Beyond Pelvic Incidence–Lumbar Lordosis Mismatch: The Importance of Assessing the Entire Spine to Achieve Global Sagittal Alignment

Study Design: Retrospective case series. Objective: To investigate which sagittal parameters contribute to a normal sagittal vertical axis (SVA) when there is a pelvic incidence-lumbar lordosis (PI-LL) mismatch >10° following adult spinal deformity (ASD) correction. Methods: We performed a retrospective review of ASD patients with >5 levels fused. Sagittal measurements between cohorts of postoperative PI-LL >10° and PI-LL<10° were compared. We correlated SVA to pelvic tilt (PT), thoracic kyphosis (TK), PI-LL, cervical lordosis (CL), and correlated the pre- to postoperative change in SVA to change in PT, change in TK, change in PI-LL, and change in CL. We also correlated SVA and the change in SVA to combined parameters of ((PI-LL) − PT + TK). Results: We analyzed 52 patients with a mean age of 59 ± 16 years. In patients with a postoperative SVA <5cm, a smaller TK was seen when PI-LL >10° than when PI-LL<10° (15.45° vs 33.04°, P =.0004). Additionally, PT was larger when PI-LL >10° than when PI-LL <10° (25.73° vs 19.07°, P =.006). SVA correlated better with ((PI-LL) − PT + TK) (R² = 0.51) than with PI-LL alone (R² = 0.33). Lastly, there was no significant correlation between change in pre- to postoperative SVA with change in TK for all cases (P =.73), but in cases where change in PI-LL was <10°, there was a significant correlation between change in TK and change in SVA (P =.009). Conclusion: Our results demonstrate that PT and TK, and not just PI-LL, play an important role in maintaining sagittal balance when there is a PI-LL mismatch >10°.