Sagittal Imbalance: Symptoms, Causes and Management

Sagittal Imbalance: Symptoms, Causes and Management

However much you may have been told to ‘Stand up straight!’ when you were at school, it’s actually a physical impossibility.

Your spine is not straight. It curves inwards in your lower back (known as lordosis) then starts to curve outward in your middle back or thoracic spine (known as kyphosis). These curves help to keep your centre of gravity nicely balanced and aligned over your pelvis and hips.

What is a sagittal imbalance?

Sagittal imbalance happens when your spine’s curves become either too flat or too pronounced. That means you may find yourself wobbling backwards or forwards.

Flatback syndrome is a type of sagittal imbalance affecting the lumbar spine (lower back), which loses its normal lordosis curve. That means the only remaining curve is in your thoracic spine. Your centre of gravity shifts forward and you overbalance.

Hyperkyphosis is another type of sagittal imbalance. In this condition, the normal curvature of your thoracic spine is exaggerated creating a hunched appearance or chin-on-chest syndrome.


Who is at risk of sagittal imbalance?

Sagittal imbalance becomes more common with age. It’s quite common for the spine to lose much of its normal lordosis (lower back curve) due to age, which creates a gradual trend towards kyphosis. Age-related disc degeneration tends to tip the spine forwards while osteoporosis may create fractures that further add to this forward tilt. For most older people, these changes cause nothing more than a slightly bent posture but, for some, the changes are significant enough to contribute to sagittal imbalance. 


Sagittal imbalance may exist as a primary condition or may be a consequence of other spinal conditions such as:

  • Ankylosing spondylitis, a type of arthritis
  • Kyphosis, excessive forward curvature in the spine
  • Degenerative disc disease
  • Traumatic injury
  • A congenital defect present at birth
  • Osteoporosis
  • Neuromuscular conditions such as cerebral palsy, spina bifida, or muscular dystrophy
  • A previous spinal fusion surgery that disrupts sagittal balance.


What are the symptoms of sagittal imbalance?

Symptoms of sagittal imbalance may include:

  • Difficulty walking
  • Inability to look straight ahead
  • Chronic back pain
  • Fatigue
  • Difficulty managing daily tasks.


Why does sagittal imbalance cause so much pain?

Sagittal imbalance can be painful because your back muscles have to work overtime to pull your head and shoulders back over your pelvis and help you maintain your balance.

That overactivity may ultimately lead to degenerative arthritis by increasing forces in your facet joints, the small joints connected to the vertebrae in your spine.

One of the deep muscles in your back, the erector spinae, can also become fatigued and ache terribly when you try to stand or walk.

As the kyphosis (forward lean) becomes more pronounced, your pelvis may struggle to compensate and keep you balanced. You might find that you’re now flexing your hips and knees to help keep you upright. That makes it difficult and exhausting to stand or walk.

By this stage, sagittal imbalance may have become a disabling condition that is limiting your independence. 


What’s the treatment for sagittal imbalance?

Your doctor will order a number of different imaging scans of your spine to determine the degree of sagittal imbalance and appropriate treatment options.


Non-surgical treatments for sagittal imbalance

The goal of treatment is to reduce the strain on your back muscles and share the load through your upper limbs.

Treatment might include:

  • Modifying activities
  • Using a walking stick or walking frame
  • A number of exercises to strengthen your core muscles and support your spine
  • Weight loss if necessary to reduce the load on your spine.

Surgical treatments for sagittal imbalance

No two surgeries for sagittal imbalance are alike. Your surgery needs to be carefully planned based on the angle of your spine and its underlying bone quality.

Surgery usually has 3 key aims:

  1. To correct the spinal deformity, often loosening the spine by removing a bone
  2. To fix the spine into its new alignment using hooks and screws attached to the vertebrae with rods between them.
  3. To stabilise the spine using spinal fusion techniques (bone grafts that will fuse different segments of the spine together).

How can the Victorian Orthopaedic Spine Service help?

Sagittal imbalance is a complex condition that requires expert assessment and treatment.

If you’re finding it hard to keep your balance and are experiencing pain and fatigue in your back muscles, please contact us for an assessment (you’ll need a referral from your GP).



All information is general in nature. Patients should consider their own personal circumstances and seek a second opinion. Any surgical or invasive procedure carries risks.

Dr David EdisAbout Dr David Edis

Dr David Edis is an Orthopaedic and Spine Surgeon. David’s areas of special interest include the management of adult spinal conditions as well as hip and knee replacements. He has extensive experience in all facets of spine surgery from simple to complex, covering cervical to lumbo-pelvic conditions. He is an active researcher and medical educator and believes in lifelong learning. He is constantly updating his skills and helping other surgeons.