Sagittal balance forms part of the plain radiographic assessment of spinal deformity including kyphotic or lordotic deformities and scoliosis.
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Usage
There are numerous ways of assessing this, using various bony landmarks and angles to evaluate whether or not a normal distribution of weight and stresses is present through the axial skeleton, some incorporating the position of the head, while others focusing on the pelvis, have been described 1,2:
- C7 plumb line
- sagittal vertical axis
- chin-brow vertical angle
- kyphosis tilt angle
- pelvic incidence
- pelvic tilt
- sacral slope
- spinopelvic angle
- spinosacral angle
Whilst many methods exist to assess sagittal balance, an abnormal plumb line (in either direction) is predictive of higher rates of micromotion and dysfunction after solid fixation ref as well as adjacent level disease 4.
Measurement
C7 plumb line
One of the simplest and most widely used methods is performed on lateral standing full-length films and requires a vertical line (plumb line) drawn from the middle of the body of the C7 vertebral body. This line should pass through the superior endplate of S1, or more precisely within 2 cm (some use 1.7 cm) of the posterosuperior corner of the S1 vertebral body 1,2.
Interpretation
C7 plumb line
The position of this line is can be positive, neutral or negative:
- positive balance: the plumb line passes more than 2 cm in front of the posterosuperior corner of the S1 vertebral body
- neutral balance: the plumb line passes within 2 cm of the posterosuperior corner of the S1 vertebral body
- negative balance: the plumb line passes more than 2 cm behind the posterosuperior corner of the S1 vertebral body