Degenerative structural changes are a hallmark of aging and are particularly significant in the context of DS [14]. The decrease in intervertebral space not only alters the load distribution along the spine but also impacts the alignment of vertebral segments [15]. As the discs lose their cushioning ability, increased stress is placed on the facet joints and surrounding ligaments. This additional stress can exacerbate spinal curvature and lead to further degeneration. Understanding the role of these structural changes is crucial for diagnosing and managing DS, as it provides insight into the underlying mechanisms driving the condition.

Recent research emphasizes the role of changes in force application on the spine in DS development and progression [14]. Evaluating anatomical measurements like PI is crucial as it affects pelvic and spinal orientation. Postural measurements, such as LL, TK, and SAV provide insights into spinal curvature changes. PT and SS, reflecting pelvic angles, significantly impact spinal alignment and scoliosis development [10]. Understanding these parameters helps identify intervention targets for DS.

while an increase in PI is often observed in patients with DS, the association between DS and other spinopelvic alignment parameters like LL, PT, and SS remains controversial [16]. In the present study, we demonstrated that patients with DS exhibited significantly larger SVA, PI, PT, LL and SS compared to the control group, aligning with the observations reported by Lai, et al. [16]. also in agreement with Lim, et al., which indicate that these parameter values increase in direct correlation with the grade of DS [17]. These parameters are crucial indicators of spinal alignment and pelvic orientation, which play a vital role in maintaining an upright posture and overall spinal health. Our findings suggest that DS patients experience more pronounced sagittal misalignment and altered pelvic mechanics, contributing to their clinical symptoms and functional limitations.

According to Kobayashi et al., typical DS alignments include smaller LL and SS, differing from our findings [18]. They proposed that patients with a larger PI compensate for decreased LL with increased PT, which could place significant stress on the lumbosacral area, potentially causing and worsening L4 slippage [18].

A difference in gender ratio between the control and DS groups is highlighted in the study. Nonetheless, the effect is probably minimal, considering that Yukawa and colleagues reported no significant differences in LL, PI, and SVA between men and women over 50 years of age in asymptomatic individuals [19].

The data showed significant differences in age, LL, PI, and PT between DS types I and III and between types II and III, while no differences were observed between types I and II. The degenerative changes in grade I and II DS may be mild and thus insufficient to affect sagittal plane alignment. Moreover, Interestingly, PI, a parameter typically unaffected by aging, tended to increase with higher DS types, with a notable and statistically significant difference between types 1 and 3. This highlights the potential influence of advanced degeneration on pelvic morphology and alignment.

While this study offers valuable insights, it has limitations such as a small sample size, the lack of sex matched analysis, and a retrospective design. These factors should be taken into account when interpreting the results. Future research must address these issues to achieve more reliable and generalizable findings.