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Sagittal vertical axis offset, or sagittal imbalance, is determined by measuring the distance from the C7 plumb line (dropped from the center of the C7 vertebral body) to the posterior-superior corner of the S1 vertebral body on a standing lateral radiograph. This is correctly illustrated in Figure B. Restoring sagittal balance is a critical component in the treatment of adult spinal deformity. With "neutral" sagittal balance, the C7 plumb line will directly intersect the posterior-superior corner of S1. Positive or negative sagittal balance is described when plumb line is anterior and posterior to this sacral landmark, respectively. Joseph et al review sagittal plane deformity in the adult patient. They report that sagittal imbalance is a reliable predictor of the clinical health status in patients with spinal deformity, and that the mainstay of treatment is surgical correction back to neutral sagittal balance. Schwab et al performed a level 2 prospective study that introduces the concept of the "gravity line" in healthy adult volunteers. The gravity line is the center of recorded pressures measured on a footplate. With further studies, they hypothesize, the gravity line may prove itself to be superior to the plumb line in measuring spinal deformity.
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