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28.05.2018 | Review

Relationship between sagittal balance and adjacent segment disease in surgical treatment of degenerative lumbar spine disease: meta-analysis and implications for choice of fusion technique

European Spine Journal
Kevin Phan, Alexander Nazareth, Awais K. Hussain, Adam A. Dmytriw, Mithun Nambiar, Damian Nguyen, Jack Kerferd, Steven Phan, Chet Sutterlin III, Samuel K. Cho, Ralph J. Mobbs
Wichtige Hinweise

Electronic supplementary material

The online version of this article (https://​doi.​org/​10.​1007/​s00586-018-5629-6) contains supplementary material, which is available to authorized users.


Study design



To conduct a meta-analysis investigating the relationship between spinopelvic alignment parameters and development of adjacent level disease (ALD) following lumbar fusion for degenerative disease.

Summary of background data

ALD is a degenerative pathology that develops at mobile segments above or below fused spinal segments. Patient outcomes are worse, and the likelihood of requiring revision surgery is higher in ALD compared to patients without ALD. Spinopelvic sagittal alignment has been found to have a significant effect on outcomes post-fusion; however, studies investigating the relationship between spinopelvic sagittal alignment parameters and ALD in degenerative lumbar disease are limited.


Six e-databases were searched. Predefined endpoints were extracted and meta-analyzed from the identified studies.


There was a significantly larger pre-operative PT in the ALD cohort versus control (WMD 3.99, CI 1.97–6.00, p = 0.0001), a smaller pre-operative SS (WMD − 2.74; CI − 5.14 to 0.34, p = 0.03), and a smaller pre-operative LL (WMD − 4.76; CI − 7.66 to 1.86, p = 0.001). There was a significantly larger pre-operative PI-LL in the ALD cohort (WMD 8.74; CI 3.12–14.37, p = 0.002). There was a significantly larger postoperative PI in the ALD cohort (WMD 2.08; CI 0.26–3.90, p = 0.03) and a larger postoperative PT (WMD 5.23; CI 3.18–7.27, p < 0.00001).


The sagittal parameters: PT, SS, PI-LL, and LL may predict development of ALD in patients’ post-lumbar fusion for degenerative disease. Decision-making aimed at correcting these parameters may decrease risk of developing ALD in this cohort.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.

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Supplementary material 1 (PPTX 205 kb)
Supplementary material 2 (DOCX 36 kb)
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