Kyphosis

Fixed Sagittal Imbalance

Nonoperative Treatment

Nonoperative treatment for fixed sagittal imbalance is similar to all other types of spinal pathology. Anti-inflammatory medications and physical therapy are typically the first recommendations. Epidural steroid injections may be helpful in diagnosing and treating a lumbar radiculopathy (pinched nerve). Bracing is ineffective because it weakens the posture muscles, and does not treat the underlying pathology. If the imbalance progresses and there is significant pain, surgery is usually indicated.

Diagnostic Workup

Upright long-cassette radiographs:
These images show the importance of obtaining
long-cassette xrays with the knees and hips extended.
The left picture shows the patient’s compensated
posture, while the right picture shows the extent of the
sagittal imbalance (same person - hips and knees
extended)

Patients often need several preoperative imaging studies to fully understand the underlying problem.

Radiographs
Standing long-cassette radiographs with the knees and hips extended are critical to understand the extent of the imbalance.
CT Scan
Often a CT scan helps define the bony anatomy. The magnets of MRI reflect off metal instrumentation (if present) making it difficult to visualize the anatomy. CT-myelograms help define the position of the instrumentation and areas of neural impingement. This study can also help identify areas of failed fusion (pseudarthrosis).
MRI
MRI is the gold-standard for demonstrating the anatomy of the nerves and discs.
Bone Scan
Triple-phase bone scans show areas of increased activity that may demonstrate pseudarthrosis or other anomalies.