CHAPTER
59
Sacro-Pelvic Morphology, Spino-
Pelvic Alignment, and the Spinal
Deformity Study Group Classification
INTRODUCTION
The two most commonly used classification systems for spon-
dylolisthesis have been presented in the preceding chapter.
The Wiltse classification30 is based on anatomical changes seen
at the lumbosacral area and is useful to differentiate between
the various etiologies, but it does not provide any insight as to
when and how surgery should be done. The system proposed
by Marchetti and Bartolozzi23 helps to distinguish between the
developmental versus the acquired forms of spondylolisthesis,
thereby providing further insight into the etiology and progno-
sis of spondylolisthesis. Recently, Herman and Pizzutillo9 com-
bined elements of both classifications to propose a modified
classification which helps to clarify the differences between
traumatic and developmental spondylolisthesis and to guide
nonoperative treatment.
Unfortunately, none of these classifications are very useful
for surgical treatment, while it has become increasingly evident
in the last decade that global sagittal plane alignment is a key
factor to consider in both adult and pediatric patients with spon-
dylolisthesis.24 The sacro-pelvic morphology modulates the
geometry of the lumbar spine and consequently, the mechani-
cal stresses at the lumbosacral junction. In patients with high-
grade developmental spondylolisthesis, this has provided a com-
pelling rationale to reduce and realign the spondylolisthesis
deformity, thus restoring global spino-pelvic balance and
improving the biomechanical environment for fusion.24
Although the exact etiology of developmental spondylolisthe-
sis remains unknown, it is most likely multifactorial. Figure 59.1
presents the authors current point of view on the pathogenesis
of developmental spondylolisthesis, in an attempt to incorpo-
rate spino-pelvic balance and unify the various findings
reported. In the presence of spondylolysis and bony dysplasia,
the mechanical stresses applied to the lumbosacral junction are
further altered by the abnormal spino-pelvic balance secondary
to the abnormal sacro-pelvic morphology. Secondary deforma-
tion of the L5 vertebral body, sacrum and pelvis due to bone
remodeling through the growth plates, according to the
HueterVolkmann law, also alters the biomechanical loads at
the lumbosacral spine, thus contributing to further progression
LWBK836_Ch59_p563-575.indd 563
Hubert Labelle
Jean-Marc Mac-Thiong
of the spondylolisthesis, in a process similar to progression in
Blount disease.
The purpose of this chapter is, first, to review our current
understanding of sacro-pelvic morphology and describe its
influence on spino-pelvic balance, and second, to present a
classification incorporating recent knowledge in spino-pelvic
balance and intended to guide the treatment of developmental
spondylolisthesis in children, adolescents, and young adults.
SAGITTAL SPINO-PELVIC ALIGNMENT
In the sagittal plane, the normal standing posture can be viewed
as a set of mutually articulating body sections: the head is bal-
anced over the trunk by the cervical spine, the trunk articulates
on the sacro-pelvis, which in turn articulates with the lower limbs
at the hip joints, to maintain a stable posture and to expend a
minimum of energy. In spondylolisthesis, sacro-pelvic morphol-
ogy is abnormal4,12,29 and, combined with the presence of a local
lumbosacral deformity and dysplasia, it can result in an abnor-
mal sacro-pelvic orientation10,26 and a disturbed global balance.21
These findings have important implications for the evaluation
and treatment of spondylolisthesis and have fostered a renewed
interest for the radiological evaluation of spino-pelvic alignment
in this condition. This section summarizes the experience of the
Spinal Deformity Study Group (SDSG) and reviews the most per-
tinent radiological measurements of sagittal spino-pelvic balance
for the evaluation of L5-S1 developmental spondylolisthesis.
SACRO-PELVIC MORPHOLOGY
AND ORIENTATION
It is of utmost importance to understand the difference between
sacro-pelvic morphology and sacro-pelvic orientation. Sacro-
pelvic morphology refers to the anatomy (shape) specific to
each individual and is therefore unaffected by the three-
dimensional position of the sacro-pelvis. On the contrary, sacro-
pelvic orientation depends on the position of the individual in
space and is best measured from standing lateral radiographs
with the hips and knees extended. Table 59.1 provides the
563
8/31/11 7:59:41 PM
 564 Section VI Spondylolisthesis

Predisposing factors
Hereditary predisposition
Congenital weakness of pars
articularis Environmental factors
Vertebral dysplasia (e.g. spina Erect posture and gait
bifida, facet aplasia) Repetitive loading of lumbosacral spine
Connective tissue abnormality
Growth plate abnormality
Abnormal sacro-pelvic morphology

Pars elongation
or lysis

Postural changes due to

Pain
Neurologic origin

Altered biomechanics
Center of gravity Degeneration of discs
Spinopelvic balance and soft tissues

Spondylolisthesis

Growth plate remodeling Bony dysplasia

Figure 59.1. Pathogenesis of developmental

spondylolisthesis.

Mean Values (and Standard Deviation) of Pertinent Sagittal Sacro-Pelvic Measurements

TABLE 59.1
in Subjects with Spondylolisthesis Compared with a Control Population

Developmental Spondylolisthesis

Normal Children Normal

and Adolescents* Adults Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
(n 341) (n 160) (n 21) (n 91) (n 74) (n 17) (n 11)
Pelvic incidence 49.1 (11.0) 51.8 (5.3) 57.7 (6.3) 66.0 (6.9) 78.8 (5.6) 82.3 (7.2) 79.4 (10.2)
Sacral slope 41.4 (8.2) 39.7 (4.1) 43.9 (4.8) 49.8 (4.2) 51.2 (5.7) 48.5 (7.6) 45.9 (13.5)
Pelvic tilt 7.7 (8.0) 12.1 (3.2) 13.8 (3.9) 16.2 (5.4) 27.6 (5.7) 33.9 (5.2) 33.5 (5.4)
*
Values from Mac-Thiong J-M, Labelle H, Berthonnaud , et al. Sagittal spinopelvic balance in normal children and adolescents. Eur Spine
J 2007;227234.

Values from Berthonnaud , Dimnet J, Roussouly P, et al. Analysis of the sagittal balance of the spine and pelvis using shape and orientation
parameters. J Spinal Disord Tech 2005;18:4047.

Values from Labelle H, Roussouly P, Berthonnaud , et al. Spondylolisthesis, pelvic incidence, and spinopelvic balance: a correlation study.
Spine 2004;29:20492954.

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 Chapter 59 Sacro-Pelvic Morphology, Spino-Pelvic Alignment, and the Spinal Deformity Study Group Classification
mean values of these radiological measurements in subjects
with spondylolisthesis compared with control populations.
The pelvic incidence (PI) is a morphological parameter
describing the sacro-pelvis, which is specific and constant for
each individual. It is important to understand that PI is a
descriptor of sacro-pelvic morphology and not of sacro-pelvic
orientation. Therefore, its value is unaffected by changes in
human posture and will remain the same whether a subject is
standing, sitting, or lying down, with the assumption that there
is no significant motion occurring at the sacro-iliac joints. This
parameter introduced by Duval-Beaupre et al5 is defined as
the angle between the line perpendicular to the upper sacral
end plate and the line joining the middle of the upper sacral
end plate and the hip axis (Fig. 59.2). Intra- and interobserver
reliability for the measurement of PI is excellent.2 Large data-
bases with normal values of PI have been published for pediat-
ric19 and adult3 subjects. PI has been shown to increase slightly
but constantly during childhood and adolescence before stabi-
lizing into adulthood.17 When compared with normal popula-
tions, PI is significantly higher4,12,29 in spondylolisthesis and the
Figure 59.2. Pelvic incidence (PI) is defined as an angle
subtended by line oa, which is drawn from the center of the femoral
head to the midpoint of the sacral end plate and a line perpendicular
to the center of the sacral end plate (a). The sacral end plate is
defined by the line segment bc constructed between the posterior
superior corner of the sacrum and the anterior tip of the S1 end plate
at the sacral promontory. For the case when the femoral heads are
not superimposed, the center of each femoral head is marked, and a
connecting line segment will connect the centers of the femoral
heads. The pelvic radius will be drawn from the center of this line to
the center of the sacral end plate. (Reprinted with permission from
Berthonnaud E, Dimnet J, Labelle H, et al. Spondylolisthesis. In
OBrien MF, Kuklo TR, Blanke KM, et al (eds). Spinal Deformity
Study Group radiographic measurement manual. Memphis, TN:
Medtronic Sofamor Danek, 2004:95108.)
LWBK836_Ch59_p563-575.indd 565
565
difference in PI tends to increase in a direct linear fashion as
the severity of spondylolisthesis increases.12 Although there is
clear evidence that PI tends to be increased in patients with
spondylolisthesis, there is still no well-designed study in the lit-
erature that is able to clarify the causeeffect relationship
between pelvic morphology and spondylolisthesis.
In contrast to the PI, the pelvic tilt (PT) and sacral slope
(SS) measure the orientation of the sacro-pelvis in the sagittal
plane. SS is defined as the angle between the sacral end plate
and the horizontal line (Fig. 59.3), whereas PT is defined as the
angle between the vertical line and the line joining the middle
of the sacral end plate and the hip axis (Fig. 59.3). Measurement
of PI, PT, and SS is particularly useful because PI represents the
arithmetic sum of the PT and SS (Fig. 59.3). Because of this
mathematical relationship between PI, SS, and PT, the mor-
phology of the sacro-pelvis, as quantified by PI, is therefore a
strong determinant of the spatial orientation of the pelvis in
the standing position: the greater the PI, the greater has to be
SS, PT, or both (Fig. 59.4).
When there is significant remodeling of the sacrum in spon-
dylolisthesis, it can be difficult to perform precise geometric
measurements involving the S1 end plate. In that case, the tech-
nique illustrated in Figure 59.5 can be used: a best fit line is
drawn along the posterior border and along the anterior border
of the sacrum. A third line is then drawn between the two tan-
gent points where these lines lose contact with the anterior and
posterior border of S1. This third line is then considered as the
Figure 59.3. Mathematical relationship between pelvic incidence
(PI), sacral slope (SS), and pelvic tilt (PT). HRL, horizontal reference
line; VRL, vertical reference line. (Reprinted with permission from
Berthonnaud E, Dimnet J, Labelle H, et al. Spondylolisthesis. In
OBrien MF, Kuklo TR, Blanke KM, et al (eds). Spinal Deformity
Study Group radiographic measurement manual. Memphis, TN:
Medtronic Sofamor Danek, 2004:95108.)
8/31/11 7:59:42 PM
 566 Section VI Spondylolisthesis
Morphology + Orientation
PI = SS + PT
Figure 59.4. Interaction between pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT). LL, lumbar
lordosis; TK, thoracic kyphosis.
sacral end plate from which the measurements of PI, PT, and
SS can be made.
As for the assessment of lumbosacral kyphosis, a recent
study7 has shown that the most widely used techniques (slip
angle, Dubousset lumbosacral angle, and lumbosacral angle)
provide similar excellent reproducibility, even in high-grade
spondylolisthesis (Fig. 59.6). Alternatively, the SDSG13 has pro-
posed to measure the L5 incidence angle, (similar to PI but
measured on the L5 vertebra), arguing that it also takes into
account the sacro-pelvic morphology and not only the local
lumbosacral deformity.
SACRO-PELVIC BALANCE
Although there is a mathematical relationship between PI, SS,
and PT, there is also a wide variability in how they interact with
each other in normal and also spondylolisthetic subjects
(Table 59.1). In other words, for two individuals with the same
sacro-pelvic morphology (same PI), the sacro-pelvic orientation
(SS and PT) can be different. In static standing position, the
way SS and PT balance themselves refers to the concept of
sacro-pelvic balance. The SDSG has specifically investigated
sacro-pelvic balance in low-grade and high-grade spondylolis-
thesis. Roussouly et al26 proposed two different subgroups of
sacro-pelvic balance observed in subjects with low-grade spon-
dylolisthesis that could be related to the etiology. In their opin-
ion, patients with high PI and SS would increase the shear
stresses at the lumbosacral junction, causing more tension on
the pars interarticularis at L5 (Fig. 59.7). On the opposite,
patients with a low PI and a smaller SS would involve impinge-
ment of the posterior elements of L5 between L4 and S1 during
extension, thereby causing a nutcracker effect on the pars
LWBK836_Ch59_p563-575.indd 566
TK=39
TK=44
LL=40 LL=69
PI=69
PI=37
PT=19
PT=9
SS=50
SS=28
interarticularis at L5 (Fig. 59.7). On the basis of K-means clus-
ter analysis, Labelle et al14 have confirmed the existence of
these two distinct subgroups of sacro-pelvic balance in a larger
SDSG cohort of low-grade isthmic spondylolisthesis: a subgroup
with normal PI (between 45 and 60) or low PI (45) and a
subgroup with high PI (60). The clinical relevance of these
findings is that since PI is always much greater than normal in
high-grade spondylolisthesis,12 it is assumed that the risk of pro-
gression in the low-grade subgroup with a normal PI is much
lower than in the subgroup with an abnormally high PI value.
It is tempting to hypothesize that the subgroup with normal PI
corresponds to traumatic cases with an acute or stress fracture
in subjects with a normal sacro-pelvic morphology, whereas the
other with high PI is associated with more dysplastic cases, but
this assumption remains to be verified.
As for high-grade spondylolisthesis, Hresko et al10 have iden-
tified two subgroups of patients: balanced versus unbalanced
pelvis (Fig. 59.8). The balanced group includes patients
standing with a high SS and a low PT, a posture similar to nor-
mal individuals with high PI, whereas the unbalanced group
includes patients standing with a retroverted pelvis and a verti-
cal sacrum, corresponding to a low SS and a high PT. Each new
subject with high-grade spondylolisthesis can be easily classified
by using the nomogram provided by Hresko et al10 (Fig. 59.9).
SPINO-PELVIC BALANCE
The study of spino-pelvic balance in the sagittal plane refers to
the evaluation of the relationships between parameters describ-
ing the sacro-pelvis, lumbar spine, thoracic spine, and cervical
spine. Globally, there is a wide variability in the relative position
of C7 relative to S1 (global spinal balance), even in the normal
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 Chapter 59 Sacro-Pelvic Morphology, Spino-Pelvic Alignment, and the Spinal Deformity Study Group Classification
Figure 59.5. Spinal Deformity Study Group (SDSG) index for
assessment of sacral doming. (Reprinted with permission from
Berthonnaud E, Dimnet J, Labelle H, et al. Spondylolisthesis. In
OBrien MF, Kuklo TR, Blanke KM, et al (eds). Spinal Deformity
Study Group radiographic measurement manual. Memphis, TN:
Medtronic Sofamor Danek, 2004:95108.)
population.21,27 However, when measured with respect to the
femoral heads, global spino-pelvic balance is maintained in a
narrower range in normal and also in spondylolisthetic
subjects.11,21 This finding supports that measurement of global
sagittal balance should take into account the important
contribution from the pelvis and therefore should be achieved
Figure 59.6. Assessment of lumbosacral kyphosis. (Reprinted with permission from Glavas P, Mac-Thiong
J-M, Parent S, et al. Assessment of lumbosacral kyphosis in spondylolisthesis: a computer assisted reliability
study of six measurement techniques. Eur Spine J 2009;18(2):212217.)
LWBK836_Ch59_p563-575.indd 567
567
relative to the femoral heads. Normally, a subject with adequate
global spino-pelvic balance should stand with the C7 plumb
line located over or behind the femoral heads, which ensures
that C7 is not in front of the center of gravity of the body (usu-
ally located over the femoral heads to expend a minimum of
energy).
In normal individuals, studies have shown that the sacro-
pelvic morphology determines the sacro-pelvic orientation,
which in turn greatly influences the shape and orientation of
the spine, especially the lumbar lordosis.3,19 This results in an
open linear chain linking the head to the pelvis where the
shape and orientation of each successive anatomical segment
are closely related and influence the adjacent segment,3,19,21
to maintain the center of gravity over the femoral heads
(Fig. 59.10). In lumbosacral spondylolisthesis, an abnormal
sacro-pelvic morphology combined with the presence of a local
lumbosacral deformity and dysplasia can result in a disturbed
spino-pelvic balance.21 By using a postural model of spino-
pelvic balance showing the relationships between parameters
of each successive anatomical segment from the thoracic spine
to the sacro-pelvis, Mac-Thiong et al21 have observed that a rela-
tively normal posture was maintained in low-grade spondylolis-
thesis (Fig. 59.10), whereas it was abnormal in high-grade
spondylolisthesis. For high-grade spondylolisthesis, the spino-
pelvic balance was particularly disturbed in the subgroup with
an unbalanced sacro-pelvis (Fig 59.11), as described by Hresko
et al.10 They also reported that for most patients with spon-
dylolisthesis, the global spino-pelvic balance (position of C7
vertebral body over the femoral heads) was relatively constant,
regardless of the local lumbosacral deformity and particularly
of the alignment of C7 with respect to S1, indicating the pre-
dominant influence of the sacro-pelvis in the achievement of a
normal global spino-pelvic balance.
SURGICAL TREATMENT OF SPONDYLOLISTHESIS
BASED ON SPINO-PELVIC BALANCE
While the need for reduction in the surgical treatment of spon-
dylolisthesis is still debated, three studies provide some insight
for the decision-making process. Hresko et al10 stated that the
8/31/11 7:59:50 PM
 568 Section VI Spondylolisthesis
SS
SS
PI
PI
PI 60 PI < 45 groups and further support the contention that reduction
Figure 59.7. Two subgroups of patients with low-grade spon-
dylolisthesis based on sacro-pelvic balance (shear mechanism if pelvic
incidence [PI] 60 vs. nutcracker mechanism if PI 45). SS, sacral
slope. (Reprinted with permission from Roussouly P, Gollogly S, Ber-
thonnaud , et al. Sagittal alignment of the spine and pelvis in the
presence of L5-S1 isthmic lysis and low-grade spondylolisthesis. Spine
2006;31:24842490.)
failure to analyze sacro-pelvic balance and therefore to distin-
guish between a balanced and an unbalanced sacro-pelvis could
account for the variability found in the literature regarding
the outcome of reduction for high-grade spondylolisthesis.
A B
Figure 59.8. Two subgroups of patients with high-grade spondylolisthesis based on sacro-pelvic balance. (A)
Balanced and (B) unbalanced spondylolisthesis. (Adapted from Hresko MT, Labelle H, Roussouly P, et al. Classifi-
cation of high-grade spondylolisthesis based on pelvic version and spine balance: possible rationale for reduction.
Spine 2007;32:22082213.)
LWBK836_Ch59_p563-575.indd 568
Accordingly, they suggest that reduction techniques might be
considered in high-grade spondylolisthesis when there is an
unbalanced sacro-pelvis. Mac-Thiong et al21 also suggested
attempting reduction of a high-grade spondylolisthesis in
the subgroup of patients with an unbalanced sacro-pelvis since
these patients present with an abnormal spino-pelvic balance,
as compared with the normal population. On the opposite,
they propose that patients with low-grade spondylolisthesis as
well as those with high-grade spondylolisthesis and a balanced
sacro-pelvis do not necessarily require reduction because their
spino-pelvic balance is similar to normal individuals. Finally, in
a multicenter study, Labelle et al15 have shown that while sacro-
pelvic shape (PI) is unaffected by attempts at surgical reduc-
tion, proper repositioning of L5 over S1 significantly improves
sacro-pelvic balance and the shape of the lumbar spine in
developmental spondylolisthesis. Their results also emphasize
the importance of subdividing subjects with high-grade spon-
dylolisthesis into unbalanced and balanced sacro-pelvis sub-
techniques might be considered for the unbalanced sacro-
pelvis subgroup.
LUMBOSACRAL DYSPLASIA
Although Marchetti and Bartolozzi23 underlined the impor-
tance of dysplastic changes in the progression and treatment of
spondylolisthesis, they did not propose any objective technique
to assess them. Dysplasia can involve the posterior and/or ante-
rior elements of the lumbosacral spine. A variable degree of
dysplasia of the posterior elements (posterior bony hook/
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 Chapter 59 Sacro-Pelvic Morphology, Spino-Pelvic Alignment, and the Spinal Deformity Study Group Classification 569

100 literature. Dysplastic changes can also involve the transverse

processes. Molinari et al25 have measured the surface area of
the L5 transverse processes from the Ferguson view, in an
80
Sacral slope (degrees)

attempt to estimate the surface area available for posterolateral

High SS/low PT
60
40
20
0
0 10 20
Pelvic tilt (degrees)
Figure 59.9. Nomogram used to classify subjects according to
their sacro-pelvic balance, by using K-means cluster analysis. PT, pelvic
tilt; SS, sacral slope.
catch dysplasia) can occur in the pars interarticularis (isthmic
or elongated), laminae (bifid or absent), and facets (hypoplas-
tic, aplastic, or abnormally oriented).4 Curylo et al4 have
observed a 62% prevalence of posterior element dysplasia in
patients with spondyloptosis. In addition, the prevalence of
spina bifida occulta is high in children with spondylolysis,
reaching 92% in the study by Fredrickson et al.6 Assessment of
the posterior bony hook/catch dysplasia, however, remains
descriptive, as there are no quantitative criteria defined in the
fusion. They suggested that in high-grade spondylolisthesis,
patients with small L5 transverse processes (surface area
2 cm2) are at an increased risk of pseudarthrosis with in situ
fusion. Abnormalities in the pedicles have also been reported,
Low SS/high PT especially in unilateral spondylolysis at L5 where there is con-
tralateral sclerosis of the L5 pedicle.1
Dysplasia of the anterior elements of the lumbosacral spine
can also be assessed. Wedging of L5 vertebral body is often but
not always found in spondylolisthesis.6 It is commonly mea-
30 40 50 60 sured by using the lumbar index, the ratio of the length of the
anterior vertebral body height over the length of the lower end
plate. The normal value of lumbar index in normal individuals
is typically 0.9 or more, whereas it is usually less than 0.8 in
patients with spondylolisthesis. Evaluation of sacral doming (or
rounding) is more important, since some authors suggest that
it could be a risk factor for slip progression.23 In addition, sacral
doming has been shown to influence spino-pelvic balance and
sacro-pelvic balance, since there is a significant correlation
between sacral doming and the presence of an unbalanced
sacro-pelvis.15 The technique proposed by the SDSG to assess
sacral doming is presented in Figure 59.5. The SDSG index has
an excellent intra- and interobserver reliability and is in agree-
ment with the clinical perspectives of spinal surgeons.20 It has
also been proposed that a SDSG index of 25% be used as a
criterion to differentiate significant from nonsignificant sacral
doming.20

Normal Subjects Low-grade Spondylolisthesis

Thoracic kyphosis Thoracic tilt Thoracic kyphosis Thoracic tilt

r=0
.45 .38 .32
r=0 r=0
r=0.46

Lumbar lordosis Lumbar tilt Lumbar lordosis r=0.52 Lumbar tilt

r= r=
0. . 65 0. 78
67 =0 91 0.
r Lumbosacral r= Lumbosacral
41 angle 44 angle
r=0. r=0.
Inferior L5 angle Inferior L5 angle
Slip r=0. Slip
30
percentage percentage
80 83
0. 0.
r= r=

Sacral slope Mathematical Pelvic tilt Sacral slope Mathematical Pelvic tilt

r= r=
0. . 67 0. 48
72
=0
80 0.
r r=

Pelvic incidence Pelvic incidence

Figure 59.10. Postural model for normal and low-grade spondylolisthesis.

LWBK836_Ch59_p563-575.indd 569 8/31/11 7:59:59 PM

 570 Section VI Spondylolisthesis

Balanced Sacro-pelvis Subgroup Retroverted Sacro-pelvis Subgroup

Thoracic kyphosis Thoracic tilt Thoracic kyphosis Thoracic tilt

.71
r=0

r=0.59

r=0.52
Lumbar lordosis r=0.72 Lumbar tilt Lumbar lordosis Lumbar tilt

r=
0 77
.6 0.
2 r= Lumbosacral Lumbosacral
53 angle angle
r=0.
Inferior L5 angle p=0.04 Inferior L5 angle
Slip Slip
percentage percentage
57
0. p=0.03
r=

Sacral slope Mathematical Pelvic tilt Sacral slope Mathematical Pelvic tilt

r= r=
0. 2 0.
96 0 .8 75
r=

Pelvic incidence Pelvic incidence

Figure 59.11. Postural model for high-grade spondylolisthesis.

Other authors28,29 have also described various dysplastic fea-

tures of the sacrum specific to spondylolisthesis. Another widely
used parameter to assess sacral dysplasia is the sacral table angle
(STA), defined as the angle between the lines tangent to the
upper sacral end plate and to the posterior wall of S1
(Fig. 59.12). Wang et al28 have shown that the shape of S1 is dif-
ferent in spondylolisthesis and that STA is smaller and that
tends to decrease as the slip increases.
Figure 59.13 shows a patient with low-grade spondylolisthe-
sis without significant dysplasia, which can be compared with a
patient with significant dysplasia of both anterior and posterior
elements. The term dysplasia is used to describe either primary
(congenital) or secondary (developmental) changes in the
lumbosacral spine. In accordance with the classification of
Wiltse et al,30 dysplasia of the lumbosacral facets and laminae
are often primary, especially when there is an associated spina
bifida. However, a spondylolysis is considered to be secondary
since it has never been reported in a newborn. Similarly, dyspla-
sia of the anterior elements are presumed to be secondary.15

SPINAL DEFORMITY STUDY

GROUP CLASSIFICATION
Currently, most treatment protocols proposed in the literature
for developmental spondylolisthesis have focused mainly on
the abnormalities noted at the L5-S1 junction, mostly the slip
grade. This is an important component of the deformity; but as
discussed in the previous sections, sacro-pelvic morphology and
balance are strong determinants of sagittal spino-pelvic align-
ment but have not yet been included in any treatment algorithm.
This limitation may explain many of the current controversies
Figure 59.12. Sacral table angle (STA). The STA is the angle
subtended by the sacral endplate line (ab) and a line drawn along the
posterior aspect of the S1 vertebral body (ac). (Reprinted with permis-
sion from Berthonnaud E, Dimnet J, Labelle H, et al. Spondylolisthe-
sis. In OBrien MF, Kuklo TR, Blanke KM, et al (eds). Spinal Deformity
Study Group radiographic measurement manual. Memphis, TN:
Medtronic Sofamor Danek; 2004:95108.)

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 Chapter 59 Sacro-Pelvic Morphology, Spino-Pelvic Alignment, and the Spinal Deformity Study Group Classification 571

A B C

D E F

Figure 59.13. (A through D) Low dysplasia. (E

G H
through H) High dysplasia.

about surgical treatment and account for the high variability of
outcomes reported after surgery. Surgery is usually recom-
mended for patients with low-grade deformities (grades 0, 1,
or 2), which are unresponsive to conservative management,
and for all high-grade slips (grades 3, 4, or spondyloptosis).
Whether high-grade spondylolisthesis should or should not be
reduced remains controversial. The gold standard for surgical
treatment of high-grade spondylolisthesis has been in situ
fusion,16 but other studies8,25 have reported a high rate of pseu-
darthrosis, slip progression, and persistent cosmetic deformity.
Spinal instrumentation with pedicle screws has generated a
renewed interest for reduction, but the indications for this
treatment and its effect on spino-pelvic balance remain poorly
defined.
On the basis of a systematic review of the literature, Mac-
Thiong and Labelle18 have presented a classification system
incorporating the recent knowledge in sagittal spino-pelvic bal-
ance and intended to guide surgical treatment of developmen-
tal spondylolisthesis in children, adolescents, and young adults.
The classification has been further refined on the basis of the

LWBK836_Ch59_p563-575.indd 571 8/31/11 8:00:01 PM

 572 Section VI Spondylolisthesis

Type 1: Pl<45 (nutcracker)

Low grade Type 2: Pl 45 to 60

Type 3: Pl60 (shear)

L5-S1 spondy

Type 4: Balanced Pelvis

High grade
Pl60 Type 5: Balanced spine

Retroverted Pelvis

Type 6: Unbalanced spine Figure 59.14. Spinal Deformity Study Group

(SDSG) classification for L5-S1 spondylolisthesis.

work done in recent years22 by the SDSG and is presented in
Figure 59.14. It is based on three important characteristics that
can be assessed on preoperative imaging studies of the spine
and pelvis: (1) the grade of slip (low or high), (2) the PI (low,
normal, or high), and (3) the spino-pelvic balance (balanced
or unbalanced). Of all potential determinants of surgical
outcome, the degree of slip (low- vs. high-grade), PI values, and
spino-pelvic balance are thought to be crucial. Accordingly,
six different subtypes have been identified (Figs. 59.15
and 59.16).
To classify a patient, the degree of slip is quantified first
from the lateral radiograph, to determine whether it is low-
grade (grades 0, 1, and 2 or 50% slip) or high-grade (grades
3, 4, and spondyloptosis or 50% slip). Next, the sagittal bal-
ance is measured by determining sacro-pelvic and spino-pelvic
balance, by using measurements of PI, SS, PT, and the C7
plumb line. Sacro-pelvic balance is assessed on the basis of the
findings of Hresko et al10 for high-grade spondylolisthesis
(Figs. 59.7 and 59.9). For low-grade spondylolisthesis, three
types of sacro-pelvic balance can be found (Fig. 59.15): a sub-
group with normal PI (between 45 and 60) or low PI (45)
and a subgroup with high PI (60).14 As stated earlier, the
clinical relevance of the classification is that PI is always much
greater than normal in high-grade spondylolisthesis,12 whereas
the risk of progression in the low-grade subgroup with a normal
PI is much lower than in the subgroup with an abnormally high

Figure 59.15. The three

types of low-grade spondylolis-
thesis. (A) Type 1, low, has a
pelvic incidence (PI) value less
than 45. (B) Type 2, normal,
has a PI value between 45 and
60. (C) Type 3, high, has a PI
A B C
value greater than 60.

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 Chapter 59 Sacro-Pelvic Morphology, Spino-Pelvic Alignment, and the Spinal Deformity Study Group Classification
Figure 59.16. Examples of the
three types of high-grade spondylolis-
thesis. The angle shown is the pelvic tilt,
and the line is the C7 plumb line. (A)
Type 3 has a balanced sacro-pelvis. (B)
Type 4 has an unbalanced sacro-pelvis
with a balanced spine. (C) Type 5 has
an unbalanced pelvis with an unbal-
anced spine. Pelvic tilt (PT) angles are
A B
shown in black, C7 plumb lines in white.
PI value. For high-grade spondylolisthesis, each subject is classi-
fied as high SS/low PT (balanced pelvis) or low SS/high PT
(unbalanced sacro-pelvis) according to the graph in Figure
59.9, which illustrates the relationship between SS and PT in
high-grade spondylolisthesis. When SS and PT are located
above the threshold line, the subject is classified as high SS/low
PT. On the other hand, when SS and PT are located below the
threshold line, the subject is classified as low SS/high PT. Next,
spino-pelvic balance is determined by using the C7 plumb line.
If this line falls over or behind the femoral heads, the spine is
balanced, whereas if it lies in front of the femoral heads, the
spine is unbalanced (Fig. 59.16). In our experience, the spine
is almost always balanced in low-grade and in high-grade spon-
dylolisthesis with a balanced sacro-pelvis; and therefore, spinal
balance needs to be measured mainly in high-grade deformi-
ties with an unbalanced pelvis.
This is the first classification that organizes subgroups of
spondylolisthesis in an ascending order of severity according to
prognosis and/or complexity of surgical treatment. Abnormal
spino-pelvic balance alters the biomechanical stresses at the
lumbosacral junction and the compensation mechanisms used
to maintain an adequate posture. Because the classification is
designed so that subgroups are in an ascending order of
severity, it becomes easier and more intuitive to develop an
associated surgical algorithm because the complexity of the sur-
gery should increase, as the severity of the spondylolisthesis
increases.
Although three subgroups of patients with low-grade spon-
dylolisthesis have been identified on the basis of the sacro-
pelvic balance,26 there are no data in the literature that have
investigated the relevance of this concept on the treatment of
low-grade spondylolisthesis. However, identification of these sub-
groups would appear useful for predicting the risk of progression
LWBK836_Ch59_p563-575.indd 573
573
C
and possibly for surgical indications. The sacro-pelvic posture
with a high PI and high SS imposes higher shear stresses at the
L5-S1 junction, which is not an ideal biomechanical environ-
ment for fusion, suggesting that L5-S1 in situ fusion may be
preferable to attempts at pars repair. In addition, shear types
have a much stronger potential for progression since high-
grade deformities are found only in subjects with that have a
high PI.10 Therefore, for highly dysplastic shear types, com-
bined anterior and posterior fusion with instrumentation may
be indicated. In contrast, identification of a sacro-pelvic pos-
ture with a normal or especially with a low PI (nutcracker
mechanism) suggests that the risk of progression is low and
that pars repair or fusion in situ with or without instrumenta-
tion may be considered.
Table 59.2 proposes a tentative algorithm for the surgical
treatment of high-grade spondylolisthesis, which is in accor-
dance with the increasing order of severity detailed in the clas-
sification and based on the recent evidence presented in the
section on Sagittal Spino-Pelvic Alignment of this chapter.10,26
Indeed, the complexity of surgery tends to increase as we prog-
ress in the classification scheme. While the current consensus24
is toward more complex surgery for high-grade deformities
with abnormal spino-pelvic balance, most authors now recom-
mend partial reduction with circumferential fusion and some
form of pelvic stabilization. However, the SDSG classification
suggests that a complex surgery may not be necessary for all
patients. When the sacro-pelvis is balanced, the spine is also
usually balanced; and therefore, adequate sagittal spino-pelvic
balance is maintained, obviating the need for complex attempts
at reduction. When the sacro-pelvis is unbalanced, as indicated
by a retroverted pelvis and a vertical sacrum, posterior decom-
pression with gradual instrumented reduction and posterolat-
eral fusion, or the Gaines procedure may be preferred if the
8/31/11 8:00:05 PM
 574 Section VI Spondylolisthesis

TABLE 59.2 Proposed Algorithm for Surgical Treatment of High-Grade Spondylolisthesis

I II III
Grade of Slip Sacro-Pelvic Balance Spino-Pelvic Balance Clinical Relevance
High grade (3, 4, or 5) Balanced Balanced Can be fused in situ with no specific attempt at reduction.
Consider circumferential fusion if highly dysplastic.
Unbalanced Balanced Attempt reduction, but fuse in situ if reduction difficult; 360
fusion preferable if highly dysplastic.
Unbalanced Reduction is mandatory; 360 fusion if highly dysplastic.

spine is also unbalanced (Fig. 59.17). In cases for which the
sacro-pelvis is unbalanced but the spino-pelvic balance is ade-
quate, surgical reduction may not be necessary.
This treatment algorithm should be seen as a proposal to sup-
port the relevancy of the new classification, because more studies
are required to define the most appropriate treatment for each
subgroup, which should be the least invasive and least complex
surgical procedure that can provide a satisfactory result with a
high union rate and a favorable clinical outcome. It is also recog-
nized that other factors such as age of the patient or dysplastic
features of the deformity can influence the surgical decision
making. For low-grade spondylolisthesis, the deformity is consid-
Grade III Pre op Grade II Post op
TK = 37
TK = 20
ered highly dysplastic if the posterior elements are significantly
dysplastic (i.e., at least two of the following features are present:
L5 and/or S1 spina bifida, L5-S1 facet dysplasia, hypoplastic L5
transverse processes, systemic bone or connective tissue disorder
such as osteogenesis imperfecta, Marfan syndrome, or Ehler
Danlos syndrome). For high-grade spondylolisthesis, the defor-
mity is considered as highly dysplastic if significant doming of
the sacrum and/or significant dysplasia of the posterior elements
is present. Doming of the S1 end plate (Fig. 59.5) is considered
significant when the height of the sacral dome is higher than
25% of the length of the sacral end plate.20
Outcome studies are still required before reaching the ulti-
mate goal of a definitive treatment algorithm for lumbosacral
spondylolisthesis. Although this is only the beginning of a long
road, the proposed classification can serve as the starting point
for future studies that will provide evidence-based data con-
cerning the progression and treatment of lumbosacral spon-
dylolisthesis. The proposed classification suggests that subjects
with spondylolisthesis are a heterogeneous group with various
adaptations of their posture and that clinicians need to keep
this fact in mind for evaluation and treatment.

REFERENCES
1. Belfi LM, Ortiz O, Katz DS. Computed tomography evaluation of spondylolysis and spon-
dylolisthesis in asymptomatic patients. Spine 2006;31:E907E910.
2. Berthonnaud , Labelle H, Roussouly P, et al. A variability study of computerized sagittal
spinopelvic radiologic measurements of trunk balance. J Spinal Disord Tech 2005;18:6671.
3. Berthonnaud , Dimnet J, Roussouly P, et al. Analysis of the sagittal balance of the spine
LL = 69 and pelvis using shape and orientation parameters. J Spinal Disord Tech 2005;18:4047.
LL = 70 Nb = 5 4. Curylo LJ, Edwards C, DeWald RW. Radiographic markers in spondyloptosis: implications
for spondylolisthesis progression. Spine 2002;27:20212025.
Nb = 9
5. Duval-Beaupre G, Schmidt C, Cosson P. A barycentremetric study of the sagittal shape of
spine and pelvis: the conditions required for an economic standing position. Ann Biomed
Eng 1992;20:451462.
6. Fredrickson BE, Baker D, McHolick WJ, et al. The natural history of spondylolysis and
spondylolisthesis. J Bone Joint Surg Am 1984;66:699707.
7. Glavas P, Mac-Thiong J-M, Parent S, et al. Assessment of lumbosacral kyphosis in spon-
PI = 80 PI = 79 dylolisthesis: a computer assisted reliability study of six measurement techniques. Eur
IL5 70 IL5 45 Spine J 2009;18(2):212217.
LSA = 15 LSA = 2 8. Grzegorzewski A, Kumar SJ. In situ posterolateral spine arthrodesis for grades III, IV, and
V spondylolisthesis in children and adolescents. J Pediatr Orthop 2000;20:506511.
PT = 35 PT = 21 9. Herman MJ, Pizzutillo PD, Cavalier R. Spondylolysis and spondylolisthesis in the child and
SS = 45 SS = 58 adolescent athlete. Orthop Clin North Am 2003;34:461467.
10. Hresko MT, Labelle H, Roussouly P, et al. Classification of high-grade spondylolisthesis
based on pelvic version and spine balance: possible rationale for reduction. Spine 2007;
Figure 59.17. Pre- and postoperative result for a type 4 spon- 32:22082213.
dylolisthesis. The sacro-pelvis is unbalanced preoperatively as evi- 11. Kuntz C, Levin LS, Ondra SL, et al. Neutral upright sagittal spinal alignment from the
denced by the high pelvic tilt (PT) and retroverted pelvis, whereas the occiput to the pelvis in asymptomatic adults: a review and resynthesis of the literature. J
Neurosurg Spine 2007;6:104112.
spine remains balanced. Although only partial slip grade reduction
12. Labelle H, Roussouly P, Berthonnaud , et al. Spondylolisthesis, pelvic incidence, and
was obtained, there is a good correction of the abnormal sacro-pelvic spinopelvic balance: a correlation study. Spine 2004;29:20492954.
balance, which has been converted to a type 3 balanced sacro-pelvis. 13. Labelle H, Roussouly P, Berthonnaud , et al. The importance of spino-pelvic balance in
Proper repositioning of L5 over S1 is also evidenced by the improve- L5-S1 developmental spondylolisthesis: a review of pertinent radiologic measurements.
Spine 2005;30:S27S34.
ment in incidence of L5 (IL5) and lumbo-sacral angle (LSA). LL,
14. Labelle H, Roussouly P, Berthonnaud E, et al. Spondylolisthesis classification based on spino-
lumbar lordosis; Nb, number of vertebrae in lordosis; PI, pelvic inci- pelvic alignment. Presented at the Scoliosis Research Society Annual Meeting; September
dence; SS, sacral slope; TK, thoracic kyphosis. 2009; San Antonio, TX.

LWBK836_Ch59_p563-575.indd 574 8/31/11 8:00:05 PM

 Chapter 59 Sacro-Pelvic Morphology, Spino-Pelvic Alignment, and the Spinal Deformity Study Group Classification
15. Labelle H, Roussouly P, Chopin D, Berthonnaud E, Hresko T, OBrien M. Spino-pelvic
alignment after surgical correction for developmental spondylolisthesis. Eur Spine J
2008;17(9):11701176.
16. Lamberg T, Remes V, Helenius I, et al. Uninstrumented in situ fusion for high-grade child-
hood and adolescent isthmic spondylolisthesis: long-term outcome. J Bone Joint Surg Am
2007;89:512518.
17. Mac-Thiong J-M, Berthonnaud , Dimar JR II, et al. Sagittal alignment of the spine and
pelvis during growth. Spine 2004;29:16421647.
18. Mac-Thiong J-M, Labelle H. A proposal for a surgical classification of pediatric lumbosacral
spondylolisthesis based on the literature. Eur Spine J 2006;15:14251435.
19. Mac-Thiong J-M, Labelle H, Berthonnaud , et al. Sagittal spinopelvic balance in normal
children and adolescents. Eur Spine J 2007;16(2):227234.
20. Mac-Thiong J-M, Labelle H, Parent S, et al. Assessment of sacral doming in lumbosacral
spondylolisthesis. Spine 2007;32(17):18881895.
21. Mac-Thiong J-M, Wang Z, de Guise JA, et al. Postural model of sagittal spino-pelvic align-
ment and its relevance for lumbosacral developmental spondylolisthesis. Spine 2008;
33(21):231625.
22. Mac-Thiong JM, Labelle H, Parent S, et al. Reliability and development of a new classifica-
tion of lumbosacral spondylolisthesis. Scoliosis 2008;3:19.
LWBK836_Ch59_p563-575.indd 575
575
23. Marchetti PC, Bartolozzi P. Classification of spondylolisthesis as a guideline for treatment.
In Bridwell KH, DeWald RL, Hammerberg KW, et al (eds). The textbook of spinal surgery,
2nd ed. Philadelphia, PA: Lippincott-Raven,1997:12111254.
24. Mardjetko S, Albert T, Andersson G, et al. Spine/SRS spondylolisthesis summary state-
ment. Spine 2005;30:S3.
25. Molinari RW, Bridwell KH, Lenke LG, et al. Complications in the surgical treatment of
pediatric high-grade, isthmic dysplastic spondylolisthesis: a comparison of three surgical
approaches. Spine 1999;24:17011711.
26. Roussouly P, Gollogly S, Berthonnaud , et al. Sagittal alignment of the spine and pelvis in the
presence of L5-S1 isthmic lysis and low-grade spondylolisthesis. Spine 2006;31:24842490.
27. Roussouly P, Gollogly S, Noseda O, et al. The vertical projection of the sum of the ground
reactive forces of a standing patient is not the same as the C7 plumb line: a radiographic
study of the sagittal alignment of 153 asymptomatic volunteers. Spine 2006;31:E320E325.
28. Wang Z, Parent S, Mac-Thiong J-M, et al. Influence of sacropelvic morphology in develop-
mental spondylolisthesis. Spine 2008;33(20):21852191.
29. Whitesides TE Jr, Horton WC, Hutton WC, et al. Spondylotic spondylolisthesis: a study of
pelvic and lumbosacral parameters of possible etiologic effect in two genetically and geo-
graphically distinct groups with high occurrence. Spine 2005;30(6S):S12S21.
30. Wiltse LL, Newman PH, Macnab I. Classification of spondylolysis and spondylolisthesis.
Clin Orthop 1976;117:2329.
8/31/11 8:00:06 PM