Global Spine J 2014; 04(04): 287-296
DOI: 10.1055/s-0034-1394126
Review Article
Georg Thieme Verlag KG Stuttgart · New York

Fixed Sagittal Plane Imbalance

Jason W. Savage1, Alpesh A. Patel1
  • 1Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
Further Information

Publication History

01 April 2014

20 August 2014

Publication Date:
10 October 2014 (eFirst)


Study Design Literature review.

Objective To discuss the evaluation and management of fixed sagittal plane imbalance.

Methods A comprehensive literature review was performed on the preoperative evaluation of patients with sagittal plane malalignment, as well as the surgical strategies to address sagittal plane deformity.

Results Sagittal plane imbalance is often caused by de novo scoliosis or iatrogenic flat back deformity. Understanding the etiology and magnitude of sagittal malalignment is crucial in realignment planning. Objective parameters have been developed to guide surgeons in determining how much correction is needed to achieve favorable outcomes. Currently, the goals of surgery are to restore a sagittal vertical axis < 5 cm, pelvic tilt < 20 degrees, and lumbar lordosis equal to pelvic incidence ± 9 degrees.

Conclusion Sagittal plane malalignment is an increasingly recognized cause of pain and disability. Treatment of sagittal plane imbalance varies according to the etiology, location, and severity of the deformity. Fixed sagittal malalignment often requires complex reconstructive procedures that include osteotomy correction. Reestablishing harmonious spinopelvic alignment is associated with significant improvement in health-related quality-of-life outcome measures and patient satisfaction.