Degree Of Lumbar Lordosis Research Articles

Gender-Specific Differences in Spinal Alignment and Muscle Power in Patients with Parkinson's Disease.

Parkinson's disease (PD) is an advancing neurodegenerative disorder characterized by spinal anomalies and muscular weakness, which may restrict daily functional capacities. A gender-focused examination of these effects could provide valuable insights into customized rehabilitation strategies for both sexes. This study investigates the influence of spinal alignment on lower-limb function during the sit-to-stand (STS) movement in patients with Parkinson's disease compared to healthy individuals. A cross-sectional study was conducted with 43 consecutive patients with PD (25 males and 18 females; average age 73.7 ± 7.1 years) and 42 healthy controls (22 males and 20 females; average age 69.8 ± 6.0 years). Assessments included the International Physical Activity Questionnaire (IPAQ), Hoehn and Yahr staging, and measurements of vertical deviations from several spinal landmarks. Lower-limb muscle power during the STS task was evaluated using the Muscle Quality Index (MQI). Both absolute (Watts) and relative (Watts/Kg) muscle power in the lower limbs were notably decreased in the PD group compared to the control group. Within the PD cohort, muscle power showed a negative relationship with age and a positive association with the degree of lumbar lordosis (PL-L3). Importantly, gender-specific analysis revealed that male patients with PD had significantly higher lower-limb muscle power compared to female patients with PD, highlighting the need for gender-tailored therapeutic approaches. The findings suggest that preserving lumbar lordosis is crucial for maintaining effective lower-limb muscle biomechanics in individuals with Parkinson's disease.

Analyzing lumbar vertebral shape and alignment in female patients with degenerative spondylolisthesis: Comparisons with spinal stenosis and risk factor exploration.

This study aimed to examine the vertebral body shape characteristics and spondylopelvic alignment in L4 degenerative spondylolisthesis (DS) as well as the risk factors for the development of DS. This cross-sectional study compared vertebral morphology and sagittal spinopelvic alignment in female patients with lumbar DS and lumbar spinal stenosis (LSS). The degree of lumbar lordosis (LL), pelvic incidence (PI), cross-sectional area (CSA), and vertebral body height ratio (ha/hp) of the lumbar spine were compared using full-length spine radiographs and computed tomography in 60 females with DS and in 60 women with LSS. No significant differences in age or body mass index were observed between the two groups; however, the DS and LSS groups significantly differed in PI (mean, 58.9±10.8 vs. 47.2±11.6, P < 0.001), L4 CSA (mean, 1,166.2 m2 vs. 1,242.0 m2, P = 0.002) and ha/hp (mean, 1.134 vs. 1.007, P < 0.001). The L4 ha/hp was significantly higher in the DS group than in the LSS group. Additionally, LL values were negatively correlated with vertebral L5 CSA in the DS group (r = -0.28, P < 0.05). The LSS and DS groups demonstrated positive correlations between LL and L2, L3, and L4 ha/hp (r = 0.331, 0.267, and 0.317; P < 0.01, < 0.05, and < 0.05, respectively) and between LL and L4 and L5 ha/hp (r = 0.333, 0.331; P < 0.01, respectively). Multivariate regression analyses revealed that PI and ha/hp ratio may be independent predictors of DS development. The DS group had significantly larger LL, PI, and L4 ha/hp and smaller L4 CSA than the LSS group. The lumbar vertebral body shape and sagittal spinopelvic alignment in females might be independent predictors of DS development.

Exploring effects of Egoscue versus lumbar stabilisation exercises for lower crossed syndrome on postural stability and hyperlordotic posture correction

Abstract The aim of the study was to evaluate the comparative effectiveness of Egoscue exercises and lumbar stabilisation exercises in individuals with the lower crossed syndrome in terms of hyperlordotic posture correction, postural stability, and patient satisfaction towards treatment. The study was a randomised controlled trial. Through randomisation, 30 participants were allocated into 2 study groups, the Egoscue Exercise (EE) group (n=15) and the lumbar stabilisation exercise (LSE) group (n=15). The outcome measures were the degree of lumbar lordosis, functional disability, and postural stability parameters (risk of fall, stability index, weight distribution, anterior-posterior sway, and lateral sway) and patient satisfaction with treatment assessed at baseline and post-10th session of the intervention. Within group analysis showed significant improvement in the outcome measures, such as Index of Lumbar Lordosis, functional disability, postural stability, and patient satisfaction towards treatment with the groups (P&lt;0.05). Between groups analysis showed that EE group and LSE groups were equally effective in improving lumbar hyperlordosis (P=0.458), functional disability (P=0.545), postural stability (risk of fall P=0.781; stability index P=0.964; weight distribution index P=0.718; anterior-posterior sway P=0.402; lateral sway P=0.212) and patient satisfaction towards treatment (P=0.999). Egoscue exercises and lumbar stabilisation exercises are equally effective in correcting lumbar hyper lordotic posture, postural stability, pain, and functional disability in low back pain individuals with the lower crossed syndrome. Clinical Trials Registry – India (CTRI): CTRI/2021/09/036733

COMPARISON OF ANTERIOR VERSUS POSTERIOR PELVIC TILT ON LUMBAR LORDOSIS

The pelvic girdle and spine vertebral column work as a long chain influenced by pelvic tilt. Spinal deformities or other musculoskeletal conditions may cause patients to compensate with excessive pelvic tilt, producing alterations in the degree of lumbar lordosis and subsequently causing pain. The objective of this study is to assess the effect of open and closed chain anterior or posterior pelvic tilt on lumbar spine kinematics using an in vitro cadaveric spine model.Three human cadaveric spines with intact pelvis were suspended with the skull fixed in a metal frame. Optotrak 3D motion system tracked real-time coordinates of pin markers on the lumbar spine. A force-torque digital gage applied consistent force to standardize the acetabular or sacral axis’ anterior and posterior pelvic tilt during simulated open and closed chain movements, respectively.In closed chain PPT, significant differences in relative intervertebral compression existed between L1/L2 [-2.54 mm] and L5/S1 [-11.84 mm], and between L3/L4 [-2.78 mm] and L5/S1 [-11.84 mm] [p &lt;.05]. In closed chain APT, significant differences in relative intervertebral decompression existed between spinal levels L1/L2 [2.87mm] and L5/S1[24.48 mm] and between L3/L4 [2.94 mm] and L5/S1 [24.48 mm] [p &lt;.05]. In open chain APT, significant differences in relative intervertebral decompression existed between spinal levels L4/L5 [1.53mm] and L5/S1 [25.14 mm] and between L2/L3 [1.68 mm] and L5/S1 [25.14 mm] [p&lt;.05 for both]. Displacement during closed chain PPT was significantly greater than during open chain PPT, whereas APT showed no significant differences.In PPT, open chain pelvic tilts did not produce as much lumbar intervertebral displacement compared to closed chain. In contrast, APT saw no significant differences between open and closed chain. Additionally, results illustrate the increase in lumbar lordosis during APT and the loss of lordosis during PPT.

Reliability of Ultrasound Measurements of the Lumbar Multifidus and Transversus Abdominis Muscles during Lying and Unstable Sitting Positions in Individuals With and Without Chronic Low Back Pain

The reliability studies are limited to support ultrasound usage during dynamic conditions; for example, unstable sitting position. This study aims to examine the reliability of ultrasound measurements of the lumbar multifidus and transversus abdominis during lying and unstable sitting positions in individuals with chronic low back pain (CLBP) and asymptomatic individuals considering abnormal lumbar lordosis. In this observational study, intrarater within-day and between-day reliability of muscle thickness and contraction ratio of the lumbar multifidus and transversus abdominis muscles were assessed using ultrasound imaging. In total, 40 participants (27 with CLBP, 13 asymptomatic individuals) with abnormal lumbar lordosis were recruited. The degree of lumbar lordosis has been measured by a flexible ruler. The muscle thickness was assessed at lying and sitting on a gym ball for both muscles in three sessions. Both groups had well to high ICCs of thickness measurement and contraction ratio in the transversus abdominis and lumbar multifidus muscles during both static (ICC=0.71-0.99) and semi-dynamic conditions (ICC=0.73-0.98). The standard error of measurements and minimal detectable changes were rather small in both groups. Ultrasound imaging is a highly reliable method to assess muscle thicknesses and contraction ratio of the transversus abdominis and lumbar multifidus during different conditions, even in patients with CLBP and abnormal lumbar lordosis.

The Effect of Three Methods of Kinesthetic Imagery, Active, and Combined Exercises on Electromyographic Pattern of Hip Hyperextension and the Muscle Strength of Gluteus Maximus and Abdominal in Women With Lumbar Hyperlordosis

Purpose: Mental exercise uses the same neuronal pathways involved in physical exercise to modify the pattern and function without stress caused by physical exercise. This study investigates the effect of kinesthetic imagery, active, and combined exercises (imagery and active) on the hip hyperextension and the power of selected lumbopelvic muscles in women suffering from lumbar hyperlordosis. Methods: In this quasi-experimental study, 36 women with lumbar hyperlordosis (age range: 30-40 years, non-athlete and without injury and surgery in the lumbar region) were selected and divided into three groups. The groups practiced three sessions per week for six weeks. We assessed the lumbar lordosis by a flexible ruler and the electromyographic (EMG) activity of the lumbopelvic muscles during hip hyperextension in the prone position by surface electromyogram. We also measured the power of the gluteus maximus using a dynamometer during hip hyperextension and the abdominal muscles using a goniometer during the double leg lowering test. All of the measurements were done before and after the intervention. The normality of the data was checked by The Shapiro-Wilk test, and the obtained data were analyzed by repeated-measures ANOVA test at the significant level of 0.05. Results: The variables of lumbar lordosis were significantly reduced in the active and combined groups in the post-test compared to the pre-test, and the strength of gluteus and abdominal muscles in the active and combined groups in the post-test significantly increased compared to the pre-test. However, the lumbar lordosis and strength of gluteus and abdominal muscles in the post-test were not significantly changed compared to the pre-test. Gluteus maximus and abdominis transverse muscle activity rates in the combined group increased significantly in the post-test compared to the pre-test, and gluteus maximus muscle activity rate in the active group increased significantly in the post-test compared to the pre-test. Gluteus maximus muscle activity in the imagery group increased significantly in the post-test compared to the pre-test. The activity of lumbar erector spinae and rectus femoris muscles decreased significantly in the active and combined groups in the post-test compared to the pre-test. However, the activity of the rectus femoris muscle decreased significantly in the image group in the post-test compared to the pre-test (P≤0.05). The results showed a significant difference between the three methods of kinesthetic imagery, active, and combined (P=0.001). There was a significant difference between the method of the imagery exercise and the active and combined exercise methods but no significant difference between methods of the active and combined exercise. Conclusion: Imagery exercises effectively modified the EMG of some lumbopelvic muscles (gluteus maximus and rectus femoris muscles). However, it had no significant effect on the strength and degree of lumbar lordosis. The combined exercise was as effective as active exercise in modifying the EMG activity of the lumbopelvic muscles and the strength of the abdominal and gluteus maximus muscles.

Clinical-Instrumental Results and Analysis of Functional Activity Restoration in Professional Athletes After Lumbar Total Disk Replacement

To analyze the clinical and biomechanical outcome of professional athletes after lumbar total disk replacement, with a focus on restoration of the functional activity. This nonrandomized retrospective single-center study included 11 professional athletes who underwent lumbar disc replacement surgery using the prosthesis M6-L (Spinal Kinetics, Schaffhausen, Switzerland). The average postoperative follow-up was 3.18 ± 1.14 years. The following outcomes were evaluated: intensity of pain in the lumbar spine and lower limbs, Oswestry Disability Index, Short-Form 36, complications, time of return to previous sports activity, range of movement, degree of lumbar lordosis, degenerative changes of the adjacent levels, and degree of heterotopic ossification. The operated patients reported significant decrease of pain on visual analog scale (P < 0.001) as well as significant improvement of Oswestry Disability Index (P= 0.001) and Short-Form 36 (P < 0.001). For the duration of follow-up, the patients maintained segmental range of motion at L4-L5 (P= 0.04) and L5-S1 (P= 0.03) levels. There was also some statistically insignificant increase of global lumbar lordosis (P= 0.84). We did not identify any significant degeneration of the adjacent intervertebral disks (P > 0.05) or progression of the facet joint degenerative changes at the implantation level and in the adjacent segments (P > 0.05). One patient (9.1%) developed grade I heterotopic ossification 5 years after surgery and in 1 patient (9.1%), a lesion of superior hypogastric plexus was recorded. The average time of return to previous sports activity was 9.72 ± 3.03 weeks. Total lumbar disc replacement using M6-L prosthesis in professional athletes made it possible to achieve statistically significant reduction of pain and facilitated early return to normal sports activities. In our opinion, preservation of movement of the operated lumbar segment can help to reduce the mechanical stress with beneficial impact on the rate of degeneration of the adjacent level.

Posterior Lumbar Interbody Fusion in Degenerative Lumbar Spine Disease and Risk of Adjacent Segment Disease

Objective: To determine the chances of adjacent segment disease (ASD) and risk factors after posterior lumbar interbody fusion (PLIF).&#x0D; Material and Methods: 110 patients of both genders with degenerative lumbar instability at L4/5 level were included in my study. We did PLIF in all our patients and followed our patients for one year. The following parameters were measured: the degree of lumbar lordosis, the degree lumbosacral angle, the disc space height and their dynamic angulation and the displacement of L3 over L4. We checked the outcome with the help of the Japanese orthopedic association (JOA) and Oswestry disability index (ODI). We divided the patients into groups A and B; group A includes patients with progression of degeneration at the proximal level (L3-L4), while group B with no progression of disease at proximal level.&#x0D; Results: The 86 patients (78.18%) were in group A, and 24 patients (21.88%) were in group B. There were no significant difference in radiological parameters of both groups; lumbosacral angle of lordosis, L3 laminar inclination angle, preoperative degenerative changes at proximal level, L4–L5 lordosis and BMD before surgery. The clinically and statistically significant differenceswere of the age of the patients falling in two groups. We found that at the completion of study ODI and JOA were not significantly different in both groups (P &gt;0.05).&#x0D; Conclusion: Degenerative lumbar disease is an age related disease with no significant effect of radiological degenerations on the final outcome of our patients.No other possible risk factor has a significant effect on outcome.

Relationships among the lumbar lordosis index, sacral horizontal angle, and chronic low back pain in the elderly aged 60-69 years: A cross-sectional study.

Spinal sagittal imbalance caused by degenerative changes or iatrogenic factors in the elderly can cause symptoms such as anteversion and low back pain (LBP). There are different and conflicting opinions about the relationship between the degree of lumbar lordosis and functional status of patients with chronic low back pain (CLBP). This study aimed to determine the relationships among the lumbar lordosis index, sacral horizontal angle, and CLBP in the elderly. Subject data were collected from Lishui City, Zhejiang Province, China, using cluster sampling according to the background information provided by national physical fitness monitoring. The 207 subjects were urban and rural individuals, 60-69 years old. Radiographs were evaluated according to a standardized protocol. The lumbar lordosis index and sacral horizontal angle were recorded. Data on the prevalence and functional status of CLBP were collected through field investigations. Statistical correlations between the radiographic parameters and the prevalence and functional status of CLBP measurements were evaluated. No significant difference was observed in the sacral horizontal angles among the subjects with and without CLBP; however, the lumbar lordosis index of CLBP subjects was significantly higher than that of those without CLBP (P= 0.028) and showed a significant association with CLBP (P= 0.013). Neither the sacral horizontal angle nor the lumbar lordosis index showed significant correlations with the Oswestry Disability Index in CLBP subjects. The lumbar lordosis index, but not the sacral horizontal angle, was significantly associated with CLBP in the subjects.

Effect of sciatic nerve neurodynamic sustained natural apophyseal glides on individuals with pelvic crossed syndrome: A randomized controlled trial

Background: Pelvic crossed syndrome (PCS) is a common predisposing factor of low back pain. If left untreated, PCS could result in various spinal and lower-limb pathologies which would hinder an individual's functional abilities and affect their quality of life. Aims: The study aimed to evaluate the effect of sciatic nerve neurodynamic sustained natural apophyseal glides (SNAGs) along with a stretching-strengthening protocol on individuals with symptomatic PCS. Settings and Design: This study was conducted in a tertiary care center; this was a randomized controlled trial. Materials and Methods: Forty-two individuals were randomly allocated to control group (conventional physical therapy) and experimental group (sciatic nerve neurodynamic SNAGs along with conventional physical therapy) using envelope method. The outcome measures – pressure pain threshold, degree of lumbar lordosis, modified Thomas test, finger-to-floor test, and Modified Oswestry Disability Questionnaire (MODQ) were obtained from the participants on day 1 and posttreatment on day 6, respectively. Both the groups received the treatment for 45 min per session for 6 consecutive days. Statistical Analysis Used: Parametric dependent t-test was applied through R software 3.5.1. Results: Intragroup analysis revealed statistically significant changes in all outcome measures in both the groups. Statistically significant changes were observed in the intergroup analysis of all the outcome measures (P Conclusion: Sciatic nerve neurodynamic SNAGS when given along with conventional therapy resulted in significant and superior improvement as compared to conventional therapy alone in patients with symptomatic PCS in terms of pain sensitivity and flexibility.

70. Anterior column realignment (ACR) performed at L2-3 achieves suboptimal lumbo-pelvic realignment compared with L2 pedicle subtraction osteotomy (PSO)

BACKGROUND CONTEXT The anterior column realignment (ACR) technique is increasingly becoming popular for treating patients with flatback deformity. The degreed of correction achieved with ACR performed at L2-3 disc has not been well studied. PURPOSE The purpose of this study was to compare the degree of deformity correction and perioperative outcomes between ACR and PSO being performed at L2 for iatrogenic flatback deformity. STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE N = 27 patients, 9 ACR and 18 PSO. The patients were matched 1:2 (ACR:PSO) based on preoperative deformity parameters. OUTCOME MEASURES Primary outcome: Lumbo-pelvic parameters (LL-PI mismatch, SVA, PT). Secondary outcomes: estimated blood loss, transfusion requirement, length of hospital stay, operative time, postoperative complication, and hospital readmission rates. METHODS Patients were identified between 2012 and 2016 who underwent revision surgery using either the PSO or ACR technique at the L2-3 level to correct sagittal deformity. Patients who underwent ACR were matched to PSO patients in a 1:2 fashion based on preoperative lumbar lordosis (LL) and lumbar lordosis pelvis incidence (LL-PI) mismatch. Patient demographics, surgical variables, pre- and postoperative radiographic parameters, and perioperative characteristics were compared between the treatment groups using t-tests, chi-square tests, and multivariable regression models. RESULTS The cohort included 27 patients; 9 ACR patients matched to 18 PSO patients. The PSO group achieved a greater degree of lumbar lordosis compared to the ACR group (31° vs 14.23°, p CONCLUSIONS PSO surgery resulted in significantly improved lumbar lordosis and sagittal alignment correction compared to the ACR group. While ACR resulted in some improvement of lumbar lordosis, it resulted in residual lumbo-pelvic mismatch compared with patients treated with PSO. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Vertebral cross-sectional growth: A predictor of vertebral wedging in the immature skeleton.

The degree of vertebral wedging, a key structural characteristic of spinal curvatures, has recently been found to be negatively related to vertebral cross-sectional area (CSA). The purpose of this longitudinal study was to examine the relation between vertebral cross-sectional growth and vertebral wedging progression within the immature lumbar spine. Using magnetic resonance imaging (MRI), we analyzed the potential association between increases in lumbar vertebral CSA and changes in L5 vertebral wedging in 27 healthy adolescent girls (ages 9–13 years) twice within a two-year period. Vertebral CSA growth was negatively associated with changes in posteroanterior vertebral wedging (r = -0.61; p = 0.001). Multiple regression analysis showed that this relation was independent of gains in age, height, and weight. When compared to the 14 girls whose vertebral wedging progressed, the 13 subjects whose vertebral wedging decreased had significantly greater vertebral cross-sectional growth (0.39 ± 0.25 vs. 0.75 ± 0.23 cm2; p = 0.001); in contrast, there were no significant differences in increases in age, height, or weight between the two groups. Changes in posteroanterior vertebral wedging and the degree of lumbar lordosis (LL) positively correlated (r = 0.56, p = 0.002)—an association that persisted even after adjusting for gains in age, height, and weight. We concluded that in the immature skeleton, vertebral cross-sectional growth is an important determinant of the plasticity of the vertebral body; regression of L5 vertebral wedging is associated with greater lumbar vertebral cross-sectional growth, while progression is the consequence of lesser cross-sectional growth.

Association Between Vertebral Cross-sectional Area and Vertebral Wedging in Children and Adolescents: A Cross-sectional Analysis

A small vertebral cross-sectional area (CSA) imparts a mechanical disadvantage that escalates the risk for vertebral fractures in elderly populations. We examined whether a small vertebral CSA is also associated with a greater degree of vertebral wedging in children. Measurements of vertebral CSA, lumbar lordosis (LL) or thoracic scoliosis angle, and vertebral wedging were obtained in 100 healthy adolescents (50 boys and 50 girls) and 25 girls with adolescent idiopathic scoliosis (AIS) using magnetic resonance imaging. Vertebral CSA of the lumbar vertebrae negatively correlated to the degree of posteroanterior vertebral wedging at L5 (r = -0.49; p < 0.0001); this was true whether all subjects were analyzed together or boys and girls independently. In contrast, we found a positive correlation between the degree of LL and vertebral wedging (r = 0.57; p < 0.0001). Multiple regression analysis showed that the association between vertebral CSA and wedging was independent of age and body mass index. In girls with AIS, vertebral CSA negatively correlated to the degree of lateral thoracic vertebral wedging (r = -0.66; p = 0.0004), an association that persisted even after accounting for age and body mass index. Additionally, Cobb angle positively correlated to lateral thoracic vertebral wedging (r = 0.46; p = 0.021). Our cross-sectional results support the hypothesis that smaller vertebral CSA is associated with greater vertebral deformity during growth, as in adulthood. © 2017 American Society for Bone and Mineral Research.

How Did the Pelvis and Vertebral Column Become a Functional Unit during the Transition from Occasional to Permanent Bipedalism?

The functional linkage between pelvis and spine remained long hidden to science. Here, we recount the history of research that led in 1992 to the discovery of the "angle of sacral incidence" by the team of G. Duval-Beaupère. This angle, formed between a ray from the hip joint center to the superior sacral surface and the perpendicular to the sacral surface, was later called pelvic incidence. Specific to each individual, pelvic incidence is tightly correlated with the degree of lumbar lordosis. It is each individual's "signature" for an efficient sagittal balance since it represents the sum of two positional parameters, sacral slope and pelvic tilt. The simultaneous experimental determination of the trunk line of gravity permitted Duval-Beaupère's team to elucidate the conditions of an efficient sagittal balance of the trunk on the lower limbs. We present an in vivo EOS study of eight spino-pelvic parameters describing the sagittal balance in 131 adults. We observe a chain of correlations between the six angular parameters and discuss the functional significance of these results. We show that pelvic incidence increases and lumbar lordosis develops when the infant learns to walk, leading to a correlation between these parameters. This process of association between pelvis and spine might have acquired a solid genetic basis during hominid evolution by natural selection acting on both pelvis and spine. We suggest that this process of functional integration was only possible in the context of bipedal locomotion becoming permanent and stereotyped, expressed by a relatively invariant, periodic walking cycle. Anat Rec, 300:912-931, 2017. © 2017 Wiley Periodicals, Inc.

Association between vertebral cross-sectional area and lumbar lordosis angle in adolescents.

Lumbar lordosis (LL) is more prominent in women than in men, but the mechanisms responsible for this discrepancy are poorly defined. A recent study indicates that newborn girls have smaller vertebral cross-sectional area (CSA) when compared to boys—a difference that persists throughout life and is independent of body size. We determined the relations between vertebral cross-sectional area (CSA) and LL angle and whether sex differences in lumbar lordosis are related to sex differences in vertebral CSA. Using multi-planar magnetic resonance imaging (MRI), we measured vertebral cross-sectional area (CSA) and vertebral height of the spine of 40 healthy boys and 40 girls, ages 9–13 years. Measures of the CSA of the lumbar vertebrae significantly differed between sexes (9.38 ± 1.46 vs. 7.93 ± 0.69 in boys and girls, respectively; P < 0.0001), while the degree of LL was significantly greater in girls than in boys (23.7 ± 6.1 vs. 27.6 ± 8.0 in boys and girls, respectively; P = 0.02). When all subjects were analyzed together, values for LL angle were negatively correlated to vertebral CSA (r = -0.47; P < 0.0001); this was also true when boys and girls were analyzed separately. Multivariate regression analysis indicated that vertebral CSA was independently associated with LL, even after accounting for sex, age, height or vertebral height, and weight. Similar negative relations were present when thoracic vertebrae were analyzed (Model P < 0.0001, R2 = 0.37, thoracic vertebral CSA slope P < 0.0001), suggesting that deficient vertebral cross-sectional dimensions are not merely the consequence of the anterior lumbar curvature. We conclude that vertebral CSA is negatively associated with LL, and that the greater degree of LL in females could, at least in part, be due to smaller vertebral cross-sectional dimensions. Studies are needed to examine the potential relations between vertebral CSA and spinal conditions known to be associated with increased LL, such as spondylolysis and spondylolisthesis.

Relationship between flexion contractures of the joints of the lower extremities and the sagittal profile of the spine in patients with cerebral palsy: a preliminary report

Background. The considerable incidence of kyphosis in patients with cerebral palsy (CP) causes back pain and aggravates movement disorders. However, few studies have investigated the pathogenesis of this condition.Aim. To identify the relationship between patient motor abilities, the severity of flexion contractures of the knee and hip joints and spinal sagittal profile changes, and the impact on the latter by surgical correction of flexion contracture of the knee joint.Material and methods. The study cohort included 17 pediatric CP patients (11 boys and 6 girls) with a mean age of 13.1 ± 1.3 (range, 10–16) years and level 2–4 spastic diplegia according to the Gross Motor Function Classification System. The relationship between radiological indicators of the spine sagittal profile and motor abilities of children, as well as the severity of flexion contractures at the hip and knee, and the degree of insufficiency of the active extension of the knee were investigated. Of these 17 patients, 12 underwent surgery to correct flexion contracture of the knee, which involved lengthening of leg flexors, to analyze the impact of contracture on the sagittal profile of the spine. The following radiological indicators were assessed: angle of thoracic kyphosis (CC), lordosis angle (UL) of the lumbar spine, and sacral inclination angle (SS). The study included patients with a CC of at least 30°.Results. Results of an X-ray study showed that the severity of kyphosis was 50.7° ± 2.1°, lordosis was 30.3° ± 4.3°, and SS was 30.5° ± 3.3°. There was a significant association between kyphosis and flexion contracture of the knee joint, as well as between lordosis and insufficient active extension of the knee joint. After elimination of the flexion contracture of the knee, the degree of severity of the CC (thoracic kyphosis) was unchanged, while UL (lordosis angle) and SS (sacral inclination angle) increased by approximately 10°.Conclusion. The severity of kyphosis in patients with CP is mainly dependent on the degree of flexion contracture of the knee joint. Although elimination of contractures does not lead to kyphosis correction, it increases the degree of lumbar lordosis and tilting of the sacrum.

Response to Comments on "Correlation between Radiologic Sign of Lumbar Lordosis and Functional Status in Patients with Chronic Mechanical Low Back Pain".

Dear Editor, We appreciate the interest in our work and for the opportunity to focus on detailed aspects of chronic mechanical low back pain. The reader attempted to emphasize the importance of pelvic incidence as a predictive factor for chronic low back pain. We should mention that concordant with this valuable comment there are several studies considering sagittal imbalance as a potential contributing factor for developing low back pain [1,2,3]. Pelvic incidence, a pelvic anatomic parameter that is specific and constant for each person determines the size of lumbar lordosis. Changes in this parameter either through relation with back muscle degeneration or other spine conditions might play a role in chronic mechanical low back pain [2,3,4]. The main focus of our study was lumbar lordosis and its effect on functional status measured by Oswestry disability index (ODI) that is not a simple pain score. According to this index, no significant correlation between the degree of lumbar lordosis and the score of functional disability was found [5]. Also, in a recent study using ODI, osteoarthritis of the facet joints as specific locations of degenerative changes to the lumbar spine, was not definitely correlated with ODI scores [6]. On the other hand, 2 studies investigating the relationship between spinopelvic parameters and clinical symptoms of severe isthmic spondylolisthesis used ODI and found a significant correlation between degree of lumbar lordosis and the Oswestry score. However, there was no correlation between pelvic incidence and the Oswestry score [7,8]. Disability is the main consequence of low back pain that should be prevented or treated once occurred. Thus, for more clarification we suggest randomized trials to evaluate possible relationships between the various spinopelvic alignment parameters such as pelvic incidence and the level of functional disability in patients with chronic mechanical low back pain.

Response to "commentary on lumbar lordosis in chronic mechanical back pain".

Dear Editor, We are extremely grateful for the opportunity to discuss the details that have been raised by Kothari et al. Although Kothari et al. have conducted an intelligent review, we would like to address a few points raised in their research. Firstly, they have suggested using magnetic resonance imaging to examine disc conditions and exclude patients with advanced disc degeneration. They also believed that we should have excluded patients with paraspinal muscle spasm and hamstring tightness from our study which was not done but we do not think so. Our response to this comment is somewhat hidden in the definition of mechanical low back pain which is the pain that does not receive a specific diagnosis. The majority of patients with mechanical low back pain have a multifactorial cause for their problems, which includes deconditioning; poor muscle recruitment; emotional stress; and changes associated with aging and injury such as disc degeneration, arthritis, and ligamentous hypertrophy. This type of lower back pain can be given many names; a few of the common names for this condition are simple backache, nonspecific lower back pain, lumbar strain, and spinal degeneration [1]. Hence, conditions that Kothari et al. listed as part of the exclusion criteria are some instances of probable causes for mechanical lower back pain. Secondly, in the article, Kothari et al. correctly pointed to the need to present values of the Oswestry Disability Index (ODI). The mean value of ODI was 30.51±13.75 (31.64±14.41 in females and 26.19±9.96 in males) and there was no significant correlation between the Oswestry Disability Questionnaire (ODQ) score and the degree of lumbar lordosis (Pearson's correlation coefficient; r=0.125, p=0.129). The mean value of lumbar lordosis (LL) in our sample was 44.69±11.43 degrees but 23 subjects had LL of more than 56.12 degrees and 20 subjects had LL that was less than 33.26 degrees. The mean ODI in patients in the outlier group (either LL greater than 56.12 degrees or less than 33.26 degrees) was 29.12±12.2 and the mean ODI in patients whose LL was within the average range was 31.02±14.29. The difference between these two groups was not statistically significant (independent samples test; p=0.45). Also, using oneway analysis of variance there was no significant statistical difference between any groups of patients who were out of range regarding the degree of lumbar lordosis (LL greater than 56.12 degrees or LL less than 33.26 degrees) and patients with an average range (p=0.38). Thirdly, we agree that our study has a skewed male to female ratio (F:M=119:31) which we should have mentioned as one of study limitations. However, we don't think that the ages of subjects will create an issue because osteoporosis mainly causes fractures in the upper spine and not the low back (except sacral insufficiency fractures). In addition, in the acute phase, patients usually experience pain in the upper back. Chronic spinal pain due to deformity caused by vertebral wedging and compression, as well as secondary ligamentous strain is often difficult to distinguish from disc deterioration. Chronic spinal pain can also be categorized as mechanical low back pain [2]. Fourthly, we agree with Kothari et al. that pelvic incidence and sacral slope are two of the other main sagittal spinopelvic parameters, which can potentially contribute to developing low back pain [3]. We have already noted this entry and mentioned that future studies should focus more on disability as the main consequence of low back pain when investigating the role of different spinopelvic parameters in chronic mechanical low back pain [4]. Thus, we recommend performing randomized trials to investigate whether there is a relationship between the various spinopelvic alignment parameters and the level of functional disability in patients suffering from chronic mechanical low back pain.

Etiology of lumbar lordosis and its pathophysiology: a review of the evolution of lumbar lordosis, and the mechanics and biology of lumbar degeneration.

The goal of this review is to discuss the mechanisms of postural degeneration, particularly the loss of lumbar lordosis commonly observed in the elderly in the context of evolution, mechanical, and biological studies of the human spine and to synthesize recent research findings to clinical management of postural malalignment. Lumbar lordosis is unique to the human spine and is necessary to facilitate our upright posture. However, decreased lumbar lordosis and increased thoracic kyphosis are hallmarks of an aging human spinal column. The unique upright posture and lordotic lumbar curvature of the human spine suggest that an understanding of the evolution of the human spinal column, and the unique anatomical features that support lumbar lordosis may provide insight into spine health and degeneration. Considering evolution of the skeleton in isolation from other scientific studies provides a limited picture for clinicians. The evolution and development of human lumbar lordosis highlight the interdependence of pelvic structure and lumbar lordosis. Studies of fossils of human lineage demonstrate a convergence on the degree of lumbar lordosis and the number of lumbar vertebrae in modern Homo sapiens. Evolution and spine mechanics research show that lumbar lordosis is dictated by pelvic incidence, spinal musculature, vertebral wedging, and disc health. The evolution, mechanics, and biology research all point to the importance of spinal posture and flexibility in supporting optimal health. However, surgical management of postural deformity has focused on restoring posture at the expense of flexibility. It is possible that the need for complex and costly spinal fixation can be eliminated by developing tools for early identification of patients at risk for postural deformities through patient history (genetics, mechanics, and environmental exposure) and tracking postural changes over time.

Correlation between Radiologic Sign of Lumbar Lordosis and Functional Status in Patients with Chronic Mechanical Low Back Pain.

Study DesignA cross-sectional study.PurposeTo describe the correlation between lumbar lordosis angle and functional status of patients with chronic mechanical low back pain (CMLBP).Overview of LiteratureThere are different and conflicting opinions regarding the relationship between the degree of lumbar lordosis and functional status of patients with low back pain. Nonetheless, the severity of lordosis is still one of the routine physical exams considered in rehabilitation clinics.MethodsThe degree of lumbar lordosis of 150 patients with CMLBP was measured by means of Cobb's method using sagittal standing spinal radiographs. Subjects with probable secondary causes of low back pain (trauma, congenital anomaly, spinal infection, rheumatologic problems and history of spinal surgery) were excluded. Besides recording demographic data, their score of functional disability was estimated using Oswestry Disability Questionnaire, one of the most useful and reliable questionnaires. Comparison between these data was made regarding different age and gender groups.ResultsIn this study, 119 subjects were female and 31 male, with an age range of 19-85 years. The average degree of lumbar lordosis was 44.69±11.43 and that of Oswestry disability index (ODI) 30.52%. Although we found a significant direct relationship between age and degree of lumbar lordosis (Pearson's correlation coefficient, p=0.016, r=0.197), while insignificant correlation was seen between the degree of lumbar lordosis and ODI (p=0.129).ConclusionsThere was no significant correlation between the degree of lumbar lordosis and the score of functional disability with regards to different age groups and gender.