Sagittal imbalance syndrome, a new concept helps determining a long fusion for patients with degenerative lumbar spinal stenosis and severe global sagittal imbalance

Sagittal imbalance syndrome, a new concept helps determining a long fusion for patients with degenerative lumbar spinal stenosis and severe global sagittal imbalance | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Sagittal imbalance syndrome, a new concept helps determining a long fusion for patients with degenerative lumbar spinal stenosis and severe global sagittal imbalance Shibao Lu, Weiguo Zhu, Yu Wang, Chao Kong, Wei Wang, Xiaolong Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3682584/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Feb, 2024 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted 8 You are reading this latest preprint version Abstract Objective: To retrospectively investigate the postoperative clinical and radiographic outcomes in elderly patients with degenerative lumbar spinal stenosis (DLSS) and severe global sagittal imbalance who underwent different fusion levels. Methods: A total of 214 patients with DLSS and severe global sagittal imbalance were included. Sagittal imbalance syndrome was defined as the severe decompensated radiographic global sagittal imbalance accompanied with the following symptoms: severe back pain in naturel posture that disappears or significantly relieves in support position, living disability with ODI score > 40% and dynamic sagittal imbalance. Thereinto, 54 patients were found with sagittal imbalance syndrome and were performed the lumbar decompression with a long thoracolumbar fusion (Group A) or a short lumbar fusion (Group B). Thirty patients without sagittal imbalance syndrome who underwent short lumbar decompression and fusion were selected as the control (Group C). Results: Patients with sagittal imbalance syndrome were detected to have more paraspinal muscle degeneration and less compensatory potentials for sagittal imbalance (smaller thoracic kyphosis and larger pelvic tilt) than those without this diagnosis. Postoperative comparisons revealed significant restoration of global sagittal alignment and balance and improvement of living quality in Groups A and C at the final follow-up. Six patients in Group B and one in Group A were found to have proximal junctional complication during follow-up. Conclusion: Our results indicated that DLSS patients with sagittal imbalance syndrome had inferior surgical outcomes in terms of living quality and proximal junctional complication after lumbar decompression with a short fusion. Sagittal imbalance syndrome Degenerative lumbar spinal stenosis Severe spinal sagittal imbalance Surgical decision-making Spinal deformity Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Global spinal sagittal imbalance refers to the spinal malalignment with a significant manifestation of forward postural instability in standing, which is becoming a gradually recognized cause of back pain and disability in adults 1 – 3 . Previous studies demonstrated that increasing sagittal imbalance was associated with inferior health-related quality-of-life (HRQoL) scores and suboptimal surgical results 4 . Despite secondary to various lesions, sagittal imbalance is common in degenerative lumbar spinal stenosis (DLSS) because of the degenerative changes of discs, vertebrae, and paravertebral muscles and the limited compensatory mechanisms. Taking this instability into consideration is necessary when assessing the severity of a DLSS and designing the optimal surgical plan. However, not all the global spinal sagittal imbalance needs to be corrected. At present, there is a lack of consensus when to simultaneously correct the sagittal imbalance with long fusion in lumbar decompression surgery. Generally, when a severe sagittal imbalance is present, a long fusion from thoracic to lumbar for regulating the global sagittal profile is more likely to be appropriate based on the previous findings that the uncorrected sagittal imbalance following short fusion predisposed inferior surgical outcomes including symptomatic instrumentation failures and revision surgeries 5 – 7 . Differently, some spinal surgeons would like to perform a short-segment decompression and fusion regardless of the global imbalance to limit operation time and blood loss 8 , 9 . Different from the young, surgical management for the elderly patients with spinal deformity should be mainly focused on relieving symptoms and improving living quality. In the present study, we described a new medical term sagittal imbalance syndrome that summarized the symptomatic conditions of decompensated sagittal imbalance. In our center, DLSS patients with sagittal imbalance syndrome were performed a relative short lumbar decompression and fusion or a long thoracolumbar fusion with lumbar decompression. We conducted this study to investigate the postoperative outcomes after different fusion managements for DLSS patients with severe sagittal imbalance and to explore the fusion level selection strategy. Materials and methods Subjects Under the approval from the Ethics Committee of Capital Medical University Xuanwu Hospital (approval number: 2018014), patients with DLSS and severe global sagittal imbalance who received surgical treatment at our center for geriatric diseases from March 2017 to March 2021 were retrospectively reviewed. Patients were exempt from the requirement of informed consent. Sagittal malalignment with PI-LL > 20°, sagittal vertical axis (SVA) > 95 mm or PT > 30° was defined as severe global sagittal imbalance 10 . Inclusion criteria were as follow: 1) aged > 60 years, 2) with a minimum 2-year follow-up, 3) with complete preoperative and postoperative clinical and radiographic data. Subjects with scoliosis, other sagittal abnormity not associated with degeneration or a surgical history of spine or pelvis were excluded. Clinical and Radiographic Evaluation Basic information. Subjects’ demographic data including age, gender distribution, body mass index (BMI), bone mineral density (BMD) of lumbar vertebra and surgical information were recorded. At the time of radiographic acquisition, patient-reported outcomes were assessed using Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores. In the present study, the following symptoms were considered as sagittal imbalance syndrome or symptomatic sagittal imbalance 11 : 1) severe back pain (VAS > 5 score) in natural standing position or in natural walking without any support (Fig. 1 a, 1 b, 1 c and 1 d). Back pain disappears or significantly relieves in support position (Fig. 1 e and 1 f); 2) significant living disability with ODI score > 40% 12, 13 and 3) dynamic sagittal imbalance in walking within 10 mins (Fig. 2 ) 14 . Patients with sagittal imbalance syndrome were performed a long thoracolumbar fusion with lumbar decompression (Group A) or a relative short lumbar decompression and fusion (Group B). Thirty DLSS patients with severe global sagittal imbalance without sagittal imbalance syndrome who underwent a relative short lumbar decompression and fusion were selected as control (Group C). Dynamic sagittal imbalance. Patient could stand upright for a while ( a, b ). After a short walk within 10 mins, the compensatory mechanisms exhausted and a significant trunk bent forward appeared ( c, d, e ). Spinopelvic parameters. Radiographic measurements were performed on long-cassette standing upright lateral radiographs of the spine and pelvis. The following radiographic parameters were measured using Surgimap software (Nemaris, Inc., New York, NY, USA) (Fig. 3 a and 3 b) 15 : thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), PI-LL mismatch (PI-LL), sagittal vertical axis (SVA), and T1 pelvic angle (TPA). Disc and facet degeneration evaluations. The degrees of lumbar disc degeneration and right facet arthritis (L1–L2 to L5–S1) were examined on 1.5-T MRI images using Pfirrmann degeneration classification 16 . Different score was given to represent different degeneration grade of disc and facet joint. Higher scores represented better disc and facet conditions. Mean values of the five levels were calculated. Muscle evaluation. Cross-sectional Area of lumbar paravertebral muscle was assessed on 1.5T MRI images with ImageJ software (National Institutes of Health, Bethesda, Maryland, USA) 17 , 18 . T2-weighted axial images at L1–2, L2–3, L3–4, and L4–5 disc levels were analyzed to measure the right muscle area. The regions of interest of back muscle were determined by outlining the fascial boundary of the muscles (Fig. 3 c). The signal intensity (in gray scale) within the region of interest was measured using the measurement function of ImageJ. Muscle area was divided by the disc area at the same level (muscle-disc ratio) to decrease the bias caused by individual size (Fig. 3 d). The percentage of fat infiltration was measured using a pseudocoloring technique (Fig. 3 e and 3 f). Mean values of the four levels were calculated. At the latest follow-up, patients’ satisfactions of surgical managements were evaluated with centesimal system score from 0 to 100. 0 represents not satisfied, while 100 represents very satisfied. All the clinical and radiographic evaluations were completed by two independent spine surgeons (X.L.C. and X.Y.L.), who were not involved in the treatment of the patients. The mean values were recorded. Spinopelvic parameters measurement and back muscle evaluation. a Measurement of spinal parameters. b Measurement of pelvic parameters. c The fascial boundary of lumbar paravertebral muscles (yellow circle): the fascia thoracolumbalis was traced down laterally and anteriorly to the dorsal side of the quadratus lumborum, followed by the posterior surface of the facet and lamina, and lateral margin of spinous process. d The boundary of vertebral body (yellow circle). Muscle-disc ratio: 16.267/17.343 = 0.94. e Cut the muscle along the fascial boundary. f Bright pixels of fat tissue in the MR images were colored in red (darker color in the black and white version) using pseudocoloring technique. The percentage of the red pixel area in the muscle compartment was the percentage of fat infiltration (29.43%). Surgical Procedure The indication for decompression of stenosed lumbar canal was that patients’ neurological symptoms and signs were not obviously resolved after conservative treatment for 6 months. Surgeries were performed by the same team, with pedicle screws and titanium rods. Decompression was completed using transforaminal lumbar interbody fusion (TLIF) technique and posterior instrumentation and fusion through open procedure. In Group A, the proximal end vertebra in the measured kyphosis was selected as the upper instrumented vertebra. The lowest instrumented vertebra was determined according to the TLIF level. In Groups B and C, instrumented segments were depended on the TLIF levels. Fusion was finished using autograft and allograft. Statistical Analysis Data were analyzed using SPSS version 16.0 statistical software (SPSS Inc.). All data were presented as the mean ± standard deviation. Comparisons between pre-operation and post-operation and between different groups were performed using the Mann–Whitney U test. Chi-square analysis was applied to assess the categorical variables. A p value < 0.05 was considered statistically significant. Results General Information A total of 214 patients (141 females and 73 males) with DLSS and severe global sagittal imbalance were included in this study. Fifty-four patients were found with sagittal imbalance syndrome. Sixteen patients did not reach a minimum 2-year follow-up, including 7 lost to follow-up. Finally, 38 patients were enrolled for the analysis of postoperative outcomes. Thereinto, 18 patients receiving thoracolumbar fusion were assigned to Group A, while 20 patients receiving lumbar fusion were assigned to Group B. During follow-up, 7 cases of proximal junctional kyphosis (PJK) were detected. No patient was observed to have pseudoarthrosis, implant failure or neurologic deficits. No revision surgery was required. Comparisons of Demographic and Radiographic Characteristics between Patients with and without Sagittal Imbalance Syndrome Patients with sagittal imbalance syndrome had older age than those without this diagnosis (Table 1 ). Comparisons of spinopelvic parameters revealed statistically smaller TK, LL and SS and statistically greater TLK, PT, PI-LL and TPA in patients with sagittal imbalance syndrome. Except the more muscle fat infiltration in those with sagittal imbalance syndrome, lumbar degenerations were similar between the two groups. As to HRQoL outcomes, patients with sagittal imbalance syndrome were showed to have severer back pain in thoracolumbar region and more significant living disability than those without sagittal imbalance syndrome. Table 1 Comparisons of clinical and preoperative radiographic characteristics between patients with and without sagittal imbalance syndrome Variables With sagittal imbalance syndrome (n = 54) Without sagittal imbalance syndrome (n = 160) P Age (year) 66.1 ± 3.9 62.3 ± 4.2 0.007 Gender distribution Female: 40; Male: 14 Female: 101; Male: 59 0.142 † Body mass index (kg/m 2 ) 25.5 ± 2.5 26.4 ± 1.6 0.303 Bone mineral density (g/cm2) 1.092 ± 0.084 1.101 ± 0.091 0.321 Spinopelvic measurements Thoracic kyphosis (°) 12.3 ± 5.0 28.7 ± 4.1 < 0.001 Thoracolumbar kyphosis (°) 16.7 ± 6.2 7.0 ± 2.9 < 0.001 Lumbar lordosis (°) 10.2 ± 7.0 34.6 ± 5.2 < 0.001 Pelvic incidence (°) 49.0 ± 3.9 48.3 ± 4.8 0.596 Pelvic tilt (°) 29.5 ± 4.3 17.2 ± 4.4 < 0.001 Sacral slope (°) 19.7 ± 3.5 32.3 ± 6.3 < 0.001 Pelvic incidence-Lumbar lordosis (°) 40.1 ± 4.7 15.0 ± 4.5 < 0.001 Sagittal vertical axis (mm) 115.9 ± 13.5 111.2 ± 18.5 0.088 T1 Pelvic angle (°) 28.8 ± 2.9 22.3 ± 1.8 < 0.001 Lumbar and muscle degeneration evaluations Disk 2.87 ± 0.15 3.07 ± 0.20 0.132 Facet 2.17 ± 0.13 2.34 ± 0.11 0.082 Muscle-disc ratio 1.34 ± 0.12 1.43 ± 0.12 0.159 Muscle fat infiltration (%) 35.3 ± 3.8 19.5 ± 3.7 < 0.001 Health-related quality-of-life Visual analogue scale (point) 6.6 ± 0.4 4.0 ± 0.4 0.001 Oswestry disability index (%) 55.3 ± 5.4 25.5 ± 4.3 < 0.001 †Calculated by Chi-square analysis. Comparisons of Clinical and Radiographic Assessments between Group A and Group B As shown in Tables 2 and 3 , demographic baselines and preoperative radiographic parameters were comparable between the 2 groups. Patients in Group A were detected to have larger average operation duration, more average estimated blood loss and more average fusion levels than those in Group B (Table 2 ). After similar follow-up time, TK, TLK, LL, PT, SS, PI-LL, SVA, and TPA were all significantly improved in Group A, while only LL, SS, and PI-LL were obviously changed in Group B. At the latest follow-up, TK was statistically greater and TLK, PI-LL, SVA and ODI scores were statistically smaller in Group A than Group B (Table 3 ). Six patients in Group B and one in Group A were found to have PJKs during follow-up. Those underwent the thoracolumbar fusion were more satisfied with their surgical management (84.6 ± 5.9 vs. 63.4 ± 7.2, P = 0.003). Table 2 Comparisons of demographic baselines and surgical data between Groups A and B and between Groups B and C Variables Group A (n = 18) Group B (n = 20) Group C (n = 30) P value P AB P BC Age (year) 70.4 ± 4.2 68.0 ± 4.8 67.1 ± 5.9 0.302 0.486 Gender Female: 15; Male: 3 Female: 16; Male: 4 Female: 17; Male: 13 0.791 † 0.088 † Body mass index (kg/m 2 ) 24.6 ± 3.2 25.2 ± 3.1 26.7 ± 1.9 0.681 0.442 Bone mineral density (g/cm2) 1.081 ± 0.087 1.103 ± 0.101 1.122 ± 0.099 0.612 0.585 Operation time (min) 342.5 ± 47.2 278.1 ± 63.3 214.6 ± 50.8 0.010 0.141 Estimated blood loss (ml) 746.4 ± 150.6 407.2 ± 84.5 332.9 ± 44.3 0.002 0.372 Fusion levels 9.0 ± 0.6 3.2 ± 0.2 2.7 ± 0.3 < 0.001 0.116 Follow-up (months) 26.4 ± 1.8 27.7 ± 2.3 28.2 ± 1.5 0.149 0.664 Disk degeneration 3.01 ± 0.19 2.90 ± 0.26 3.12 ± 0.23 0.462 0.315 Facet degeneration 2.13 ± 0.15 2.17 ± 0.18 2.38 ± 0.14 0.504 0.261 Paravertebral Muscle Degeneration Muscle-disc ratio 1.36 ± 0.15 1.33 ± 0.13 1.37 ± 0.11 0.456 0.363 Fat infiltration (%) 32.2 ± 4.1 36.6 ± 5.2 20.9 ± 4.2 0.340 < 0.001 Group A includes the patients with DLSS and sagittal imbalance syndrome who underwent a thoracolumbar fusion including lumbar decompression and global sagittal restoration, Group B includes the patients with DLSS and sagittal imbalance syndrome who underwent lumbar decompression and fusion, Group C includes patients with DLSS and severe sagittal deformity without sagittal imbalance syndrome who underwent lumbar decompression and fusion. †Calculated by Chi-square analysis. Table 3 Comparisons of preoperative and postoperative radiographic measurements and HRQOL outcomes between Groups A and B and between Groups B and C Variables Group A (n = 18) Group B (n = 20) Group C (n = 30) P value P AB P BC Thoracic kyphosis (°) Preoperatively 10.7 ± 5.4 12.4 ± 6.3 30.8 ± 5.4 0.515 < 0.001 At the latest follow-up 22.0 ± 7.6 15.8 ± 5.0 32.5 ± 3.7 0.022 0.003 P value 0.033 0.319 0.446 - - Thoracolumbar kyphosis (°) Preoperatively 19.3 ± 6.5 17.7 ± 9.0 11.8 ± 4.1 0.391 0.060 At the latest follow-up 4.7 ± 3.6 12.9 ± 7.8 5.0 ± 4.4 < 0.001 0.014 P value 0.010 0.209 0.366 - - Lumbar lordosis (°) Preoperatively 5.8 ± 9.2 5.2 ± 7.4 20.5 ± 6.9 0.524 0.001 At the latest follow-up 41.5 ± 8.3 39.0 ± 6.8 40 ± 5.2 0.512 0.660 P value < 0.001 < 0.001 0.001 - - Pelvic incidence (°) Preoperatively 47.7 ± 4.1 49.2 ± 5.7 49.4 ± 6.2 0.483 0.499 At the latest follow-up 51.2 ± 6.3 50.4 ± 5.2 47.7 ± 4.5 0.491 0.605 P value 0.102 0.283 0.329 - - Pelvic tilt (°) Preoperatively 29.5 ± 5.7 29.2 ± 6.5 15.3 ± 5.3 0.601 0.001 At the latest follow-up 20.6 ± 6.9 23.1 ± 7.3 9.8 ± 7.2 0.272 < 0.001 P value 0.044 0.103 0.112 - Sacral slope (°) Preoperatively 17.4 ± 7.1 19.3 ± 3.7 34.9 ± 7.5 0.366 0.021 At the latest follow-up 31.3 ± 8.9 28.6 ± 5.5 40.8 ± 6.2 0.280 0.098 P value 0.009 0.030 0.443 - Pelvic incidence-Lumbar lordosis (°) Preoperatively 41.5 ± 6.3 42.4 ± 6.0 27.2 ± 6.4 0.407 < 0.001 At the latest follow-up 8.5 ± 5.2 19.8 ± 5.5 7.3 ± 4.8 0.001 0.002 P value < 0.001 0.001 0.014 - - Sagittal vertical axis (mm) Preoperatively 125.3 ± 16.1 120.7 ± 24.4 108.2 ± 18.5 0.529 0.106 At the latest follow-up 32.7 ± 7.2 93.5 ± 24.0 31.5 ± 9.3 < 0.001 < 0.001 P value < 0.001 0.077 < 0.001 - - T1 Pelvic angle (°) Preoperatively 30.2 ± 3.1 29.0 ± 4.7 27.6 ± 2.1 0.614 0.422 At the latest follow-up 16.7 ± 4.4 22.3 ± 5.3 16.0 ± 3.3 0.191 0.184 P value 0.036 0.113 0.074 - - Visual analogue scale (point) Preoperatively 6.9 ± 0.5 6.5 ± 0.7 4.2 ± 0.4 0.701 0.026 At the latest follow-up 2.4 ± 0.8 3.8 ± 0.5 1.3 ± 0.5 0.101 0.003 P value 0.009 0.084 < 0.001 - - Oswestry disability index (%) Preoperatively 59.5 ± 7.0 56.3 ± 5.6 28.1 ± 4.6 0.214 < 0.001 At the latest follow-up 28.7 ± 6.4 40.3 ± 10.8 22.4 ± 6.5 0.011 < 0.001 P value < 0.001 0.057 0.168 - - Group A includes the patients with DLSS and sagittal imbalance syndrome who underwent a thoracolumbar fusion including lumbar decompression and global sagittal restoration, Group B includes the patients with DLSS and sagittal imbalance syndrome who underwent lumbar decompression and fusion, Group C includes patients with DLSS and severe sagittal deformity without sagittal imbalance syndrome who underwent lumbar decompression and fusion. Comparisons of Clinical and Radiographic Assessments between Group B and Group C The 2 groups were matched in terms of demographic baselines, surgical data, and lumbar degenerations (Table 2 ). Patients with sagittal imbalance syndrome in Group B were found to have more significant degeneration of back muscle and inferior patient-reported outcomes than those without sagittal imbalance syndrome in Group C. TK, LL and SS were significantly smaller, whereas TLK, PT and PI-LL were statistically greater in Group B (Table 3 ). Despite with the same surgical procedure, the postoperative outcomes regarding the restoration of global sagittal balance were distinct: SVA was decreased from 108.2 ± 18.5mm to 31.5 ± 9.3mm (P < 0.001) in Group C, whereas was not significantly changed in Group B (Table 3 ). At the latest follow-up, no complication at the proximal segment was found in Group C. Patients’ postoperative self-reported scores and satisfactions of their surgical treatment were superior in Group C than Group B. Discussion Ideal global spinal alignment allows an individual to assume an upright posture with minimal muscular energy expenditure. Increasing positive global sagittal imbalance will add the trunk muscular effort and energy expenditure, which can result in muscular back pain, fatigue, and even living disability 19 . The operative treatment of sagittal imbalance is complex and potentially associated with significant complications, especially in the elderly population. We previously discovered severe back pain (VAS > 5 score), significant living disability (ODI > 40%) and dynamic sagittal imbalance were the risk factors of suboptimal postoperative outcomes in patients with DLSS and severe global sagittal imbalance after short lumbar fusion 11 . In this study, severe back pain without support (Fig. 1 ), significant living disability and dynamic sagittal imbalance (Fig. 2 ) were considered as sagittal imbalance syndrome or symptomatic sagittal imbalance. Comparisons between patients with and without sagittal imbalance syndrome revealed that those with sagittal imbalance syndrome had more fat infiltration in lumbar muscle (35.3 ± 3.8% vs. 19.5 ± 3.7%, P < 0.001, Table 1 ). The clinical importance of trunk muscle on quality of life and upright posture have been well documented 20 , 21 . Paraspinal muscle plays an essential role in spine compensating for sagittal imbalance. High quality muscle had the power to maintain an upright position with no or minor muscular back pain. It would be hard for dysfunctional spinal muscle to compensate for the severe sagittal imbalance. Besides, patients with sagittal imbalance syndrome were revealed to have smaller TK and SS, which indicated the insufficient potentials for sagittal compensation (Table 1 ). When the compensatory mechanisms exhausted, patients would present dynamic sagittal instability in walking and develop the related symptoms (Fig. 2 ). Gilad et al. 7 retrospectively reviewed the surgical outcomes in 47 patients with sagittal plane deformity and found those with uncorrected sagittal imbalance were more likely to develop symptomatic instrumentation failure over a 2-year period. Hori et al. 22 reported postoperative sagittal decompensation significantly impact the surgical outcomes of short fusion for DLSS after at least 2-year follow-up. Our preliminary investigation also revealed that patients with postoperative sagittal decompensation were susceptible to PJKs after short lumbar fusion 11 . Uncorrected sagittal imbalance would increase the stress concentration at the proximal adjacent segment, which then induced the development of mechanical complications. Paraspinal musculature deterioration was also demonstrated to be an important and existing risk factor of PJK after spinal fusion for adult spinal deformity 23 , 24 . This study presented the consistent result that SVA and TPA in patients with sagittal imbalance syndrome who underwent relatively short lumbar fusion were not significantly modified after more than 2-year follow-up. As a result, 30% of them (6/20) were detected to have PJK complication (Fig. 4 ), which contributed to their unconspicuous improvement of living quality and low satisfaction of surgical management. To sum up, a relative short lumbar fusion was not adequate for DLSS with sagittal imbalance syndrome. In this study, 18 patients with DLSS and sagittal imbalance syndrome underwent a thoracolumbar fusion to simultaneously decompress the stenosed canal and realign the sagittal profile. After 2-year follow-up, the significant symptoms were resolved and their living quality were obviously improved (Table 2 , Fig. 5 ). Previous studies also reported the importance of sagittal imbalance correction on the improvement of patients’ quality of life. Savage J and Patel A 25 reviewed the evaluation and management of fixed sagittal plane imbalance and concluded that fixed sagittal malalignment often required surgical reconstructive procedures. Reestablishing harmonious spinopelvic alignment was associated with significant improvement in HRQoL outcomes and patients’ satisfaction. Lee et al. 26 conducted a meta-analysis including 327 adult patients from 10 studies on the efficacy of surgical correction of PDSI. They drew a conclusion that the restoration of global sagittal alignment was essential for relieving back pain and improving patients’ living quality. However, not all the global spinal sagittal deformity is needed to be corrected. If patients only have radiographic sagittal deformity without the clinical symptoms, their global imbalance might be a temporary lenitive or relieving posture for low back pain that is associated with spinal stenosis. Hence, correcting the global malalignment with thoracolumbar fusion might be an overtreatment. The present study discovered that patients in Group C who underwent lumbar decompression and fusion obtained a satisfied spontaneous restoration of global sagittal balance at the final follow-up, with SVA decreased from 108.2 ± 18.5 mm to 31.5 ± 9.3 mm (Table 3 , Fig. 6 ). We deemed their substantial quality of paraspinal muscle contributed to the optimistic results (Table 2 ). As the posterior tension band of spine, trunk muscle played an important role in compensating for sagittal imbalance 20 . The functional back muscle had the ability to self-regulate the sagittal alignment and self-restore the sagittal balance after short lumbar fusion. Severe sagittal imbalance could cause significant pain and functional limitations. The surgical procedures are potentially associated with a relatively high rate of untoward events and suboptimal outcomes. A reasonable indication for correcting sagittal imbalance could benefit patients from operation more than loss. Surgical intervention for degenerative spinal deformity in elderly should focus on relieving related symptoms. Sagittal imbalance syndrome, summarizing the related symptoms attributable to decompensated sagittal deformity, was demonstrated to have poor paraspinal muscle quality and limited compensatory ability, which were not a reasonable indication for short lumbar fusion. The present findings could help designing a superior surgical plan for elderly patients who suffer from both DLSS and severe sagittal deformity. Despite, this study still has some limitations. First, this study was a retrospective design with a possible selection bias. The final surgical option for DLSS and sagittal imbalance syndrome was determined by patients and their relatives. Despite the clinical and radiographic data were comparable between Group A and Group B, we could not deny the possibility that their pathogenesis of sagittal imbalance was unhomogeneous. Second, the sample size of patients with DLSS and sagittal imbalance syndrome was relatively small, because we excluded all the subjects with any other sagittal spinal anomaly that was not associated with degeneration. Third, thoracic paravertebral muscle was not evaluated. Most of the patients with DLSS were not performed thoracic MRI in our center, therefore, we only focused on the lumbar paravertebral muscle. Fourth, follow-up time was relative short. Despite of these, the new term sagittal imbalance syndrome could play an important role in the fusion level decision-making for PDSI in elderly DLSS patients. Conclusion Our results indicated that DLSS patients with sagittal imbalance syndrome had inferior surgical outcomes in terms of living quality and proximal junctional complication after lumbar decompression with a short fusion. For patients without sagittal imbalance syndrome, short lumbar decompression and fusion might be an adequate option. Declarations Source of funding This work was supported by R&D program of Beijing Municipal Education Commission (Grant number: KZ202210025038), project of Capital Medical University (Grant number: PYZ22047) and Elite Seed program of Beijing Xuanwu Hospital (Grant number: YC20220104). Disclosure This study was performed under the approval from the Institutional Review Board of Capital Medical University Xuanwu Hospital (IRB approval number: 086[2018]). The authors have no conflict of interest to declare. Ethical Approval This study was performed under the approval from the Institutional Review Board of Capital Medical University Xuanwu Hospital (IRB approval number: 086[2018]). The authors have no conflict of interest to declare. Funding This work was supported by R&D program of Beijing Municipal Education Commission (Grant number: KZ202210025038), project of Capital Medical University (Grant number: PYZ22047) and Elite Seed program of Beijing Xuanwu Hospital (Grant number: YC20220104). References Bridwell KH. Causes of sagittal spinal imbalance and assessment of the extent of needed correction. Instructional course lectures. 2006;55: 567–575. Joseph SA, Jr., Moreno AP, Brandoff J, Casden AC, Kuflik P, Neuwirth MG. Sagittal plane deformity in the adult patient. 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Advances in clinical and experimental medicine: official organ Wroclaw Medical University. 2019;28(8): 1005–1011. https://doi.org/10.17219/acem/94150 . Zhu W, Kong C, Zhang S, et al. Different acute behaviors of pelvic incidence after long fusion to sacrum between elderly patients with severe and minor sagittal deformity: a retrospective radiographic study on 102 cases. 2020. Zhu W, Kong C, Zhang S, Wang P, Sun X, Lu S. The radiographic characteristics and developmental mechanism of the lumbar degenerative retrolisthesis under a high-grade PI. Journal of orthopaedic science: official journal of the Japanese Orthopaedic Association. 2020. https://doi.org/10.1016/j.jos.2020.02.012 . Lee JC, Cha JG, Kim Y, Kim YI, Shin BJ. Quantitative analysis of back muscle degeneration in the patients with the degenerative lumbar flat back using a digital image analysis: comparison with the normal controls. Spine (Phila Pa 1976). 2008;33(3): 318–325. https://doi.org/10.1097/BRS.0b013e318162458f . Zhou H, Binmadi NO, Yang YH, Proia P, Basile JR. Retraction Note to: Semaphorin 4D cooperates with VEGF to promote angiogenesis and tumor progression. Angiogenesis. 2020;23(2): 267. https://doi.org/10.1007/s10456-020-09709-x . Frank S, Ashish P, Benjamin U, Jean-Pierre F, Virginie L. Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine. 2010;35(25): 2224. Ohyama S, Hoshino M, Terai H, et al. Sarcopenia is related to spinal sagittal imbalance in patients with spinopelvic mismatch. European Spine Journal. 2019. Hori Y, Hoshino M, Inage K, et al. ISSLS PRIZE IN CLINICAL SCIENCE 2019: clinical importance of trunk muscle mass for low back pain, spinal balance, and quality of life-a multicenter cross-sectional study. European Spine Journal. 2019. Hori Y, Matsumura A, Namikawa T, et al. Does sagittal imbalance impact the surgical outcomes of short-segment fusion for lumbar spinal stenosis associated with degenerative lumbar scoliosis? Journal of Orthopaedic Science. 2018. Pennington Z, Cottrill E, A Hm Ed AK, Passias P, Sciubba DM. Paraspinal muscle size as an independent risk factor for proximal junctional kyphosis in patients undergoing thoracolumbar fusion. Journal of neurosurgery Spine. 2019;31(3): 1–9. Choi UY, Kang JI, Park JY, Kuh SU, Kim KH. Residence could influence the surgical outcome after corrective surgery in adult spinal deformity: comparison study between urban and rural area in Korea. European Spine Journal. 2019(12). Savage J, Patel A. Fixed Sagittal Plane Imbalance. Global spine journal.04(04): 287–296. Lee CH, Chung CK, Jang J-S, et al. Effectiveness of deformity-correction surgery for primary degenerative sagittal imbalance: a meta-analysis. Journal of Neurosurgery Spine. 1–12. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Feb, 2024 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted Editorial decision: Revision requested 03 Jan, 2024 Reviews received at journal 11 Dec, 2023 Reviewers agreed at journal 07 Dec, 2023 Reviewers agreed at journal 30 Nov, 2023 Reviewers invited by journal 30 Nov, 2023 Editor assigned by journal 30 Nov, 2023 Submission checks completed at journal 30 Nov, 2023 First submitted to journal 29 Nov, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3682584","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":255044675,"identity":"a813b018-eef7-4f71-89fd-da0c37abdebc","order_by":0,"name":"Shibao Lu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYBACPgYGNobEBjjfhoefvwGnajBgQ9OSJiM54wARWhgRWg7bGDQkENAikf7swcMddnIGN5KfPeZtO89jwHCA8cPHHHxacswNEs8kG0vOSDM35m27zWPO3MAsOXMbXi1sEoltzIn9Eglm0rlALZYNB9iYefFqSX8G1FKf2CaR/g2o5RyPwYEEQloSzIBaDgNtyQHZcoAILTxvgFrOHDeW7HlTJv3nXDKP5IyDzXj9ws+e/kzy545qOYPj6dskZ5TZ2fPzNx/88BGPFmwAKZpGwSgYBaNgFJAHAPoOSziHzSVbAAAAAElFTkSuQmCC","orcid":"","institution":"Capital Medical University Xuanwu Hospital","correspondingAuthor":true,"prefix":"","firstName":"Shibao","middleName":"","lastName":"Lu","suffix":""},{"id":255044679,"identity":"dc25533f-55f8-4a49-af99-a0884aa91383","order_by":1,"name":"Weiguo Zhu","email":"","orcid":"","institution":"Capital Medical University Xuanwu Hospital","correspondingAuthor":false,"prefix":"","firstName":"Weiguo","middleName":"","lastName":"Zhu","suffix":""},{"id":255044682,"identity":"f7e0d646-de8d-4233-9375-ae4c91c79fd7","order_by":2,"name":"Yu Wang","email":"","orcid":"","institution":"Capital Medical University Xuanwu Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Wang","suffix":""},{"id":255044684,"identity":"5479f015-19a6-4e55-9962-afe95a36260c","order_by":3,"name":"Chao Kong","email":"","orcid":"","institution":"Capital Medical University Xuanwu Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chao","middleName":"","lastName":"Kong","suffix":""},{"id":255044687,"identity":"c6ac3f01-537e-44e6-8c8f-d8804cad26bb","order_by":4,"name":"Wei Wang","email":"","orcid":"","institution":"Capital Medical University Xuanwu Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Wang","suffix":""},{"id":255044689,"identity":"f3f2f93c-3fa1-45d3-bb76-aae5814a0765","order_by":5,"name":"Xiaolong Chen","email":"","orcid":"","institution":"Capital Medical University Xuanwu Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaolong","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2023-11-29 15:46:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3682584/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3682584/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13018-024-04613-2","type":"published","date":"2024-02-13T15:01:23+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":47578867,"identity":"f6908b21-063a-4b98-9994-6525c0034bed","added_by":"auto","created_at":"2023-12-04 18:11:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2033542,"visible":true,"origin":"","legend":"\u003cp\u003eSevere back pain in natural position and comfort with a support. When in natural standing or in natural walking without any support, patient could not maintain an upright position and would complain of a severe back pain (VAS \u0026gt;5 score) (\u003cstrong\u003ea, b, c, d\u003c/strong\u003e). Using a walking aid, patient could walk freely and the severe back pain would disappear or significantly relieve (\u003cstrong\u003ee, f\u003c/strong\u003e).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3682584/v1/c7d796f472c71c90734189b5.png"},{"id":47577888,"identity":"e50b0d43-e7bf-4e05-a946-1443d6272020","added_by":"auto","created_at":"2023-12-04 18:03:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1224458,"visible":true,"origin":"","legend":"\u003cp\u003eDynamic sagittal imbalance. Patient could stand upright for a while (\u003cstrong\u003ea, b\u003c/strong\u003e). After a short walk within 10 mins, the compensatory mechanisms exhausted and a significant trunk bent forward appeared (\u003cstrong\u003ec, d, e\u003c/strong\u003e).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3682584/v1/f3a099073237c5a63177b9f2.png"},{"id":47577892,"identity":"4b960682-e8e9-4d43-8a83-683f80a1cc2a","added_by":"auto","created_at":"2023-12-04 18:03:45","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1574430,"visible":true,"origin":"","legend":"\u003cp\u003eSpinopelvic parameters measurement and back muscle evaluation. \u003cstrong\u003ea\u003c/strong\u003e Measurement of spinal parameters. \u003cstrong\u003eb\u003c/strong\u003e Measurement of pelvic parameters. \u003cstrong\u003ec\u003c/strong\u003e The fascial boundary of lumbar paravertebral muscles (yellow circle): the fascia thoracolumbalis was traced down laterally and anteriorly to the dorsal side of the quadratus lumborum, followed by the posterior surface of the facet and lamina, and lateral margin of spinous process. \u003cstrong\u003ed \u003c/strong\u003eThe boundary of vertebral body (yellow circle). Muscle-disc ratio: 16.267/17.343=0.94. \u003cstrong\u003ee\u003c/strong\u003e Cut the muscle along the fascial boundary. \u003cstrong\u003ef\u003c/strong\u003e Bright pixels of fat tissue in the MR images were colored in red (darker color in the black and white version) using pseudocoloring technique. The percentage of the red pixel area in the muscle compartment wasthe percentage of fat infiltration (29.43%).\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-3682584/v1/589a35ee381c68ede0826b27.png"},{"id":47577891,"identity":"60aea07c-1505-4390-99f6-0179103cb6da","added_by":"auto","created_at":"2023-12-04 18:03:45","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1049519,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea\u003c/strong\u003e A 68-year-old female patient diagnosed with DLSS and sagittal imbalance syndrome. \u003cstrong\u003eb\u003c/strong\u003eParavertebral muscle from L1–2 to L4–5 were infiltrated with fat, with a mean percentage of 36.0% and a mean muscle-disc ratio of 1.41. \u003cstrong\u003ec\u003c/strong\u003e Twenty-five months after a short-segment lumbar decompression and fusion from L2 to S1, sagittal imbalance was not substantially modified. A complication of PJK was observed.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-3682584/v1/b30fa01a3ca4b0ee7fc11812.png"},{"id":47577893,"identity":"88e462d6-8982-4b0d-826e-02b9ca89b624","added_by":"auto","created_at":"2023-12-04 18:03:45","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1238785,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea\u003c/strong\u003e A 68-year-old female patient with DLSS and sagittal imbalance syndrome. \u003cstrong\u003eb\u003c/strong\u003e Paravertebral muscles from L1–2 to L4–5 were featured with fatty infiltration, with a mean infiltrated percentage of 32.86% and a mean muscle-disc ratio of 1.46. \u003cstrong\u003ec\u003c/strong\u003e A long fusion from T11 to S1 with lumbar decompression and sagittal realignment was performed. At 24-month follow-up, the global sagittal malalignment and imbalance were completely regulated, without any mechanical complication.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-3682584/v1/31dfc49bc484ea24ca7a9e1e.png"},{"id":47577889,"identity":"d7e9740f-0a72-43b6-8565-be1f83aeae05","added_by":"auto","created_at":"2023-12-04 18:03:45","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":937324,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea\u003c/strong\u003e A 66-year-old male patient with DLSS and PDSI who was not diagnosed with sagittal imbalance syndrome. \u003cstrong\u003eb\u003c/strong\u003e He had a good lumbar muscle status. The mean muscle-disc ratio was 1.35 and the mean percentage of fatty infiltrated was 19.4%. \u003cstrong\u003ec\u003c/strong\u003e Two years after lumbar decompression and short fusion, his global sagittal imbalance was spontaneously compensated. No internal-related untoward event was revealed.\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-3682584/v1/7c9acf2c370eb1e1c48a9722.png"},{"id":51322965,"identity":"828c37d1-d49a-4ade-a600-5b44b2d03729","added_by":"auto","created_at":"2024-02-19 15:13:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":8939422,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3682584/v1/2d326a67-768d-46d2-b28a-f39850f5fb05.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sagittal imbalance syndrome, a new concept helps determining a long fusion for patients with degenerative lumbar spinal stenosis and severe global sagittal imbalance","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGlobal spinal sagittal imbalance refers to the spinal malalignment with a significant manifestation of forward postural instability in standing, which is becoming a gradually recognized cause of back pain and disability in adults \u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Previous studies demonstrated that increasing sagittal imbalance was associated with inferior health-related quality-of-life (HRQoL) scores and suboptimal surgical results \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Despite secondary to various lesions, sagittal imbalance is common in degenerative lumbar spinal stenosis (DLSS) because of the degenerative changes of discs, vertebrae, and paravertebral muscles and the limited compensatory mechanisms. Taking this instability into consideration is necessary when assessing the severity of a DLSS and designing the optimal surgical plan.\u003c/p\u003e \u003cp\u003eHowever, not all the global spinal sagittal imbalance needs to be corrected. At present, there is a lack of consensus when to simultaneously correct the sagittal imbalance with long fusion in lumbar decompression surgery. Generally, when a severe sagittal imbalance is present, a long fusion from thoracic to lumbar for regulating the global sagittal profile is more likely to be appropriate based on the previous findings that the uncorrected sagittal imbalance following short fusion predisposed inferior surgical outcomes including symptomatic instrumentation failures and revision surgeries \u003csup\u003e\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Differently, some spinal surgeons would like to perform a short-segment decompression and fusion regardless of the global imbalance to limit operation time and blood loss \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDifferent from the young, surgical management for the elderly patients with spinal deformity should be mainly focused on relieving symptoms and improving living quality. In the present study, we described a new medical term sagittal imbalance syndrome that summarized the symptomatic conditions of decompensated sagittal imbalance. In our center, DLSS patients with sagittal imbalance syndrome were performed a relative short lumbar decompression and fusion or a long thoracolumbar fusion with lumbar decompression. We conducted this study to investigate the postoperative outcomes after different fusion managements for DLSS patients with severe sagittal imbalance and to explore the fusion level selection strategy.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSubjects\u003c/h2\u003e \u003cp\u003e Under the approval from the Ethics Committee of Capital Medical University Xuanwu Hospital (approval number: 2018014), patients with DLSS and severe global sagittal imbalance who received surgical treatment at our center for geriatric diseases from March 2017 to March 2021 were retrospectively reviewed. Patients were exempt from the requirement of informed consent. Sagittal malalignment with PI-LL\u0026thinsp;\u0026gt;\u0026thinsp;20\u0026deg;, sagittal vertical axis (SVA)\u0026thinsp;\u0026gt;\u0026thinsp;95 mm or PT\u0026thinsp;\u0026gt;\u0026thinsp;30\u0026deg; was defined as severe global sagittal imbalance \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Inclusion criteria were as follow: 1) aged\u0026thinsp;\u0026gt;\u0026thinsp;60 years, 2) with a minimum 2-year follow-up, 3) with complete preoperative and postoperative clinical and radiographic data. Subjects with scoliosis, other sagittal abnormity not associated with degeneration or a surgical history of spine or pelvis were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eClinical and Radiographic Evaluation\u003c/h2\u003e \u003cp\u003e \u003cb\u003eBasic information.\u003c/b\u003e Subjects\u0026rsquo; demographic data including age, gender distribution, body mass index (BMI), bone mineral density (BMD) of lumbar vertebra and surgical information were recorded. At the time of radiographic acquisition, patient-reported outcomes were assessed using Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores. In the present study, the following symptoms were considered as sagittal imbalance syndrome or symptomatic sagittal imbalance \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e: 1) severe back pain (VAS\u0026thinsp;\u0026gt;\u0026thinsp;5 score) in natural standing position or in natural walking without any support (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec and \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ed). Back pain disappears or significantly relieves in support position (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ee and \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ef); 2) significant living disability with ODI score\u0026thinsp;\u0026gt;\u0026thinsp;40% \u003csup\u003e12, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e and 3) dynamic sagittal imbalance in walking within 10 mins (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Patients with sagittal imbalance syndrome were performed a long thoracolumbar fusion with lumbar decompression (Group A) or a relative short lumbar decompression and fusion (Group B). Thirty DLSS patients with severe global sagittal imbalance without sagittal imbalance syndrome who underwent a relative short lumbar decompression and fusion were selected as control (Group C).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDynamic sagittal imbalance. Patient could stand upright for a while (\u003cb\u003ea, b\u003c/b\u003e). After a short walk within 10 mins, the compensatory mechanisms exhausted and a significant trunk bent forward appeared (\u003cb\u003ec, d, e\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eSpinopelvic parameters.\u003c/b\u003e Radiographic measurements were performed on long-cassette standing upright lateral radiographs of the spine and pelvis. The following radiographic parameters were measured using Surgimap software (Nemaris, Inc., New York, NY, USA) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb) \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e: thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), PI-LL mismatch (PI-LL), sagittal vertical axis (SVA), and T1 pelvic angle (TPA).\u003c/p\u003e \u003cp\u003e \u003cb\u003eDisc and facet degeneration evaluations.\u003c/b\u003e The degrees of lumbar disc degeneration and right facet arthritis (L1\u0026ndash;L2 to L5\u0026ndash;S1) were examined on 1.5-T MRI images using Pfirrmann degeneration classification \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Different score was given to represent different degeneration grade of disc and facet joint. Higher scores represented better disc and facet conditions. Mean values of the five levels were calculated.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMuscle evaluation.\u003c/b\u003e Cross-sectional Area of lumbar paravertebral muscle was assessed on 1.5T MRI images with ImageJ software (National Institutes of Health, Bethesda, Maryland, USA) \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. T2-weighted axial images at L1\u0026ndash;2, L2\u0026ndash;3, L3\u0026ndash;4, and L4\u0026ndash;5 disc levels were analyzed to measure the right muscle area. The regions of interest of back muscle were determined by outlining the fascial boundary of the muscles (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ec). The signal intensity (in gray scale) within the region of interest was measured using the measurement function of ImageJ. Muscle area was divided by the disc area at the same level (muscle-disc ratio) to decrease the bias caused by individual size (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ed). The percentage of fat infiltration was measured using a pseudocoloring technique (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ee and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ef). Mean values of the four levels were calculated.\u003c/p\u003e \u003cp\u003eAt the latest follow-up, patients\u0026rsquo; satisfactions of surgical managements were evaluated with centesimal system score from 0 to 100. 0 represents not satisfied, while 100 represents very satisfied. All the clinical and radiographic evaluations were completed by two independent spine surgeons (X.L.C. and X.Y.L.), who were not involved in the treatment of the patients. The mean values were recorded.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSpinopelvic parameters measurement and back muscle evaluation. \u003cb\u003ea\u003c/b\u003e Measurement of spinal parameters. \u003cb\u003eb\u003c/b\u003e Measurement of pelvic parameters. \u003cb\u003ec\u003c/b\u003e The fascial boundary of lumbar paravertebral muscles (yellow circle): the fascia thoracolumbalis was traced down laterally and anteriorly to the dorsal side of the quadratus lumborum, followed by the posterior surface of the facet and lamina, and lateral margin of spinous process. \u003cb\u003ed\u003c/b\u003e The boundary of vertebral body (yellow circle). Muscle-disc ratio: 16.267/17.343\u0026thinsp;=\u0026thinsp;0.94. \u003cb\u003ee\u003c/b\u003e Cut the muscle along the fascial boundary. \u003cb\u003ef\u003c/b\u003e Bright pixels of fat tissue in the MR images were colored in red (darker color in the black and white version) using pseudocoloring technique. The percentage of the red pixel area in the muscle compartment was the percentage of fat infiltration (29.43%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Procedure\u003c/h2\u003e \u003cp\u003eThe indication for decompression of stenosed lumbar canal was that patients\u0026rsquo; neurological symptoms and signs were not obviously resolved after conservative treatment for 6 months. Surgeries were performed by the same team, with pedicle screws and titanium rods. Decompression was completed using transforaminal lumbar interbody fusion (TLIF) technique and posterior instrumentation and fusion through open procedure. In Group A, the proximal end vertebra in the measured kyphosis was selected as the upper instrumented vertebra. The lowest instrumented vertebra was determined according to the TLIF level. In Groups B and C, instrumented segments were depended on the TLIF levels. Fusion was finished using autograft and allograft.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using SPSS version 16.0 statistical software (SPSS Inc.). All data were presented as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Comparisons between pre-operation and post-operation and between different groups were performed using the Mann\u0026ndash;Whitney U test. Chi-square analysis was applied to assess the categorical variables. A p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eGeneral Information\u003c/h2\u003e \u003cp\u003eA total of 214 patients (141 females and 73 males) with DLSS and severe global sagittal imbalance were included in this study. Fifty-four patients were found with sagittal imbalance syndrome. Sixteen patients did not reach a minimum 2-year follow-up, including 7 lost to follow-up. Finally, 38 patients were enrolled for the analysis of postoperative outcomes. Thereinto, 18 patients receiving thoracolumbar fusion were assigned to Group A, while 20 patients receiving lumbar fusion were assigned to Group B. During follow-up, 7 cases of proximal junctional kyphosis (PJK) were detected. No patient was observed to have pseudoarthrosis, implant failure or neurologic deficits. No revision surgery was required.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eComparisons of Demographic and Radiographic Characteristics between Patients with and without Sagittal Imbalance Syndrome\u003c/h2\u003e \u003cp\u003ePatients with sagittal imbalance syndrome had older age than those without this diagnosis (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Comparisons of spinopelvic parameters revealed statistically smaller TK, LL and SS and statistically greater TLK, PT, PI-LL and TPA in patients with sagittal imbalance syndrome. Except the more muscle fat infiltration in those with sagittal imbalance syndrome, lumbar degenerations were similar between the two groups. As to HRQoL outcomes, patients with sagittal imbalance syndrome were showed to have severer back pain in thoracolumbar region and more significant living disability than those without sagittal imbalance syndrome.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of clinical and preoperative radiographic characteristics between patients with and without sagittal imbalance syndrome\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith sagittal imbalance syndrome (n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWithout sagittal imbalance syndrome (n\u0026thinsp;=\u0026thinsp;160)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender distribution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale: 40;\u003c/p\u003e \u003cp\u003eMale: 14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale: 101;\u003c/p\u003e \u003cp\u003eMale: 59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.142\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.303\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBone mineral density (g/cm2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.092\u0026thinsp;\u0026plusmn;\u0026thinsp;0.084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.101\u0026thinsp;\u0026plusmn;\u0026thinsp;0.091\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eSpinopelvic measurements\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracic kyphosis (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracolumbar kyphosis (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumbar lordosis (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic incidence (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.596\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic tilt (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSacral slope (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic incidence-Lumbar lordosis (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSagittal vertical axis (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115.9\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e111.2\u0026thinsp;\u0026plusmn;\u0026thinsp;18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1 Pelvic angle (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eLumbar and muscle degeneration evaluations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.132\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.082\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuscle-disc ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.159\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuscle fat infiltration (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eHealth-related quality-of-life\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual analogue scale (point)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOswestry disability index (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026dagger;Calculated by Chi-square analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eComparisons of Clinical and Radiographic Assessments between Group A and Group B\u003c/h2\u003e \u003cp\u003eAs shown in Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, demographic baselines and preoperative radiographic parameters were comparable between the 2 groups. Patients in Group A were detected to have larger average operation duration, more average estimated blood loss and more average fusion levels than those in Group B (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). After similar follow-up time, TK, TLK, LL, PT, SS, PI-LL, SVA, and TPA were all significantly improved in Group A, while only LL, SS, and PI-LL were obviously changed in Group B. At the latest follow-up, TK was statistically greater and TLK, PI-LL, SVA and ODI scores were statistically smaller in Group A than Group B (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Six patients in Group B and one in Group A were found to have PJKs during follow-up. Those underwent the thoracolumbar fusion were more satisfied with their surgical management (84.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9 vs. 63.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2, P\u0026thinsp;=\u0026thinsp;0.003).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of demographic baselines and surgical data between Groups A and B and between Groups B and C\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup A (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup B (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup C (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003csub\u003eAB\u003c/sub\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003csub\u003eBC\u003c/sub\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.302\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.486\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale: 15;\u003c/p\u003e \u003cp\u003eMale: 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale: 16;\u003c/p\u003e \u003cp\u003eMale: 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale: 17;\u003c/p\u003e \u003cp\u003eMale: 13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.791\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.088\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.681\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.442\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBone mineral density (g/cm2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.081\u0026thinsp;\u0026plusmn;\u0026thinsp;0.087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.103\u0026thinsp;\u0026plusmn;\u0026thinsp;0.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.122\u0026thinsp;\u0026plusmn;\u0026thinsp;0.099\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.612\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.585\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e342.5\u0026thinsp;\u0026plusmn;\u0026thinsp;47.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e278.1\u0026thinsp;\u0026plusmn;\u0026thinsp;63.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e214.6\u0026thinsp;\u0026plusmn;\u0026thinsp;50.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstimated blood loss (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e746.4\u0026thinsp;\u0026plusmn;\u0026thinsp;150.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e407.2\u0026thinsp;\u0026plusmn;\u0026thinsp;84.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e332.9\u0026thinsp;\u0026plusmn;\u0026thinsp;44.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.372\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFusion levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.116\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.664\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisk degeneration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.90\u0026thinsp;\u0026plusmn;\u0026thinsp;0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.462\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.315\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacet degeneration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.504\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.261\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eParavertebral Muscle Degeneration\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuscle-disc ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.456\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.363\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFat infiltration (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.340\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eGroup A includes the patients with DLSS and sagittal imbalance syndrome who underwent a thoracolumbar fusion including lumbar decompression and global sagittal restoration, Group B includes the patients with DLSS and sagittal imbalance syndrome who underwent lumbar decompression and fusion, Group C includes patients with DLSS and severe sagittal deformity without sagittal imbalance syndrome who underwent lumbar decompression and fusion.\u003c/p\u003e \u003cp\u003e\u0026dagger;Calculated by Chi-square analysis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of preoperative and postoperative radiographic measurements and HRQOL outcomes between Groups A and B and between Groups B and C\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup A (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup B (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup C (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003csub\u003eAB\u003c/sub\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003csub\u003eBC\u003c/sub\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eThoracic kyphosis (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.515\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt the latest follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.319\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.446\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eThoracolumbar kyphosis (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.391\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.060\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt the latest follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.366\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eLumbar lordosis (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.524\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt the latest follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.0\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.512\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.660\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003ePelvic incidence (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.483\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.499\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt the latest follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.491\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.605\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003ePelvic tilt (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.601\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt the latest follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.272\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.044\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eSacral slope (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.366\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt the latest follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.443\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003ePelvic incidence-Lumbar lordosis (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.407\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt the latest follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eSagittal vertical axis (mm)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e125.3\u0026thinsp;\u0026plusmn;\u0026thinsp;16.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120.7\u0026thinsp;\u0026plusmn;\u0026thinsp;24.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e108.2\u0026thinsp;\u0026plusmn;\u0026thinsp;18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.529\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.106\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt the latest follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.5\u0026thinsp;\u0026plusmn;\u0026thinsp;24.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eT1 Pelvic angle (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.614\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.422\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt the latest follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.184\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eVisual analogue scale (point)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.701\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt the latest follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eOswestry disability index (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt the latest follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eGroup A includes the patients with DLSS and sagittal imbalance syndrome who underwent a thoracolumbar fusion including lumbar decompression and global sagittal restoration, Group B includes the patients with DLSS and sagittal imbalance syndrome who underwent lumbar decompression and fusion, Group C includes patients with DLSS and severe sagittal deformity without sagittal imbalance syndrome who underwent lumbar decompression and fusion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eComparisons of Clinical and Radiographic Assessments between Group B and Group C\u003c/h2\u003e \u003cp\u003eThe 2 groups were matched in terms of demographic baselines, surgical data, and lumbar degenerations (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Patients with sagittal imbalance syndrome in Group B were found to have more significant degeneration of back muscle and inferior patient-reported outcomes than those without sagittal imbalance syndrome in Group C. TK, LL and SS were significantly smaller, whereas TLK, PT and PI-LL were statistically greater in Group B (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Despite with the same surgical procedure, the postoperative outcomes regarding the restoration of global sagittal balance were distinct: SVA was decreased from 108.2\u0026thinsp;\u0026plusmn;\u0026thinsp;18.5mm to 31.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3mm (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in Group C, whereas was not significantly changed in Group B (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). At the latest follow-up, no complication at the proximal segment was found in Group C. Patients\u0026rsquo; postoperative self-reported scores and satisfactions of their surgical treatment were superior in Group C than Group B.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIdeal global spinal alignment allows an individual to assume an upright posture with minimal muscular energy expenditure. Increasing positive global sagittal imbalance will add the trunk muscular effort and energy expenditure, which can result in muscular back pain, fatigue, and even living disability \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. The operative treatment of sagittal imbalance is complex and potentially associated with significant complications, especially in the elderly population. We previously discovered severe back pain (VAS\u0026thinsp;\u0026gt;\u0026thinsp;5 score), significant living disability (ODI\u0026thinsp;\u0026gt;\u0026thinsp;40%) and dynamic sagittal imbalance were the risk factors of suboptimal postoperative outcomes in patients with DLSS and severe global sagittal imbalance after short lumbar fusion \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In this study, severe back pain without support (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e), significant living disability and dynamic sagittal imbalance (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) were considered as sagittal imbalance syndrome or symptomatic sagittal imbalance. Comparisons between patients with and without sagittal imbalance syndrome revealed that those with sagittal imbalance syndrome had more fat infiltration in lumbar muscle (35.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8% vs. 19.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The clinical importance of trunk muscle on quality of life and upright posture have been well documented \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Paraspinal muscle plays an essential role in spine compensating for sagittal imbalance. High quality muscle had the power to maintain an upright position with no or minor muscular back pain. It would be hard for dysfunctional spinal muscle to compensate for the severe sagittal imbalance. Besides, patients with sagittal imbalance syndrome were revealed to have smaller TK and SS, which indicated the insufficient potentials for sagittal compensation (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). When the compensatory mechanisms exhausted, patients would present dynamic sagittal instability in walking and develop the related symptoms (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eGilad et al.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e retrospectively reviewed the surgical outcomes in 47 patients with sagittal plane deformity and found those with uncorrected sagittal imbalance were more likely to develop symptomatic instrumentation failure over a 2-year period. Hori et al.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e reported postoperative sagittal decompensation significantly impact the surgical outcomes of short fusion for DLSS after at least 2-year follow-up. Our preliminary investigation also revealed that patients with postoperative sagittal decompensation were susceptible to PJKs after short lumbar fusion \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Uncorrected sagittal imbalance would increase the stress concentration at the proximal adjacent segment, which then induced the development of mechanical complications. Paraspinal musculature deterioration was also demonstrated to be an important and existing risk factor of PJK after spinal fusion for adult spinal deformity \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. This study presented the consistent result that SVA and TPA in patients with sagittal imbalance syndrome who underwent relatively short lumbar fusion were not significantly modified after more than 2-year follow-up. As a result, 30% of them (6/20) were detected to have PJK complication (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e), which contributed to their unconspicuous improvement of living quality and low satisfaction of surgical management. To sum up, a relative short lumbar fusion was not adequate for DLSS with sagittal imbalance syndrome.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this study, 18 patients with DLSS and sagittal imbalance syndrome underwent a thoracolumbar fusion to simultaneously decompress the stenosed canal and realign the sagittal profile. After 2-year follow-up, the significant symptoms were resolved and their living quality were obviously improved (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e). Previous studies also reported the importance of sagittal imbalance correction on the improvement of patients\u0026rsquo; quality of life. Savage J and Patel A \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e reviewed the evaluation and management of fixed sagittal plane imbalance and concluded that fixed sagittal malalignment often required surgical reconstructive procedures. Reestablishing harmonious spinopelvic alignment was associated with significant improvement in HRQoL outcomes and patients\u0026rsquo; satisfaction. Lee et al. \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e conducted a meta-analysis including 327 adult patients from 10 studies on the efficacy of surgical correction of PDSI. They drew a conclusion that the restoration of global sagittal alignment was essential for relieving back pain and improving patients\u0026rsquo; living quality.\u003c/p\u003e\n\u003cp\u003eHowever, not all the global spinal sagittal deformity is needed to be corrected. If patients only have radiographic sagittal deformity without the clinical symptoms, their global imbalance might be a temporary lenitive or relieving posture for low back pain that is associated with spinal stenosis. Hence, correcting the global malalignment with thoracolumbar fusion might be an overtreatment. The present study discovered that patients in Group C who underwent lumbar decompression and fusion obtained a satisfied spontaneous restoration of global sagittal balance at the final follow-up, with SVA decreased from 108.2\u0026thinsp;\u0026plusmn;\u0026thinsp;18.5 mm to 31.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3 mm (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e). We deemed their substantial quality of paraspinal muscle contributed to the optimistic results (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). As the posterior tension band of spine, trunk muscle played an important role in compensating for sagittal imbalance \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. The functional back muscle had the ability to self-regulate the sagittal alignment and self-restore the sagittal balance after short lumbar fusion.\u003c/p\u003e\n\u003cp\u003eSevere sagittal imbalance could cause significant pain and functional limitations. The surgical procedures are potentially associated with a relatively high rate of untoward events and suboptimal outcomes. A reasonable indication for correcting sagittal imbalance could benefit patients from operation more than loss. Surgical intervention for degenerative spinal deformity in elderly should focus on relieving related symptoms. Sagittal imbalance syndrome, summarizing the related symptoms attributable to decompensated sagittal deformity, was demonstrated to have poor paraspinal muscle quality and limited compensatory ability, which were not a reasonable indication for short lumbar fusion. The present findings could help designing a superior surgical plan for elderly patients who suffer from both DLSS and severe sagittal deformity.\u003c/p\u003e\n\u003cp\u003eDespite, this study still has some limitations. First, this study was a retrospective design with a possible selection bias. The final surgical option for DLSS and sagittal imbalance syndrome was determined by patients and their relatives. Despite the clinical and radiographic data were comparable between Group A and Group B, we could not deny the possibility that their pathogenesis of sagittal imbalance was unhomogeneous. Second, the sample size of patients with DLSS and sagittal imbalance syndrome was relatively small, because we excluded all the subjects with any other sagittal spinal anomaly that was not associated with degeneration. Third, thoracic paravertebral muscle was not evaluated. Most of the patients with DLSS were not performed thoracic MRI in our center, therefore, we only focused on the lumbar paravertebral muscle. Fourth, follow-up time was relative short. Despite of these, the new term sagittal imbalance syndrome could play an important role in the fusion level decision-making for PDSI in elderly DLSS patients.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur results indicated that DLSS patients with sagittal imbalance syndrome had inferior surgical outcomes in terms of living quality and proximal junctional complication after lumbar decompression with a short fusion. For patients without sagittal imbalance syndrome, short lumbar decompression and fusion might be an adequate option.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eSource of funding\u0026nbsp;\u003c/strong\u003eThis work was supported by R\u0026amp;D program of Beijing Municipal Education Commission (Grant number: KZ202210025038), project of Capital Medical University (Grant number: PYZ22047) and Elite Seed program of Beijing Xuanwu Hospital (Grant number: YC20220104).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure\u0026nbsp;\u003c/strong\u003eThis study was performed under the approval from the Institutional Review Board of Capital Medical University Xuanwu Hospital (IRB approval number: 086[2018]). The authors have no conflict of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed under the approval from the Institutional Review Board of Capital Medical University Xuanwu Hospital (IRB approval number: 086[2018]). The authors have no conflict of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by R\u0026amp;D program of Beijing Municipal Education Commission (Grant number: KZ202210025038), project of Capital Medical University (Grant number: PYZ22047) and Elite Seed program of Beijing Xuanwu Hospital (Grant number: YC20220104).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBridwell KH. Causes of sagittal spinal imbalance and assessment of the extent of needed correction. 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Residence could influence the surgical outcome after corrective surgery in adult spinal deformity: comparison study between urban and rural area in Korea. European Spine Journal. 2019(12).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSavage J, Patel A. Fixed Sagittal Plane Imbalance. Global spine journal.04(04): 287\u0026ndash;296.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee CH, Chung CK, Jang J-S, et al. Effectiveness of deformity-correction surgery for primary degenerative sagittal imbalance: a meta-analysis. Journal of Neurosurgery Spine. 1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Sagittal imbalance syndrome, Degenerative lumbar spinal stenosis, Severe spinal sagittal imbalance, Surgical decision-making, Spinal deformity","lastPublishedDoi":"10.21203/rs.3.rs-3682584/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3682584/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To retrospectively investigate the postoperative clinical and radiographic outcomes in elderly patients with degenerative lumbar spinal stenosis (DLSS) and severe global sagittal imbalance who underwent different fusion levels.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA total of 214 patients with DLSS and severe global sagittal imbalance were included. Sagittal imbalance syndrome was defined as the severe decompensated radiographic global sagittal imbalance accompanied with the following symptoms: severe back pain in naturel posture that disappears or significantly relieves in support position, living disability with ODI score \u0026gt; 40% and dynamic sagittal imbalance. Thereinto, 54 patients were found with sagittal imbalance syndrome and were performed the lumbar decompression with a long thoracolumbar fusion (Group A) or a short lumbar fusion (Group B). Thirty patients without sagittal imbalance syndrome who underwent short lumbar decompression and fusion were selected as the control (Group C).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Patients with sagittal imbalance syndrome were detected to have more paraspinal muscle degeneration and less compensatory potentials for sagittal imbalance (smaller thoracic kyphosis and larger pelvic tilt) than those without this diagnosis. Postoperative comparisons revealed significant restoration of global sagittal alignment and balance and improvement of living quality in Groups A and C at the final follow-up. Six patients in Group B and one in Group A were found to have proximal junctional complication during follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eOur results indicated that DLSS patients with sagittal imbalance syndrome had inferior surgical outcomes in terms of living quality and proximal junctional complication after lumbar decompression with a short fusion.\u003c/p\u003e","manuscriptTitle":"Sagittal imbalance syndrome, a new concept helps determining a long fusion for patients with degenerative lumbar spinal stenosis and severe global sagittal imbalance","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-12-04 18:03:40","doi":"10.21203/rs.3.rs-3682584/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-01-03T12:18:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-12-11T22:05:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2d5d60a8-0306-4185-aeff-c52c5efe7240","date":"2023-12-08T02:11:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"eba1c214-e58d-4055-b2cd-a328c66337ff","date":"2023-12-01T03:28:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-12-01T02:23:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-12-01T01:23:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-12-01T00:50:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2023-11-29T15:43:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bde6e055-a710-4eca-8c4a-b0a252c2cb59","owner":[],"postedDate":"December 4th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-02-19T15:07:21+00:00","versionOfRecord":{"articleIdentity":"rs-3682584","link":"https://doi.org/10.1186/s13018-024-04613-2","journal":{"identity":"journal-of-orthopaedic-surgery-and-research","isVorOnly":false,"title":"Journal of Orthopaedic Surgery and Research"},"publishedOn":"2024-02-13 15:01:23","publishedOnDateReadable":"February 13th, 2024"},"versionCreatedAt":"2023-12-04 18:03:40","video":"","vorDoi":"10.1186/s13018-024-04613-2","vorDoiUrl":"https://doi.org/10.1186/s13018-024-04613-2","workflowStages":[]},"version":"v1","identity":"rs-3682584","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3682584","identity":"rs-3682584","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}