title: TheT1 pelvic angle, a novel radiographic measure of global sagittal deformity, accounts for both spinal inclination and pelvic tilt and correlates with health-related quality of life.
abstract: BACKGROUND
  Adult spinal deformity is a prevalent cause of pain and disability. Established measures of sagittal spinopelvic alignment such as sagittal vertical axis and pelvic tilt can be modified by postural compensation, including pelvic retroversion, knee flexion, and the use of assistive devices for standing. We introduce the T1 pelvic angle, a novel measure of sagittal alignment that simultaneously accounts for both spinal inclination and pelvic retroversion. The purpose of this study was to investigate the relationship of the T1 pelvic angle and other established sagittal alignment measures and to correlate these parameters with health-related quality-of-life measures.
  
  
  METHODS
  This is a multicenter, prospective, cross-sectional analysis of consecutive patients with adult spinal deformity. Inclusion criteria were adult spinal deformity, an age of greater than eighteen years, and any of the following: scoliosis, a Cobb angle of ≥ 20°, sagittal vertical axis of ≥ 5 cm, thoracic kyphosis of ≥ 60°, and pelvic tilt of ≥ 25°. Clinical measures of disability included the Oswestry Disability Index (ODI), Scoliosis Research Society (SRS)-22, and Short Form-36 (SF-36) questionnaires.
  
  
  RESULTS
  Five hundred and fifty-nine consecutive patients with adult spinal deformity (mean age, 52.5 years) were enrolled. The T1 pelvic angle correlated with the sagittal vertical axis (r = 0.837), pelvic incidence minus lumbar lordosis (r = 0.889), and pelvic tilt (0.933). Categorizing the patients by increasing T1 pelvic angle (<10°, 10° to 20°, 21° to 30°, and > 30°) revealed a significant and progressive worsening in health-related quality of life (p < 0.001 for all). The T1 pelvic angle and sagittal vertical axis correlated with the ODI (0.435 and 0.455), SF-36 Physical Component Summary (-0.445 and -0.458), and SRS (-0.358 and -0.383) (p < 0.001 for all). Utilizing a linear regression analysis, a T1 pelvic angle of 20° corresponded to a severe disability (an ODI of >40), and the meaningful change in T1 pelvic angle corresponding to one minimal clinically important difference was 4.1° on the ODI.
  
  
  CONCLUSIONS
  The T1 pelvic angle correlates with health-related quality of life in patients with adult spinal deformity. The T1 pelvic angle is related to both pelvic tilt and sagittal vertical axis; however, unlike sagittal vertical axis, it does not vary on the basis of the extent of pelvic retroversion or patient support in standing. Since the T1 pelvic angle is an angular and not a linear measure, it does not require calibration of the radiograph. Thus, the T1 pelvic angle measures sagittal deformity independent of many postural compensatory mechanisms, and it can be useful as a preoperative planning tool, with a target T1 pelvic angle of < 14°.
  
  
  METHODS
  Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopedic Surgery, New York University School of Medicine, 306 East 15th Street, New York, NY 10003. E-mail address for T. Protopsaltis: Themistocles.Protopsaltis@nyumc.org.
authors.forename: Themistocles
authors.initials: T
authors.lastname: Protopsaltis
authors.affiliation: Department of Orthopedic Surgery, New York University School of Medicine, 306 East 15th Street, New York, NY 10003. E-mail address for T. Protopsaltis: Themistocles.Protopsaltis@nyumc.org.
authors.forename: Frank
authors.initials: F
authors.lastname: Schwab
authors.affiliation: Department of Orthopaedic, Trauma, and Spine Surgery, Hôpital Saint Roch, 5, rue Pierre-Dévoluy, 06000 Nice, France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Bronsard
authors.affiliation: Department of Neurosurgery, University of Virginia School of Medicine, P.O. Box 800212, Charlottesville, VA 22908.
authors.forename: Justin S
authors.initials: JS
authors.lastname: Smith
authors.affiliation: Department of Orthopedic Surgery, University of California Davis, 4860 Y Street, Suite 3800, Sacramento, CA 95817.
authors.forename: Eric
authors.initials: E
authors.lastname: Klineberg
authors.affiliation: San Diego Center for Spinal Disorders, 5130 La Jolla Village Drive, Suite 300, La Jolla, CA 92037.
authors.forename: Gregory
authors.initials: G
authors.lastname: Mundis
authors.affiliation: Department of Orthopedic Surgery, New York University School of Medicine, 306 East 15th Street, New York, NY 10003. E-mail address for T. Protopsaltis: Themistocles.Protopsaltis@nyumc.org.
authors.forename: Devon J
authors.initials: DJ
authors.lastname: Ryan
authors.affiliation: Baylor Scoliosis Center, 4708 Alliance Boulevard, Suite 800, Plano, TX 75093.
authors.forename: Richard
authors.initials: R
authors.lastname: Hostin
authors.affiliation: Department of Orthopedic Surgery, University of Oregon Health Sciences Center, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239.
authors.forename: Robert
authors.initials: R
authors.lastname: Hart
authors.affiliation: Department of Orthopedic Surgery, University of Kansas School of Medicine, 3901 Rainbow Boulevard, Kansas City, KS 66160.
authors.forename: Douglas
authors.initials: D
authors.lastname: Burton
authors.affiliation: Department of Neurosurgery, University of California San Francisco, 505 Parnassus Aveneue, Room M779, San Francisco, CA 94143.
authors.forename: Christopher
authors.initials: C
authors.lastname: Ames
authors.affiliation: Department of Neurosurgery, University of Virginia School of Medicine, P.O. Box 800212, Charlottesville, VA 22908.
authors.forename: Christopher
authors.initials: C
authors.lastname: Shaffrey
authors.affiliation: Rocky Mountain Hospital for Children, Presbyterian/St Luke's Medical Center, 2055 High Street, Suite 130, Denver, CO 80205.
authors.forename: Shay
authors.initials: S
authors.lastname: Bess
authors.affiliation: Department of Orthopedic Surgery, New York University School of Medicine, 306 East 15th Street, New York, NY 10003. E-mail address for T. Protopsaltis: Themistocles.Protopsaltis@nyumc.org.
authors.forename: Thomas
authors.initials: T
authors.lastname: Errico
authors.affiliation: Department of Orthopedic Surgery, New York University School of Medicine, 306 East 15th Street, New York, NY 10003. E-mail address for T. Protopsaltis: Themistocles.Protopsaltis@nyumc.org.
authors.forename: Virginie
authors.initials: V
authors.lastname: Lafage
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010384:Pelvic Bones / Q000000981:diagnostic imaging*; D011446:Prospective Studies; D011788:Quality of Life; D011859:Radiography; D012044:Regression Analysis; D013121:Spinal Curvatures / Q000000981:diagnostic imaging* / Q000503:physiopathology; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging*