Change In Lumbar Lordosis Research Articles

84. Low density pedicle screw constructs are associated with lower incidence of proximal junctional failure in adult spinal deformity surgery

BACKGROUND CONTEXT Proximal junctional failure (PJF) is a common and particularly adverse complication of adult spinal deformity (ASD) surgery. There is evidence that the rigidity of posterior spinal constructs may impact risk of PJF. PURPOSE We hypothesized that lower mean screws per level and decreased rod stiffness would be associated with lower incidence of PJF. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Patients with ASD and 2-year minimum follow-up were included. Only patients undergoing fusion of ≥5 levels, and with LIV at the sacro-pelvis were included. Patients undergoing revision surgery were excluded. In total, 420 patients were analyzed. OUTCOME MEASURES The primary outcome variable was PJF, defined using previously published radiographic criteria (PJ angle >28°and ∆PJ angle >22°, and ≥8mm/≥3mm listhesis at upper thoracic / thoracolumbar levels, respectively). METHODS The primary independent variables were the mean number of screws per level fused analyzed with a cutoff of 1.8 (determined by ROC analysis) and rod material/diameter. Multivariable logistic regression was utilized to investigate confounding factors, including age, history of osteoporosis, BMI, gender, CCI, preoperative Schwab modifiers, preoperative TPA, postoperative change in lumbar lordosis, upper instrumented vertebra, osteotomy, approach, UIV type (ie, pedicle screw vs other), and number of levels fused. RESULTS Of the total patients, 78.8% were female. PJF occurred in 14.1% of patients. The mean screws per level was 1.7 (SD 0.2), and 57.6% of patients had 0.2) were not significantly associated with PJF. Screw density specifically adjacent to the UIV was not related to PJF (p>0.2). CONCLUSIONS Among ASD patients undergoing long-segment primary fusion to the pelvis, the risk of PJF was lower among patients with FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Long-Term Efficacy of Treatment Effects After a Kyphosis Exercise and Posture Training Intervention in Older Community-Dwelling Adults: A Cohort Study.

Treatments that prevent worsening kyphosis are important due to the progressive nature of kyphosis with aging. We assessed long-term efficacy of treatment effects after a short-term kyphosis exercise and posture training intervention in a cohort study among older adults with hyperkyphosis, and investigated whether long-term treatment effects differ among males and females. In the original kyphosis intervention, 112 older adults enrolled in a waitlist design randomized controlled trial. One hundred three participants, mean age 70.0 (5.7) years and kyphosis 52.0° (7.4°), completed a twice weekly, 3-month, group exercise and posture training intervention, and were eligible to enroll in the follow-up study. We compared (1) change in outcomes pre-/postintervention to change postintervention over the follow-up period, (2) change in outcomes pre-/postintervention and postintervention to follow-up, stratified by sex, and (3) long-term change postintervention to follow-up in males and females. Primary outcome was change in kyphometer-measured thoracic kyphosis. Secondary outcomes were change in lumbar lordosis, objective measures of physical function, self-reported measures of physical activity, and health-related quality of life (HRQoL). Forty-three participants, 42% of the eligible cohort, returned for follow-up, a mean 3.0 (0.7) years after completing the original intervention. Participants (27 females and 16 males) were 73.8 (6.1) years old, with mean kyphosis 48.9° (11.9°) at follow-up. Kyphosis declined -1.5° (95% confidence interval [CI]: -3.9° to 1.0°) postintervention to follow-up and this was no different than change pre-/postintervention, P = .173. Lordosis improved 8.9° (95% CI: 6.2° to 11.6°), more than change pre-/postintervention, P < .001. Gait speed measure of physical function increased 0.08 (95% CI: 0.02 to 0.14) m/s, Physical Activity Scale for the Elderly (PASE) measure of physical activity increased 4 (95% CI: -16 to 24) points, and Patient-Reported Outcomes Measurement Information System (PROMIS) mental health T-score measure of HRQoL increased 1.1 (95% CI: -1.0 to 3.1) points, but these improvements were not significantly more than change pre-/postintervention, P > .050. Other measures of physical function (modified Physical Performance Test [PPT], Timed Up and Go, and 6-minute walk) and HRQoL (Scoliosis Research Society [SRS-30] self-image and PROMIS physical function and physical health) declined at follow-up, significantly more than change pre/postintervention, P ≤ .050. Comparing change in outcomes pre-/postintervention and postintervention to follow-up, stratified by sex, both males and females increased lordosis, and decreased modified PPT and 6-minute walk measures of physical function, P < .050. Males and females differed in long-term change postintervention to follow-up. Time loaded standing and PASE improved in females compared with males, P = .008 and P = .092, respectively, and PROMIS mental health, physical health, and physical function declined in females compared with males, P = .073, P = .025, and P = .005, respectively. In our follow-up study, a mean of 3.0 (0.07) years after a 3-month kyphosis exercise and posture training intervention, kyphosis maintained and did not progress as expected with age. There was long-term improvement in lordosis. Compared with treatment effects from the short-term intervention, gait speed maintained equally well in males and females, while trunk endurance improved in females. Further investigation of long-term benefits of a short-term kyphosis exercise and posture training intervention is warranted.

Seated Lateral X-ray Is a Better Stress Radiograph of the Lumbar Spine Compared to Standing Flexion

Study Design:Prospective lumbar radiograph analysis.Objective:To compare changes in lumbar lordosis in standing flexion versus seated lateral radiographs.Methods:Standing lateral, standing flexion, and seated lateral X-rays of the lumbar spine were obtained in patients presenting with low back pain. Trauma, tumor, and revision cases were excluded. Changes in global lumbar as well as segmental lordosis were measured in each position.Results:Seventy adult patients were reviewed. Overall, the greatest changes in lordosis were seen at L4-S1 in both the seated and flexion X-rays (12.5° and 6.3°, respectively). Greater kyphosis was seen in seated versus flexion X-rays (21.6° vs 15.8°); changes in lordosis from L1-L3 were similar in both positions, with little change seen at these levels (approximately 5° to 7°). On subgroup analysis, these differences were magnified in analyzing only patients that moved at least 20° globally, and there were no significant differences between sitting and flexion in “stiff” patients that moved less than 20° globally.Conclusion:Greater lumbar kyphosis was seen in the seated position compared to standing flexion, especially from L4-S1. Given these results we suggest the use of seated lateral X-rays to dynamically assess the lumbar spine. These findings may also guide future research into the mechanism and clinical relevance of a stiff versus mobile lumbar spine, as well as into the sensitivity of seated X-rays in detecting instability.

Impact of L4/5 Posterior Interbody Fusion With or Without Decompression on Spinopelvic Alignment and Health-related Quality-of-Life Outcomes.

This was a retrospective case control study. The objective was to determine the impact of single-level interbody fusion at L4/5 with or without concomitant decompression on various spinopelvic parameters and health-related quality-of-life (HRQOL) outcomes. Recently, focus has swayed from a regional concern to a global sagittal alignment, more comprehensive approach in multilevel, corrective fusion for adult spinal deformity. However, only a few comprehensive studies have investigated the relationships between the various related spinopelvic parameters and HRQOL outcomes using single-level interbody fusion. In total, 119 patients with lumbar degenerative disorders (mean age, 68 y; 38 males and 81 females) who underwent L4/5 single-level posterior interbody fusion with a minimum 2-year follow-up were included. Participants were divided into 2 groups according to preoperative sagittal modifiers of the SRS-Schwab adult spinal deformity classification. The correlation between spinopelvic parameters and HRQOL outcomes was investigated. Negative or positive values indicated lordosis. HRQOL outcomes were assessed using visual analog scale scores, Japanese Orthopedic Association Back Pain Evaluation Questionnaires (JOABPEQ), and short form-36 (SF-36). L4/5 local lordosis increased from 6.4±4.4 degrees preoperatively to 11.3±4.5 degrees at 2 years postoperatively (P<0.0001). Further analysis of the results also showed a correlation between change in L4/5 local lordosis and change in lumbar lordosis (LL) (rs=0.229, P=0.0143). The high pelvic incidence-LL (≥20 degrees, n=28) and high sagittal vertical axis groups (≥5 cm, n=29) had lower scores in walking ability, social life domains of JOABPEQ, and physical component summary scores of SF-36 preoperatively, and 2 years postoperatively. Fusion status did not affect the HRQOL outcomes, except that concomitant decompression at the adjacent disk level yielded lower SF-36 physical component summary scores 2 years postoperatively. Improvement in L4/5 local lordosis possibly triggers a simultaneous sequence of change in total LL after posterior single-level fusion. HRQOL outcomes were negatively affected by both preoperative and postoperative pelvic incidence-LL mismatch and global sagittal malalignment. Level III.

Analysis of the Change Patterns of Sagittal Alignment Values After Selective Thoracic Fusion in Lenke 1 Adolescent Idiopathic Scoliosis According to Preoperative Thoracic Kyphosis Status

This was a retrospective study. The objective of this study was to demonstrate the different change patterns in reciprocal sagittal alignment values after selective thoracic fusion (STF) in Lenke type 1 adolescent idiopathic scoliosis (AIS) according to preoperative thoracic kyphosis (TK). Several studies have found significant increase in TK after STF, while other studies have reported decrease in TK postoperatively. Similar inconclusive results on changes in lumbar lordosis (LL) have been reported, showing LL increase, decrease, or no change. Ninety-three patients presenting with Lenke type 1 AIS treated by posterior STF with a minimum follow-up of 2 years were included in this study. Using whole spine radiographs, sagittal parameters including TK, LL, and upper lumbar lordosis (ULL) were compared preoperatively and at the last follow-up between a hypokyphosis group (preoperative TK<20 degrees) and a normokyphosis group (preoperative TK≥20 degrees). Health-related quality of life (HRQOL) was assessed using scoliosis research society health-related quality of life-30 (SRS-30) and short from health survey-36 questionnaire at the last visit. The mean follow-up duration was 74.9 months. In the hypokyphosis group (35 patients), TK, LL, and ULL statistically significantly increased after surgery by mean 7.7, 5.1, and 3.7 degrees (P<0.001, <0.001, and 0.001). In the normokyphosis group (58 patients), these parameters did not show significant changes after STF. Final TK was significantly lower in hypokyphosis group than that in the normokyphosis group (21.2 vs. 30.9 degrees, P<0.001) while final LL did not differ between 2 groups (52.4 vs. 54.6 degrees, P=0.194). HRQOL did not differ significantly between the 2 groups. After STF in Lenke 1 AIS, TK, and LL statistically significantly increased through an increase in the mean ULL in the hypokyphosis group while those mean values did not change in the normokyphosis group. Despite the final mean value of the TK in the hypokyphosis group increasing by 7.7 degrees, it was statistically significantly lower than the final mean TK value in the normokyphosis group which did not increase after STF surgery by posterior approach. However, HRQOL showed no significant difference between the 2 groups.

Impact of obesity on restoration of sagittal balance and clinical efficacy after posterior lumbar interbody fusion

To investigate the impact of obesity on the restoration of sagittal balance after posterior lumbar interbody fusion (PLIF). To examine the correlation between obesity and sagittal balance and their influence on clinical efficacy. A total of 183 patients who underwent PLIF for degenerative lumbar diseases between Jan 2015 and Dec 2015 were enrolled in this study. Based on their BMI, patients were divided into three groups: normal weight group (Group A), overweight group (Group B), and obesity group (Group C). Demographic data, intraoperative data, sagittal balance parameters, and clinical function scores were compared between each group. Correlation analysis was conducted between the BMI scores and each sagittal balance parameter. Multiple linear regression was used to assess the impact of each variable on clinical outcomes. All patients finished an average of 22.3 months follow-up. Group C had significantly higher blood loss and longer operations than Group A. SL and PT improved significantly in Group A while did not change in Group C. Compared with Group C, Group postoperative pelvic tilt (PT) was better restored in Group A. BMI was significantly correlated with change of lumbar lordosis (LL) and PT. Multiple linear regression analysis indicated that BMI and change of PT had a great influence on ODI improvement. Obesity may hinder the correction of sagittal balance and improvement of clinical efficacy in patients who undergo PLIF. Restoration of PT should be paid more attention to during surgery, as it may be associated with satisfactory clinical outcomes especially for obesity.

Analysis of the Functional and Radiological Outcomes of Lumbar Decompression without Fusion in Patients with Degenerative Lumbar Scoliosis.

Study DesignRetrospective study.PurposeThis study aimed to analyze the functional and radiological outcomes of lumbar decompression in patients with degenerative lumbar scoliosis (DLS).Overview of LiteraturePatients with DLS have symptoms related to lumbar canal stenosis (LCS) and those due to compensated spinal imbalance. Whether the deformity is the cause of pain or is an adaptive change for the ongoing LCS remains debatable. The extensive surgery for deformity correction along with spinal fusion is reported to have high perioperative morbidity and complication rate.MethodsThis retrospective analysis involved 51 patients who underwent lumbar decompression for LCS associated with DLS from October 2006 to October 2016. The magnitude of the curve was determined using Cobb’s angle and lumbar lordosis (D12–S1) on the preoperative and final follow-up, respectively. The Visual Analog Scale (VAS) and modified Oswestry Disability Index (mODI) scores at the preoperative and final follow-up indicated the functional outcome. Statistical analyses were performed using Student t-test.ResultsAll 51 patients were included in the statistical analyses. The mean patient age at presentation was 63.88±7.21 years. The average follow-up duration was 48±18.10 months. The average change in the Cobb’s angle at the final follow-up was statistically insignificant (1°±1.5°, p=0.924; 20.8°±5.1° vs. 21.9°±5.72°). The mean change in lumbar lordosis at the final follow-up was statistically insignificant (3.29°±1.56°, p=0.328; 30.2°±7.9° vs. 27.5°±7.1°). There was statistically insignificant worsening in the back VAS scores at the final follow-up (4.9±1.9 vs. 6.0±1.2, p=0.07). There was statistically significant improvement in the leg pain component of the VAS score at the final follow-up (5.8±1.05 vs. 2.6±1.2, p<0.001). There was statistically significant improvement in the mODI scores at the final follow-up (p<0.001).Conclusions Lumbar decompression in DLS is associated with good functional outcome, especially when the symptoms are related to LCS. Curve progression following lumbar decompression is very less at mid-term and is similar to that in the natural course of the disease.

Outcomes of direct lateral interbody fusion (DLIF) in an Australian cohort.

Direct lateral interbody fusion (DLIF) mitigates many of the vascular complications and bony resections associated with other interbody fusion techniques. However, there are concerns regarding postoperative neural complications and that indirect decompression of the foramen has not been consistently demonstrated. This study prospectively assessed the clinical and radiological outcomes and the complication rates of the DLIF approach. A prospective review was conducted of the first 50 consecutive DLIF cases of a single neurosurgeon between 2010 and 2014. Clinical outcomes were assessed using Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and Roland Morris Disability Questionnaire (RMDQ) surveys. Radiological outcomes, including spondylolisthesis, disc height, local disc angle, lumbar lordosis and foraminal height and width, were measured using Surgimap Spine software at the preoperative, 6 weeks, 6 months, and 12 months postoperative follow-up. Complication rates were also reported. A total of 50 patients (84 levels) were treated with DLIF. The mean patient age was 68.2±9.8 years and 62.0% were female. At latest follow-up, mean VAS pain score improved from 7.7±1.5 to 1.9±0.9 (P<0.0001), mean ODI improved from 42.1±14.5 to 16.9±6.7 (P<0.0001) and mean RMDQ score improved from 12.1±5.2 to 6.2±4.7 (P<0.0001). Mean spondylolisthesis reduced from 7.5%±6.5% to 1.3%±1.1% at 6 weeks (P<0.0001), 0.95%±0.74% at 6 months (P<0.0001) and recurred to 1.9%±1.7% at 12 months postoperatively (P=0.0006). Mean anterior disc height improved from 7.3±3.2 to 11.6±2.5 mm at 6 weeks (P<0.0001), 12.2±3.3 mm at 6 months (P<0.0001) and 9.8±2.1 mm at 12 months (P=0.0032) postoperatively. Mean posterior disc height improved from 4.4±2.0 to 6.8±2.1 mm at 6 weeks (P<0.0001), 6.6±2.5 mm at 6 months (P=0.0003), and 5.9±1.4 mm at 12 months (P=0.0039) postoperatively. Mean local disc angle improved from 7.0°±3.7° to 9.2°±3.3° at 6 weeks (P=0.0072), 10.4°±3.9° at 6 months (P=0.0013) and 8.2°±2.9° at 12 months (P=0.2487) postoperatively. No significant postoperative changes in lumbar lordosis were observed. Mean foraminal height improved from 18.3±3.5 to 21.5±3.9 mm at 6 weeks (P=0.0004), 20.6±3.4 mm at 6 months (P=0.0266), and 18.7±1.9 mm at 12 months (P=0.8021) postoperatively. Mean foraminal width improved from 7.9±2.0 to 10.2±2.8 mm at 6 weeks (P=0.0001), 9.4±2.6 mm at 6 months (P=0.0219) and 8.3±1.6 mm at 12 months (P=0.5734) postoperatively. Fusion rate at 6 and 12 months was 62.2% and 89.2%, respectively. A total of 6 patients (12%) had postoperative complications. Three patients (6%) had pain-related psoas muscle weakness and 3 patients (6%) had sensory neural complications that had resolved entirely by 8 and 16 weeks postoperatively, respectively. The study provides encouraging short and medium-term clinical and radiological results for DLIF. In this patient series, there was a low complication rate with no permanent neural injury reported.

A Pilot Study on Posterior Polyethylene Tethers to Prevent Proximal Junctional Kyphosis After Multilevel Spinal Instrumentation for Adult Spinal Deformity

Proximal junctional kyphosis (PJK) is a common problem after multilevel spine instrumentation. To determine if junctional tethers reduce PJK after multilevel instrumented surgery for adult spinal deformity (ASD). ASD patients who underwent posterior instrumented fusion were divided into 3 groups: no tether (NT), polyethylene tether-only (TO; tied securely through the spinous processes of the uppermost instrumented vertebra [UIV]+1 and UIV-1), and tether with crosslink (TC; passed through the spinous process of UIV+1 and tied to a crosslink between UIV-1 and UIV-2). PJK was defined as proximal junctional angle≥10° and≥10° greater than the corresponding preoperative measurement. One hundred eighty-four (96%) of 191 consecutive patients achieved minimum 3-mo follow-up (mean=20 mo [range:3-56 mo]; mean age=66 yr; 67.4% female). There were no significant differences between groups based on demographic, surgical, and sagittal radiographic parameters. PJK rates were 45.3% (29/64), 34.4% (22/64), and 17.9% (10/56) for NT, TO, and TC, respectively. PJK rate for all tethered patients (TO+TC; 26.7% [32/120]) was significantly lower than NT (P=.011). PJK rate for TC was significantly lower than NT (P=.001). Kaplan-Meier analysis showed significant time-dependent PJK reduction for TC vs NT (log rank test, P=.010). Older age and greater change in lumbar lordosis were independent predictors of PJK, while junctional tethers had a significant protective effect. Junctional tethers significantly reduced occurrence of PJK. This difference was progressive from NT to TO to TC, but only reached pairwise significance for NT vs TC. This suggests potential benefit of tethers to reduce PJK, and that future prospective studies are warranted.

Особенности хирургической тактики при лечении больных с поясничным дегенеративным спондилолистезом

Purpose Carry out a comparative study of the effectiveness of surgical treatment of patients with grade I degenerative spondylolisthesis treated with rigid transpedicular and dynamic interlaminar fixation. Material and methods Surgical treatment of patients with grade I degenerative spondylolisthesis at L4 vertebra was reviewed. The inclusion criteria were as follows, L4 spondylolisthesis measuring up to 5 mm; translation of ≤ 3 mm; L4-L5 segmental kyphosis of ≤ 17 degrees, local scoliosis of ≤ 10 degrees, absence of severe osteoporosis (T-score of > – 2.5). Decompression and dynamic stabilization of the spine was produced in group I (n = 24) with Coflex and Interfix implants. Group II included 20 patients who underwent transpedicular fixation and posterolateral spondylodesis. Standard and functional spondylography, MRI were performed for all the cases. Modified Pfirrmann grading system was used to assess intervertebral disk degeneration. L4 vertebral slippage and lumbar lordosis, intervertebral disc height, L4-L5 angle, translation at lumbar flexion/extension were measured. Results Oswestry Disability Index (ODI) score was insignificantly lower in the group of dynamic fixation. Pain intensity in the leg and the spine was comparable at follow-up. Adjacent segment syndrome was not common in group I and graded not more than Pfirrmann V. Both groups showed slight changes in lumbar lordosis. Advantages of dynamic interlaminar fixation included decrease in surgical trauma, blood loss and surgical time, and lower risk of complications avoiding overstress to adjacent level. Conclusion The use of interlaminar fixation for selective patients with grade I degenerative spondylolisthesis showed advantages over rigid transpedicular fixation. However, further research is needed for extended indications to the fixators to be used for this cohort of patients.

Chronic Low Back Pain in Young Population: An MRI Study

Background: Low back pain is a common health problem in the younger population. Spinal degeneration is the most common cause of low back pain. Objectives: The purpose of this study was to investigate the most common causes of low back pain with MRI in young people under the age of 40 and to determine gender differences, if any. Methods: This is a retrospective study on 200 consecutive patients between the ages of 17 - 39 who had lumbar MRI (1.5 T MRI). Patients were included in the study based on the information collected from the radiological database system and neurosurgical clinical archives between September - October 2017. Spinal mass, spondylolisthesis, disc degeneration, multifidus muscular atrophy, and congenital anomalies were investigated. Studied parameters were compared in male and female patients. Results: Disc degeneration or hernia was observed in 132 patients (66%) and no gender difference was found for a disc hernia (P = 0.376 Chi-Square test). The most frequent disc hernia was detected at the level L5 - S1. Multifidus muscular atrophy was identified in 54 (27%) of all patients and it was higher in women (P < 0.001). Accepted change of lumbar lordosis was detected only in 10 patients. Conclusions: Disc herniation is the most common causes of low back pain in young people under the age of 40 and there are no gender differences.

Immediate effect of application of the pressure technique to the psoas major on lumbar lordosis.

[Purpose] To demonstrate immediate alteration in lumbar lordosis and the lumbar angle in each segment after the application of the mechanical pressure technique to the psoas major muscle (PM). [Participants and Methods] In all, 34 participants were assigned to either the PM pressure technique group (n=17) or control group (n=17). Three dimensional (3D) coordinates of the 12th thoracic spinous process and lumbar spinous processes were measured with a 3D digitizer in the prone position with 15° bilateral hip extension to compare the changes in lumbar lordosis and the lumbar extension angle in each segment in both the PM pressure technique group and control group. [Results] Mann-Whitney’s U test revealed no significant differences in lumbar lordosis in either group. However, the lumbar extension angle at L4 decreased significantly after the PM pressure technique compared with that before the pressure technique. Additionally, the lumbar extension angle at L4 also decreased significantly after the PM pressure technique compared with the control group. Conversely, lumbar extension angle at L1 increased significantly after the PM pressure technique compared with that before. There was no significant difference in the lumbar extension angle at L2, L3 and L5 after the PM pressure technique. [Conclusion] This study suggests that the PM pressure technique possibly attenuates PM stiffness while reducing lumbar extension in each segment.

Normal aging of the lumbar spine in women.

Lumbar lordosis is required for bipedalism. To investigate age-related changes in lumbar lordosis and to clarify the relationships between lumbar lordosis and vertebral wedging and disc degeneration. A total of 300 women were included in this retrospective study, 50 in each of six age groups (20-, 30-, 40-, 50-, 60- and 70-year-olds). Patients with vertebral collapse, instable fracture or disc sequestration were excluded. In each patient, lumbar lordosis angle, posterior vertebral wedging, L5-S1 intervertebral disc angle, L5/L1 vertebral height ratio and L5-S1 intervertebral disc/L1-L2 intervertebral disc height ratio were examined. Significance level was set at p< 0.05 and two-sided tests were used. Significant differences were found in lumbar lordosis according to age group (p< 0.001). Lumbar lordosis correlated most strongly with L4 posterior vertebral wedging, L5 posterior vertebral wedging and L5-S1 intervertebral disc angle, in that order (r= 0.50, r= 0.40, r= 0.32, respectively; p< 0.001). In this cohort, strong spinal structure was maintained during physiological aging from 20 to 40 years of age; lumbar lordosis increased by 50 years of age. Increased lordosis correlated with increased posterior vertebral wedging and loss of posterior disc height.

Effectiveness of deformity-correction surgery for primary degenerative sagittal imbalance: a meta-analysis.

OBJECTIVE As life expectancy continues to increase, primary degenerative sagittal imbalance (PDSI) is diagnosed in an increasing number of elderly people. Although corrective surgery for this sagittal deformity is becoming more popular, the effectiveness of the procedure remains unclear. The authors aimed to collate the available evidence on the effectiveness and complications of deformity-correction surgery in patients with PDSI. METHODS The authors carried out a meta-analysis of clinical studies regarding deformity correction in patients with PDSI. The studies were identified through searches of the PubMed, Embase, Web of Science, and Cochrane databases. Surgery outcomes were evaluated and overall treatment effectiveness was assessed in terms of the minimum clinically important difference (MCID) in Oswestry Disability Index (ODI) values and pain levels according to visual analog scale (VAS) scores and in terms of restoration of spinopelvic parameters to within a normal range. Data are expressed as mean differences with 95% CIs. RESULTS Ten studies comprising 327 patients were included. The VAS and ODI values improved after deformity-correction surgery. The smallest treatment effect exceeded the MCID for VAS values (4.15 [95% CI 3.48-4.82]) but not for ODI values (18.11 [95% CI 10.99-25.23]). At the final follow-up visit, the mean lumbar lordosis angle (-38.60° [95% CI -44.19° to -33.01°]), thoracic kyphosis angle (31.10° [95% CI 24.67°-37.53°]), C-7 sagittal vertical axis (65.00 mm [95% CI 35.27-94.72 mm]), and pelvic tilt angle (30.82° [95% CI 24.41°-37.23°]) remained outside their normal ranges. Meta-regression analyses revealed a significant effect of ODI change in relation to lumbar lordosis change (p = 0.004). After a mean of 2 years after deformity correction, the mean lumbar lordosis angle and C-7 sagittal vertical axis decreased by 5.82° and 38.91 mm, respectively, and the mean thoracic kyphosis angle increased by 4.7°. The incidences of proximal junctional kyphosis and pseudarthrosis were 23.7% and 12.8%, respectively. CONCLUSIONS Deformity correction substantially relieves back pain for about 2 years in adult patients with PDSI. Sufficient surgical restoration of lumbar lordosis can lead to substantial improvement in patient disability and reduced decompensation. Deformity correction represents a viable therapeutic option for patients with PDSI, but further technical advancements are necessary to achieve sufficient lumbar lordosis and reduce complication rates.

Characterisation of the correlation between standing lordosis and degenerative joint disease in the lower lumbar spine in women and men: a radiographic study

BackgroundDegenerative joint disease (DJD) in the lumbar spine is a common condition that is associated with chronic low back pain. Excessive loading of lumbar joints is a risk factor for DJD. Changes in lumbar lordosis significantly redistribute the forces of weight-bearing on the facet joints and the intervertebral discs. However, the relationship between lumbar lordosis and DJD has not been characterized in men and women.MethodsWe characterised the correlation between standing lumbar lordosis and DJD in standing radiographic images from 301 adult female and male chiropractic patients. DJD was rated using the Kellgren-Lawrence scale, and lordosis was measured using the Cobb angle. Linear and curvilinear correlations were investigated while controlling for age and sex.ResultsWe found a highly significant curvilinear correlation between lordosis and DJD of the lower lumbar spine in both sexes, but especially in women, irrespective of the effects of age. We found the effect size of lordosis on lower lumbar DJD to be between 17.4 and 18.1% in women and 12.9% in older men. In addition, lordosis of 65 (95% CI 55.3–77.7) and 68 (98% CI 58.7–73.3) degrees were associated with minimal DJD in the lower lumbar spine of women and men respectively, and were therefore considered ‘optimal’. This optimal lordotic angle was 73 (95% CI 58.8–87.2) degrees in older men.ConclusionsBoth hypo- and hyper-lordosis correlate with DJD in the lumbar spine, particularly in women and in older men. These findings may well be of relevance to spinal pain management and spinal rehabilitation.

Pelvic retroversion: a compensatory mechanism for lumbar stenosis.

OBJECTIVE The flexed posture of the proximal (L1-3) or distal (L4-S1) lumbar spine increases the diameter of the spinal canal and neuroforamina and can relieve symptoms of neurogenic claudication. Distal lumbar flexion can result in pelvic retroversion; therefore, in cases of flexible sagittal imbalance, pelvic retroversion may be compensatory for lumbar stenosis and not solely compensatory for the sagittal imbalance as previously thought. The authors investigate underlying causes for pelvic retroversion in patients with flexible sagittal imbalance. METHODS One hundred thirty-eight patients with sagittal imbalance who underwent a total of 148 fusion procedures of the thoracolumbar spine were identified from a prospective clinical database. Radiographic parameters were obtained from images preoperatively, intraoperatively, and at 6-month and 2-year follow-up. A cohort of 24 patients with flexible sagittal imbalance was identified and individually matched with a control cohort of 23 patients with fixed deformities. Flexible deformities were defined as a 10° change in lumbar lordosis between weight-bearing and non-weight-bearing images. Pelvic retroversion was quantified as the ratio of pelvic tilt (PT) to pelvic incidence (PI). RESULTS The average difference between lumbar lordosis on supine MR images and standing radiographs was 15° in the flexible cohort. Sixty-eight percent of the patients in the flexible cohort were diagnosed preoperatively with lumbar stenosis compared with only 22% in the fixed sagittal imbalance cohort (p = 0.0032). There was no difference between the flexible and fixed cohorts with regard to C-2 sagittal vertical axis (SVA) (p = 0.95) or C-7 SVA (p = 0.43). When assessing for postural compensation by pelvic retroversion in the stenotic patients and nonstenotic patients, the PT/PI ratio was found to be significantly greater in the patients with stenosis (p = 0.019). CONCLUSIONS For flexible sagittal imbalance, preoperative attention should be given to the root cause of the sagittal misalignment, which could be compensation for lumbar stenosis. Pelvic retroversion can be compensatory for both the lumbar stenosis as well as for sagittal imbalance.

Lumbar lordosis in prone position and prone hip extension test: comparison between subjects with and without low back pain

BackgroundProne hip extension (PHE) is a common and widely accepted test used for assessment of the lumbo-pelvic movement pattern. Considerable increased in lumbar lordosis during this test has been considered as impairment of movement patterns in lumbo-pelvic region. The purpose of this study was to investigate the change of lumbar lordosis in PHE test in subjects with and without low back pain (LBP).MethodA two-way mixed design with repeated measurements was used to investigate the lumbar lordosis changes during PHE in two groups of subjects with and without LBP. An equal number of subjects (N = 30) were allocated to each group. A standard flexible ruler was used to measure the size of lumbar lordosis in prone-relaxed position and PHE test in each group.ResultThe result of two-way mixed-design analysis of variance revealed significant health status by position interaction effect for lumbar lordosis (P < 0.001). The main effect of test position on lumbar lordosis was statistically significant (P < 0.001). The lumbar lordosis was significantly greater in the PHE compared to prone-relaxed position in both subjects with and without LBP. The amount of difference in positions was statistically significant between two groups (P < 0.001) and greater change in lumbar lordosis was found in the healthy group compared to the subjects with LBP.ConclusionsGreater change in lumbar lordosis during this test may be due to more stiffness in lumbopelvic muscles in the individuals with LBP.

Valgus Hip Osteotomy in Children With Spondyloepiphyseal Dysplasia Congenita: Midterm Results

Coxa vara has been frequently reported in spondyloepiphyseal dysplasia congenita (SEDC), and proximal femoral osteotomy has been described as a useful treatment. The aim of this study was to discuss the clinical, radiographic, and gait outcomes after valgus extension osteotomy of the proximal femur. Changes of lumbar lordosis, associated with coxa vara correction, are reported as well as the outcome differences between different ages. Records of children with SEDC, who were followed at our institution between 2004 and 2014, were reviewed; and children had hip surgery were identified. Hip pain and passive range of motion, radiographic neck shaft angle (NSA), and Hilgenreiner trochanteric (H-T) angle, sagittal spinopelvic parameters, and gait data were recorded. Preoperative and last follow-up data were compared. Outcomes were also compared between 3 age groups. Of the 79 children with SEDC, 26 children (12 boys and 14 girls) had hip osteotomy in 48 hips. Mean age at surgery was 9.6 years and the mean follow-up was 5 years. Preoperative hip pain was noted in 30 hips. At the last follow-up, 3 hips were painful at the extreme range of motion. Passive range of motion, NSA, and H-T improved postoperatively. Although NSA was maintained over the follow-up, H-T deterioration was noted. Spinopelvic measurements changed significantly and gait data remained stable except pelvic tilt that reduced significantly after surgery. The changes of radiographic measurements in each age group were similar to the total group of patients. In children with SEDC, surgical correction of coxa vara, by proximal femoral valgus osteotomy, is an effective treatment that improves hip pain and range of motion in addition to the radiographic alignment of the proximal femur and the sagittal spinopelvic alignment. Children are expected to maintain their level of function after surgery and to have good results over the midterm regardless of their age at surgery. Level IV-therapeutic study.

Lumbar Lordosis Minus Thoracic Kyphosis: Remain Constant in Adolescent Idiopathic Scoliosis Patients Before and After Correction Surgery.

A retrospective study. To explore the relationship between the change of lumbar lordosis (LL) and thoracic kyphosis (TK) in AIS patients after correction surgery. TK tends to decrease in Lenke 1 and Lenke 2 AIS patients after correction surgery using pedicle screws, with the compensation of LL decrease. We hypothesize that lumbar lordosis minus thoracic kyphosis (LL-TK) remains constant after correction surgery to achieve the sagittal balance in AIS patients. Medical records of Lenke 1 or Lenke 2 AIS patients who received posterior correction surgery using pedicle screws in our hospital from January 2010 to January 2013 were reviewed. General characters of patients and radiological parameters were evaluated before the surgery and at two years' follow-up. Correlation analysis between TK and LL was conducted. LL-TK and the change of LL and TK were analyzed at preoperation and final follow-up. A total of 76 Lenke 1 and Lenke 2 AIS patients were included. Both TK and LL decreased significantly after correction surgery (P = 0.019 and P = 0.040, respectively). There were significant correlations between TK and LL before and after surgery, respectively (preoperative: r = 0.234, P = 0.042; postoperative: r = 0.310, P = 0.006). Preoperative and postoperative LL-TK was 23.80° and 25.09°, respectively, and no significant difference of LL-TK was observed (P = 0.372). The same tendency was observed in the change of LL and TK, and significant correlation was also found between the change of TK and LL (r = 0.626, P = 0.002). The same change of LL and TK and no significant difference in LL-TK indicated that LL-TK might be an important compensatory mechanism in keeping sagittal balance.

Effects of upper extremity training in a standing position on trunk alignment in stroke patients.

[Purpose] This study aimed to examine the effect of upper extremity training in the standing position on trunk alignment of patients with stroke. [Subjects and Methods] Twelve stroke patients were enrolled in the study and divided into two groups: a group of six patients in a sitting position and a group of six patients in a standing position. Upper extremity training for 30 min per day, five times a week for six weeks was given to subjects in both groups. In order to assess trunk alignment, lumbar lordosis and thoracic kyphosis were examined before and after upper extremity training using Formetric 4D. [Results] After training the standing position group had no significant change in lumbar lordosis but a significant change in thoracic kyphosis. The sitting position group showed no significant changes in either lumbar lordosis or thoracic kyphosis. The comparison between groups showed there was no significant difference in the change in lumbar lordosis but there was a significant difference in the change in thoracic kyphosis. [Conclusion] Examination of trunk alignment showed that upper extremity training conducted in a standing position reduced thoracic kyphosis more than in a sitting position.