시상면 불균형 = Sagittal Imbalance

다국어 초록 (Multilingual Abstract)

Sagittal spinal balance is an essential factor for not only the external appearance, but also for the spine’s function. Fixed sagittal
imbalance is the result of different causes, and this generally requires surgical treatment. Sagittal imbalance is mainly caused by
decreased lumbar lordosis and increased thoracic kyphosis, and it can also be influenced by the pelvic incidence and flexion
contracture of the hip and knee joints. So, a careful understanding and clinically considering the many factors and compensatory
mechanisms that are associated with sagittal imbalance are needed. Proper surgical treatments provide a satisfactory outcome
for these patients and good radiographic results. Correction of sagittal imbalance generally requires spinal osteotomy and long
segment fusion. For the surgical treatment, we should consider the perioperative and postoperative complications of osteotomy
and long segment fusion and then make proper decisions for the range of fusion of the proximal and distal sides and the selection
of the correct method of osteotomy, the ideal correction angle and the best method of internal fixation. Problems such as
loss of correction may occur postoperatively due to kyphotic change and pseudarthrosis of the proximal and distal sides. Therefore,
we need to conduct a thorough analysis and make a detailed plan for the surgical approach. We should also study and
understand the radiological factors when treating sagittal spinal balance because not only the spine, but also the pelvis, hip and
knee joints are involved in forming the sagittal balance.

국문 초록 (Abstract)

척추의 시상면 균형은 외모뿐만 아니라 기능에 필수적인 요소로 다양한 원인으로 발생된 시상면 불균형은 대부분
수술적 치료가 필요하다. 시상면 불균형은 요추전만 감소 및 흉추후만 증가가 주된 원인이지만 골반지표, 고관절 및
슬관절의 관절구축도 관여한다. 따라서 시상면 불균형에 관계된 여러 요인과 보상기전에 대한 이해와 임상적 적용
이 필요하다. 적절한 수술적 치료는 임상 결과 및 방사선 결과를 얻을 수 있다. 대부분 시상면 교정은 절골술과 장분
절 고정술이 필요하다. 수술적 치료에서 근위부 및 원위부 유합범위의 결정, 절골술의 선택, 이상적인 교정각도, 내
고정 방법에 대한 이해와 적용으로 절골술 및 장분절 고정술 등으로 복잡하고 수술에 따른 합병증이 많은 문제를 해
결해야 하며, 수술후에도 근위부 및 원위부 후만변형과 가관절증이 발생하여 교정 소실 등의 문제가 발생할 수 있으
므로 수술적 접근부터 철저한 분석과 세밀한 계획이 필요하다. 또한 시상면 균형은 척추 뿐만 아니라 골반, 고관절
및 슬관절 등이 관여하고 있고 이러한 요소들에 대한 방사선학적 지표들에 대한 연구와 이해로 시상면의 불균형을
치료에 효과적으로 적용할 수 있어야 하겠다.

참고문헌 (Reference)

1 이종서, "이상 척추시상 만곡의 발현에 있어서 Perlvic Incidence가 가지는 의의 -전향적 연구-" 대한정형외과학회 41 (41): 274-280, 2006

2 Gertzbein SD, "Wedge osteotomy for the correction of post-traumatic kyphosis. A new technique and a report of three cases" 17 : 374-379, 1992

3 Edwards CC 2nd, "Thoracolumbar deformity arthrodesis to L5 in adults: the fate of the L5-S1 disc" 28 : 2122-2131, 2003

4 Kaneda K, "The treatment of osteoporotic-posttraumatic vertebral collapse using the Kaneda device and a bioactive ceramic vertebral prosthesis" 17 : 295-303, 1992

5 Suk KS, "Significance of chin-brow vertical angle in correction of kyphotic deformity of ankylosing spondylitis patients" 28 : 2001-2005, 2003

6 Bernhardt M, "Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and thoracolumbar junction" 14 : 717-721, 1989

7 Kim YJ, "Sagittal thoracic decompensation following long adult lumbar spinal instrumentation and fusion to L5 or S1: causes, prevalence, and risk factor analysis" 31 : 2359-2366, 2006

8 Rhee JM, "Sagittal plane analysis of adolescent idiopathic scoliosis: the effect of anterior versus posterior instrumentation" 27 : 2350-2356, 2002

9 Legaye J, "Sagittal plane alignment of the spine and gravity: a radiological and clinical evaluation" 71 : 213-220, 2005

10 Stagnara P, "Reciprocal angulation of vertebral bodies in a sagittal plane: approach to references for the evaluation of kyphosis and lordosis" 7 : 335-342, 1982

11 Vialle R, "Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects" 87 : 260-267, 2005

12 Jackson RP, "Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age, sex, and size. A prospective controlled clinical study" 19 : 1611-1618, 1994

13 Kim YJ, "Proximal junctional kyphosis in adolescent idiopathic scoliosis following segmental posterior spinal instrumentation and fusion: minimum 5-year follow-up" 30 : 2045-2050, 2005

14 Kwon BK, "Progressive junctional kyphosis at the caudal end of lumbar instrumented fusion: etiology, predictors, and treatment" 31 : 1943-1951, 2006

15 Potter BK, "Prevention and management of iatrogenic flatback deformity" 86 : 1793-1808, 2004

16 Suk SI, "Posterior vertebral column resection in fixed lumbosacral deformity" 30 : 703-710, 2005

17 Legaye J, "Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves" 7 : 99-103, 1998

18 Moshirfar A, "Pelvic fixation in spine surgery. Historical overview, indications, biomechanical relevance, and current techniques" 87 : 89-106, 2005

19 Bridwell KH, "Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. Surgical technique" 86 : 44-50, 2004

20 Law WA, "Osteotomy of the spine" 66 : 70-76, 1969

21 Bernhardt M, "Normal spinal anatomy" normal sagittal plane alignment 185-191, 1997

22 Ondra SL, "Mathematical calculation of pedicle subtraction osteotomy size to allow precision correction of fixed sagittal deformity" 31 : 973-979, 2006

23 Farcy JP, "Management of flatback and related kyphotic decompensation syndromes" 22 : 2452-2457, 1997

24 Farfan HF, "Lumbar intervertebral disc degeneration: the influence of geometrical features on the pattern of disc degeneration--a post mortem study" 54 : 492-510, 1972

25 Takemitsu Y, "Lumbar degenerative kyphosis. Clinical, radiological and epidemiological studies" 13 : 1317-1326, 1988

26 Chang TL, "Low profile pelvic fixation: anatomic parameters for sacral alar-iliac fixation versus traditional iliac fixation" 34 : 436-440, 2009

27 Horton WC, "Is there an optimal patient stance for obtaining a lateral 36” radiograph? A critical comparison of three techniques" 30 : 427-433, 2005

28 Suk SI, "Incidence of proximal adjacent failure in adult lumbar deformity correction" 2003

29 Lee GA, "Huss GK: Proximal kyphosis after posterior spinal fusion in patients with idiopathic scoliosis" 24 : 795-799, 1999

30 Tveit P, "Erector spinae lever arm length variations with changes in spinal curvature" 19 : 199-204, 1994

31 Holdsworth FW, "Early treatment of paraplegia from fractures of the thoraco-lumbar spine" 35 : 540-550, 1953

32 Lee CS, "Dynamic sagittal imbalance of the spine in degenerative flat back: significance of pelvic tilt in surgical treatment" 26 : 2029-2035, 2001

33 Bridwell KH, "Decision making regarding Smith-Petersen vs. pedicle subtraction osteotomy vs. vertebral column resection for spinal deformity" 31 : 171-178, 2006

34 Shufflebarger H, "Debate: determining the upper instrumented vertebra in the management of adult degenerative scoliosis: stopping at T10 versus L1" 31 : 185-194, 2006

35 Glassman SD, "Correlation of radiographic parameters and clinical symptoms in adult scoliosis" 30 : 682-688, 2005

36 Horton WC, "Controversy. Fusion of L5-S1 in adult scoliosis" 21 : 2520-2522, 1996

37 Doherty JH, "Complications of Fusion in Lumbar Scoliosis. In Proceedings of the Scoliosis Research Society" 55 : 438-, 1973

38 Jackson RP, "Compensatory spinopelvic balance over the hip axis and better reliability in measuring lordosis to the pelvic radius on standing lateral radiographs of adult volunteers and patients" 23 : 1750-1767, 1998

39 Kostuik JP, "Combined single stage anterior and posterior osteotomy for correction of iatrogenic lumbar kyphosis" 13 : 257-266, 1988

40 Roussouly P, "Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position" 30 : 346-353, 2005

41 Bradford DS, "Ankylosing spondylitis: experience in surgical management of 21 patients" 12 : 238-243, 1987

42 Hosman AJ, "Analysis of the sagittal plane after surgical management for Scheuermann’s disease: a view on overcorrection and the use of an anterior release" 27 : 167-175, 2002

43 Berthonnaud E, "Analysis of the sagittal balance of the spine and pelvis using shape and orientation parameters" 18 : 40-47, 2005

44 Lee JH, "Analysis of Pelvic Incidence in Spinal Stenosis, Spondylolisthesis, and bLumbar Degenerative Kyphosis" 2007

45 Gelb DE, "An analysis of sagittal spinal alignment in 100 asymptomatic middle and older aged volunteers" 20 : 1351-1358, 1995

46 Milne JS, "Age effects in kyphosis and lordosis in adults" 1 : 327-337, 1974

47 Swank ML, "Adjacent segment failure above lumbosacral fusions instrumented to L1 or L2" 2002

48 Duval-Beaupere G, "A Barycentremetric study of the sagittal shape of spine and pelvis: the conditions required for an economic standing position" 20 : 451-462, 1992