The importance of sagittal balance in adult scoliosis surgery

Adult spinal deformity is an important health issue worldwide with our aging population. Understanding ideal sagittal alignment parameters is crucial for planning reconstructive surgery. Despite its variability, sagittal spinopelvic parameters are well recognized as the most crucial factor in predicting postoperative outcomes and risks of revision surgery. Thus, understanding the fundamental concepts of spinopelvic harmony is of utmost importance because they provide useful recommendations for what should be achieved during surgery. The main pathology in degenerative spine disease is the loss of lumbar lordosis (LL), which contributes to lower back pain. The loss of LL may occur as a result of natural history with spinal degeneration or by previous lumbar spine fusion. With adult spinal deformity, understanding the compensatory mechanisms available to patients is important for determining the timing of surgery. The main compensatory mechanisms patients adopt to maintain an upright posture include decreased sacral slope (SS), increased pelvic tilt (PT), decreased thoracic kyphosis (TK). Failure of these compensatory mechanisms leads to recruitment of the lower limbs with flexed hips and knees. At this stage, the patient is decompensated and result in positive sagittal alignment. This sagittal imbalance can be easily measured by the sagittal vertical axis (SVA) and is associated with worse patient-perceived outcome scores. These sagittal parameters also indicate whether surgical reconstruction is required and provides the necessary alignment goals. Depending on the value of pelvic incidence (PI), there are different LL goals. High PI has increased capacity for pelvic retroversion but requires greater lordosis correction. Proper restoration of the LL according to the PI will reduce pelvic retroversion reflected by reduced PT. Without adherence to these surgical goals, complications such as proximal junctional kyphosis (PJK) may occur. It is imperative to restore normal spinopelvic balance to maximize functional outcomes, reduce pain, and avoid complications.