DOI: 10.1177/21925682241235611 ISSN: 2192-5682

Characteristics of Spinal Morphology According to the “Current” and “Theoretical” Roussouly Classification Systems in a Diverse, Asymptomatic Cohort: Multi-Ethnic Alignment Normative Study (MEANS)

Yong Shen, Zeeshan M. Sardar, Matan Malka, Prerana Katiyar, Gabriella Greisberg, Fthimnir Hassan, Justin L. Reyes, Jean-Charles Le Huec, Stephane Bourret, Kazuhiro Hasegawa, Hee Kit Wong, Gabriel Liu, Hwee Weng Dennis Hey, Hend Riahi, Michael Kelly, Joseph M. Lombardi, Lawrence G. Lenke,
  • Neurology (clinical)
  • Orthopedics and Sports Medicine
  • Surgery

Study Design

Cross-sectional cohort study.


To classify spinal morphology using the “current” and “theoretical” Roussouly systems and assess sagittal alignment in an asymptomatic cohort.


467 asymptomatic volunteers were recruited from 5 countries. Radiographic parameters were measured via the EOS imaging system. “Current” and “theoretical” Roussouly classification was assigned with sagittal whole spine imaging using sacral slope (SS), pelvic incidence (PI), and the lumbar apex. One-way analysis of variance (ANOVA) was performed to compare subject characteristics across Roussouly types, followed by post hoc Bonferroni correction.


Volunteers were categorized into 4 groups (Types 1-4) and 1 subgroup (Type 3 AP) using the “current” and “theoretical” Roussouly systems. The mean PI in “current” Roussouly groups was 40.8° (Type 1), 43.6° (Type 2), 52.4° (Type 3), 62.4° (Type 4), and 43.7° (Type 3AP). The mean PI in “theoretical” Roussouly groups was 36.5° (Type 1), 39.1°(Type 2), 52.5° (Type 3), 67.3° (Type 4), and 51.0° (Type 3AP). The difference in PI between “current” and “theoretical” Roussouly types was significant for Type 1 ( P = .02), Type 2 ( P < .001), Type 4 ( P < .001), and Type 3AP ( P < .001). 34.7% of subjects had a “current” Roussouly type different from the “theoretical” type. Type 3 theoretical shape had the most frequent mismatch, constituting 61.1% of the mismatched subjects. 51.5% of mismatched Type 3 become “current” Type 4.


The distribution of Roussouly types differs depending on whether the “current” or “theoretical” classification are employed. A sizeable proportion of volunteers exhibited current and theoretical type mismatch, highlighting the need to interpret sagittal alignment cautiously when utilizing the Roussouly system.

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