Objective To quantify the effect of different hip positions on lumbar lordosis (LL) and spinopelvic parameters in the right lateral decubitus position (RLDP) and identify the configuration that most closely replicates physiologic standing alignment during lateral lumbar interbody fusion in minimally invasive spinal surgery.
Methods Thirty healthy volunteers (15 males, 15 females; mean age, 27.8±8.6 years) underwent lateral lumbar radiographs in standing position and 5 RLDP configurations: neutral hips (NN), 30° flexion of both hips (30FF), 30° flexion of the right hip with left hip neutral (30FN), 60° flexion of both hips (60FF), and 60° flexion of the right hip with left hip neutral (60FN). LL, pelvic tilt (PT), sacral slope (SS), and pelvic incidence (PI) were measured. Each position was compared to standing using paired t-tests. Intra- and interobserver reliability were evaluated using intraclass correlation coefficients (ICCs).
Results LL decreased significantly in all RLDP positions compared with standing (51.1°±3.8°). The 30FN position showed the smallest change (ΔLL=-4.9°, p<0.001), whereas 60FF showed the greatest (ΔLL=-15.0°, p<0.001). In 30FN, PT decreased (p=0.013) and SS increased (p=0.003), indicating mild anterior pelvic rotation. PI showed minimal variation across positions. Intra- and interobserver ICCs ranged from 0.92 to 0.99, confirming high measurement reliability.
Conclusion Hip position significantly influences lumbar and pelvic alignment in RLDP. Among tested configurations, the 30FN position (right hip flexed 30°, left neutral) showed the smallest numerical deviation from standing alignment and spinopelvic harmony relative to standing in RLDP.
Jun Jae Shin, Sun Joon Yoo, Se Jun Park, Dong Kyu Kim, Hyun Jun Jang, Bong Ju Moon, Kyung Hyun Kim, Jeong Yoon Park, Sung Uk Kuh, Dong Kyu Chin, Keun Su Kim, Yong Eun Cho, Chang Kyu Lee, Dong Ah Shin, Seong Yi, Keung Nyun Kim, Joongkyum Shin, Yoon Ha
Neurospine 2025;22(4):937-948. Published online December 31, 2025
Objective To evaluate the clinical significance of a negative K-line in the neck flexion position (FK-line [-]), which indicates that cervical ossification of the posterior longitudinal ligament (OPLL) crosses the K-line during flexion, and to compare surgical outcomes between laminoplasty (LP) and laminectomy with fusion (LF) for multilevel FK-line (-) cervical OPLL.
Methods A total of 349 patients with multiple cervical OPLL who underwent posterior decompression surgery (LP or LF) with a minimum of 2 years of follow-up were stratified by FK-line status. Clinical and radiological parameters were compared between the FK-line (+) and FK-line (-) groups. Subgroup analysis of FK-line (-) patients evaluated the efficacy of LP versus LF. Multivariate regression identified predictors of neurological recovery.
Results Patients with FK-line (-) OPLL exhibited a smaller FK-line distance, more kyphotic alignment, greater cervical flexion, and lower recovery ratios compared to those with FK-line (+). In the FK-line (-) subgroup, LF achieved a significantly greater increase in FK-line distance, better correction of the flexion angle, and more neurological recovery than LP. Multivariate analyses identified postoperative FK-line distance, C2–7 flexion angle, and preoperative dynamic extension reserve as independent predictors of neurological outcomes.
Conclusion FK-line status reflects the sagittal cord position and predicts surgical outcomes in cervical OPLL. In FK-line (-) patients, LF provides better neurological recovery and more effective posterior cord shift and kyphotic alignment correction than LP. Incorporating FK-line assessment to guide surgical planning could improve individualized treatment outcomes for multilevel OPLL.
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From the Editor-in-Chief: Featured Articles in the December 2025 Issue Inbo Han Neurospine.2025; 22(4): 877. CrossRef
Objective To evaluate the correlation between lumbar degenerative spondylolisthesis (LDS) and facet joint orientation, and to examine the factors influencing facet joint orientation in patients with double-level LDS (dLDS).
Methods A total of 40 patients with L3–5 dLDS (mean age, 64.1 years) and 106 patients with L4–5 single-level LDS (sLDS; mean age, 63.5 years) were included. Besides, 100 age-matched healthy participants were recruited as the control group. Facet joint angles at each level from L2–3 to L5–S1 were measured on axial computed tomogrpahy images. Slippage and spinopelvic sagittal parameters were measured using lateral full-spine x-rays.
Results Both dLDS and sLDS groups had significantly larger facet joint angles from L2–3 to L5–S1 than those in the control group, except for left L5–S1. In patients with spondylolisthesis, the facet joint angles at the L2–3 and L3–4 levels in the dLDS group were significantly greater than those in the sLDS group, while the angles at the L4–5 and L5–S1 levels showed no significant differences. In contrast to the sLDS group, the dLDS group had significantly greater pelvic tilt, sagittal vertical axis, L3 slope, and L4 slope, as well as smaller sacral slope, lumbar lordosis, L3–4 disc height, L4–5 disc height, L4–5 slippage angle, and L3–S1 height. Age and dLDS were identified as independent factors influencing the changes in the L3–4 facet joint angles between the 2 LDS groups.
Conclusion Spondylolisthesis and aging are associated with facet joint sagittalization. The present study provides evidence that the combined effects of preexisting degeneration and spondylolisthesis alter the morphology of the facet joints.
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Objective This multicenter study aimed to evaluate the impact of paravertebral muscles (PVMs) degeneration, particularly fat infiltration, on preoperative sagittal imbalance, and postoperative complications and sagittal alignment change in patients with adult spinal deformity (ASD).
Methods A retrospective analysis was conducted on 454 patients who underwent ASD surgery across 5 institutions. Patients were classified into 2 groups based on paraspinal muscle fat infiltration on MRI: those with significant infiltration (FI-PVM(+)) and those with minimal or no infiltration (FI-PVM(-)). Propensity score matching was performed to adjust for demographic factors and preoperative radiographical parameters. Spinopelvic parameters were assessed preoperatively, postoperatively, and at a 2-year follow-up. Mechanical complications were compared between the groups.
Results The FI-PVM(+) group showed greater sagittal vertical axis (86.4 ± 57.5 vs. 51.8 ± 59.2, p < 0.001) preoperatively and required more extensive surgical correction with a significantly greater number of fused vertebral levels (7.3 ± 3.7 vs. 6.7 ± 3.7, p < 0.039). After propensity score matching, both groups showed significant improvement in spinopelvic alignment postoperatively, maintained throughout the 2-year follow-up. However, the FI-PVM(+) group demonstrated a trend toward a higher incidence of distal junctional kyphosis (6.3% vs. 0.9%, p = 0.070) and exhibited significantly greater decrease in pelvic tilt postoperatively (4.3° ± 7.6° vs. 1.3° ± 8.2°, p = 0.006).
Conclusion Fat infiltration in PVM is associated with increased surgical complexity and a higher risk of mechanical complications. Preoperative assessment of muscle quality, along with targeted rehabilitation and closer postoperative monitoring, may be crucial for improving long-term outcomes in ASD surgery.
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Cervical spinal deformity (CSD) is a complex condition characterized by abnormal curvature and cervical spine alignment. It can lead to a multitude of symptoms, including chronic pain, neurological deficits, and functional impairments, severely impacting an individual’s health-related quality of life (HRQoL). Surgical intervention is often necessary to address the deformity and alleviate symptoms, but optimal surgical strategies remain a topic of ongoing research and debate. This narrative review aims to provide an in-depth overview of the surgical management of CSD, focusing on optimizing patient outcomes and enhancing readers’ understanding of the complexities involved. We begin by discussing the importance of preoperative assessment, including comprehensive radiographic evaluation and careful consideration of the global spinal alignment. The relationship between the cervical spine and the reciprocal changes that occur are explored to guide surgeons in their decision-making process. Furthermore, we delve into the selection of fusion levels, emphasizing the significance of identifying the primary driver of deformity. We review the current literature on optimal alignment targets and strategies to optimize surgical planning. By providing a comprehensive analysis of the surgical management of CSD, this review aims to enhance the readers’ knowledge and assist surgeons in making informed decisions when planning and executing surgical interventions. Understanding the intricacies of CSD correction and the latest advancements in the field can ultimately improve patient outcomes and enhance HRQoL for individuals suffering from this challenging condition.
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Objective The goal of this study was to determine if patients with mild scoliosis and age-appropriate sagittal alignment have favorable outcomes following surgical correction.
Methods Retrospective review of a prospective, multicenter adult spinal deformity database. Inclusion criteria: operative patients age ≥18 years, and preoperative pelvic tilt, mismatch between pelvic incidence and lumbar lordosis (PI–LL), and C7 sagittal vertical axis all within established age-adjusted thresholds with minimum 2-year follow-up. Health-related quality of life (HRQoL) scores: Oswestry Disability Index (ODI), 36-item Short Form health survey (SF-36), Scoliosis Research Society-22R (SRS22R), back/leg pain Numerical Rating Scale and minimum clinically important difference (MCID)/substantial clinical benefit (SCB). Two-year and preoperative HRQoL radiographic data were compared. Patients with mild scoliosis (Mild Scoli, Max coronal Cobb 10°–30°) were compared to those with larger curves (Scoli).
Results One hundred fifty-one patients included from 667 operative patients (82.8% women; average age, 56.4 ± 16.2 years). Forty-two patients (27.8%) included in Mild Scoli group. Mild Scoli group had significantly worse baseline leg pain, ODI, and physical composite scores (p < 0.02). Mean 2-year maximum coronal Cobb angle was significantly improved compared to baseline (p < 0.001). All 2-year HRQoL measures were significantly improved compared to (p < 0.001) except mental composite score, SRS activity and SRS mental for the Mild Scoli group (p > 0.05). From the mild Scoli group, 36%–74% met either MCID or SCB for the HRQoL measures. Sixty-four point three percent had minimum 1 complication, 28.6% had a major complication, 35.7% had reoperation.
Conclusion Mild scoliosis patients with age-appropriate sagittal alignment benefit from surgical correction, decompression, and stabilization at 2 years postoperative despite having a high complication rate.
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Objective To define a novel radiographic measurement, the posterior cranial vertical line (PCVL), in an asymptomatic adult population to better understand global sagittal alignment.
Methods We performed a multicenter retrospective review of prospectively collected radiographic data on asymptomatic volunteers aged 20–79. The PCVL is a vertical plumb line drawn from the posterior-most aspect of the occiput. The horizontal distances of the PCVL to the thoracic apex (TA), posterior sagittal vertical line (PSVL, posterosuperior endplate of S1), femoral head center, and tibial plafond were measured. Classification was either grade 1 (PCVL posterior to TA and PSVL), grade 2 (PCVL anterior to TA and posterior to PSVL), or grade 3 (PCVL anterior to TA and PSVL).
Results Three hundred thirty-four asymptomatic patients were evaluated with a mean age of 41 years. Eighty-three percent of subjects were PCVL grade 1, 15% were grade 2, and 3% were grade 3. Increasing PCVL grade was associated with increased age (p < 0.001), C7–S1 sagittal vertical axis (SVA) (p < 0.001), C2–7 SVA (p < 0.001). Additionally, it was associated with decreased SS (p = 0.045), increased PT (p < 0.001), and increased knee flexion (p < 0.001).
Conclusion The PCVL is a radiographic marker of global sagittal alignment that is simple to implement and interpret. Increasing PCVL grade was significantly associated with expected changes and compensatory mechanisms in the aging population. Most importantly, it incorporates cervical alignment parameters such as C2–7 SVA. The PCVL defines global sagittal alignment in adult volunteers and naturally distributes into 3 grades, with only 3% being grade 3 where the PCVL lies anterior to the TA and PSVL.
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Over the last few decades, the importance of the sagittal plane and its contour has gained significant recognition. Through full-body stereoradiography, the understanding of compensatory mechanisms, and the concept of global balance and reciprocal change has expanded. There have been a few reports describing how cervical realignment surgery affects global spinal alignment (GSA) and global balance. Despite the research efforts, the concept of reciprocal change and global balance is still perplexing. Understanding the compensatory status and main drivers of deformity in a patient is vital because the compensatory mechanisms may resolve reciprocally following cervical realignment surgery. A meticulous preoperative evaluation of the whole-body alignment, including the pelvis and lower extremities, is paramount to appreciate optimal GSA in the correction of spinal malalignment. This study aims to summarize relevant literature on the reciprocal changes in the whole body caused by cervical realignment surgery and review recent perspectives regarding cervical compensatory mechanisms.
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Objective C2 slope (C2S), a cervical parameter mathematically approximated as T1 slope minus cervical lordosis (T1S–CL), predicts functional improvement in cervical deformity patients. Nonetheless, C2S is a positional parameter based only on the horizontal axis. The current study aims to introduce novel odontoid parameters and establish their relationships with patient-reported health-related quality of life (HRQoL).
Methods Lateral plain radiographs of 32 adults who underwent multilevel posterior cervical fusion were analyzed. The odontoid parameters included odontoid incidence (OI), C2S, odontoid tilt (OT), and gravity line-C2 distance (GL-C2), while the cervical parameters were the Cobb angle at C0–1, C1–2, C0–2, C2–7, C2–7 sagittal vertical axis (cSVA), T1 slope, and T1S–CL. The range of motion (ROM) of the occipito-atlantoaxial complex was measured in flexion and extension plain radiographs. Scores on the Neck Disability Index (NDI) and visual analogue scale (VAS) for axial neck (VASn) and arm pain were measured.
Results Compared to asymptomatic subjects, patients had larger C2S, cSVA, and T1S–CL, and smaller OT. Preoperatively, OI was significantly correlated with the ROM of C1–2 (r = 0.37, p < 0.05) and C0–2 (r = 0.46, p < 0.01). OT and C2S had significant correlations with the C0–1, C1–2, and C0–2 angles, GL-C2, and T1S–CL. Postoperative NDI scores were significantly correlated with OI (r = -0.40, p < 0.05) and OT (ρ = -0.37, p < 0.05). VASn was significantly correlated with GL-C2 (r = -0.35, p < 0.05).
Conclusion The odontoid parameters were significantly correlated with established cervical parameters and HRQoL measures. OI is a constant parameter representing the individual's compensatory reservoir at the upper cervical spine.
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Objective Combined with different configuration types of syringomyelia, to analyze the correlation between syrinx resolution and changes in cervical sagittal alignment following Foramen magnum and Magendie dredging (FMMD) for syringomyelia associated with Chiari I malformation (CM-I), and to further explore the respective relationship with clinical outcome.
Methods A consecutive series of 127 patients with CM-I and syringomyelia who underwent FMMD in our center met the inclusion criteria of this study. Their clinical records and radiologic data were retrospectively reviewed. The Japanese Orthopedic Association (JOA) scoring system and the Chicago Chiari Outcome Scale (CCOS) were used to evaluate the surgical efficacy. The phenotypes of syringomyelia and the clinical characteristics of the patients were analyzed according to grouping by cervical curvature at baseline.
Results The preoperative straight or kyphotic cervical alignment is more common in the moniliform syrinx. After surgery, the syrinx resolution and cervical sagittal realignment in the moniliform group are more obvious, and the corresponding prognosis is relatively better. Spearman correlation analysis showed that the ΔS/C ratio (the change ratio of syrinx/cord) was positively correlated with the CCOS (p = 0.001, r = 0.897) and ΔC2–7A (the change of lower cervical angle) (p = 0.002, r = 0.560). There was also a correlation between the ΔJOA score (the change rate of the JOA score) and ΔC2–7A (p = 0.012, r = 0.467).
Conclusion After decompression surgery, syrinx resolution may coexist with the changes in the subaxial lordosis angle, especially for syrinx in moniliform type, and the relationship between syrinx resolution and cervical sagittal realignment might be valuable for evaluating the surgical outcome.
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Bernardo de Andrada Pereira, Jennifer N. Lehrman, Anna G.U. Sawa, Piyanat Wangsawatwong, Jakub Godzik, David S. Xu, Jay D. Turner, Brian P. Kelly, Juan S. Uribe
Neurospine 2022;19(3):828-837. Published online September 30, 2022
Objective The high mechanical stress zone at the sudden transition from a rigid to flexible region is involved in proximal junctional kyphosis (PJK) physiopathology. We evaluated the biomechanical performance of polyetheretherketone (PEEK) rods used as a nontraditional long semirigid transition phase from a long-segment metallic rod construct to the nonfused thoracic spine.
Methods Pure moment range of motion (ROM) tests (7.5 Nm) were performed on 7 cadaveric spine segments followed by compression (200 N). Specimens were tested in the following conditions: (1) intact; (2) T10-pelvis pedicle screws and rods (PSRs); and (3) extending the proximal construct to T6 using PEEK rods (PSR+PEEK). T10–11 rod strain, T9 anterolateral bone strain, and T10 screw bending moments were analyzed.
Results At the upper instrumented vertebra (UIV)+1, PSR+PEEK versus PSR significantly decreased ROM in flexion (115%, p = 0.02), extension (104%, p = 0.003), left lateral bending (46%, p = 0.02), and right lateral bending (63%, p = 0.008). Also, at UIV+1, PSR+PEEK versus intact significantly decreased ROM in flexion (111%, p = 0.01) and extension (105%, p = 0.003). The UIV+1 anterior column bone strain was significantly reduced with PSR+PEEK versus PSR during right lateral bending (p = 0.02). Rod strain polarities reversed with PEEK rods in all loading directions except compression.
Conclusion Extending a long-segment construct using PEEK rods caused a decrease in adjacent-level hypermobility as a consequence of long-segment immobilization and also redistributed the strain on the UIV and adjacent levels, which might contribute to PJK physiopathology. Further studies are necessary to observe the clinical outcomes of this technique.
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Objective By using angulation of the axis itself, this study aims to define and analyze odontoid incidence (OI) and odontoid tilt (OT) as novel cervical alignment parameters and investigate their correlations with cervical alignment.
Methods Novel and existing parameters were measured with whole-spine lateral plain radiographs and EOS images of 42 adults without cervical symptoms. The correlations of OI, OT, C2 slope (C2S), and T1 slope (T1S) were calculated.
Results The OI, OT, and C2S showed significant correlations with C2–7 angle (r = 0.43, r = -0.42, r = 0.62, respectively) and C0–2 angle (r = -0.33, r = 0.48, r = -0.61, respectively). OI, OT, T1S were independent predictors of the C2–7 angle in univariate regression analysis (adjusted-R2 = 0.17, R2 = 0.15, R2 = 0.28, respectively). OI, OT, and T1S were independent predictors in the multivariable regression analysis with estimated standardized coefficients of 0.36, -0.67, -0.69, respectively (adjusted- R2 = 0.80, p < 0.001). Regarding the C0–2 angle, OI and OT were independent predictors in the univariate regression analysis (adjusted-R2 = 0.08, R2 = 0.21, respectively).
Conclusion OI, OT, and C2S had significant correlations with cervical alignment. As the pelvic incidence, the OI is the only anatomical and constant parameter that could be used as a reference point related to the cervical spine from the rostral end. The study results may serve as baseline data for further studies on the alignment and balance of the cervical spine.
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Objective To evaluate the cervical dynamics, neurological function, pain, and quality of life in patients with mild cervical kyphotic alignment who underwent expansive unilateral open-door laminoplasty (ELAP).
Methods In this retrospective single-center study, we reviewed the surgical outcomes of 80 patients with cervical spondylotic myelopathy who were followed for at least 2 years. The patients were categorized into the preoperative kyphotic group (C2–7 angle < 0°) and nonkyphotic group (angle ≥ 0°). We compared clinical information, radiographic parameters, Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) scores, and cervical Japanese Orthopaedic Association (JOA) scores between the groups.
Results The kyphotic and nonkyphotic groups comprised 17 and 63 patients, respectively. The preoperative C2–7 angles were -3.7° in the kyphotic group and 15.4° in the nonkyphotic group (p < 0.01). In the kyphotic group, kyphotic alignment improved to lordosis at the final follow-up (2.6°, p = 0.01). The preoperative (16.4° vs. 24.1°, p < 0.01) and finalfollow-up (17.8° vs. 24.5°, p < 0.01) C7 slopes were significantly smaller in the kyphotic group. ELAP reduced pain in the arms or hands (p = 0.02) and improved the JOA scores (p < 0.01) in the kyphotic group. Patient-reported outcomes assessed using the JOACMEQ showed comparable effective rates in both groups.
Conclusion Patients with mild cervical kyphosis showed smaller C7 slopes as a compensatory mechanism. Kyphotic angles significantly improved to lordosis after ELAP, resulting in favorable clinical outcomes. ELAP is a useful surgical option for patients even if they present mild kyphotic cervical angles.
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Objective This study aimed to analyze the prediction rate of the modified Global Alignment and Proportion (GAP) scoring system with body mass index and bone mineral density (GAPB) in each GAP of the 3 categories.
Methods Between January 2009 and December 2016, 203 consecutive patients with adult spinal deformity (ASD) underwent corrective fusion of more than 4 levels and were followedup for more than 2 years. As a validation of the GAPB, the GAPB was divided into tertiles (Q1, Q2, Q3) for each section of the GAP score. Each patient’s GAP score and GAPB system complication rate were examined.
Results Of the 203 patients, 89 patients (44%) developed mechanical complications after ASD surgery. A GAP score analysis of the patients found that 42 patients were proportioned, 85 patients were moderately disproportioned, and 76 patients were severely disproportioned. Mechanical complications occurred with increasing GAPB in the proportioned group, but were not statistically significant (p = 0.0534). However, mechanical complications occurred in a statistically significant manner in the moderately disproportioned and severely disproportioned groups as GAPB increased (p < 0.001).
Conclusion The GAPB system showed improved predictability for mechanical complications after surgery for ASD in each category of the GAP score.
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Neurospine 2021;18(3):475-480. Published online September 30, 2021
Objective To evaluate Obeid-coronal malalignment (O-CM) modifiers according to age, sagittal alignment, and patient-reported outcome measures (PROMs), in the mobile spine.
Methods Retrospective review of a prospective multicenter adult spinal deformity (ASD) database with 1,243 (402 nonoperative, 841 operative) patients with no prior fusion surgery. Patients were included if they were aged over 18 years and were affected by spinal deformity defined by one of: Cobb angle ≥ 20°, pelvic tilt ≥ 25°, sagittal vertical axis ≥ 5 cm, thoracic kyphosis ≥ 60°. Patients were classified according to the O-CM classification and compared to coronally aligned patients. Multivariate analysis was performed on the relationship between PROMs and age, global tilt (GT) and coronal malalignment (CM).
Results Four hundred forty-three patients had CM of more than 2 cm compared to 800 who did not. The distribution of these modifiers was correlated to age. After multivariate analysis, using age and GT as confounding factors, we found that before the age of 50 years, 2A1 patients had worse sex life and greater satisfaction than patients without CM. After 50 years of age, patients with CM (1A1, 1A2) had worse self-image and those with 2A2, 2B had worse self-image, satisfaction, and 36-item Short Form Health Survey physical function. Self-image was the consistent determinant of patients opting for surgery for all ages.
Conclusion CM distribution according to O-CM modifiers is age dependent. A clear correlation between the coronal malalignment and PROMs exists when using the O-CM classification and in the mobile spine, this typically affects self-image and satisfaction. Thus, CM classified according to O-CM modifiers is correlated to PROMs and should be considered in ASD.
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The Obeid-coronal malalignment classification is reliable and helps guiding decision-making and surgical management of adult spinal deformities: letter to the editor of BMC Musculoskeletal Disorders Anouar Bourghli, Louis Boissière, Ibrahim Obeid BMC Musculoskeletal Disorders.2023;[Epub] CrossRef
A bibliometric analysis of patient-reported outcome measures in adult spinal deformity, and the future of patient-centric outcome assessments in the era of predictive analytics David B. Kurland, Darryl Lau, Nora C. Kim, Christopher Ames Seminars in Spine Surgery.2023; 35(2): 101032. CrossRef
Fixed coronal malalignment (CM) in the lumbar spine independently impacts disability in adult spinal deformity (ASD) patients when considering the obeid-CM (O-CM) classification Louis Boissiere, Anouar Bourghli, David Kieser, Daniel Larrieu, Ahmet Alanay, Ferran Pellisé, Frank Kleinstück, Markus Loibl, Javier Pizones, Ibrahim Obeid The Spine Journal.2023; 23(12): 1900. CrossRef
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