Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 Oct 3:21925682251386853.
doi: 10.1177/21925682251386853. Online ahead of print.

Normal Global Sagittal Alignment Radiographic Parameters in Patients Without Spinal Deformity

Akiro H Duey  1 , Timothy Hoang  1 , Yash S Lahoti  1 , Mark Kurapatti  1 , Alexander Yu  1 , Kareem S Mohamed  1 , Ryan Hoang  1 , Junho Song  1 , Ula N Isleem  1 , Samuel Q Li  1 , Jun S Kim  1 , Samuel K Cho  1
Affiliations

Normal Global Sagittal Alignment Radiographic Parameters in Patients Without Spinal Deformity

Akiro H Duey et al. Global Spine J. .

Abstract

Study DesignRetrospective cohort study.ObjectivesThe purpose of this study was to report reference ranges for global sagittal alignment parameters stratified by age and sex in patients without spinal deformity.MethodsThis retrospective cohort study included consecutive patients undergoing biplanar full-body spine x-rays at a single institution, excluding those with spinal deformity or prior spine surgery. Global sagittal alignment parameters included cranial sagittal vertical axis to the sacrum (CrSVA-S), hip (CrSVA-H), knee (CrSVA-K), and ankle (CrSVA-A) as well as the cranium-hip-sacrum (CrHS), cranium-knee-sacrum (CrKS), and cranium-ankle-sacrum (CrAS) angles. Patients were stratified by age and sex, and ANOVA and multivariable logistic regression were used to compare groups, with age and sex as predictors of each radiographic parameter. Multivariable logistic regression models were created using age and sex as predictors, and each radiographic parameter as the outcome. In these models, age was treated as a continuous variable.ResultsA total of 518 patients were included, 253 (48.8%) male and 265 (51.2%) female, with ages ranging from 12 to 91 years old. In multivariable linear regression models, each 10-year increase in age was associated with a 0.6 cm increase in CrSVA-S (P < .001) and a 0.3 cm increase in CrSVA-H (P < .001). Conversely, age was associated with a 0.3 cm decrease in CrSVA-K per decade (P = .002), with no significant association observed between age and CrSVA-A. Male sex was associated with greater CrSVA-S (1.3 cm; P < .001), CrSVA-H (1.2 cm; P < .001), and CrSVA-A (1.2 cm; P < .001) compared to females. CrSVA-K did not differ significantly by sex.ConclusionThis study establishes reference values for normal global sagittal alignment to support operative planning and improve understanding of global sagittal alignment in spinal deformity.

Keywords: EOS; alignment; global; sagittal.

PubMed Disclaimer

Conflict of interest statement

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article

Figures

Figure 1.
Figure 1.
Example Radiograph Demonstrating (A) Landmarks for Global Sagittal Alignment Parameters, (B) CrSVA Measurements, and (C) Cranium Angle Measurements
Figure 2.
Figure 2.
Boxplots Showing Variation in Global Alignment With Age and Stratified by Sex for CrSVA-S, CrSVA-H, CrSVA-K, and CrSVA-A
Figure 3.
Figure 3.
Boxplots Showing Variation in Global Alignment With Age and Stratified by Sex for CrHS, CrKS, and CrAS
Figure 4.
Figure 4.
Forest Plot for Multivariable Linear Regression Models With Age as a Predictor of Global Sagittal for Peer Review Alignment Radiographic Parameters
Figure 5.
Figure 5.
Forest Plot for Multivariable Linear Regression Models With Male Sex as a Predictor of Global Sagittal Alignment Radiographic Parameters
See this image and copyright information in PMC

References

    1. Husson JL, Mallet JF, Parent H, et al. The lumbar-pelvic-femoral complex: applications in spinal imbalance. Orthop Traumatol Surg Res. 2010;96(4):S1-S9. - PubMed
    1. Lamartina C, Berjano P. Classification of sagittal imbalance based on spinal alignment and compensatory mechanisms. Eur Spine J. 2014;23(6):1177-1189. - PubMed
    1. Berthonnaud E, Dimnet J, Roussouly P, Labelle H. Analysis of the sagittal balance of the spine and pelvis using shape and orientation parameters. J Spinal Disord Tech. 2005;18(1):40-47. - PubMed
    1. Kim S, Hyun SJ, Lee JK, Kim KJ. Narrative review of clinical impact of head-hip offset following adult spinal deformity surgery. J Korean Neurosurg Soc. 2024;67(2):137-145. - PMC - PubMed
    1. Chaléat-Valayer E, Mac-Thiong JM, Paquet J, Berthonnaud E, Siani F, Roussouly P. Sagittal spino-pelvic alignment in chronic low back pain. Eur Spine J. 2011;20(5):634-640. - PMC - PubMed

LinkOut - more resources