Suboptimal age-adjusted lumbo-pelvic mismatch predicts negative cervical-thoracic compensation in obese patients

Samantha R. Horn, Cole A. Bortz, Subaraman Ramachandran, Gregory W. Poorman, Frank Segreto, Matt Siow, Akhila Sure, Dennis Vasquez-Montes, Bassel Diebo, Jared Tishelman, John Moon, Peter Zhou, Bryan Beaubrun, Shaleen Vira, Cyrus Jalai, Charles Wang, Kartik Shenoy, Omar Behery, Thomas Errico, Virginie LafageAaron Buckland, Peter G. Passias

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Background: Given the paucity of literature regarding compensatory mechanisms used by obese patients with sagittal malalignment, it is necessary to gain a better understanding of the effects of obesity on compensation after comparing the degree of malalignment to age-adjusted ideals. This study aims to compare baseline alignment of obese and nonobese patients using age-adjusted spino-pelvic alignment parameters, describing associated spinal changes. Methods: Patients ≥ 18 years with full-body stereoradiographs were propensity-score matched for sex, baseline pelvic incidence (PI), and categorized as nonobese (body mass index, 30kg/m2) or obese (body mass index ≥ 30). Age-adjusted ideals were calculated for sagittal vertical axis, spino-pelvic mismatch (PI-LL), pelvic tilt, and T1 pelvic angle using established formulas. Patients were stratified as meeting alignment ideals, being above ideal, or being below. Spinal alignment parameters included C0-C2, C2-C7, C2-T3, cervical thoracic pelvic angle, cervical sagittal vertical axis SVA, thoracic kyphosis, T1 pelvic angle, T1 slope, sagittal vertical axis, lumbar lordosis (LL), PI, PI-LL, pelvic tilt. Lower-extremity parameters included sacrofemoral angle, knee flexion (KA), ankle flexion (AA), pelvic shift (PS), and global sagittal angle (GSA). Independent t tests compared parameters between cohorts. Results: Included: 800 obese, 800 nonobese patients. Both groups recruited lower-extremity compensation: sacrofemoral angle (P = .004), KA, AA, PS, GSA (all P, .001). Obese patients meeting age-adjusted PI-LL had greater lower-extremity compensation than nonobese patients: lower sacrofemoral angle (P = .002), higher KA (P = .008), PS (P = .002), and GSA (P = .02). Obese patients with PI-LL mismatch higher than age-adjusted ideal recruited greater lower-extremity compensation than nonobese patients: higher KA, AA, PS, GSA (all P < .001). Obese patients showed compensation through the cervical spine: increased C0-C2, C2-C7, C2-T3, and cervical sagittal vertical axis (all P, .001), high T1 pelvic angle (P < .001), cervical thoracic pelvic angle (P = .03), and T1 slope (P < .001), with increased thoracic kyphosis (P = .015) and decreased LL (P < .001) compared to nonobese patients with PI-LL larger than age-adjusted ideal. Conclusions: Regardless of malalignment severity, obese patients recruited lower-limb compensation more than nonobese patients. Obese patients with PI-LL mismatch larger than age-adjusted ideal also develop upper-cervical and cervicothoracic compensation for malalignment.

Original languageEnglish (US)
Pages (from-to)252-261
Number of pages10
JournalInternational Journal of Spine Surgery
Issue number3
StatePublished - Jun 1 2019
Externally publishedYes


  • Compensation
  • Ideal alignment
  • Lower extremity
  • Obese
  • Sagittal alignment

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine


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