• Akshay Sharma, Sina Pourtaheri, Jason Savage, Iain Kalfas, Thomas E Mroz, Edward C Benzel, and Michael P Steinmetz.
• Case Western Reserve University School of Medicine, Cleveland, Ohio.
• Neurosurgery. 2018 Sep 1; 83 (3): 465-470.

BackgroundScoliosis X-rays are the gold standard for assessing preoperative lumbar lordosis; however, particularly for flexible lumbar deformities, it is difficult to predict from these images the extent of correction required, as standing radiographs cannot predict the thoracolumbar alignment after intraoperative positioning.ObjectiveTo determine the utility of preoperative MRI in surgical planning for patients with flexible sagittal imbalance.MethodsWe identified 138 patients with sagittal imbalance. Radiographic parameters including pelvic incidence and lumbar lordosis were obtained from images preoperatively.ResultsThe mean difference was 2.9° between the lumbar lordosis measured on supine MRI as compared to the intraoperative X-rays, as opposed to 5.53° between standing X-rays and intraoperative X-ray. In patients with flexible deformities (n = 24), the lumbar lordosis on MRI measured a discrepancy of 3.08°, as compared to a discrepancy of 11.46° when measured with standing X-ray.ConclusionMRI adequately determined which sagittal deformities were flexible. Furthermore, with flexible sagittal deformities, lumbar lordosis measured on MRI more accurately predicted the intraoperative lumbar lordosis than that measured on standing X-ray. The ability to preoperatively predict intraoperative lumbar lordosis with positioning helps with surgical planning and patient counseling regarding expectations and risks of surgery.

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