH, Meaike JJ, Bronheim RS, Suchman KI, Nowacki D, Gidumal SS, Cho SK (2017) Differences in fundamental sagittal pelvic parameters based on age, sex, and race. Clin Spine Surg. Google Scholar
  27. 27.
    Yilgor C, Sogunmez N, Boissiere L, Yavuz Y, Obeid I, Kleinstück F, Pérez-Grueso FJS, Acaroglu E, Haddad S, Mannion AF, Pellise F, Alanay A, European Spine Study Group (ESSG) (2017) Global alignment and proportion (GAP) score: development and validation of a new method of analyzing spinopelvic alignment to predict mechanical complications after adult spinal deformity surgery. J Bone Joint Surg Am 99(19):1661–1672CrossRefGoogle Scholar
  28. 28.
    Ha KY, Lee JS, Kim KW (2008) Degeneration of sacroiliac joint after instrumented lumbar or lumbosacral fusion: a prospective cohort study over five-year follow-up. Spine (Phila Pa 1976) 33(11):1192–1198CrossRefGoogle Scholar
  29. 29.
    Cecchinato R, Redaelli A, Martini C, Morselli C, Villafane JH, Lamartina C, Berjano P (2017) Long fusions to S1 with or without pelvic fixation can induce relevant acute variations in pelvic incidence: a retrospective cohort study of adult spine deformity surgery. Eur Spine J 26(Suppl 4):436–441CrossRefGoogle Scholar
  30. 30.
    Finger T, Bayerl S, Onken J, Czabanka M, Woitzik J, Vajkoczy P (2014) Sacropelvic fixation versus fusion to the sacrum for spondylodesis in multilevel degenerative spine disease. Eur Spine J 23(5):1013–1020CrossRefGoogle Scholar
  31. 31.
    Volkheimer D, Reichel H, Wilke HJ, Lattig F (2017) Is pelvic fixation the only option to provide additional stability to the sacral anchorage in long lumbar instrumentation? A comparative biomechanical study of new techniques. Clin Biomech (Bristol, Avon) 43:34–39CrossRefGoogle Scholar
  32. 32.
    Koller H, Zenner J, Hempfing A, Ferraris L, Meier O (2013) Reinforcement of lumbosacral instrumentation using S1-pedicle screws combined with S2-alar screws. Oper Orthop Traumatol 25(3):294–314CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Service de Chirurgie du Rachis, Hôpitaux Universitaires de Strasbourg, Fédération de Médecine Translationnelle (FMTS)Université de StrasbourgStrasbourg CedexFrance
  2. 2.Département de Santé Publique, Hôpitaux Universitaires de StrasbourgUniversité de StrasbourgStrasbourgFrance

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