Chau et al.

BMC Musculoskeletal Disorders (2021) 22:476

https://doi.org/10.1186/s12891-021-04311-8

RESEARCH Open Access

Global sagittal alignment of the spine,

pelvis, lower limb after vertebral
compression fracture and its effect on
quality of life
Leo Tsz Ching Chau1†, Zongshan Hu2†, Koko Shaau Yiu Ko1, Gene Chi Wai Man1, Kwong Hang Yeung3,
Ying Yeung Law3, Lawrence Chun Man Lau1, Ronald Man Yeung Wong1, Winnie Chiu Wing Chu3,
Jack Chun Yiu Cheng1 and Sheung Wai Law1*

Abstract
Background: Vertebral compression fractures (VCFs) are the most common among all osteoporotic fractures. The
body may compensate to the kyphosis from vertebral compression fractures with lordosis of the adjacent spinal
segments, rotation of the pelvis, knee flexion and ankle dorsiflexion. However, the detailed degree of body
compensation, especially the lower limb, remains uncertain. Herein, the aim of this study is to investigate the values
of global sagittal alignments (GSA) parameters, including the spine, pelvis and lower limbs, in patients with and
without VCFs, as well as to evaluate the effect of VCFs on various quality of life (QoL) parameters.
Methods: A cross-sectional study was conducted from May 2015 to June 2018. A total of 142 patients with VCFs
aged over 60 years old and 108 age-matched asymptomatic controls were recruited. Whole body sagittal alignment
including thoracic kyphosis (TK), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), sagittal vertical axis (SVA),
T1-pelvic angle (TPA), knee-flex angle (KA) and ankle-flex angle (AA) were measured. In addition, lower back pain
and quality of life were assessed using self-reported questionnaires.
Results: Compared to asymptomatic controls, patients with VCF showed significantly greater TK (33.4o ± 16.4o vs
28.4o ± 11.4o; p < 0.01), PT (25.4o ± 10.5o vs 16.6o ± 8.9o; p < 0.001), PI (54.6o ± 11.8o vs 45.8o ± 12.0o; p < 0.001), SVA
(49.1 mm ± 39.6 mm vs 31.5 mm ± 29.3 mm; p < 0.01), and TPA (28.6o ± 10.8o vs 14.8o ± 8.6o; p < 0.001). Whereas for
lower limb alignment, patients with VCF showed significantly higher KA (10.1o ± 7.8o vs 6.0o ± 6.4o; p < 0.001) and
AA (7.0o ± 3.9o vs 4.8o ± 3.6o; p < 0.001) than controls. The number of VCF significantly correlated with lower limb
alignments (KA and AA) and global sagittal balance (TPA). VCF patients showed poorer quality of life assessment
scores in terms of SF-12 (30.0 ± 8.3 vs 72.4 ± 16.9; p < 0.001), ODI (37.8 ± 24.0 vs 18.7 ± 16.6; p < 0.001) and VAS
(3.8 ± 2.8 vs 1.9 ± 2.2; p < 0.001).
(Continued on next page)

* Correspondence: [email protected]
†
Leo Tsz Ching Chau and Zongshan Hu contributed equally to this work.
1
Department of Orthopaedics and Traumatology, Faculty of Medicine, The
Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong
Kong SAR, China
Full list of author information is available at the end of the article

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
Chau et al. BMC Musculoskeletal Disorders (2021) 22:476 Page 2 of 7

(Continued from previous page)

Conclusion: This is the first study to illustrate the abnormal lower limb alignment exhibited in patients with VCF.
Patients with VCF showed an overall worse global sagittal alignment and decreased quality of life. Poorer global
sagittal alignment of VCF patients also imply worse quality of life and more severe VCF.
Keywords: Global sagittal alignment, Vertebral compression fracture, Biplanar radiographs, Quality of life, Lower
limb

Background 2015 to June 2018. The exclusion criteria for the current
Osteoporosis and its related complications have been in- study are as follows: history of previous lower limb frac-
creasing within the aging population. Vertebral compres- ture, history of previous surgery of spine, pelvis or lower
sion fractures (VCF) are the most common among all limb, rheumatic diseases and secondary osteoporosis
osteoporotic fractures. The occurrence of this condition (e.g., osteopenia with hyperparathyroidism, hyperthy-
steadily increases as a person age, with an estimated 40% roidism, chronic kidney disease, or osteomalacia). In
of women age 50 and older affected [1]. This manifest- addition, 108 age-matched subjects without VCF were
ation occurs when the bony block or vertebral body in recruited as asymptomatic controls from the whole of
the spine collapses, which are associated with spinal de- Hong Kong through designated advertisements, flyers
formity, chronic back pain, increased morbidity and and recruitment brochures. Subject aged over 60 years
mortality, and overall decline in quality of life (HRQoL) old and without VCF were subjected to confirmation on
[2–4]. Importantly, people who have had one osteopor- the absence of VCF and exclusion criteria by two ortho-
otic VCF are at five times the risk of sustaining a second paedics surgeons (L.T.C.C. and S.W.L.). Written in-
VCF [5]. formed consent was obtained for all subjects before
Sagittal spinal alignment has been reported to play an participating in this study. Ethical approval was obtained
important role in the biomechanical adaptation of the from the ethics review board of the joint NTEC-CUHK
spine in pathology. In response to VCFs, our body may clinical research ethics committee. All study procedures
compensate globally to the kyphosis by drastic change of were conducted in accordance with the guidelines ap-
the whole body sagittal alignment, with lordosis of the ad- proved by the ethics committee and the Declaration of
jacent spinal segments, posterior tilting of the pelvis, hip Helsinki.
extension, knee flexion and even ankle dorsiflexion, in
order to maintain horizontal gaze and balance of the body Demographic data collection
[6]. These compensatory mechanisms aim to recreate an Demographic characteristics of the subjects, including
optimal alignment of the spine, with the objective of keep- age, body height, and body weight, were recorded. Body
ing the appropriate position of the gravity line, and the mass index (BMI) was then determined. Quality of life
horizontal gaze. Previous studies have shown that VCF pa- assessment was completed for each subject by locally
tients have higher thoracic kyphosis and lower lumbar lor- validated questionnaires: the Oswestry Disability Index
dosis [7]. Similarly, our team previously also investigated (ODI), Short-form (SF)-12 and Visual Analogue Scale
on the relationship between global sagittal alignment and (VAS) [10–12].
VCF, and T1-pelvic angle was found to be increased in
VCF patients [8]. Moreover, poor sagittal alignment of the
spine in osteoporotic patients is reported to be an inde- Low-dose Biplanar whole-body radiographic assessment
pendent risk factor for subsequent VCF [9]. All subjects underwent whole body biplanar stereo-
However, the detailed influence of lower limb compen- graphs (EOS imaging, Paris, France) with a standardized
sation, including the contribution from the knee and radiographic protocol by a team of experienced radiog-
ankle, in VCF patients remains unknown. Herein, the aim rapher (Fig. 1). Subjects were instructed to stand in a
of this study is to investigate the values of global sagittal comfortable position with hips and knees extended and
alignments (GSA), including lower limbs, in patients with with hands on a support [7]. EOS images were measured
and without VCFs, and to establish the relationships be- using validated software (Surgimap, Nemaris Inc., New
tween GSA with other clinical and radiological parameter. York, NY) for sagittal parameters. Spinal parameters
measured includes thoracic kyphosis (T5–12, TK) and
lumbar lordosis (L1–S1, LL). Pelvic parameters mea-
Methods sured includes pelvic incidence (PI) and pelvic tilt (PT).
Study population Global sagittal parameters measured includes sagittal
We prospectively recruited 142 elderly women aged over vertical axis (SVA) and T1 pelvic angle (TPA: the angle
60 who consulted for VCF in our institution from May between the line from the femoral head axis to the
Chau et al. BMC Musculoskeletal Disorders (2021) 22:476 Page 3 of 7

coefficient. The intra- and inter-observer reliability were

obtained as intraclass correlation coefficients (ICC). P-
value less than 0.05 was considered statistically signifi-
cant for all analyses.

Results
Patient demographic data
The mean age of the elderly subjects with vertebral com-
pression fracture was 77.1 ± 8.4 years, including 132 fe-
males and 10 males. Whereas, 108 asymptomatic age-
matched adults, including 64 females and 44 males, with
mean age of 77.8 ± 8.1 years were compared. There is no
significant difference on the age between VCF patients
and asymptomatic controls. Patients with VCF are found
to have lower height, weight and BMI when compared
with controls (Table 1).
In addition, VCF patients has significantly lower SF-12
(p < 0.001), higher ODI (p < 0.001), and higher VAS (p <
0.001) than asymptomatic controls (Table 1). This indi-
cates more pain and poorer quality of life in VCF pa-
tients than the age-matched asymptomatic controls.

Reliability of the measurement between observers

The intra- and interobserver ICCs for estimating the
Fig. 1 Representative radiographs of elderly adults recruited in this
study. a 66 year-old female patient with VCF and b 66 year-old
whole-body sagittal parameters were from 0.83 to 0.96,
female patient without VCF in lateral views suggesting good to excellent reliability of these measure-
ments among the two observers (L.T.C.C. and Z.H.)

centroid of T1 and the line from the femoral head axis Comparison on the GSA between subjects with and
to the middle of the S1 superior endplate). Lower limb without VCF
parameters evaluated includes knee flexion angle (KA: The mean values and standard deviations of the radio-
angle between the mechanical axis of the femur and the graphic parameters are showed in Table 2. Compared to
mechanical axis of the tibia) and ankle dorsiflexion angle asymptomatic controls, patients with VCF has signifi-
(AA: angle between the mechanical axis of the tibia and cantly higher spinopelvic parameters in terms of TK
the vertical axis) [13] (Fig. 2). In clinical practice, the (p < 0.01) PT (p < 0.001), and PI (p < 0.001). In addition,
outline of thoracic vertebra above T5 on the x-ray radio- VCF patients also has significantly higher global parame-
graphs are often difficult to identify and mark in the sa- ters, in terms of SVA (p < 0.01) and TPA (p < 0.001),
gittal plane, owing to the obstruction of rib cage and than the controls. The mean SVA in VCF patients and
upper arm. controls were 49.1 mm ± 39.6 mm and 31.5 mm ± 29.3
All the parameters were measured by two independent mm, respectively. Similarly, the mean TPA in VCF pa-
observers (L.T.C.C. and Z.H.). Intraobserver and interob- tients and controls were 28.6o ± 10.8o and 14.8o ± 8.6o,
server variations were estimated by using intraclass correl- respectively.
ation coefficient (ICC), which were graded using Whereas for the lower limb parameters, significantly
previously described semi-quantitative criteria: excellent higher flexion angles are observed at the knee and ankle
(ICC ≥ 0.9), good (0.7 ≥ ICC < 0.9), acceptable (0.6 < ICC ≥ in patients with VCF than in the asymptomatic controls
0.7), poor (0.5 ≥ ICC < 0.6), or unpredictable (ICC < 0.5). (p < 0.001). The mean KA in VCF patients and controls
were 10.1o ± 7.8o and 6.0o ± 6.4o, respectively. Similarly,
Statistical analysis the mean AA in VCF patients and controls were 7.0o ±
Data were expressed as mean ± standard deviation. All 3.9o and 4.8o ± 3.6o, respectively.
analyses were conducted with the SPSS software (Ver-
sion 25.0; SPSS, Chicago, IL, USA). Comparisons of Relationship between global sagittal alignment with
means between variables were performed using inde- clinical outcomes
pendent Student t test. The correlations between vari- The whole-body sagittal alignment was found to vary in
ables were analyzed using the Pearson correlation patients with VCF with the associated compensation
Chau et al. BMC Musculoskeletal Disorders (2021) 22:476 Page 4 of 7

Fig. 2 Illustration of measurements of spinal, pelvic, global and lower limb parameters in sagittal radiograph. AA indicates ankle flexion angle; KA
indicates knee flexion angle; LL indicates lumbar lordosis; PI indicates pelvic incidence; PT indicates pelvic tilt; SVA indicates sagittal vertical axis;
TK indicates thoracic kyphosis; TPA indicates T1-pelvic angle

mechanism from spine to lower limb (Table 3). When Discussion

analyzing patients with VCFs alone, the changes in KA This study is the first to illustrate the abnormal lower
and AA significantly correlated with the number of VCF limb alignment exhibited in patients with VCF. Patients
(p < 0.01). Although both TPA and SVA significantly with VCF have significantly increased KA and AA when
correlated with spinal, pelvic, and lower-limb alignment, compared with asymptomatic controls. This provides
a stronger tendency was observed in TPA when com- evidence on the contribution of the lower limb to the
pared with SVA. Moreover, TPA was also found to be global compensation after insufficiency fracture of the
significantly correlated with the number of VCFs and spine occurs. Patients with VCF have an overall worse
SF-12 (Table 4). global sagittal alignment and decreased quality of life.
Chau et al. BMC Musculoskeletal Disorders (2021) 22:476 Page 5 of 7

Table 1 Comparisons between the patients with and without vertebral fracture (VCF) in terms of baseline characteristics
Variables Presence of VCF (n = 142) Absence of VCF (n = 108) P value
Age (years) 77.1 ± 8.4 76.5 ± 8.4 0.567
Height (cm) 149.1 ± 6.9 156.4 ± 7.8 < 0.001
Weight (kg) 50.1 ± 8.4 59.2 ± 9.86 < 0.001
BMI (kg/m2) 22.5 ± 3.2 24.2 ± 3.2 < 0.001
SF12 (PCS) 30.0 ± 8.3 72.4 ± 16.9 < 0.001
ODI 37.8 ± 24.0 18.7 ± 16.6 < 0.001
VAS 3.8 ± 2.8 1.9 ± 2.2 < 0.001
BMI Body mass index, SF-12 Short Form 12, PCS The physical component summary, ODI Oswestry disability index, VAS Visual analogue scale
Data expressed as mean ± SD

The changes in global sagittal alignment of VCF patients (TK), pelvic tilt (PT) and pelvic incidence (PI). Fechten-
also imply worse quality of life and more severe VCF. baum et al. also documented higher thoracic kyphosis in
Traditionally, vertebral collapse can lead to a structural osteoporotic patients with VCF [7]. The global parame-
kyphotic deformity of the spine [14, 15]. With this local- ters, including SVA and TPA, are higher in VCF pa-
ized kyphotic change of the sagittal balance, our body tients, signifying a global forward shift of the balance.
compensates globally, with pelvic rotation, hip extension, This finding further correlates with our previous study
knee flexion and ankle dorsiflexion [6], in order to main- on global sagittal compensation [8]. We documented
tain the optimal alignment of the spine and horizontal and quantified the lower limb compensation in VCF pa-
gaze [16, 17]. The development of EOS whole body tients, with an increased knee flexion and ankle dorsi-
biplanar X-ray provides a tool for better understanding flexion. Waters et al. documented a significant increase
of the compensatory mechanisms, which is previously in energy expenditure when a person walks with a knee
difficult to assess using traditional radiographs [18, 19]. flexion gait [20]. With the global compensation of the
To ensure a proper treatment or rehabilitation regime is body, despite the balance and the gait is compensated, a
given, it would be essential to understand the sagittal higher energy expenditure is resulted. In the long run,
compensation in VCF patients. The local kyphosis due this can lead to chronic back pain, easy falls, or second-
to compression fracture is translated into the imbalance ary osteoarthritis of the knees.
of the body alignment, causing a forward movement of By understanding the lower limb compensation after
the center of gravity. This predisposes to subsequent de- VCF occurs, clinicians and therapists can better evaluate
compensation of the other segments, and ultimately the severity of VCF and its effect on QoL by observing
leads to further vertebral collapses [9]. This may explain the posture and lower limb compensation of the patient,
the overall reduced height, weight, and BMI in VCF pa- which helps formulate patient-specific rehabilitation plan
tients, as observed in our study. to maximize its effectiveness. Surgeons can also better
Our study demonstrated the increased spinopelvic pa- evaluate the optimal spinal alignment during surgical
rameters in VCF patients, including thoracic kyphosis planning for spinal instrumentation, considering the

Table 2 Mean value of whole-body sagittal parameters between the patients with and without vertebral fracture (VCF)
Parameter Presence of VCF (n = 142) Absence of VCF (n = 108) P value
Spinopelvic
Thoracic kyphosis (o) 33.4 ± 16.4 28.4 ± 11.4 0.004
Lumbar lordosis (o) 40.2 ± 18.0 40.8 ± 11.3 0.719
Pelvic tilt (o) 25.4 ± 10.5 16.6 ± 8.9 < 0.001
Pelvic incidence (o) 54.6 ± 11.8 45.8 ± 12.0 < 0.001
Global
SVA (mm) 49.1 ± 39.6 31.5 ± 29.3 0.003
o
T1 pelvic angle ( ) 28.6 ± 10.8 14.8 ± 8.6 < 0.001
Lower-limb
KneeFlex Angle (o) 10.1 ± 7.8 6.0 ± 6.4 < 0.001
AnkleFlex Angle (o) 7.0 ± 3.9 4.8 ± 3.6 < 0.001
Data expressed as mean ± SD
Chau et al. BMC Musculoskeletal Disorders (2021) 22:476 Page 6 of 7

Table 3 Correlation Coefficient between Radiographic Parameters in Patients with VCF

TK LL PT PI SVA TPA KA AA
TK / 0.620b 0.019 0.196a −0.040 − 0.054 0.010 0.085
LL 0.620b / −0.161 0.393b −0.277b −0.361b − 0.268b −0.129
PT 0.019 −0.161 / 0.574 b
0.193 a
0.877 b
0.356 b
0.352b
a b b b
PI 0.196 0.393 0.574 / 0.077 0.493 0.073 0.084
SVA −0.040 −0.277 b
0.193 a
0.077 / 0.408 b
0.250 b
0.065
TPA −0.054 − 0.361b 0.877b 0.493b 0.408b / 0.489b 0.356b
KA 0.010 −0.269b 0.356b 0.073 0.250b 0.489b / 0.849b
AA 0.085 −0.129 0.352 b
0.084 0.065 0.356 b
0.849 b
/
TK thoracic kyphosis, LL lumbar lordosis, PT pelvic tilt, PI pelvic incidence, SVA sagittal vertical axis, TPA T1 pelvic angle, KA kneeflex angle, AA ankleflex angle
a
Correlation significance at the 0.05 level
b
Correlation significance at the 0.01 level

alignment of the lower limb, to formulate the suitable musculature toward sagittal balance was not investi-
degree of correction for best clinical function. gated. As sarcopenia is one of the associated conditions
In addition, we have also documented a significant in patients with VCFs, its effect on sagittal alignment
correlation between the number of VCFs with global sa- warrants further research and investigation.
gittal alignment, in terms of TPA, as well as lower limb
alignments in terms of KA and AA. The more VCFs the Conclusion
patient has, the more drastic the compensatory deform- In conclusion, patients with VCFs had a generally
ity over the whole body as well as the lower limb. This worsen global sagittal alignment and decreased quality
stress the importance of timely diagnosis of VCF with of life when compared with age-matched individuals.
early relevant treatment and rehabilitation to prevent Our current study is the first to demonstrate a poor
the occurrence of multiple vertebral collapses. lower limb alignment, in terms of knee-flex angle (KA)
However, there remains some limitations that would and ankle-flex angle (AA), in patients with VCF. VCF
need to be addressed in the current study. This study patients are found to have high thoracic kyphosis (TK),
has the limitations of being a cross-sectional study. pelvic tilt (PT) and pelvic incidence (PI). T1 pelvic angle
Hence, the temporal relationship between VCF and glo- (TPA), a global sagittal balance parameter, correlates
bal sagittal alignments cannot be addressed. Although with multiple local sagittal parameters of the spinopelvis
our study has provided an important indication of lower and lower limb. The change in lower limb alignments
limb malalignment in patients with VCFs, the compen- was found to be strongly affected by the number of VCF
satory mechanism of the body would need a longitudinal in these patients. Based on our current result, there is an
follow-up study to demonstrate the changes after an increased importance on the need to provide critical at-
acute collapse of the vertebral body. Associated degen- tention or rehabilitation strategy on the lower limb in
erative condition, including lumbar spinal stenosis or patients with VCFs.
early osteoarthritis of the hips and knees, might be con-
founders between the two groups, and might be further Abbreviations
AA: Ankleflex angle; BMI: Body mass index; GSA: Global sagittal aligments;
investigated by magnetic resonance imaging in future ICC: Intra-correlation coefficients; KA: Kneeflex angle; LL: Lumbar lordosis;
studies. In addition, the relationship of body ODI: Oswestry disability index; PI: Pelvic incidence; PT: Pelvic tilt; SF-12: Short
form 12; SVA: Sagittal vertical axis; TK: Thoracic kyphosis; TPA: T1 pelvic angle;
Table 4 Correlation of whole-body sagittal parameters between VAS: Visual analogue scale; VCF: Vertebral compression fracture
different parameters in patients with vertebral fracture (VCF)
(n = 142) Acknowledgements
The authors would like to thank all the patients and subjects who
No. of VCF SF12 (PCS) ODI VAS participated in this study and the medical staff at the Prince of Wales
KA 0.293b −0.123 0.730 −0.012 Hospital, Hong Kong.

AA 0.254b −0.137 0.057 −0.011 Authors’ contributions

SVA 0.125 −0.074 0.106 0.058 LTCC handled the conception and design, acquisition of data, analysis and
interpretation of data, drafting of the manuscript, and statistical analysis, ZH
TPA 0.431b −0.196a 0.163 0.082 handled the conception and design, acquisition of data, analysis and
SF-12 short form 12, PCS The physical component summary, ODI Oswestry interpretation of data, drafting of the manuscript, and statistical analysis,
disability index, VAS visual analogue scale, KA kneeflex angle, AA ankleflex KSYK handled the acquisition of data, GCWM handled the conception and
angle, SVA sagittal vertical axis, TPA T1 pelvic angle design, statistical analysis, and supervision, KHY handled the acquisition of
a
Correlation significance at the 0.05 level data, YYL handled the acquisition of data, LCML handled the acquisition of
b
Correlation significance at the 0.01 level data, RMYW handled the acquisition of data, WCWC handled acquisition of
Chau et al. BMC Musculoskeletal Disorders (2021) 22:476 Page 7 of 7

data, administrative and material support, JCYC handled acquisition of data, 9. Dai J, Yu X, Huang S, Fan L, Zhu G, Sun H, et al. Relationship between
administrative and material support, SWL handled the conception and sagittal spinal alignment and the incidence of vertebral fracture in
design, acquisition and data, administrative and material support, and menopausal women with osteoporosis: a multicenter longitudinal follow-up
supervision. All authors read and approved the final manuscript. study. Eur Spine J. 2015;24(4):737–43.
10. Lam CL, Eileen Y, Gandek B. Is the standard SF-12 health survey valid and
Funding equivalent for a Chinese population? Qual Life Res. 2005;14(2):539–47.
The authors would like to acknowledge the Health and Medical Research 11. Chow JH, Chan CC. Validation of the Chinese version of the Oswestry
Fellowship Scheme 2019 (Grant number: 05190047) awarded to G.C.W.M. for disability index. Work. 2005;25(4):307–14.
funding experimental costs in this study. 12. Wei X, Chen Z, Bai Y, Zhu X, Wu D, Liu X, et al. Validation of the simplified
chinese version of the functional rating index for patients with low back
Availability of data and materials pain. Spine (Phila Pa 1976). 2012;37(18):1602–8.
The datasets generated and/or analyzed during the current study are not 13. Hu Z, Man GCW, Yeung KH, Cheung WH, Chu WCW, Law SW, et al. 2020
publicly available due to the privacy and sensitivity of the patients involved, young investigator award winner: age- and sex-related normative value of
but are available from the corresponding author on reasonable request. whole-body sagittal alignment based on 584 asymptomatic Chinese adult
population from age 20 to 89. Spine (Phila Pa 1976). 2020;45(2):79–87.
Declarations 14. Chang BS, Jung JH, Park SM, Lee SH, Lee CK, Kim H. Structural femoral shaft
allografts for anterior spinal column reconstruction in osteoporotic spines.
Ethics approval and consent to participate Biomed Res Int. 2016;2016:8681957.
Ethical approval was obtained and conducted in accordance to guidelines 15. Hyun SE, Ko JY, Lee E, Ryu JS. The prognostic significance of pedicle
approved by the institutional clinical research ethics committee (The Joint enhancement from contrast-enhanced MRI for the further collapse in
Chinese University of Hong Kong – New Territories East Cluster Clinical osteoporotic vertebral compression fractures. Spine (Phila Pa 1976). 2018;
Research Ethics Committee (Joint CUHK-NTEC CREC); CREC No. 2017.689). All 43(22):1586–94.
study procedures were conducted in accordance with the guidelines ap- 16. Roussouly P, Nnadi C. Sagittal plane deformity: an overview of interpretation
proved by the ethics committee and the Declaration of Helsinki. Written in- and management. Eur Spine J. 2010;19(11):1824–36.
formed consent was obtained for all subjects before participating in this 17. Ferrero E, Liabaud B, Challier V, Lafage R, Diebo BG, Vira S, et al. Role of
study. pelvic translation and lower-extremity compensation to maintain gravity
line position in spinal deformity. J Neurosurg Spine. 2016;24(3):436–46.
18. Bassani T, Galbusera F, Luca A, Lovi A, Gallazzi E, Brayda-Bruno M.
Consent for publication
Physiological variations in the sagittal spine alignment in an asymptomatic
Consent for publication of the subject not applicable.
elderly population. Spine J. 2019;19(11):1840–9.
19. Kim SB, Heo YM, Hwang CM, Kim TG, Hong JY, Won YG, et al. Reliability of
Competing interests
the EOS imaging system for assessment of the spinal and pelvic alignment
The authors declare that they have no competing interests.
in the sagittal plane. Clin Orthop Surg. 2018;10(4):500–7.
20. Waters RL, Mulroy S. The energy expenditure of normal and pathologic gait.
Author details
1 Gait Posture. 1999;9(3):207–31.
Department of Orthopaedics and Traumatology, Faculty of Medicine, The
Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong
Kong SAR, China. 2Spine Surgery, Drum Tower Hospital of Nanjing University Publisher’s Note
Medical School, Nanjing, China. 3Department of Imaging and Interventional Springer Nature remains neutral with regard to jurisdictional claims in
Radiology, Faculty of Medicine, The Chinese University of Hong Kong, Prince published maps and institutional affiliations.
of Wales Hospital, Shatin, Hong Kong SAR, China.

Received: 4 December 2020 Accepted: 14 April 2021

References
1. Cooper C, Atkinson EJ, O'Fallon WM, Melton LJ 3rd. Incidence of clinically
diagnosed vertebral fractures: a population-based study in Rochester,
Minnesota, 1985-1989. J Bone Miner Res. 1992;7(2):221–7.
2. Ferrar L, Roux C, Felsenberg D, Glüer C, Eastell R. Association between
incident and baseline vertebral fractures in European women: vertebral
fracture assessment in the osteoporosis and ultrasound study (OPUS).
Osteoporos Int. 2012;23(1):59–65.
3. Ettinger B, Black DM, Nevitt MC, Rundle AC, Cauley JA, Cummings SR, et al.
Contribution of vertebral deformities to chronic back pain and disability. J
Bone Miner Res. 1992;7(4):449–56.
4. Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA. Mortality risk
associated with low-trauma osteoporotic fracture and subsequent fracture
in men and women. Jama. 2009;301(5):513–21.
5. Svensson HK, Olofsson EH, Karlsson J, Hansson T, Olsson LE. A painful, never
ending story: older women's experiences of living with an osteoporotic
vertebral compression fracture. Osteoporos Int. 2016;27(5):1729–36.
6. Barrey C, Roussouly P, Le Huec JC, D'Acunzi G, Perrin G. Compensatory
mechanisms contributing to keep the sagittal balance of the spine. Eur
Spine J. 2013;22(Suppl 6):S834–41.
7. Fechtenbaum J, Etcheto A, Kolta S, Feydy A, Roux C, Briot K. Sagittal balance
of the spine in patients with osteoporotic vertebral fractures. Osteoporos
Int. 2016;27(2):559–67.
8. Hu Z, Man GCW, Kwok AKL, Law SW, Chu WWC, Cheung WH, et al. Global
sagittal alignment in elderly patients with osteoporosis and its relationship
with severity of vertebral fracture and quality of life. Arch Osteoporos. 2018;
13(1):95.