JC. Le Huec - ArgoSpine

SAGITTAL BALANCE AND TDR: 

WHAT IS THE BEST CHOICE 

J-C Le Huec M.D.Ph.D.* 

*Chairman SPINE UNIT, 

orthopaedic department 

Dir. surg research lab 

BORDEAUX university, France, 

JC LE HUEC SPINE UNIT BORDEAUX UNIVERSITY

THE PELVIS S IS THE 

BASEMENT 

: 

anatomical 

Pelvic Parameters 


JC LE HUEC SPINE UNIT BORDEAUX UNIVERSITY 

C. 

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S


C. 

S 

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C. 

. 

S


C. 

. 

S

SS 


- PELVIC TILTING and SACRAL SLOPE are 

variable positional parameters 

PT 

SS 

PI 

PT

Duval-Beaupère & al. 


Harmonious alignment of the trunk 

Anatomical parameters !!! 

Allows to stand spending 

the least amount of 

energy ++++ 


Biomechanical analysis 

of the shape of the spine 

NO MORE 

anatomical based 

The french revolution 


NEW WAY TO ANALYSE SAGITTAL PLAN 

Software analysis to help to analyse contour 

CC 

THORACIC 

KYPHOSIS 

TC 

Inflexion point 

Superior arch 

LUMBAR 

LORDOSIS 

spine balance angle 

Apex 

β 

θ 

LL 

inferior arch 

PT 

PI 

SS 

OPTISPINE 



EOS DEVICE 

2 mtres 

2 mtres 

ENTREE 

Passage 

ENTREE 

425 mm 

BIOSPACE-

THE EOS SYSTEM 



EFFECT OF THE INCIDENCE 

ANGLE ON THE SHAPE OF 

LORDOSIS

PI = 41° 

LL = 52° 

GLOBAL RESULTS 

PI = 44° 

LL = 52° 

TYPE 1 SS < 35° 

TYPE 2 SS < 35° 

PI = 51° 

LL = 61° 

35°< SS < 45° 

TYPE 3 

PI = 63° 

LL = 71° 

TYPE 4 SS > 45° 



1) Shape of Lordosis depends on Sacral Slope 

Type 3 

Type 1 Type 2 

Type 4

C7 plumb line and Sacral slope 


C7 plumb line and Sacral slope 


CONCLUSION 

Lumbar lordosis is highly correlated with 

pelvic parameters 

and particularly sacral slope 

Respect or restoration of lordosis is 

crucial 


Effect of one level TDR on saggital alignment 

Le huec jc, Basso y, Eur Spine J, 2005 

Prospective study design: 

Total disc prosthesis restore: motion, disc height, and 

finally function close to anatomy 

Study design: to determine the effect of single level TDA 

on sagital balance 

the idea: this can protect accelerated DDD at adjacent 

levels or improve back pain 


Material and Method 

CC 

1. Global lordosis- angle upper endplate of L1 

and the sacral endplate 

2. Segmental lordosis L4-L5- angle upper 

endplate of L4 and lower endplate of L5 

3. Segmental lordosis L5-S1- angle upper 

endplate of L5 and the sacral endplate 

4. Global kyphosis- angle between the upper 

endplate of T4 and lower endplate of T12 


TC 

PT 

LL 

PI 

SS

Results: 

global analysis after TDR at L5S1 or L4L5 

SAGITTAL BALANCE PARAMETERS 

60 

50 

Pre-op 

Post-op 

40 

30 

20 

10 

0 

Global 

Lordosis 

L4/L5 L5/S1 ST PT Kyphosis 

No statistical difference with regards to the overall : 

lordosis, ST, PT, kyphosis 


Results: each group 

L4-L5 

PROSTHESIS AT L5/S1 

L5-S1 

60 

50 

P=0.61 

Pre-op 

Post-op 

40 

P=0.63 

P=0.24 

30 

20 

10 

0 

Global 

Lordosis 

P=0.05 

P=0.03 

L4/L5 L5/S1 ST PT Kyphosis 

No statistical difference with regards to the overall : 

lordosis, ST, PT, kyphosis 

P=0.57 

But significant difference in local lordosis ++++at L4L5 


Results: each group 

PROSTHESIS AT L4/L5 

60 

50 

P=0.72 

Pre-op 

Post-op 

40 

30 

P=0.84 

P=0.39 

20 

10 

0 

Global 

Lordosis 

P=0.001 

P=0.053 

P=0.49 

L4/L5 L3L4 L5/S1 ST PT Kyphosis 

No statistical difference with regards to the overall :lordosis, ST, PT, kyphosis 

No significant difference in local lordosis at L5S1 p = 0,39 

But significant difference in local lordosis ++ at L3L4 


Results 

Analyzis of each group: L4L5 and L5S1 prosthesis level: 

Segmental lordosis significantly increase 

at the level of prosthesis L4-L5 or L5-S1 

and decreased at above adjacent level 

But the overall lordosis did not change ++++ 

No statistical difference in each group 

of overall lordosis, ST, PT, kyphosis 



balance 

A1= 26° A1= 6° 

Standing position: balance of the spine

COMPARATIVE study: 

Maverick, CharitéIII, Prodisc 

(Tournier C, Le Huec JC, Eur Spine J, 2007) 

AT L5S1: 

location of MCR is very variable 

and difficult to calculate 

like in a healthy young population 

AT L4L5: 

location of MCR is posterior under superior L5 plateau 

ARE TDR more adapted to L4L5 than L5S1 


Discussion 

TDA restore the local balance in between L4-L5-S1 

This is the inferior arch ++++ 

TDA in between L4-L5-S1 

allows maintenance of motion and 

simultaneously allows the patient 

to adapt his own sagittal balance 


TWO LEVELS TDR OR 

HYBRID 

Hybrid surgery: fusionL5S1 and disc arthroplasty L4L5 

OR 

two disc arthroplasties 


Biomechanics of 2 levels charité in comparison to fusion plus 

single level disc placement combination 

spine J 2006, Grauer JN 

Finite element model analysis 

Cage +TDR / 2 level TDR 

The motion at L4L5 level were larger in cage+TDR as compared 

to 2 levelTDR 

But it is impossible to speculate if an increase in motion across a 

segment , as compared with the intact case, is more harmful than 

a decrease in motion 


Hybrid testing of charité disc versus fusions 

spine, 2007 april, Penjabi M, Malcolmson G 

Cadaveric study Comparison: 

TDR, Fusion, TDR 2 levels, Fusion + TDR on top 

One and two levels fusion increased motions at proximal levels 

(22,9%) 

Two levels TDR showed some amount of variable effects at 

adjacent levels 


One or two levels PRODISC versus fusions 

spine, 2007 may, Penjabi M, henderson G 

Cadaveric study Comparison: 

TDR, Fusion, TDR 2 levels, Fusion + TDR on top 

One and two levels TDR showed only small Adj Level Effect 

One and two levels fusions showed increased Adj Level Effect in 

all direction (7,8%, 35,3%) 

One level TDR + fusion showed small Adj Level Effect to One level 

fusion alone 


BUT: clinical experience is different 

. Siepe CJ, Mayer HM, Heinz-Leisenheimer M, Korge A. 

Total lumbar disc replacement: different results 

for different levels. Spine. 2007; 32:782-90. 

showed a deterioration in postoperative results 

in both ODI and VAS for two-level TDA. the 

reduction in mean VAS back was 2.9 and 

reduction in mean ODI was 20%. 

TDA L4L5 better indication 

Two levels TDR isn’t as good as one level 


Hybrid construct for two levels 

discopathies: a better compromise 

Le Huec JC, Meyrat R, Eur Spine J, 2009 

Group A: 

42 patients 

hybrid 

Group B: 28 patients double TDR 


esults 

The hybrid construct provides same clinical outcomes 

as single level TDR in our experience 

Two levels TDR (Prodisc, Korge Siepe, Spine 07) 

have inferior results than single level 

This is probably in relation with the difficulty 

to ideally position the mean center of rotation on multilevels 

For hybrid The use of the BMP erases the problem of iliac crest pain 

In two levels TDR one third weren’t mobile at L5S1 

L4L5 TDR alone seems to be able to adapt spine balance 


CONCLUSION 


Take home message 

Pelvis shape and Spine shape are very important 

factors to analyse for the indication 

Pelvis shape and lumbar lordosis and incidence angle are highly 

correlated 

Type of spine , sacral slope and incidence angle determine good or bad 

indication for TDR 

ALIF L5S1 or TDR L5S1: : a lot of equivalence, difficult to show 

superiority 

TDR at L4L5 seems to be the best indication 

Two levels 

2 levels TDR hasn’ demonstrated superiority compare to fusion 

Hybrid construct (ALIF L5S1 and TDR L4L5) demonstrated better spine 

balance compare to two levels fusion 


Bordeaux : 

Saggital spine balance course 

September 24 – 25th 2010 

Objectives 1: analysis of spine and pelvis 

parameters 

Objectives 2: how to integrate balance 

parameters in your daily practice 

J-c.lehuec@u-bordeaux2.fr

JC. Le Huec - ArgoSpine

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