Chizuo Iwai, Javier Pizones, Louis Boissière, Sreenath Jakinapally, Çaglar Yilgor, Daniel Larrieu, Ferran Pellise, Jean-Marc Vital, Anouar Bourghli, Ibrahim Obeid

May 2021, Volume 30, Issue 5, pp 1155 - 1163 Original Article Read Full Article 10.1007/s00586-021-06767-7

First Online: 19 February 2021


Sagittal lumbar apex has been demonstrated to be a key parameter in sagittal plane morphology. Our aim was to understand its behavior with postural changes, analyzing two different concepts of lumbar apex.

Materials and methods

Prospective observational study with a cohort of patients presenting sagittal malalignment identified from a monocenter database of adult spinal deformities (ASD). Inclusion criteria were age > 30 years, SVA > 40 mm, and/or PT > 20. All patients had full-spine EOS radiographs in 2 different positions: (P1: natural position) and position 2 (P2: compensated position).

Sagittal alignment, spinopelvic values, and two different methods of assessing lordosis apex location were analyzed in both P1 and P2 positions. Changes between P1 and P2 were compared using a paired t test with a significance level at p 


Twenty-five patients were recruited (21 women and 4 men). The mean age was 64.8 years (range 21–79). The patient’s main compensation was based on an increase in the femoral shaft angle, and pelvic retroversion, with a subsequent decrease in sacral slope, and therefore of the lower lumbar arc.

When the lumbar apex was calculated as the most anterior point touching the vertical line in a lateral radiograph, postural compensation changes modified its location usually shifting it to a more caudal position. When the lumbar apex was assessed as the most distant point of the global lumbar lordosis, its position remained stable regardless of compensation.


Postural changes can modify the location of the lumbar apex when understanding its location as the cornerstone of sagittal plane harmonic distribution. This concept can be useful as an additional sign to assess compensation. However, if the lumbar apex was calculated as the angular point of the global lordosis, its position remained stable regardless of postural changes. This concept can help to mold lumbar lordosis in ASD surgery.

Level of evidence IV

Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

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