PERBANDINGAN HASIL RADIOGRAF PEMERIKSAAN

VERTEBRAE LUMBOSACRAL PROYEKSI AP DENGAN

POSISI KAKI FLEKSI DAN LURUS

KARYA TULIS ILMIAH

Diajukan sebagai Salah Satu Syarat untuk Menyelsaikan

Program Studi Diploma III Radiologi

Oleh

Muhammad Faishal
171493

AKADEMI TEKNIK RADIODIAGNOSTIK DAN

RADIOTERAPI (ATRO) CITRA BANGSA YOGYAKARTA
2020
 HALAMAN PERSEJUTUAN

Telah diperiksan dan disetujui untuk memenuhi mata kuliah tugas akhir di

Akademi Teknik Radiodiagnostik dan Radioterapi (ATRO) Citra Bangsa

Yogyakarta.

Nama : Muhammad Faishal

NIM : 171493

Judul Tugas Akhir : Perbandingan Hasil Radiograf Pemeriksaan Vertebrae

Lumbosacral Proyeksi AP dengan Posisi Kaki Fleksi

dan Lurus

Yogyakarta, Agustus 2020

Pembimbing

SUHARIADI ATMANTA, S.ST

196812221993031001

ii
Scanned by TapScanner
 PERNYATAAN BEBAS PLAGIAT

Yang bertanda tangan dibawah ini :

Nama : Muhammad Faishal

NIM : 171493

Judul Tugas Akhir : Perbandingan Hasil Radiograf Pemeriksaan Vertebrae

Lumbosacral Proyeksi AP Dengan Posisi Kaki Fleksi

dan Lurus

Menyatakan bahwa karya tulis ilmiah dengan judul tersebut diatas, saya susun

dengan sejujurnya berdasarkan norma akademik dan bukan merupakan hasil

plagiat. Adapun semua kutipan di dalam karya tulis ini saya sertakan nama

penulisnya dan telah saya cantumkan ke daftar pustaka.

Pernyataan ini saya buat dengan sebenarnya dan apabila dikemudian hari

ternyata saya terbukti melanggar pernyataan saya tersebut diatas, saya bersedia

menerima sanksi sesuai aturan yang berlaku.

Yogyakarta, Agustus 2020

Yang menyatakan,

Muhammad Faishal

171493

iv
 HALAMAN MOTTO

 Maju terus pantang mundur.

 Jangan lupa rebahan. Sesibuk apapun kamu sempatkan waktu buat rebahan, tapi

jangan kelamaan nanti jadi terlalu nyaman.

v
 HALAMAN PERSEMBAHAN

Karya tulis ini dipersembahkan untuk :

1. Bapak, ibu, keluarga besar serta adik – adik dan saudara yang saya sayangi,

terima kasih atas segala bentuk dukungan dan doa yang selalu kalian berikan

kepada saya hingga bisa sukses seperti sekarang ini.

2. Buat teman-teman dimanapun kalian berada terima kasih atas bantuan-bantuan

serta dukungan kalian semua.

vi
 KATA PENGANTAR

Puji syukur penulis panjatkan kepada kehadirat Allah SWT, yang telah

melimpahkan rahmat, karunia, dan hidayahNya, sehingga penulis dapat

menyelesaikan karya tulis ilmiah ini dengan judul “Perbandingan Hasil Radiograf

Pemeriksaan Vertebrae Lumbosacral Proyeksi AP Dengan Posisi Kaki Fleksi dan

Lurus”. Karya tulis ilmiah ini diajukan sebagai salah satu syarat untuk

menyelesaikan Pendidikan Diploma III Akademi Teknik Radiodiagnostik dan

Radioterapi (ATRO) Citra Bangsa Yogyakarta.

Tugas akhir ini dibuat oleh penulis kemudian diseminarkan untuk

mempertimbangkan mutu, kelayakan, dan materi dari tugas akhir. Berkenaan

dengan hal tersebut, penulis mengucapkan terima kasih atas bimbingan, arahan, dan

bantuan dari berbagai pihak, kepada yang terhormat :

1. Bapak Prof. Dr. H. Arif Faisal, Sp. Rad, DFM selaku Ketua Yayasan Citra

Bangsa Yogyakarta.

2. Ibu dr. Enny Suci Wahyuni, Sp. Rad selaku Direktur Akademi Teknik

Radiodiagnostik dan Radioterapi Citra Bangsa Yogyakarta.

3. Bapak Suhariadi Atmanta, S.ST selaku Dosen Pembimbing Karya Tulis

Ilmiah.

4. Seluruh staf karyawan dan karyawati Akademi Teknik Radiodiagnostik dan

Radioterapi Citra Bangsa Yogyakarta.

5. Rekan-rekan mahasiswa/mahasiswi angkatan XXI Akademi Teknik

Radiodiagnostik dan Radioterapi Citra Bangsa Yogyakarta.

vii
6. Bapak dan Ibu serta keluarga yang telah memberikan dukungan dan motivasi

agar selalu semangat dalam menjalankan kegiatan sehari-hari.

7. Semua pihak yang telah membantu dalam menyusun karya tulis ilmiah ini.

Penulis menyadari bahwa masih banyak kekurangan dalam penyusunan karya

tulis ilmiah ini karena keterbatasan pengetahuan penulis, untuk itu penulis

mengharapkan kritik dan saran yang membangun dari pembaca untuk perbaikan

yang selanjutnya.

Penulis berharap semoga karya tulis ilmiah ini dapat bermanfaat bagi para

akademis dan peneliti-peneliti selanjutnya.

Yogyakarta, Agustus 2020

Penulis

viii
 DAFTAR ISI

Hal.

HALAMAN JUDUL .............................................................................................. i

HALAMAN PERSETUJUAN ............................................................................ ii
HALAMAN PENGESAHAN ............................................................................. iii
HALAMAN PERNYATAAN BEBAS PLAGIAT ........................................... iv
HALAMAN MOTTO ...........................................................................................v
HALAMAN PERSEMBAHAN ......................................................................... vi
KATA PENGANTAR ........................................................................................ vii
DAFTAR ISI ........................................................................................................ ix
DAFTAR GAMBAR ........................................................................................... xi
DAFTAR TABEL .............................................................................................. xii
INTISARI .......................................................................................................... xiii

BAB I PENDAHULUAN

A. Latar Belakang ................................................................................1

B. Rumusan Masalah ............................................................................2
C. Tujuan Penulisan ..............................................................................2
D. Manfaat Penelitian ...........................................................................2
E. Keaslian Penelitian ...........................................................................3

BAB II TINJAUAN PUSTAKA

A. Landasan Teori .................................................................................5

1. Anatomi Columna Vertebrae ..........................................................5
2. Vertebrae Lumbalis.........................................................................6
3. Vertebrae Sacrum ...........................................................................9

ix
 4. Prosedur Pemeriksaan ...................................................................11
B. Kerangka Teori ...............................................................................16

BAB III METODE PENELITIAN

A. Rancangan Penelitian .....................................................................17

1. Jenis Penelitian .............................................................................17
2. Tempat dan Waktu Penelitian .......................................................17
3. Subyek Penelitian .........................................................................17
B. Variabel Penelitian .........................................................................17
1. Variabel Bebas ..............................................................................17
2. Variabel Terikat ............................................................................18
3. Variabel Kontrol ..........................................................................18
C. Pengolahan Data .............................................................................18
1. Penyajian Data ..............................................................................18
2. Analisa Data ..................................................................................20
D. Alur Penelitian ................................................................................20

BAB IV HASIL DAN PEMBAHASAN

A. Daftar Studi Literatur Jurnal ......................................................21

B. Hasil Studi Literatur Jurnal .........................................................23
C. Pembahasan ...................................................................................28

BAB V. KESIMPULAN DAN SARAN

A. Kesimpulan ....................................................................................30
B. Saran ...............................................................................................30

DAFTAR PUSTAKA

LAMPIRAN

x
 DAFTAR GAMBAR

Gambar 1. Columna vertebralis ..............................................................................5

Gambar 2. Vertebrae lumbalis ................................................................................6
Gambar 3. Vertebrae lumbal posterior view ...........................................................7
Gambar 4. Vertebrae lumbal anterior view .............................................................7
Gambar 5. Vertebrae lumbal axial view .................................................................8
Gambar 6. Vertebrae lumbal lateral view ...............................................................9
Gambar 7. Vertebrae sacrum anterior view ..........................................................10
Gambar 8. Vertebrae sacrum lateral view .............................................................11
Gambar 9. Posisi pemotretan ................................................................................13
Gambar 10. Hasil radiograf vertebrae lumbosacral ..............................................14
Gambar 11. Posisi pemotretan ..............................................................................15
Gambar 12. Hasil radiograf vertebrae lumbosacral ..............................................16
Gambar 15. Proyeksi AP kaki fleksi dan hasil radiograf .......................................26
Gambar 16. Proyeksi AP kaki lurus dan hasil radiograf ........................................26

xi
 DAFTAR TABEL

Tabel 1. Penilaian anatomi vertebrae lumbosacral ...............................................18

Tabel 2. Penilaian diskus intervertebralis .............................................................19
Tabel 3. Daftar studi literatur .................................................................................21
Tabel 4. Hasil studi literatur ...................................................................................23
Tabel 5. Informasi diagnostik ................................................................................23
Tabel 6. Hasil penilaian anatomi vertebrae lumbosacral .......................................27
Tabel 7. Hasil penilaian discus intervertebralis .....................................................27

xii
 INTISARI

Telah dilakukan penelitian untuk mengetahui perbedaan hasil radiograf

pemeriksaan vertebrae lumbosacral posisi AP dengan posisi kaki fleksi dan lurus.
Metode penelitian yang digunakan adalah penelitian kualitatif dengan
pendekatan secara studi literatur jurnal. Variabel yang digunakan adalah variabel
bebas, variabel terikat, dan variabel control. Pada penelitian ini menggunakan
review jurnal sebanyak 3 jurnal.
Hasil penelitian menjelaskan bahwa pemeriksaan vertebrae lumbosacral
proyeksi AP dengan posisi kaki fleksi lebih baik dalam memperlihatkan
intervertebral disk space dan kualitas citra radiograf dari ketajaman dan
homogenitas densitas.

Kata kunci : pemeriksaan vertebrae lumbosacral AP, posisi kaki fleksi, posisi kaki
lurus.

xiii
 BAB I

PENDAHULUAN

A. Latar Belakang

Columna vertebralis atau rangkaian tulang belakang adalah struktur

lentur sejumlah tulang yang disebut vertebrae atau ruas tulang belakang. Di

antara tiap dua ruas tulang pada tulang belakang terdapat bantalan tulang

rawan. Panjang rangkaian tulang belakang pada orang dewasa dapat mencapai

57 sampai 67 sentimeter. Seluruhnya terdapat 33 ruas tulang, 24 buah di

antaranya adalah tulang-tulang terpisah dan 9 ruas sisanya bergabung

membentuk 2 tulang.

Columna Vertebralis diklasifikasi menjadi lima bagian, yaitu vertebrae

cervicalis, vertebrae thoracalis, vertebrae lumbalis, vertebrae sacralis, dan

vertebrae coccygealis. (Pearce, 2019).

Pemeriksaan vertebrae lumbosacral adalah pemeriksaan radiologi pada

vertebrae lumbosacral untuk melihat kelainan-kelainan yang terjadi pada

vertebrae lumbosacral. Pada teori Merrill’s (2016) pemeriksaan vertebrae

lumbosacral proyeksi AP terdapat posisi kaki fleksi dan lurus. Di lapangan

pada umumnya, pemeriksaan vertebrae lumbosacral proyeksi AP

menggunakan posisi kaki lurus.

1
 2

Karena hal tersebut, penulis sangat tertarik untuk mengangkat masalah

ini sebagai tugas akhir dengan judul “PERBANDINGAN HASIL

RADIOGRAF PEMERIKSAAN VERTEBRAE LUMBOSACRAL

PROYEKSI AP DENGAN POSISI KAKI FLEKSI DAN LURUS”.

B. Rumusan Masalah

1. Bagaimana perbedaan hasil radiograf pemeriksaan vertebrae lumbosacral

proyeksi AP dengan posisi kaki fleksi dan lurus?

2. Manakah yang lebih baik dari hasil radiograf pemeriksaan vertebrae

lumbosacral proyeksi AP dengan posisi kaki fleksi dan lurus?

C. Tujuan Penelitian

1. Mengetahui perbedaan hasil radiograf pemeriksaan vertebrae lumbosacral

proyeksi AP dengan posisi kaki fleksi dan lurus.

2. Mengetahui manakah yang lebih baik dari hasil radiograf pemeriksaan

vertebrae lumbosacral proyeksi AP dengan posisi kaki fleksi dan lurus.

D. Manfaat Penelitian

Dari penelitian ini diharapkan dapat memberikan informasi yang lebih

jelas kepada penulis dan pembaca terkait perbandingan hasil radiograf

pemeriksaan vertebrae lumbosacral dengan posisi kaki fleksi dan lurus. Serta

manakah hasil radiograf yang lebih baik dari pemeriksaan tersebut.

 3

E. Keaslian Penelitian

Sejauh pengetahuan penulis, terdapat beberapa penelitian yang

berhubungan dengan judul yang penulis angkat. Adapun yang sudah pernah

diangkat sebelumnya dari angkatan XV (lima belas) sampai angkatan XIX

(sembilan belas) diantaranya yaitu :

1. Didik Irawan (angkatan XV)

Perbandingan Informasi Anatomi Vertebra Lumbosacral Dinamik Dengan

Posisi Pasien Tidur dan Berdiri Pada Kasus Spondylolisthesis.

2. Nawang Prabowo (angkatan XV)

Perbedaan Informasi Radiograf Pada Pemeriksaan Vertebrae Lumbosacral

Proyeksi Anteroposterior Antara Dengan Penyudutan 15º – 20º Caudal

dan Tanpa Penyudutan.

3. Vety Anggreani (angkatan XV)

Teknik Pemeriksaan Vertebrae Lumbosacral Pada Kasus Suspect Fraktur

Spine Di Instalasi Radiologi RSUP. Dr. Sardjito Yogyakarta.

4. Nizar Adha (angkatan XVI)

Perbandingan Hasil Radiograf Pemeriksaan Lumbosacral Junction

Proyeksi AP Supine Dengan Penyudutan Arah Sinar 30º. 35º. 45º.

Chepalad.

5. Nyemas Winda Winiarti (angkatan XVI)

Teknik Pemeriksaan Vertebrae Lumbosacral Dengan Kasus Low Back

Pain Di Instalasi Radiologi RSUD Salatiga.

 4

6. Tri Siwi Fatmawati (angkatan XVI)

Analisa Perbandingan Kontras Radiograf Vertebrae Lumbosacral Lateral

Dengan Menggunakan Lysolm dan Bucky.

Persamaan dan Perbedaan

Persamaan dan perbedaan KTI yang penulis buat terhadap KTI yang

sudah pernah diangkat :

1. Persamaan

Berdasarkan daftar-daftar judul KTI dari angkatan XV (lima belas) sampai

angkatan XIX (sembilan belas) terdapat persamaan pada obyeknya yaitu

vertebrae lumbosacral.

2. Perbedaan

Berdasarkan daftaf-daftar judul KTI dari angkatan XV (lima belas) sampai

angkatan XIX (sembilan belas) terdapat perbedaan yaitu :

Pada angkatan XV dilakukan penelitian Perbedaan Informasi Radiograf

Pada Pemeriksaan Vertebrae Lumbosacral Proyeksi Anteroposterior

Antara Dengan Penyudutan 15º – 20º Caudal dan Tanpa Penyudutan, dan

Perbandingan Hasil Radiograf Pemeriksaan Lumbosacral Junction

Proyeksi AP Supine Dengan Penyudutan Arah Sinar 30º. 35º. 45º.

Chepalad. Angkatan yang lainnya mengangkat studi kasus pada

pemeriksaan vertebrae lumbosacral. Sedangkan yang penulis buat adalah

Perbandingan Hasil Radiograf Pemeriksaan Vertebrae Lumbosacral

Proyeksi AP dengan Posisi Kaki Fleksi dan Lurus.

 BAB II

TINJAUAN PUSTAKA

A. Landasan Teori

1. Anatomi Columna Verterbralis

Columna vertebralis atau rangkaian tulang belakang adalah struktur

lentur sejumlah tulang yang disebut vertebrae atau ruas tulang belakang.

Di antara tiap dua ruas tulang pada tulang belakang terdapat bantalan

tulang rawan. Panjang rangkaian tulang belakang pada orang dewasa dapat

mencapai 57 sampai 67 sentimeter. Seluruhnya terdapat 33 ruas tulang, 24

buah di antaranya adalah tulang-tulang terpisah dan 9 ruas sisanya

bergabung membentuk 2 tulang (Pearce, 2019).

Columna Vertebralis diklasifikasi menjadi lima bagian, yaitu

vertebrae cervicalis, vertebrae thoracalis, vertebrae lumbalis, vertebrae

sacralis, dan vertebrae coccygealis. (Pearce, 2019).

Gambar 1. Columna Vertebralis Anterior view dan Lateral view (Merrill’s, 2016)

5
 6

2. Vertebrae Lumbalis

Vertebrae lumbalis atau ruas tulang pinggang adalah yang terbesar.

Badannya sangat besar dibandingkan dengan badan vertebrae lainnya dan

berbentuk seperti ginjal. Prosesus spinosusnya lebar dan berbentuk seperti

kapak kecil. Prosesus transversusnya panjang dan langsing. Ruas kelima

membentuk sendi dengan sacrum pada sendi lumbosacral (Pearce, 2019).

Keterangan :
1
1. Inferior articular process
2. Superior articular process
3. Intervertebral disk
2 4. Zygopophyseal joint
5. Superior articular process
3 6. Lamina
4 7. Inferior articular process
5
6
7

Gambar 2. Vertebrae Lumbalis (Merrill’s, 2016).

Penampilan umum vertebrae lumbal yang dilihat dari anterior dan

posterior menunjukkan prosesus spinosus berada dibagian belakang pada

corpus vertebrae dan prosesus transversus ditunjukkan menonjol keluar

di tepi lateral corpus vertebrae (Bontrager, 2014)

 7

1
2

4
3
6
5

Gambar 3. Vertebrae Lumbal Posterior View (Bontrager, 2014).

Keterangan :

1. Superior articular process

2. Transverse process
3. Pars interarticularis (part of lamina)
4. Body
5. Inferior articular process
6. Spinous process

3
4

Gambar 4. Vertebrae Lumbal Anterior View (Bontrager, 2014).

Keterangan :

1. Superior articular process

2. Transverse process
3. Body
4. Inferior articular process
 8

2
4 3

7
5 6
8

10 9

Gambar 5. Vertebrae Lumbal Axial View (Merrill’s, 2016).

Keterangan :

1. Body
2. Pedicle
3. Vertebral foramen
4. Transverse process
5. Mammillary process
6. Lamina
7. Superior articular process
8. Accessory process
9. Pars interarticularis
10. Spinous process

Dilihat dari lateral, vertebrae lumbal memiliki corpus yang lebih

besar dibandingkan dengan vertebrae thoracic dan vertebrae cervical.

Lumbal lima (L5) adalah yang paling besar diantara lumbal yang lainnya.

Prosesus transversus lebih kecil dibandingkan dengan prosesus spinosus

yang memiliki ukuran lebih besar dan tumpul (Bontrager, 2014).

 9

1 2
3

6
5

8
7

Gambar 6. Vertebrae Lumbal Lateral View (Bontrager, 2014).

Keterangan :

1. Superior articular process

2. Superior vertebral notch
3. Pedicle
4. Transverse process
5. Spinous process
6. Body
7. Inferior articular process
8. Inferior vertebral notch (forms intervertebral foramina)

3. Vertebrae Sacrum

Sacrum atau tulang kelangkang berbentuk segitiga dan terletak pada

bagian bawah columna vertebralis, terjepit di antara kedua tulang

inominata (atau tulang koksa) dan membentuk bagian belakang rongga

pelvis (panggul). Dasar sacrum terletak di atas dan bersendi dengan

vertebrae lumbalis kelima dan membentuk sendi intervertebral yang khas.

Tepi anterior basis sacrum membentuk promontorium sakralis. Kanalis

sakralis terletak di bawah kanalis vertebralis (saluran tulang belakang)

yang memang kelanjutannya. Dinding kanalis sakralis berlubang-lubang

untuk dilalui saraf sakral. Prosesus spinosus yang rudimenter dapat dilihat

pada pandangan posterior dari sacrum. Permukaan anterior sacrum adalah

 10

cekung dan memperlihatkan empat gili-gili melintang, yang menandakan

tempat penggabungan kelima vertebrae sakralis. Pada ujung gili-gili ini,

disetiap sisi terdapat lubang-lubang kecil untuk dilewati urat-urat saraf.

Lubang-lubang ini disebut foramina. Apeks sacrum bersendi dengan

tulang koksigeus. Di sisinya, sacrum bersendi dengan tulang ileum dan

membentuk sendi sakro-iliaka kanan dan kiri (Pearce, 2019).

1 2

Gambar 7. Vertebrae Sacrum Anterior View (Bontrager, 2014).

Keterangan :

1. Promontory
2. Superior articular process
3. Ala
4. Body
5. Pelvic (anterior) sacral foramina
6. Apex
 11

1 2

4
6

5
7

8
9

Gambar 8. Vertebrae Sacrum Lateral View (Bontrager, 2014).

Keterangan :

1. Superior articular process

2. Sacral canal (between superior articular processes)
3. Sacral promontory
4. Base (body)
5. Auricular surface (sacroiliac joint)
6. Median sacral crest
7. Sacral horn (cornu)
8. Horn (cornu) of coccyx
9. Coccyx

4. Prosedur Pemeriksaan

a. Persiapan Pasien

Tidak ada persiapan khusus hanya saja pasien diberitahukan untuk

melepas semua benda logam di daerah yang akan diperiksa agar tidak

mengganggu hasil gambaran radiograf, seperti resliting, ikat

pinggang, peniti, dan benda logam lainnya. Radiografer memberi

penjelasan terkait prosedur pemeriksaan.

 12

b. Persiapan alat dan bahan

1) Pesawat Sinar-X

2) Kaset dan Film Roentgen

3) Marker R atau L

4) Grid atau Bucky

5) Baju Pasien

c. Teknik pemeriksaan

Menurut Merrill’s (2016) dan Bontrager (2014) proyeksi pemotretan

vertebrae lumbosacral yaitu :

1) Proyeksi Antero Posterior (AP) dengan posisi kaki lurus.

Posisi Pasien : Tidur supine diatas meja pemeriksaan.

Posisi Objek : Atur midsagital plane (MSP) pasien

dipertengahan meja pemeriksaan, atur bahu

dan pinggul agar simetris kanan dan kiri,

kedua lengan fleksi diletakkan diatas dada

atau lurus disamping tubuh, kedua kaki lurus.

Arah Sinar : Vertikal tegak lurus kaset.

Titik Bidik : Pada MSP setinggi krista iliaka.

Ukuran kaset : 35 x 43 cm

FFD : 102 cm

Kriteria : Mampu memperlihatkan anatomi dari lumbar

vertebral bodies, intervertebral joint,

 13

prosesus spinosus dan prosesus transversus,

sacroilliaca joint, dan sacrum.

Tidak ada rotasi pada pasien ditandai dengan

sacroilliaca joint berjarak sama jauh dari

prosesus spinosus.

Prosesus spinosus berada pada pertengahan

kolumna vertebralis dan prosesus transversus

berjarak sama kanan dan kiri.

Gambar 9. Posisi pasien proyeksi AP dengan posisi kaki lurus (Merrill’s, 2016).
 14

Gambar 10. Hasil radiograf proyeksi AP dengan posisi kaki lurus (Merrill’s,
2016).

2) Proyeksi Antero Posterior (AP) dengan posisi kaki fleksi.

Posisi Pasien : Tidur supine diatas meja pemeriksaan.

Posisi Objek : Atur midsagital plane (MSP) pasien

dipertengahan meja pemeriksaan, atur bahu

dan pinggul agar simetris kanan dan kiri,

kedua lengan fleksi diletakkan diatas dada

atau lurus disamping tubuh, kedua lutut di

fleksikan sehingga kaki menumpu pada meja

pemeriksaan.

Arah Sinar : Vertikal tegak lurus kaset.

Titik Bidik : Pada MSP setinggi krista iliaka.

Ukuran kaset : 35 x 43 cm

FFD : 102 cm
 15

Kriteria : Mampu memperlihatkan anatomi dari lumbar

vertebral bodies, intervertebral joint,

prosesus spinosus dan prosesus transversus,

sacroilliaca joint, dan sacrum.

Tidak ada rotasi pada pasien ditandai dengan

sacroilliaca joint berjarak sama jauh dari

prosesus spinosus.

Prosesus spinosus berada pada pertengahan

kolumna vertebralis dan prosesus transversus

berjarak sama kanan dan kiri.

Intervertebral disk space lebih terbuka.

Gambar 11. Posisi pasien proyeksi AP dengan posisi kaki fleksi (Marrill’s, 2016).
 16

Gambar 12. Hasil radiograf proyeksi AP dengan posisi kaki fleksi (Merrill’s,
2016).

B. Kerangka Teori

1. Columna Vertebralis
Anatomi 2. Vertebrae Lumbalis
3. Vertebrae Sacrum

1. Proyeksi AP dengan
Teknik Pemeriksaan posisi kaki lurus
Vertebrae Lumbosacral 2. Proyeksi AP dengan
posisi kaki fleksi
 BAB III

METODE PENELITIAN

A. Rancangan Penelitian

1. Jenis Penelitian

Penelitian ini merupakan penelitian kualitatif dengan pendekatan secara

studi literatur jurnal tentang pemotretan lumbosacral proyeksi AP dengan

posisi kaki fleksi dan lurus.

2. Tempat dan Waktu Penelitian

Pengumpulan data untuk menyusun Karya Tulis Ilmiah ini dilakukan

menggunakan data sekunder dalam bentuk review jurnal.

3. Subyek Penelitian

Pelaku yang terlibat aktif dalam penelitian ini adalah jurnal dan teori.

B. Variabel Penelitian

1. Variabel bebas

Variabel bebas merupakan variabel yang memperngaruhi atau yang

menjadi sebab berubahnya atau timbulnya variabel terikat. Variabel bebas

yang digunakan pada penelitian ini adalah posisi kaki fleksi dan lurus.

17
 18

2. Variabel terikat

Variabel terikat merupakan variabel yang dipengaruhi atau yang

menjadi akibat, karena adanya variabel bebas. Variabel terikat yang

digunakan pada penelitian ini adalah hasil radiograf vertebrae

lumbosacral.

3. Variabel kontrol

Variabel kontrol merupakan variabel yang dikendalikan atau dibuat

konstan. Variabel kontrol yang digunakan pada penelitian ini adalah

pesawat sinar-X, obyek, kaset, faktor eksposi, arah sinar, titik bidik, FFD,

luas kolimasi.

C. Pengolahan Data

1. Penyajian data

Penyajian data dilakukan dengan menampilkan data kuesioner

penilaian radiograf pemeriksaan vertebrae lumbosacral proyeksi AP

dengan posisi kaki fleksi dan lurus berdasarkan pengamatan penulis

sebagai berikut :

Tabel 1: Format penilaian anatomi vertebrae lumbosacral.

NO Anatomi Posisi Kaki Jelas Tidak Jelas

Fleksi
1 Corpus
Lurus

Fleksi
2 Intervertebral Joint
Lurus
 19

Fleksi
3 Sacroiliaca Joint
Lurus

Fleksi
4 Lumbosacral Joint
Lurus

Fleksi
5 Prosessus Spinosus
Lurus

Tabel 2 : Format penilaian Discus Intervertebralis (DIV)

NO Anatomi Posisi Kaki Jelas Tidak Jelas

DIV thoracal 12 – Fleksi

1
lumbal 1 Lurus

DIV lumbal 1 – Fleksi

2
lumbal 2 Lurus

DIV lumbal 2 – Fleksi

3
lumbal 3 Lurus

DIV lumbal 3 – Fleksi

4
lumbal 4 Lurus

DIV lumbal 4 – Fleksi

5
lumbal 5 Lurus

DIV lumbal 5 – Fleksi

6
Sacrum 1 Lurus

Standar Penilaian : Ceklist (√)

 20

2. Analisa data

a. Membuat kuesioner untuk menilai perbandingan tersebut dengan

penilaian kualitatif yang akan diisi menurut pengamatan penulis.

b. Data dianalisa dengan melihat hasil pada tabel 1 dan 2.

D. Alur Penelitian

Perbandingan hasil radiograf pemeriksaan vertebrae

lumbosacral proyeksi AP dengan posisi kaki fleksi dan lurus

Pemeriksaan vertebrae Pemeriksaan vertebrae

lumbosacral dengan lumbosacral dengan
posisi kaki fleksi posisi kaki lurus

Membedakan hasil radiograf pemeriksaan vertebrae

lumbosacral proyeksi AP dengan posisi kaki fleksi dan
lurus

Analisa data

Kesimpulan
 BAB IV

HASIL DAN PEMBAHASAN

A. Daftar Studi Literatur Jurnal

Dari beberapa literatur, dipilih 3 (tiga) literatur yang diterbitkan tidak lebih

dari sepuluh tahun terakhir. Literatur yang memenuhi kriteria untuk direview

adalah terkait dengan penelitian tentang vertebrae lumbosacral.

Daftar studi literatur yang direview adalah sebagai berikut :

Judul Tahun Penulis Publisher

Perbandingan 2019 Adeliana Rosa https://perpus.poltekke

Hasil Gambar sjkt2.ac.id

Radiografi

Pemeriksaan

Collumna

Vertebrae Lumbal

Proyeksi AP

Dengan Kedua

Lutut Ditekuk dan

Diluruskan Pada

Klinis Low Back

Pain (LBP).

21
 22

Penggunaan 2020 Jasfiar Yulia https://perpus.poltekke

Proyeksi AP Lutut Ningsih sjkt2.ac.id

Fleksi Pada

Pemeriksaan

Radiografi

Vertebrae

Lumbosacral

Untuk

Mendiagnosa

Klinis Low Back

Pain.

The effect of 2013 Chong Suh https://www.ncbi.nlm.ni

simulated knee Lee, Se Jun h.gov/pmc/articles/PMC

flexion on sagittal Park, Sung So 3657059/

spinal alignment: Chung, and

novel Keun Ho Lee

interpretation of

spinopelvic

alignment.

Tabel 3. Daftar Studi Literatur

 23

B. Hasil Studi Literatur

No Jenis Metode Penulis

1 Metode penelitian Review jurnal Adeliana Rosa

kuantitatif deskriptif

2 Metode penelitian Review jurnal Jasfiar Yulia Ningsih

kualitatif

3 Metode penelitian Review jurnal Chong Suh Lee, Se

kuantitatif Jun Park, Sung So

Chung, and Keun Ho

Lee

Tabel 4. Hasil Studi Literatur

Informasi diagnostik yang diperoleh pada pemeriksaan vertebrae lumbosacral

proyeksi AP dengan posisi kaki fleksi dan lurus berdasarkan review jurnal

adalah sebagai berikut :

Proyeksi AP
No Penulis
Posisi kaki fleksi Posisi kaki lurus

1 Adeliana Rosa Hasil gambaran Hasil gambaran

radiografi collumna radiografi collumna

vertebrae lumbal vertebrae lumbal

proyeksi AP dengan proyeksi AP dengan

posisi objek lutut objek kedua lutut

ditekuk dapat diluruskan sudah cukup

 24

menghasilkan citra baik dalam

radiografi dengan mendiagnosa klinis

ketajaman dan Low Back Pain (LBP).

homogenitas densitas

yang lebih baik,

sehingga anatomi dari

collumna vertebrae

lumbal lebih

informatif.

2 Jasfiar Yulia Gambaran hasil Gambaran hasil

Ningsih radiografi vertebrae radiografi lumbosacral

lumbosacral dengan proyeksi AP supine

proyeksi AP supine dengan lutut flat yang

dengan lutut fleksi menampakkan

yaitu tampak gambaran

gambaran collumna intervertebral disk

vertebrae lumbosacral space yang terhalangi

keseluruhan dengan oleh lordotic lumbal.

batas atas dan batas

bawah tidak terpotong,

dan tampak gambaran

scoliotic vertebrae

lumbal kearah sinistra,

 25

tampak intervertebral

disk space,

interpedicular spaces,

lamina, spinosus, dan

prosesus spinosus.

Gambaran

intervertebral disk

space lebih terbuka

karena tidak terhalangi

oleh bentuk

lengkungan dari

lumbal.

3 Chong Suh Lee, Fleksi lutut Tidak dijelaskan secara

Se Jun Park, Sung mengakibatkan jelas

So Chung, and penurunan lordosis

Keun Ho Lee lumbal tanpa

perubahan yang

signifikan pada postur

panggul dibandingkan

dengan parameter

pada pengaturan lutut

0º.

Tabel 5. Informasi diagnostic

 26

Gambar 15. Proyeksi AP kaki fleksi dan hasil radiograf

Gambar 16. Proyeksi AP kaki lurus dan hasil radiograf

 27

Tabel 6. Hasil penilaian anatomi vertebrae lumbosacral

NO Anatomi Posisi Kaki Jelas Tidak Jelas

Fleksi √
1 Corpus
Lurus √

Fleksi √
2 Intervertebral Joint
Lurus √

Fleksi √
3 Sacroiliaca Joint
Lurus √

Fleksi √
4 Lumbosacral Joint
Lurus √

Fleksi √
5 Prosessus Spinosus
Lurus √

Tabel 7. Hasil penilaian DIV vertebrae lumbosacral

NO Anatomi Posisi Kaki Jelas Tidak Jelas

DIV thoracal 12 – Fleksi √

1
lumbal 1 Lurus √

DIV lumbal 1 – Fleksi √

2
lumbal 2 Lurus √

DIV lumbal 2 – Fleksi √

3
lumbal 3 Lurus √

4 DIV lumbal 3 – Fleksi √

 28

lumbal 4 Lurus √

DIV lumbal 4 – Fleksi √

5
lumbal 5 Lurus √

DIV lumbal 5 – Fleksi √

6
Sacrum 1 Lurus √

C. Pembahasan

Pada kajian literatur ini diperoleh literatur yang membahas tentang

pemeriksaan vertebrae lumbosacral. Terdapat 3 literatur penelitian yang

hasilnya perbedaannya tidak terlalu signifikan, sehingga ketiga literatur ini

dapat dianalisis lebih lanjut sebagai bahan kajian literatur, dan didapatkan

pembahasan sebagai berikut :

Berdasarkan hasil review jurnal perbandingan vertebrae lumbosacral

proyeksi AP dengan posisi kaki fleksi dan lurus, penulis berpendapat bahwa

tidak ada perbedaan yang terlalu signifikan dari hasil radiograf pemeriksaan

vertebrae lumbosacral proyeksi AP dengan posisi kaki fleksi dan lurus. Hanya

saja pada proyeksi AP dengan posisi kaki fleksi gambaran intervertebral disk

space lebih terbuka, dikarenakan tidak terhalangi oleh bentuk lengkungan dari

verterbrae lumbal. Sedangkan pada posisi kaki lurus, gambaran intervertebral

disk space terhalang oleh bentuk lengkungan dari vertebrae lumbal. Pada

kualitas citra radiograf, untuk posisi kaki fleksi dapat menghasilkan kualitas

citra radiografi dengan ketajaman dan homogenitas densitas yang lebih baik,

sehingga anatomi vertebrae lumbosacral lebih informatif karena tidak ada jarak
 29

antara tulang vertebrae lumbosacral dengan meja pemeriksaan. Pada posisi

kaki lurus, terdapat jarak antara lengkungan vertebrae lumbosacral dengan

meja pemeriksaan. hal ini membuat hasil radiograf mengalami magnifikasi.

Magnifikasi terjadi karena adanya faktor jarak antara objek dengan film

radiografi (Object Film Distance) atau jarak antara focus dengan film radiografi

(Focus Film Distance).

Penilaian anatomi hasil radiograf pemeriksaan vertebrae lumbosacral

proyeksi AP dengan posisi kaki fleksi dan lurus pada table 3 menurut

pengamatan penulis yaitu :

Tampak jelas anatomi dari corpus vertebralis, prosesus spinosus, intervertebral

joint, lumbosacral joint, dan sacroiliaka joint pada posisi kaki fleksi dan lurus,

hanya saja pada posisi kaki fleksi intervertebral disk space lebih terbuka

dibandingkan dengan posisi kaki lurus.

Penilaian discus intervertebralis dari hasil radiograf pemeriksaan vertebrae

lumbosacral proyeksi AP dengan posisi kaki fleksi dan lurus pada table 4

menurut pengamatan penulis yaitu :

Tampak jelas discus intervertebralis dari thoracal 12 sampai sacrum 1 untuk

posisi kaki fleksi dan lurus. Hanya saja pada discus intervertebralis lumbal 5 –

sacrum 1 pada posisi kaki lurus sedikit terhalang oleh gambaran dari vertebrae

lumbal.
 BAB V

KESIMPULAN DAN SARAN

A. Kesimpulan

Berdasarkan kajian literatur diatas, maka penulis dapat mengambil

kesimpulan sebagai berikut :

1. Tidak ada perbedaan yang terlalu signifikan dari hasil radiograf

pemeriksaan vertebrae lumbosacral proyeksi AP dengan posisi kaki fleksi

dan lurus.

2. Kualitas citra radiograf yang lebih baik adalah pada posisi kaki fleksi.

Dengan posisi kaki fleksi dapat menghasilkan ketajaman dan homogenitas

densitas yang lebih baik karena tidak ada jarak antara objek dengan film

radiograf yang mengakibatkan magnifikasi sehingga anatomi dari vertebrae

lumbosacral lebih informatif dibandingkan dengan posisi kaki lurus.

B. Saran

1. Sebaiknya jika ingin memperlihatkan intervertebral disk space dan

lumbosacral joint lebih terbuka maka lebih baik menggunakan posisi kaki

fleksi untuk proyeksi AP supine, selain itu kualitas citra radiograf juga lebih

informatif.

30
 DAFTAR PUSTAKA

Adeliana Rosa (2019). Perbandingan Hasil Gambar Radiografi Pemeriksaan

Collumna Vertebrae Lumbal Proyeksi AP Dengan Kedua Lutut Ditekuk dan
Diluruskan Pada Klinis Low Back Pain (LBP). [online]. Available at:
www.poltekkesjkt2.ac.id [accessed 1 agustus 2020].

Bontrager, K. and Lampignano, J. (2014). Textbook of Radiographic Positioning

and Related Anatomy. Eight Edition. Missouri : Mosby.

Chong Suh Lee, Se Jun Park, Sung So Chung, and Keun Ho Lee (2013). The effect
of simulated knee flexion on sagittal spinal alignment: novel interpretation of
spinopelvic alignment. [online]. Available at:
www.ncbi.nlm.nih.gov/pmc/articles [accessed 1 agustus 2020].

Jasfiar Yulia Ningsih (2020). Penggunaan Proyeksi AP Lutut Fleksi Pada

Pemeriksaan Radiografi Vertebrae Lumbosacral Untuk Mendiagnosa Klinis
Low Back Pain. [online]. Available at: www.poltekkesjkt2.ac.id [accessed 1
agustus 2020].

Long, B., Rollins, J. and Smith, B. (2016). Merrill’s Atlas of Radiographic

Positioning and Procedures. Thirteenth Edition. Volume One. Missouri :
Mosby.

Pearce, E. (2019). Anatomi dan Fisiologi untuk Paramedis. Jakarta : Gramedia.

LAMPIRAN
Eur Spine J (2013) 22:1059–1065
DOI 10.1007/s00586-013-2661-4
ORIGINAL ARTICLE
The effect of simulated knee flexion on sagittal spinal alignment:
novel interpretation of spinopelvic alignment
Chong Suh Lee • Se Jun Park • Sung Soo Chung •
Keun Ho Lee
Received: 12 February 2012 / Revised: 16 December 2012 / Accepted: 6 January 2013 / Published online: 22 January 2013
Ó Springer-Verlag Berlin Heidelberg 2013
Abstract
Introduction Many studies regarding spinal sagittal
alignment were focused mainly on above-hip structures,
not considering the knee joint. Knee–spine syndrome was
proposed earlier, but the mechanism of this phenomenon
has not been revealed. The aim of the study was to dem-
onstrate how spinopelvic alignment and sagittal balance
change in response to simulated knee flexion in normal
non-diseased population.
Methods Thirty young male were enrolled in the study
cohort. Two motion-controlled knee braces were used to
simulate knee flexion of 0°, 15°, and 30° settings. Whole spine
and lower extremity lateral radiographs were taken at each
knee setting of 0°, 15°, and 30° flexion. Spinal and pelvic
parameters were measured, including two angular parameters,
femoropelvic angle (FPA) and femoral tilt angle (FTA).
Results The following equation can be made; PT (pelvic
tilt) = FPA ? FTA. The mean values of FPA and lumbar
lordosis decreased significantly at 15° and 30° knee settings
compared to the parameters at the 0° knee setting, while the
mean values of pelvic tilt and sacral slope rarely changed.
Results also showed FTA was not correlated with PT, but
strongly correlated with FPA (R = -0.83, p \ 0.01).
Conclusions The knee flexion resulted in decrease of
lumbar lordosis without a significant change of pelvic
posture in non-diseased population group.
Keywords Simulation
Knee flexion
Femoral tilt angle

Femoropelvic angle
Lumbar lordosis
Pelvic posture
C. S. Lee
S. J. Park (&)
S. S. Chung
K. H. Lee
Department of Orthopedic Surgery, Spine Center, Samsung
Medical Center, Sungkyunkwan University School of Medicine,
50 Ilwon-dong, Kangnam-gu, Seoul 135-710, Korea
e-mail: sejunos@gmail.com
Introduction
With aging population increased, there are many patients
who have multiple degenerative diseases. The knee and
spine are two of the most commonly affected sites of
degenerative diseases. Therefore, it is not uncommon to
encounter the patients who had combined knee and spine
problems such as knee flexion contracture as well as sagittal
spinal imbalance.
With regard to a reciprocal relationship between knee
and spine, it has been well known that sagittal imbalance
leads to adaptive changes in the pelvis, hip, and knee joint
through a compensatory mechanism [5, 10, 12]. To main-
tain an upright posture, the patient tilts the pelvis back-
wards, extends the hips and flexes the knees in order to
shift the entire rigid spine backwards [12]. However, the
reverse way, the effect of knee position on spinal column
has rarely been addressed. Murata et al. [11] examined 366
patients with knee pain or low back pain. They observed
that the limitation of knee extension was correlated with
decrease in lumbar lordosis. They postulated that symp-
toms from the lumbar spine may be caused by degenerative
change in the knee and called this phenomenon as ‘‘knee–
spine syndrome’’. They could suggest the relationship
between the knee and spine, but failed to reveal whether
the knee flexion limitation results in loss of lumbar lordosis
and lumbar spinal symptoms, or vice versa.
In order to elucidate the actual effect of knee flexion on
spinal column, it might be helpful to observe the change of
spinal alignment or symptoms after eliminating the flexion
contracture, e.g., by total knee arthroplasty. Before dealing
with the patients with degenerative conditions, we thought it
should be taken priority to know the normal response of the
spinal column and pelvis to the knee flexion. Thus, this study
was designed to demonstrate the normal response of the spinal
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1060 Eur Spine J (2013) 22:1059–1065

column to the simulated bilateral knee flexion for healthy

young adults who have no pathology in the knee and spine. In
addition, we introduced two new parameters to describe the
relationship between the knee and pelvic posture. The appli-
cation of these two parameters in interpreting the spinopelvic
alignment will be addressed in discussion section.

Materials and methods

Subjects

The current study was performed under IRB approval in

our institute. Thirty young male volunteers were enrolled
for the study cohort. They were in 20s or 30s of age with no
history of spinal diseases and no radiological abnormalities
in the spine. Subjects with a history of hip, knee, ankle
diseases were excluded. They were all male with a mean
age of 30.4 years (range 26–37).

Simulation of knee flexion and radiographic

measurement

All subjects were asked to put on motion-controlled knee

braces on the bilateral knees to produce the knee flexion
(Fig. 1). Two different knee settings of 15° and 30° flexion
was simulated using this brace. The study was carried out
in three steps that consisted of the standing position with-
out the brace and with a 15°-fixed, and 30°-fixed brace. In
the current paper, we named the standing position without
the brace as 0° position for simplicity.
At each step, 14 9 36-in. lateral whole spine and lower
extremity lateral radiographs were taken with a 72-in. distance
between the subject and radiographic source. Before taken the
radiographs of each step, the subjects were asked to wear the
brace for 5 min to give a sufficient time so that the simulated
knee flexion works. The subjects were instructed to stand in a
comfortable position with the fist-on-clavicle position. After
taking required position, the subjects had whole spine radio-
graph taken first followed by lower extremity radiograph, and
were asked to keep the position during the term between the
two radiographic examinations. The time between the whole
spine and lower extremity radiographs took about 10 s. The
radiograph of the whole spine was centered on the 12th tho-
racic vertebra and the radiograph of the lower extremity was
centered on the proximal thigh to encompass the cranial
endplate of S1 proximally and the knee joint distally.
Parameters
Four parameters were measured on each whole spine
radiograph. The lumbar lordosis (LL) is the Cobb’s angle
between the cranial endplate of L1 and S1. The thoracic
Fig. 1 Photograph shows a subject putting on two motion-controlled
knee braces
kyphosis (TK) is the Cobb’s angle between the cranial
endplate of T4 and T12. The sagittal balances were mea-
sured by the perpendicular distance from the plumb line of
the center of C7 body to the superoposterior corner of S1
(B1) and the bicoxofemoral axis (B2) to represent the
spinal and spinopelvic balance, respectively [17]. The
sagittal balance was defined as negative when the C7
plumb line fell behind each reference point.
Five pelvic parameters were measured on each lower
extremity radiograph. The measurements of sacral slope
(SS), pelvic tilt (PT), and pelvic incidence (PI) confirm
with the currently used methods [17].
Two angular parameters, the femoral tilt angle (FTA)
and femoropelvic angle (FPA), were introduced [9, 13].
The FTA was defined as the angle between a vertical axis
and the sagittal femoral axis to represent femoral inclina-
tion caused by knee flexion (Fig. 2). The sagittal femoral
axis was defined as the line connecting the center of the
bicoxofemoral axis and the center of the distal femur.
However, the center of the distal femur was difficult to
identify because of the metallic hinge images of the knee
braces. Hence, an alternative distal reference point was
used; the midpoint of two femoral diaphyseal centers at the
level of the upper pole of the two patellae. The FPA was
defined as the angle between the sagittal femoral axis and a
line joining the middle of the cranial S1 endplate to the

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Eur Spine J (2013) 22:1059–1065 1061

Figure 2 shows a simple equation; PT = FPA ? FTA.

This equation was proposed earlier by Roussouly and
Pinheiro-Franco [13].

Mean values of parameters at three different knee

settings

Table 1 lists the mean values of all parameters at each knee

setting. Compared to the parameters at the 0° knee setting,
the mean values of FPA and LL decreased significantly at
15° and 30° (p \ 0.001 for both FPA and LL between 0°
and 15° and between 0° and 30°) and the mean values of
B1 and B2 increased significantly at 15° and 30°
(p = 0.002 for B1 between 0° and 15°, p = 0.032 for B2
between 0° and 15°, p \ 0.001 for both B1 and B2 between
0° and 30°). The change of PT and SS at the 15°, 30° knee
setting was not significant compared with 0° knee setting.
The three different postures are described schematically in
Fig. 3 based on the mean value of parameters at each knee
setting.

Correlations among all parameters

The correlations between all parameters are summarized in

Table 2. We observed a very strong correlation between
FTA and FPA, between SS and LL, and between B1 and
B2 (cc [ 0.7). There was also large correlation between
FTA and B1, between FPA and PT, between FPA and B2,
and between SS and PI (cc [ 0.5) [3]. However, there were
Fig. 2 New pelvic parameters; FPA and FTA (asterisk). Note that PT
no correlations between FTA and pelvic parameters such as
is equal to the sum of FPA and FTA
PT, SS, and PT.
center of the bicoxofemoral axis (Fig. 2). All radiographs
were digitalized into PACS, and measurements were per-
Table 1 Mean values and changes of all parameters at each knee
formed using software (SagimeterÒ, Optimum Solution Co.
setting
Ltd., Bundang, Gyoenggi, Korea).
Parameters  0° (n = 30) 15° (n = 30) 30° (n = 30)
Analysis FTA (°) -2.5 ± 3.0 10.1 ± 5.9à 17.8 ± 7.8à
à
FPA (°) 16.4 ± 7.3 5.1 ± 10.6 -2.3 ± 13.1à
Three different sets of parameters were obtained from one PT (°) 13.9 ± 5.3 15.2 ± 7.3 15.5 ± 8.7
subject according to the three different knee settings of 0° SS (°) 36.4 ± 7.0 35.7 ± 8.9 34.9 ± 9.9
(without brace), 15°, and 30°. The analysis was performed in PI (°) 50.4 ± 9.1 50.9 ± 8.9 50.4 ± 9.5
three steps. First, the mean values of each parameter obtained LL (°) 50.7 ± 8.7 45.9 ± 10.5 à
42.7 ± 10.3à
at the different knee settings were compared each other using
TK (°) 31.5 ± 7.0 33.1 ± 7.8 30.7 ± 6.7
a paired t test. Second, the relationship between all param-
B1 (mm) -1.2 ± 19.6 23.1 ± 36.4à 47.6 ± 43.5à
eters was investigated using the Pearson correlation test. à
B2 (mm) -45.2 ± 18.8 -27.5 ± 39.9 5.5 ± 53.2à
Values are given by mean ± SD
Results FPA femoropelvic angle, PT pelvic tilt, SS sacral slope, PT pelvic
incidence, LL lumbar lordosis, TK thoracic kyphosis, B1 distance
between C7 plumb line and S1 posterior corner, B2 distance between
Relationship among the angular parameters C7 plumb line and bicoxofemoral axis
 
FTA indicates femoral tilt angle
By definition, FPA is determined by the position of both à
Significantly different compared with parameters at 0° knee setting
the femur and pelvis, which is represented by FTA and PT. (p \ 0.05)

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1062 Eur Spine J (2013) 22:1059–1065

spinal alignment were focused mainly on the alignment of

Fig. 3 Schematic diagrams of the three different postures based on
the mean value of parameters at each knee setting. Note that as the
angle of knee flexion increases, lumbar lordosis decreases, and
sagittal balance shifts anteriorly, while pelvic tilt and sacral slope
rarely changed
Discussion
The sagittal standing posture depends not only on the
spinal alignment, but also on the hip and knee joint
alignment. Currently many studies addressing sagittal
above-hip structures, i.e., the hip, pelvis, and spinal column
[1, 2, 4, 6, 14, 15, 17]. However, there were few reports
including the knee in evaluating sagittal spinal alignment.
Considering many patients have both knee osteoarthritis
causing unilateral or bilateral flexion contracture and spine
problems such as low back pain or sagittal imbalance, we
hypothesized knee flexion contracture caused by knee
osteoarthritis would affect the spinal column. The investi-
gation of the change in spinal sagittal alignment and
lumbar symptoms after removal of knee flexion contracture
by total knee arthroplasty will be one of the feasible
methods to prove this hypothesis. However, it is nearly
impossible to reveal the subsequent change of spinal col-
umn as to the knee flexion contracture in case the patients
have concurrent diseases at the knee and spine. We wished
to know the change of spinopelvic alignment and spinal
sagittal balance as to the different knee positions, so the
current study was designed simulating knee flexion in
normal populations. Two new parameters, FTA and FPA,
were used to describe the relationship between the femur
and pelvis.
The current data show that FTA was correlated nega-
tively with LL and positively with B1 and B2. This means
that knee flexion resulted in loss of lumbar lordosis and
anterior shift of sagittal balance. The mean decreases of
FPA were 11.3° and 18.7° at 15° and 30° settings while the
mean increases of PT were just 1.3° and 1.6° at 15° and 30°
settings. Results also show FTA was not correlated with PT,
but FTA was strongly correlated with FPA (cc = -0.83,
p \ 0.01). Taken together, this means that knee flexion did
not influence the position of pelvis significantly, while it did
cause loss of lumbar lordosis and anterior shift of sagittal
balance.
Some might wonder the fact that knee flexion results in
a forward push of sagittal balance because that is

Table 2 Matrix of correlation among all of the parameters (n = 90)

FTA FPA PT SS PI LL TK B1 B2

FTA 1 -0.83  -0.07 -0.16 -0.20 -0.41  0.00 0.54  0.49 

     
FPA 1 0.61 -0.08 0.42 0.21 -0.01 -0.45 -0.59 
   
PT 1 -0.36 0.46 -0.20 -0.02 -0.04 -0.36 
SS 1 0.67  0.81  -0.13 0.19 0.36 
PI 1 0.61  -0.14 0.15 0.05
  
LL 1 0.02 -0.26 -0.10  
TK 1 -0.05 -0.06
B1 1 0.89 
B2 1
Correlation coefficient (R value) after the Pearson correlation test
 
Statistically significant with p value of \0.01
  
Statistically significant with p value of \0.05

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Eur Spine J (2013) 22:1059–1065
counterintuitive to what we normally see. In pathologic
patients who stand with a forward sagittal imbalance, knee
flexion actually helps compensate their spinal malalign-
ment even without changing their pelvic parameters. The
important point is what is a primary factor, the knee or
spine. We focused on the knee condition primarily and the
subsequent change of spinal column secondarily. Thus, the
current results should be discriminated from the phenom-
enon found in the patients with fixed sagittal imbalance.
The results were further analyzed in terms of the con-
cept of compensation. Figure 4 compares two different
postures in response to knee flexion and gives a detailed
explanation of spinopelvic alignment including the knee
joint. Figure 4a shows a person standing without knee
flexion and hip flexion where FTA is 0° and FPA is equal
to PT. Figure 4b shows as to the knee flexion the rela-
tionship between the femur and pelvis is unchanged, which
means that knee flexion is not compensated by the pelvis.
Because the pelvis does not rotate around the axis of the
femoral head, FPA does not change compared with Fig. 4a.
However, PT does increase as much as FTA increases. On
the other hand, Fig. 4c shows as to the knee flexion the
pelvis remains unchanged where PT does not change.
However, from the standpoint of the femur, the pelvis
rotates anteriorly around the axis of the femoral head where
FPA decreases as much as FTA increases. The current
results can be well explained (Fig. 4c).
Fig. 4 Two different responses
according to the knee flexion.
a Standing without knee and hip
flexion. The angle of FPA
(asterisk) is equal to PT. b No
pelvic compensation. Note that
FPA does not change and PT
increases with knee flexion.
c Pelvic compensation. Note
that PT does not change and
FPA decreases with knee
flexion
1063
It has been known that the key parameters representing
pelvic compensation is PT in evaluation of sagittal
imbalance [7, 16]. However, considering the knee joint and
femur together, Fig. 4b shows no pelvic compensation
occurs in spite of PT increase while Fig. 4c shows pelvic
compensation occurs without PT change. These findings
suggest that PT might not represent the pelvic rotation or
pelvic compensation properly when considering the posture
of the femur and knee joint. FPA, determined by the
relationship between the femur and pelvis, describes better
the pelvic rotation as to the femur. Thus, we assume that
FPA would be a suitable parameter for representing pelvic
rotation or compensation if the patient have flexion con-
tracture of the knee or hip. We suggest that FPA can rep-
resent true pelvic compensation and PT can represent
apparent pelvic compensation.
Here, it needs to re-look the terminology for describing
the compensation of the sagittal plane imbalance. A positive
imbalance of spinal curvature induces a compensatory
mechanism, which consists of retroversion of the pelvis, hip
extension, knee flexion, and ankle dorsiflexion [7, 8, 18].
The terms, ‘‘pelvic retroversion’’ and ‘‘hip extension’’, need
to be clarified because it possibly lacks a reference point to
measure. As outlined earlier, the femur has an inseparable
relationship with the pelvis. Therefore, the description of
pelvic compensation should include the femur as the ref-
erence point. Figure 5 shows two different compensatory
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1064 Eur Spine J (2013) 22:1059–1065

postures. Both of two compensatory postures render the Table 3 Different compensating mechanisms according to the pri-
sagittal balance shift posteriorly and PT appears to be mary events
approximately about the same. The pelvis apparently looks Primary event Severe kyphosis Knee flexion
retroverted in both postures, compensation I occurs only by contracture
pelvic retroversion and hip extension without knee flexion
Trunk movement Forward Backward
and compensation II occurs by knee flexion without pelvic
Stiffness of lumbar spine Stiff Flexible
retroversion or hip extension. It should be of note that FPA
Primary compensation Pelvic retroversion Decrease of LL
is increased in compensation I and decreased in compen-
Secondary compensation Hip extension Hip flexion
sation II. Given that the knee and hip posture should be
Knee flexion No pelvic rotation
included for the an assessment of the sagittal imbalance and
Correlation LL µ PT LL µ FTA
its compensation, it was assumed that FPA could serve as an
important angular parameter to describe the compensatory
posture in addition to PT.
Our findings should be distinguished from the conven- between the femoral shaft and lumbar spine. If the lumbar
tional compensating mechanism to the severe kyphosis spine is flexible, PT will not be directly correlated to LL.
(Table 3). In case of fixed sagittal imbalance where the Decrease of LL is influenced directly by the flexion of
spine is rigid, the first response to compensate imbalance is knees, thus loss of LL is correlated with FTA, which
pelvic retroversion and hip extension. If hip extension represents the degree of knee flexion.
reaches its limitation, flexion of the knees may occur. We acknowledge that the current study has several limi-
Pelvic retroversion makes PT increase and knee flexion tations. Although we put a short period (10 s), there can be
makes more increase of PT. Thus, because of the stiffness some normal swaying of the subjects that may render their
of lumbar spine, loss of LL is well correlated with the sagittal balance somewhat variable over a course of two sets
increase of PT. In the our study, in case of experimental of radiographs. The EOS system would enable more accurate
knee flexion contracture, trunk tends to move backward. analysis of spinopelvic balance and knee position. The brace
We think the lumbar spine would response first to maintain could simulate knee flexion, but it cannot represent the real
the balance because the lumbar spine is flexible. The pelvis flexion contracture as seen in patients with a longstanding
does not need to rotate, so the hip has the flexion posture. established flexion contracture. However, it is impossible to
PT was the product of an adaptation of the pelvic position make a long-period flexion contracture in normal subjects.

Fig. 5 Two different

compensating postures for
positive sagittal imbalance.
Compensation I occurs only by
pelvic retroversion or hip
extension without knee flexion.
Compensation II occurs by knee
flexion without pelvic
retroversion or hip extension. It
should be noted that although
PT (dagger) in both
compensatory postures appears
similar, FPA (asterisk) increases
in compensation I and decreases
in compensation II

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Eur Spine J (2013) 22:1059–1065
Instead, we gave 5 min before taking radiograph of each step
to secure the sufficient time. The relative small volume of the
study is a potential source of bias. Enrolling a sufficient
number of subjects was difficult because this study was
carried out targeting young asymptomatic volunteers and the
six-time radiation exposures might be onerous. Finally, it is
not sure that this experimental study reflects the pathologic
condition because it is relatively rare to find bilateral knee
flexion contracture due to arthritis. A unilateral flexion
contracture would give an effect of leg discrepancy rather
than trunk displacement.
In current study, we revealed that the knee position can
affect the spinopelvic alignment and sagittal balance by the
quantitative measurements of the pelvic and spinal
parameters for normal population. Considering many
patients have combined spine and knee degenerative dis-
ease, and understanding the relationship between the knee
and spine is as important as that of above-hip structures
when evaluating and managing these patients properly. The
two angular parameters, FTA and FPA, could be utilized to
interpret the complex association of the knee joint, femur,
hip joint, and pelvis. We hope that the current data can
serve as a basic background for the future study.
Acknowledgments The current study was supported by Central
Research Fund (nonprofit academic fund) from our institute. This
study was conducted under approval of IRB.
Conflict of interest None.
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