Eur Spine J
DOI 10.1007/s00586-016-4665-3
ORIGINAL ARTICLE
Normal sagittal parameters of global spinal balance in children
and adolescents: a prospective study of 646 asymptomatic subjects
Gabriel Gutman1,2 • Hubert Labelle1,2 • Soraya Barchi2 • Pierre Roussouly4
Éric Berthonnaud5 • Jean-Marc Mac-Thiong1,2,3
Received: 25 January 2016 / Revised: 18 May 2016 / Accepted: 15 June 2016
Ó Springer-Verlag Berlin Heidelberg 2016
Abstract
Purpose To document values for parameters of global
spinal balance in asymptomatic children and adolescents.
Methods Multicenter prospective study of normal sagittal
global spinal balance in Caucasian children and adoles-
cents. Spinosacral angle (SSA), spinal tilt (ST), and C7
translation ratio were evaluated in 646 asymptomatic
children and adolescents (276 males and 370 females).
Results Mean and standard deviation for SSA, ST, and C7
translation ratio were, respectively 132.1° ± 8.3°,
93.2° ± 4.6° and -0.7 ± 8.3. Mean ± 2 standard devia-
tions were, respectively 116°–149° for SSA and 84°–102°
for ST. C7 plumbline was behind the HA (hip axis) in 78 %
of subjects. Correlations between global balance and age
were small (-0.17 B r B 0.19).
Conclusion Asymptomatic children and adolescents tend
to stand with a stable global balance, and 95 % have an
SSA and ST between 116° and 149° and 85°–102°,
respectively. C7 plumbline in front of the HA is not nec-
essarily associated with a spinal pathology.
& Jean-Marc Mac-Thiong
macthiong@gmail.com
1
Department of Surgery, Faculty of Medicine, University of
Montreal, C.P. 6128, Succursale Centre-ville, Montréal,
Québec H3C 3J7, Canada
2
Department of Surgery, CHU Sainte-Justine, 3175 Ch. de la
Côte-Sainte-Catherine, Montréal, Québec H3T 1C4, Canada
3
Department of Surgery, Hôpital du Sacré-Coeur de Montréal,
5400 Boul Gouin O, Montréal, Québec H4J 1C5, Canada
4
Department of Orthopedic Surgery, Centre Médico-
Chirurgical de Réadaptation des Massues, Lyon, France
5
Clinical Research Unit, L’Hôpital Nord Ouest Villefranche,
Villefranche/Saône, France
•
Keywords Sagittal alignment
Global spinal balance

Posture
Normal population
Children
Adolescents
Introduction
Global spinal balance (GSB) refers to the overall
alignment of the spine with respect to another reference
point such as the sacrum or pelvis. Existing relationships
between regional parameters described in the cervical,
thoracic, lumbar and sacropelvic spine are assessed to
provide the information of the GSB [1–8]. When eval-
uating patients with spinal pathology, the GSB plays an
important role in surgical planning and in attempting to
minimize complications such as adjacent segment dis-
ease, sagittal imbalance, implant failure, pseudarthrosis
and progressive deformity, particularly with long
constructs.
In a previous publication, Mac-Thiong et al. [9]
described the sagittal sacropelvic anatomy and regional
sagittal spinal alignment in the pediatric population but did
not correlate with the global balance.
Vedantam et al. [6] described the global balance with
one parameter, the sagittal vertical axis (SVA), in adoles-
cents only and without analyzing the changes with age and
gender. Most statistical analyses were done without taking
into consideration the differences in gender and correla-
tions between parameters of spinal balance were not
assessed. The study of Cil et al. [3] focused on the analysis
of the segmental sagittal alignment and the global balance
was only assessed from the SVA.
Mac-Thiong et al. [10] reported the GSB in asymp-
tomatic adults and its influence of age, gender and sacro-
pelvic morphology using different parameters, but did not
report any values for children and adolescents.
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The objective of this study is to build a large database on
sagittal global balance of healthy children and adolescents.
To achieve this goal, 3 parameters of GSB and the relative
position of C7 plumbline respective to sacrum and hips will
be evaluated in a prospective cohort of 646 asymptomatic
subjects. The influence of age, gender, and sacropelvic
morphology and balance will also be assessed. This study
should be helpful to better recognize and treat patients with
spinal deformities, as well as to guide the surgery in
patients with abnormal sagittal balance.
Materials and methods
Following local ethics committee approval and obtainment
of informed consent from volunteer’s parents or legal
guardians, a cohort of 646 asymptomatic children and
adolescents without spinal and lower limbs pathology was
enrolled in this prospective study. These subjects had
spinal radiographs done in the period 2000–2007 to rule
out a spinal deformity because their primary physician was
suspecting the presence of a scoliosis. However, no spinal
deformity or spinal pathology was diagnosed from the
evaluation by the spine surgeon. The inclusion criteria were
as follows: (1) age under 18 years at the time of evaluation;
(2) absence of spinal pathology as confirmed by evaluation
from a spine surgeon and from plain radiographs; (3) no
history of spine, hip, or pelvic disorder; and (4) no con-
traindication for radiographic exposure. All subjects were
Caucasian, with a mean age of 12.1 ± 3.1 years (range
3–17.5). There were 276 males and 370 females aged
12.4 ± 3.1 years (range 3–17.5) and 11.9 ± 3.1 years
(range 3–17.5), respectively.
The radiographic protocol was standardized for all
participating institutions. For each subject, a standing left
lateral radiograph including the spine and pelvis was
obtained with a long 36-in cassette and a 72-in distance
with the radiograph tube. Subjects were instructed to stand
in a comfortable position with fists on clavicles, hips and
knees fully extended. Sacropelvic morphology, as well as
sacropelvic and GSB were then measured by a single
observer with the Optispine software (Optispine, France).
To avoid errors related to linear measurements, only
angular or linear ratio parameters were selected.
Sacropelvic morphology was measured by pelvic inci-
dence (PI), whereas sacropelvic balance was measured
from pelvic tilt (PT) and sacral slope (SS).
The following 3 parameters of GSB were measured for
this study (Fig. 1): Spinosacral angle (SSA); Spinal tilt
(ST) and the C7 translation ratio. In addition, the relative
position of C7 plumbline relative to the center of upper
sacral endplate and to HA was assessed to determine global
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Eur Spine J
balance type (Fig. 2). Subjects with different types of
global balance were referred to subgroups (Table 1) to
conceptualize different normal standing positions in this
population.
Data were analyzed using SPSS 22.0 software (SPSS
Inc, Chicago, IL). Statistical tests were done with a level of
significance set at 0.01. The Lilliefors test was used to
assess if parameters were normally distributed in female
and male cohorts. Comparisons for parameters of GSB
between males and females were performed using analysis
of covariance with age as a covariate. Relationships
between parameters of GSB and age, as well as PI, PT, and
SS were also assessed separately for males and females,
using Spearman’s coefficients. Statistically significant
correlation coefficients were considered clinically large if
greater than 0.5, moderate if greater than 0.3 and small if
greater than 0.1. Finally, C7, sacrum and HA anterior
subgroups were compared with C7, sacrum and HA pos-
terior subgroups, respectively, using bilateral Student
t tests for independent samples to evaluate whether there
was any difference in age, SSA, ST, PI, PT, and SS
between the different subgroups. In the same way, 10 years
old subjects or younger were compared with subjects older
than 10 years.
Results
The values of SS, SSA, and ST—but not PI, PT and C7
translation ratio—were normally distributed in both female
and male cohorts.
PI, PT, and SS were, respectively, 46.3° ± 10.8°,
7.2° ± 8.1°, and 39.0° ± 7.7° in females, in contrast to
45.7° ± 11.1°, 7.03° ± 8.2°, and 38.7° ± 7.5°, respec-
tively, for males. No statistical significant difference was
found between them (p [ 0.5). ST was 93.2° ± 4.6° for all
subjects and showed the lowest variability. Mean ST in
females was less than 2° increased when compared with
men (Table 2). This increase in ST remained less than 2°
when controlling for age (p \ 0.01) corresponding to
slightly more posterior position of C7 with respect to the
sacrum in females. This result correlates with the tendency
of females in showing a more negative C7 translation ratio
when comparing with males and controlling for age
(Table 3, p = 0.1). Overall, SSA was slightly higher in
females than males (1.3° mean difference (Table 4), and
change to 1.4° when controlling for age using analysis of
covariance (p = 0.001).)
Type 1 balance was most prevalent in all age groups,
followed by types 2 and 3 (Table 5). Type 1 balance was
present in 43–53 % of subjects in all age groups, type 2 in
17–22 %, and type 3 in 9–19 %. Of all subjects, 117
Eur Spine J

Fig. 1 Measurement of global spinal balance: a Spinosacral angle:
angle subtended by the upper sacral endplate and the line from the
center of C7 vertebral body to the center of upper sacral endplate,
b Spinal tilt: angle subtended by the horizontal line and the line from
the center of C7 vertebral body to the center of upper sacral endplate.
A value greater than 90° indicates that the center of C7 vertebral body
is behind the center of upper sacral endplate, whereas for values less
than 90°, the center of C7 vertebral body is in front of the center of
upper sacral endplate, and c C7 translation ratio: horizontal distance
from the center of upper sacral endplate to C7 plumbline (drawn from
the center of C7 vertebral body) divided by horizontal distance from
the center of upper sacral endplate to the Hip Axis (HA). The
horizontal distance is positive when in front of the center of upper
sacral endplate. For cases in which HA is in front of the center of
upper sacral endplate (positive PT), C7 translation ratio will be
positive when C7 plumbline is in front of the center of upper sacral
endplate and negative when behind it, and greater than 1 when C7
plumbline is in front of both HA and center of upper sacral endplate.
For cases in which HA is behind the center of upper sacral endplate
(negative PT), C7 translation ratio will be positive when C7
plumbline is behind the center of upper sacral endplate and negative
when in front of it, and greater than 1 when C7 plumbline is behind
both HA and center of upper sacral endplate

Fig. 2 Determination of the

global balance type (type 1–6)
from the position of C7
plumbline relative to the center
of upper sacral endplate of S1
(S1) and to the hip axis (HA).
Types 1–3 correspond to cases
when HA lies in front of S1,
whereas types 4–6 are present
when HA is behind S1

(18.1 %) had negative PT with the center of upper sacral When analyzing different age groups separately, it can
endplate in front of HA, in contrast to 529 (81.9 %) with be seen that mean SSA varied by 1.6° between age groups
positive PT. for females and by 3.5° for males (Table 4). There was a

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Table 1 Subjects with different types of global balance referred to subgroups

Subgroup Description Type of global balance

C7 anterior C7 plumbline in front of middle of upper sacral endplate and HA 3-6

C7 posterior C7 plumbline behind middle of upper sacral endplate and HA 1-4
Sacrum-anterior C7 plumbline in front of middle of upper sacral endplate 2-3-6
Sacrum-posterior C7 plumbline behind middle of upper sacral endplate 1-4-5
HA-anterior C7 plumbline in front of HA 3-5-6
HA-posterior C7 plumbline behind HA 1-2-4
Sacropelvic retroversion Middle of upper sacral endplate behind HA (positive PT) 1-2-3
Sacropelvic anteversion Middle of upper sacral endplate in front of HA (negative PT) 4-5-6
HA hip axis

Table 2 Mean and standard deviation (mean ± 2 standard deviations) of spinal tilt (°) based on gender and age
Age Group All Subjects Females Males

All (370 females; 276 males) 93.2 ± 4.6 (84; 102.4) 93.6 ± 4.6 (84.4; 102.8) 92.3 ± 4.6 (83.1; 101.5)
3.5–10 years (103 females; 64 males) 92.2 ± 5.7 (80.8; 103.6) 93.0 ± 5.3 (82.4; 103.6) 91.0 ± 6.2 (78.6; 103.4)
10.5–17.5 years (267 females; 212 males) 93.5 ± 4.1 (85.3; 101.7) 93.9 ± 4.3 (85.3; 102.5) 93.1 ± 4.0 (85.1; 101.1)

Table 3 Mean and standard deviation (mean ± 2 standard deviations) of C7 translation ratio based on gender and age
Age Group All Subjects Females Males

All (370 females; 276 males) -0.7 ± 8.3 (-17.3; 15.6) -1.2 ± 10.0 (-21.2; 18.8) -0.1 ± 5.1 (-10.2; 10.1)
3.5–10 years (103 females; 64 males) -0.8 ± 9.8 (-20.4; 18.8) -1.4 ± 11.3 (-24; 21.2) 0.3 ± 6.8 (-13.9; 13.3)
10.5–17.5 years (267 females; 212 males) -0.7 ± 7.7 (-16.1; 14.7) -1.1 ± 9.5 (-20.1; 17.9) -0.2 ± 4.5 (-9.2; 8.8)

Table 4 Mean and standard deviation (mean ± 2 standard deviations) of spinosacral angle (°) based on gender and age
Age Group All Subjects Females Males

All (370 females; 276 males) 132.9 ± 8.3 (116.3; 149.2) 132.6 ± 8.5 (115.6; 149.6) 131.3 ± 8.1 (115.1; 147.5)
3.5–10 years (103 females; 64 males) 130.4 ± 9.0 (112.4; 148.4) 131.5 ± 8.5 (114.5; 148.5) 128.6 ± 9.5 (109.6; 147.6)
10.5–17.5 years (267 females; 212 males) 132.7 ± 8.0 (116.7; 148.7) 133.1 ± 8.4 (116.3; 149.9) 132.1 ± 7.4 (117.3; 146.9)

Table 5 Number of male (M) and female (F) subjects with each global balance type based on age
Age Group Type 1 Type 2 Type 3 Type 4 Type 5 Type 6

All (N = 646) 135 M; 190F 59 M; 72F 36 M; 37F 20 M; 25F 3 M; 4F 23 M; 42F

(50.3 %) (20.3 %) (11.3 %) (7.0 %) (1.1 %) (10.1 %)
3.5–10 years 23 M; 49F 12 M; 16F 13 M; 19F 8 M; 11F 1 M; 1F 7 M; 7F
(N = 167) (43.1 %) (16.8 %) (19.2 %) (11.4 %) (1.2 %) (8.4 %)
10.5–17.5 years 112 M; 141F 47 M; 56F 23 M; 18F 12 M; 14F 2 M; 3F 16 M; 35F
(N = 479) (52.85 %) (21.5 %) (8.6 %) (5.4 %) (1.0 %) (10.6 %)
For each age group, the percentage of subjects (males plus females) included in each global balance type is shown in parentheses

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Table 6 Correlation
Correlation All n = 646 Females n = 370 Males n = 276
Coefficients Between Global
Spinal Balance, Age, and SSA vs age 0.10* 0.05 0.19*
Spinopelvic Parameters
ST vs age 0.08 0.07 0.12
C7 translation ratio vs age -0.09 -0.09 -0.01
Global balance type vs age -0.11* -0.06 -0.17*
SSA vs PI 0.51* 0.50* 0.53*
ST vs PI -0.15* -0.15* -0.16*
C7 translation ratio vs PI 0.13* 0.15* 0.11
Global balance type vs PI -0.28* -0.34* -0.17*
SSA vs PT -0.09 -0.07 -0.07
ST vs PT -0.05 -0.05 -0.04
C7 translation ratio vs PT 0.09 0.12 0.06
Global balance type vs PT -0.49* -0.52* -0.45*
SSA vs SS 0.82* 0.82* 0.80*
ST vs SS -0.16* -0.14* -0.19*
C7 translation ratio vs SS 0.01 0.1 0.10
Global balance type vs SS 0.14* 0.06 0.26*
* Correlation is significant at the 0.01 level (2-tailed)

significant difference in SSA (p = 0.002) when comparing Table 7 Mean and standard deviation of age, parameters of pelvic
subjects younger than 10 years (130.4° ± 9.0°) with sub- morphology, position and global spinal balance with regard to C7
ject aged 10.5 years or older (132.7° ± 8.0°). Similarly, subgroup
there was a significant difference in ST (p = 0.001) when C7-anterior subgroup C7-posterior subgroup p
comparing subjects younger than 10 years (92.2° ± 5.7°) n = 138 (21.4 % of n = 370 (57.3 % of
with subjects aged 10.5 years or older (93.5° ± 4.1°). subjects) subjects)
There was no specific pattern observed for the variation of Age 11.5 ± 3.3 years 12.2 ± 3.0 years 0.02
C7 translation ratio between age groups. PI showed a sig- PI 41.5° ± 9.9° 45.9° ± 10.0° \0.001
nificant difference (p = 0.001) in subjects younger than PT 1.7° ± 7.0° 7.5° ± 7.4° \0.001
10 years (43.7° ± 9.0°) compared to subjects older than SS 39.8° ± 7.4° 38.4° ± 7.3° 0.05
10.5 years (46.9° ± 11.4°). SSA 130.1° ± 9.1° 133.8° ± 7.5° \0.001
Results from the correlation analysis are presented in ST 90.3° ± 6.0° 95.4° ± 3.4° \0.001
Table 6. Correlations coefficients between parameters of
GSB and age were small clinically (-0.17 B r B 0.19).
GSB and SSA reached statistical significance (GSB and
SSA vs age for all subjects and males), reflecting a slight (57.3 % of subjects) with type 1 and 4 balance with respect
tendency for SSA to increase with age. Statistically sig- to SS (p = 0.05). However, they differed significantly in
nificant correlations between GSB and parameters of terms of age (11.5 ± 3.3 years vs 12.2 ± 3.0 years;
sacropelvic morphology and balance were generally small p = 0.02), PI (41.5° ± 9.9° vs 45.9° ± 10.0°; p \ 0.001),
clinically (-0.3 \ r \ 0.3), except from SSA and PI PT (1.7° ± 7.0° vs 7.5° ± 7.4°; p \ 0.001), SSA
(r = 0.51), global balance type and PT (r = -0.49), and (130.1° ± 9.1° vs 133.8° ± 7.5°; p \ 0.001), ST
SSA and SS (R = 0.82). Correlations coefficients were (90.3° ± 6.0° vs 95.4° ± 3.4°; p \ 0.001) (Table 7). 46
almost similar between males and females, reflecting a subjects (33 %) were younger than 10 years (26 females
similar clinical strength of the relationships. and 20 males) in comparison to 92 subjects (67 %) that
were older than 10 years (53 females and 39 males). These
C7 anterior and posterior subgroups proportions did not differ significantly from the C7 poste-
rior subgroup in which 91 subjects (25 %) were younger
C7 anterior subgroup was composed of 138 subjects than 10 years (60 females and 31 males; p = 0.35) and 279
(21.4 % of subjects) with type 3 or 6 balance and was subjects (75 %) were older than 10 years (155 females and
similar to C7 posterior subgroup that included 370 subjects 124 males; p = 0.8).

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Table 8 Mean and standard deviation of age, parameters of pelvic Table 9 Mean and standard deviation of age, parameters of pelvic
morphology, position and global spinal balance with regard to Sacrum morphology, position and global spinal balance with regard to HA
subgroup subgroup
Sacrum-anterior Sacrum-posterior p HA-anterior subgroup HA-posterior subgroup p
subgroup n = 269 subgroup n = 377 n = 145 (22 % of n = 501 (78 % of
(42 % of subjects) (58 % of subjects) subjects) subjects)

Age 12.1 ± 3.2 years 12.2 ± 3.0 years 0.64 Age 11.5 ± 3.3 years 12.3 ± 3.0 years 0.005
PI 46.5° ± 12.0° 45.7° ± 10.1° 0.36 PI 41.3° ± 10.0° 47.4° ± 10.8° \10-9
PT 7.0° ± 9.0° 7.3° ± 7.5° 0.64 PT 1.5° ± 6.9° 8.8° ± 7.7° \10-23
SS 39.5° ± 7.9° 38.4° ± 7.4° 0.07 SS 39.8° ± 7.5° 38.6° ± 7.6° 0.09
-10
SSA 129.7° ± 8.8° 133.8° ± 7.5° \10 SSA 130.2° ± 9.1° 132.6° ± 8.0° 0.002
ST 90.2° ± 4.4° 95.4° ± 3.4° \10-53 ST 90.4° ± 5.9° 94.0° ± 3.9° \10-18

Sacrum anterior and posterior subgroups Table 10 Mean and standard deviation of age, parameters of pelvic
morphology, position and global spinal balance with regard to
Sacrum-anterior subgroup was composed of 269 subjects sacropelvic version subgroup
(42 % of subjects) and was similar to sacrum-posterior Sacropelvic retroversion Sacropelvic anteversion p
subgroup with respect to age (12.1 ± 3.2 years vs subgroup n = 529 subgroup n = 117
(82 % of subjects) (18 % of subjects)
12.2 ± 3.0 years; p = 0.64), PI (46.5° ± 12.0° vs
45.7° ± 10.1°; p = 0.36), PT (7.0° ± 9.0° vs 7.3° ± 7.5°; Age 12.2 ± 3.1 years 11.8 ± 2.9 years 0.14
p = 0.64), SS (39.5° ± 7.9° vs 38.4° ± 7.4°; p = 0.07). PI 48.1° ± 10.6° 36.5° ± 6.5° \10-27
However, both subgroups differed significantly in terms of PT 9.6° ± 6.8° -3.9° ± 3.2° \10-75
SSA (129.7° ± 8.8° vs 133.8° ± 7.5°; p \ 10-10) and ST SS 38.5° ± 7.8° 40.5° ± 6.3° 0.01
(90.2° ± 4.4° vs 95.4° ± 3.4°; p \ 10-53) (Table 8). SSA 131.6° ± 8.4° 134.1° ± 7.6° 0.004
ST 93.1° ± 4.6° 93.6° ± 4.8° 0.30
HA anterior and posterior subgroups

HA-anterior subgroup was composed of 145 subjects

(22 % of subjects) and was similar to HA-posterior sub-
group only with respect to SS (39.8° ± 7.5° vs
38.6° ± 7.6°; p = 0.09). In consequence, HA-anterior and
HA-posterior subgroups differed significantly in terms of
age (11.5 ± 3.3 years vs 12.3 ± 3.0 years; p = 0.005), PI
(41.3° ± 10.0° vs 47.4° ± 10.8°; p \ 10-9), PT (1.5° ±
6.9° vs 8.8° ± 7.7°; p \ 10-23), SSA (130.2° ± 9.1° vs
132.6° ± 8.0°; p = 0.002), ST (90.4° ± 5.9° vs 94.0° ±
3.9°; p \ 10-18) (Table 9).
Sacropelvic retroversion and anteversion subgroups
Sacropelvic retroversion subgroup was composed of 529
subjects (82 % of subjects and was similar to sacropelvic
anteversion subgroup with respect to age (12.2 ± 3.1 years
vs 11.8 ± 2.9 years; p = 0.14) and ST (93.1° ± 4.6° vs
93.6° ± 4.8°; p = 0.30). On the other hand, both sub-
groups differed significantly in terms of PI (48.1° ± 10.6°
vs 36.5° ± 6.5°; p \ 10-27), PT (9.6° ± 6.8° vs
-3.9° ± 3.2°; p \ 10-75), SS (38.5° ± 7.8° vs
40.5° ± 6.3°; p = 0.01) and SSA (131.6° ± 8.4° vs
134.1° ± 7.6°; p = 0.004) (Table 10).
Discussion
This study reports the largest cohort of asymptomatic
children and adolescents in the literature pertaining to the
evaluation of sagittal GSB. Results from this study could
be used as reference values when evaluating patients with
spinal pathology. Overall, asymptomatic children and
adolescents tend to stand with a relatively stable global
balance, as demonstrated by a narrow range of values for
SSA and ST. Therefore, SSA between 116° and 149°, and
ST between 84° and 102° are typically expected in 95 % of
normal children. More specifically, it was observed that the
line from the center of C7 vertebral body to the center of
upper sacral endplate used to measure ST was very close to
the vertical line, confirming the findings from a previous
study [7]. In this study, older children were standing with a
more negative sagittal balance, as a reflect of the increase
in ST, confirming results from a previous study [3].
We found that SSA in children and adolescents has close
relation with sacropelvic balance (SS) and morphology
(PI), in a similar way as in adults [10, 11]. Both SSA and
ST could be used to maintain or restore the global balance

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when treating different pathologies. SSA could be used to
quantify the global kyphotic alignment of the spine. On the
other hand, ST could be easier to evaluate due to its close
relationship with the vertical line. In this study, angular
parameters (SSA and ST) were preferred over linear (dis-
tance) parameters because they are less sensitive to varia-
tions in radiographic protocols and magnification, allowing
easier comparison between different institutions or studies.
In addition, SSA and ST have the advantage of taking into
account the spinal length.
Global balance type is useful to characterize the position
of C7 plumbline within the sacropelvis. Describing the
global balance type could be easier than calculating the C7
translation ratio. Furthermore, subgrouping the global
balance type may be a useful clinical tool to classify
patients before and after surgery. Subjects in C7-anterior
subgroup are able to maintain a stable balance in spite of
having a lower PI and a more anteverted sacropelvis. This
could be attributable to the smaller thoracic kyphosis and
lumbar lordosis in these subjects. To maintain the global
balance, the sacrum anterior subgroup presents with less
kyphosis and the C7 plumbline falls closer to the center of
the upper sacral plate in comparison to the sacrum posterior
subgroup. The HA anterior subgroup is less frequent than
the HA posterior subgroup and subjects tend to be younger,
with lower PI and less global kyphosis. It is interesting to
observe that despite the differences in PI and SSA between
the sacropelvic retroverted and anteverted subgroups, both
adjust to have similar ST, or in other words, to have a
stable global balance.
In this study, 21.4 % of asymptomatic children and
adolescents had C7 plumbline in front of HA and sacrum
(C7-anterior subgroup with type 3 or 6 balance). This result
suggests that an anterior sagittal alignment is not neces-
sarily associated with spinal pathology. The smaller PI in
the HA-anterior subgroup could also suggest that a small PI
could interfere with the ability to position the C7 plumbline
behind the hip axis, which is the position most often seen in
normal subjects for the C7 plumbline. Moreover, it is
possible that subjects with smaller PI will have a greater
tendency to have a C7 plumbline in front of the HA,
although this assumption would need to be verified in a
larger cohort also involving adult subjects.
Correlations between GSB, parameters of sacropelvic
morphology and balance were generally small clinically
(r \ 0.3), except for large correlations found with respect
to PI and SS. These results reflect the high variability in
GSB in the normal population, suggesting that regulation
of GSB also depends on other factors such as spinal and
chest cage geometry, body morphology, muscle tone, and
lower extremities that cannot be taken into account in the
current study. Correlations for global balance parameters
were particularly smaller with respect to PT, when
compared with PI and SS. The strong correlation between
SSA and SS, however, underlines the importance of SS in
the maintenance of a normal stable posture. The significant
change in PI between both age groups may be attributed to
the modification in pelvic morphology before and after the
growth spurt, confirming results from previous studies
[9, 12, 13].
One limitation of this study is that the recruited subjects
were all discharged after their consultant spine surgeon
ruled out a spinal pathology. It is possible that some of
them could develop a spinal disorder in the future and as
for any cross-sectional study, no definite conclusion about
the evolution of the GSB over time can be drawn. Ideally, a
longitudinal study would allow adequate selection of nor-
mal subjects and accurate assessment of the association
between age and the parameters of the GSB and pelvis.
Unfortunately, such methodology would require serial
radiographs in normal children and is thus problematic
because of ethical concerns.
Conclusion
Asymptomatic children and adolescents tend to stand with
a stable global balance when measured from SSA and ST.
The small difference in global balance parameters between
males and females does not justify any clinical distinction
between them when referring to normal values. It is
expected that 95 % of normal children and adolescents
have an SSA and ST between 116° and 149° and 85°–102°,
respectively. C7 plumbline in front of the HA and sacrum
is not necessarily associated with a spinal pathology in this
population as almost 22 % of them had C7 plumbline in
front of them. However, comparison of normal values to
the sagittal balance parameters found in patients with
spinal pathology should be addressed in the future to better
define the characteristics of normal sagittal balance.
Improved knowledge of normal spinal balance could be
helpful in recognizing and treating patients with spinal
deformities, as well as to guide the surgery in patients with
abnormal sagittal balance.
Compliance with ethical standards
Conflict of interest None.
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