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How do anterior/posterior translations of the thoracic cage affect the sagittal lumbar spine, pelvic tilt, and thoracic kyphosis?

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Abstract and Figures

Anterior and posterior thoracic cage translations in the sagittal plane have not been reported for their range of motion and effects on the lumbar spine and pelvis. Twenty subjects volunteered for full-spine radiography in neutral, anterior, and posterior thoracic cage translation postures in a standing position. While grasping an anterior vertical pole, with hands at elbow level, subjects were instructed on how to translate their thoracic cage without any flexion/extension, utilizing a full-length mirror. On the radiographs, all four vertebral body corners of T1 through S1 and the superior margin of the acetabulum were digitized. Segmental and global angles of thoracic kyphosis, sagittal lumbar curvature, and pelvic flexion/extension in translation postures were compared to alignment in the neutral posture. Using the femur heads as an origin, the mean range of thoracic cage translation, measured as horizontal movement of T12 from neutral posture, was found to be 85.1 mm anterior and 73 mm posterior. In anterior translation, the thoracic kyphosis is hypokyphotic (Cobb T1-T12 reduced by 16 degrees). In posterior translation, the segmental angles at T12-L1 and L1-L2 flexed, creating an "S" shape in the sagittal lumbar spine, while the thoracic kyphosis increased by 10 degrees. Using posterior tangents from L1 to L5 and T12 to S1, and Cobb angles at T12-S1, the lumbar curve reduced slightly (by less than 3.3 degrees for all global angle measurements) in anterior translation and reduced by 7.4 degrees, 5.7 degrees, and 8.1 degrees respectively in posterior thoracic translation. The angle of pelvic tilt (measured as the angle of intersection of a line through posterior-inferior S1 to the superior acetabulum and the horizontal) reduced by a mean of 15.9 degrees, and Ferguson's sacral base angle to horizontal reduced by a mean of 13.1 degrees in posterior translation. In anterior translation, pelvic tilt and Ferguson's sacral base angle increased by 15.1 degrees and 12.8 degrees, respectively. The findings of this study show that thoracic cage anterior/posterior translations cause significant changes in thoracic kyphosis (26 degrees ), lumbar curve, and pelvic tilt. An understanding of this main motion and consequent coupled movements might aid the understanding of spinal injury kinematics and spinal displacement analysis on full spine lateral radiographs of low back pain and spinal disorder populations.
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Abstract Anterior and posterior
thoracic cage translations in the
sagittal plane have not been reported
for their range of motion and effects
on the lumbar spine and pelvis.
Twenty subjects volunteered for full-
spine radiography in neutral, anterior,
and posterior thoracic cage translation
postures in a standing position. While
grasping an anterior vertical pole,
with hands at elbow level, subjects
were instructed on how to translate
their thoracic cage without any flex-
ion/extension, utilizing a full-length
mirror. On the radiographs, all four
vertebral body corners of T1 through
S1 and the superior margin of the ac-
etabulum were digitized. Segmental
and global angles of thoracic kypho-
sis, sagittal lumbar curvature, and
pelvic flexion/extension in translation
postures were compared to alignment
in the neutral posture. Using the fe-
mur heads as an origin, the mean
range of thoracic cage translation,
measured as horizontal movement of
T12 from neutral posture, was found
to be 85.1 mm anterior and 73 mm
posterior. In anterior translation, the
thoracic kyphosis is hypokyphotic
(Cobb T1–T12 reduced by 16°). In
posterior translation, the segmental
angles at T12–L1 and L1–L2 flexed,
creating an “S” shape in the sagittal
lumbar spine, while the thoracic
kyphosis increased by 10°. Using
posterior tangents from L1 to L5 and
T12 to S1, and Cobb angles at
T12–S1, the lumbar curve reduced
slightly (by less than 3.3° for all
global angle measurements) in ante-
rior translation and reduced by 7.4°,
5.7°, and 8.1° respectively in poste-
rior thoracic translation. The angle of
pelvic tilt (measured as the angle of
intersection of a line through poste-
rior-inferior S1 to the superior acetab-
ulum and the horizontal) reduced by
a mean of 15.9°, and Ferguson’s
sacral base angle to horizontal re-
duced by a mean of 13.1° in posterior
translation. In anterior translation,
pelvic tilt and Ferguson’s sacral base
angle increased by 15.1° and 12.8°,
respectively. The findings of this
study show that thoracic cage ante-
rior/posterior translations cause sig-
nificant changes in thoracic kyphosis
(26°), lumbar curve, and pelvic tilt.
An understanding of this main mo-
tion and consequent coupled move-
ments might aid the understanding of
spinal injury kinematics and spinal
displacement analysis on full spine
lateral radiographs of low back pain
and spinal disorder populations.
Keywords
Lordosis · Kyphosis ·
Spinal coupling · Translation · Posture
ORIGINAL ARTICLE
Eur Spine J (2002) 11:287–293
DOI 10.1007/s00586-001-0350-1
Deed E. Harrison ·
René Cailliet ·
Donald D. Harrison ·
Tadeusz J. Janik
How do anterior/posterior translations
of the thoracic cage affect
the sagittal lumbar spine, pelvic tilt,
and thoracic kyphosis?
Received: 29 November 2000
Revised: 16 July 2001
Accepted: 30 August 2001
Published online: 1 November 2001
© Springer-Verlag 2001
D.E. Harrison
Private Practice, Elko, Nevada, USA
R. Cailliet
Department of Rehabilitative Medicine,
University of Southern California School
of Medicine, Pacific Palisades, California,
USA
D.D. Harrison ()
Biomechanics Laboratory,
Université du Quebec a Trois-Rivières,
Canada
e-mail: drcbp@idealspine.com,
Tel.: +1-307-789-2088,
Fax: +1-307-789-2154
T.J. Janik
Time Domain, Huntsville, Alabama, USA
Contact address:
Donald D. Harrison,
PO BOX 1590, Evanston, WY,
USA 82931–1590
Introduction
Recently, there has been renewed interest, with regard to
both surgical and conservative care, in the sagittal plane
alignment of the human thoracic, lumbar, and pelvic re-
gions of the spine. Alterations in the sagittal plane align-
ment of the human spine have been implicated in the de-
velopment of a variety of spinal disorders or diseases in-
cluding: acute and chronic back pain [7], disc degenera-
tion [33], spondylosis [23, 33], ossification of the spinal
ligaments [6], adolescent idiopathic scoliosis (AIS) [4, 5],
Scheuermann’s kyphosis [38], impaired ribcage expansion
during respiration [3, 24], osteoporosis and vertebral com-
pression fractures [24], and spondylolisthesis [1]. Before
surgical or conservative rehabilitative treatment is initi-
ated, factors affecting the sagittal plane alignment of the
spine must be identified and understood. Advanced age,
weight, pelvic morphology, and body posture have all been
shown to affect sagittal plane alignment of the human spine
[7, 13, 16].
Concerning upright human posture, there are six degrees
of freedom of posture of the head and thoracic cage. Only
the rotational movements, termed “traditional planes of mo-
tion” by White and Panjabi [39], have been widely stud-
ied for their two-dimensional (2-D) and three-dimensional
(3-D) spinal displacement (coupling) patterns [2, 26, 27,
28, 39, 40]. As there is a renewed interest in reducing
sagittal plane deformities of the thoracic, lumbar, and pelvic
regions, all postural movements in the sagittal plane need
to be evaluated for their vertebral coupling patterns.
Currently, pelvic morphology and the angle of pelvic
flexion/extension are thought to be the primary factors
that affect changes in lumbar lordosis [13, 18, 19]. Like-
wise, thoracic cage flexion and extension are the primary
movements thought to increase or decrease the thoracic
kyphosis [32, 34, 39]. As such, pelvic tilt and/or thoracic
cage flexion/extension are the primary movements utilized
in today’s clinical and surgical management for the cor-
rection/reduction of sagittal plane deformities [13, 18, 19,
32, 34, 39]. However, “fixed” sagittal plane translations of
the thoracic cage have been overlooked as main motions
in range of motion, spinal coupling, and in X-ray projec-
tion studies [8, 9, 29, 30, 31]. Using the 3-D Cartesian co-
ordinate system suggested by Panjabi et al. [25], the ante-
rior and posterior postural translations of the thoracic cage
are z-axis translations (±Tz).
Penning studied cervical coupling during z-axis (sagit-
tal) translations of the head, now known as protrusion and
retraction [29, 30, 31]. He reported “S” shapes in the sagit-
tal cervical spine during these head translation movements,
and related these movements to whiplash injuries [30].
We hypothesized that changes in thoracic kyphosis,
pelvic tilt, and lumbar curvature (similar to Penning’s cer-
vical findings) would occur during these rib cage postural
translation movements. The present study seeks to quan-
tify the range of motion of the thoracic cage in anterior/
posterior translations and the associated thoracic, lumbar,
and pelvic 2-D radiographic coupling patterns.
Materials and methods
In the standing position, three lateral full-spine radiographs of 15
men and five women volunteers, who were students at Life Uni-
versity in Marietta, Georgia, were obtained in 1999 in the follow-
ing postures: neutral, anterior thoracic z-axis translation, and pos-
terior thoracic z-axis translation (Fig.1). All aspects of this study
were approved by our internal review board (IRB). The subjects
were without a history of back pain and/or prior spinal surgery. On
a visual analog scale (VAS: 0=”perfect health”, 1=”slight discom-
fort, only intermittently, annoyance”,...,10=”bedridden with unbear-
able pain”) the volunteers had an average score of 0.5, indicating
that they were pain free on the day of study participation. Subjects
had an average age of 28.0 years (SD 6.6 years), an average height
288
Fig.1 Full-spine radiographs
of 20 normal subjects were ob-
tained in neutral and anterior/
posterior translational main
motions of the thoracic cage
(±Tz), (known as protrusion/re-
traction for head movements).
These thoracic cage movements
have been neglected in the lit-
erature for lumbar/pelvic cou-
pling research. In the middle
photograph, a neutral posture
is depicted. The subject is hold-
ing onto a vertical pole to keep
the upper extremities from pro-
jecting over the spine. In the
left photograph, anterior (hori-
zontal) translation of the tho-
racic cage is illustrated. In the
right photograph, posterior
(horizontal) translation of the
thoracic cage is shown
of 176.7 cm (SD 10.0 cm), and an average weight of 76.6 kg (SD
15.3 kg).
A supervising instructor taught each subject, utilizing a full-
length mirror, how to translate their thoracic cage with respect to
their pelvis. The subjects were instructed to keep T1 approximately
over the level of T12. Because this is not a common range of mo-
tion, specific attention was taken to avoid any thoracic cage flex-
ion and extension. During all radiographs, the subjects grasped an
anteriorly placed vertical pole at waist level to keep the humerus
from overlapping the thoracic spine. After obtaining a neutral lat-
eral full-spine radiograph, radiographs were obtained in the two
thoracic cage translated positions.
Full-spine radiographs were obtained in each of these trans-
lated postures at a tube-film distance of 182.9 cm. To ensure the
radiographic visibility of the T1–T4 area on the full-spine radio-
graphs, special split/variable cassette screens were purchased from
X-ray Cassette Repair Company (Crystal Lake, Illinois).
The radiographic images were digitized with a sonic digitizer
(GP-9, purchased from GTCO CalComp, Columbia, Maryland). All
four vertebral body corners of T1–S1 and the superior margin of
the acetabulum were digitized. Digitized points were processed with
our own code developed with Trent Computer Systems (Harvest,
Alabama).
Adjacent segmental angles or relative rotation angles (RRAs)
and global angles or absolute rotation angles (ARAs) of thoracic
kyphosis and lumbar lordosis were determined with the posterior
tangent method (Fig.2). Also, Cobb angles were computed at
T1–T12, T2–T11, and T12–S1. Ferguson’s sacral base angle to
horizontal was calculated. An angle of pelvic tilt was calculated by
the intersection of a line through posterior-inferior S1 to the supe-
rior acetabulum and a horizontal line. To ensure that the subjects
were not adding excessive flexion/extension of the thoracic cage to
the desired anterior/posterior translations, lines connecting the cen-
troids of T1 and T12 and T2 and T11 were compared to the true
vertical. The range of thoracic cage anterior/posterior translation was
measured as a horizontal translational movement of the T12 verte-
bral body compared to a vertical line through the superior margin
of the femur heads. The reliability of the digitizing system in cal-
culating the above rotation angles and translation distances has
been found to have high inter- and intraclass correlation coeffi-
cients and low standard errors of measurement [10, 11].
Since the mean absolute differences of observers’ measurements
of the computed angles and distance have been reported as small
(between 0.6° and 2° for angles) [10, 11], only means and plus/mi-
nus one standard deviation were required to analyze our results.
Results
Subjects could translate their rib cages forward 85.1 mm
(+Tz) and backward 73.0 mm (–Tz), measured as horizon-
tal movement from neutral alignment of T12 compared to
a vertical line through the femur head (Table 1). After ac-
counting for magnification, these distances were esti-
mated to be anterior 76.7 mm and posterior 65.0 mm in
vivo. Subjects who started in a posterior translated posture
(mean of –69.4 mm) were able to translate a greater dis-
tance forward (101.8 mm) and less backwards (56.2 mm).
Subjects whose neutral posture was an anterior translation
of T12 relative to the femur head (mean of –36.9 mm)
were able to translate less distance forward (79 mm) and
more backward (77.7 mm). During these translational
movements, subjects were able to minimize thoracic cage
flexion/extension to a mean of less than 4.2° (Table 1).
Means and standard deviations are provided for all
movements in all of the tables. There were changes in
pelvic tilt, measured as the angle between a line from the
posterior-inferior S1 to the superior acetabulum and the
horizontal, during anterior/posterior translations of the tho-
289
Fig.2A–C Posterior tangents and Cobb angles were used to ana-
lyze vertebral positions on the full-spine radiographs. A Tangents
at the posterior body margins of each segment can be intersected to
create relative rotation angles (RRAs – segmental angles). Absolute
rotation angles (ARAs – global angles) are the combined sum of
the RRAs between the posterior tangents. B Cobb angles were drawn
at T1–T12, T2–T11, and T12–S1. C The sagittal alignment of T1
above T12 was measured with a vertical line compared to a line
through the centroids of T1 and T12. The range of translation mo-
tion was measured as a horizontal distance of posterior-inferior
T12 from a vertical line through the superior margin of the femur
heads. Ferguson’s sacral base angle to the horizontal was com-
puted. Also an angle of pelvic tilt to the horizontal was determined
from inferior-posterior S1 to the superior margin of the femur head
Table 1 Displacement of the thoracic cage and rotations of the
pelvis for 20 normal subjects during anterior translations (±Tz) and
posterior translations (–Tz) of the thoracic cage. (These values are
radiographic measurements, not corrected for magnification, and
are presented as mean±SD)
Measure +Tz Neutral –Tz
Tz
T12–S1
(mm)
a
76.9±16.9 11.8±20.8 –43.1±21.6
Tz
T12–femur head
(mm)
a
39.0±16.8 –46.1±15.9 –119.1±23.5
T1–T12 to vertical
b
(°) –4.2± 6.0 0.5± 4.0 –0.5± 6.8
Sacral base to horizontal (°) 54.1± 8.5 41.3±10.0 28.2± 9.8
Pelvic tilt
c
(°) 81.2±11.7 66.1± 7.9 50.2± 9.5
a
Anterior/posterior translational (horizontal) displacement of T12
above S1 or T12 above the superior margin of the femur head
b
Line through the centroids of T1 and T12, used to check for any
flexion/extension during thoracic cage anterior/posterior transla-
tion. Negative angle values indicate extension
c
Posterior-inferior S1 to superior margin of acetabulum to hori-
zontal
racic cage. In anterior translation, the pelvis rotated for-
ward (+Rx) on the femur heads by a mean of 81.2°–
66.1°=15.1°. During posterior translation, the pelvis ex-
tended (–Rx) by a mean of 66.1°–50.2°=15.9° (Table 1).
In the sagittal lumbar spine, posterior translation created
an “S” configuration as the segmental angles at T12–L1,
L1–L2, and L2–L3 flexed, on average, by a combined to-
tal of 12.7° compared to the neutral position, while L4–L5
and L5–S1 extended by a combined total of 7°.
In anterior translation, T12–L1 and L1–L2 extended,
on average, by a combined total of 5° from the neutral po-
sition, while L4–L5 and L5–S1 flexed by a combined to-
tal of 6°. The global angles, Cobb
T12–S1
, ARA
L1–L5
, and
ARA
T12–S1
, slightly reduced (by less than 3.5° in all cases)
in anterior translation, and reduced more (by 8.1°, 7.4°,
and 5.7° respectively) in posterior translation (Table 2).
In posterior translation, the thoracic kyphosis increased
in all global angles; the mean increase in ARA
T1–T12
was
9.4°, in ARA
T2–T11
7.1°, in Cobb
T1–T12
10°, and in
Cobb
T2–T11
7.2°. Anterior translation of the thoracic cage
caused hypokyphosis of the thoracic curve with mean an-
gle decreases between posterior tangents at ARA
T1–T12
of
13.6° and at ARA
T2–T11
of 11.5°, with Cobb
T1–T12
decreas-
ing by 16° and Cobb
T2–T11
by 13.3° (Table 3).
Discussion
This paper is the first to report ranges of motion and
spinal coupling patterns in the thoracic and lumbo-pelvic
spines for anterior/posterior translation postures of the
thoracic cage. As hypothesized, large changes in lumbar
curvature and pelvic movements occur during anterior/
posterior translations of the thoracic cage. Additionally,
unexpectedly large changes in thoracic kyphosis occurred.
Figure 3 and Fig.4 illustrate the changes in the thoracic
kyphosis, lumbar lordosis, and pelvic tilt caused by ante-
rior/posterior translation of the thoracic cage.
290
Table 2 Rotational changes of lumbar lordosis for 20 normal sub-
jects during anterior and posterior translations (±Tz) of the tho-
racic cage. (These values are radiographic measurements, not cor-
rected for magnification, and are presented as mean±SD)
Measure +Tz Neutral –Tz
Cobb
T12–S1
(°) –60.4±14.1 –62.0±12.0 –53.9±15.7
RRA
T12–L1
a
(°) –4.0± 4.9 –0.4± 4.2 4.3± 3.9
RRA
L1–L2
(°) –4.6± 4.1 –3.3± 6.2 2.5± 5.9
RRA
L2–L3
(°) –7.1± 4.5 –7.5± 3.9 –5.3± 5.3
RRA
L3–L4
(°) –10.3± 5.3 –10.6± 3.8 –10.6± 5.3
RRA
L4–L5
(°) –14.8± 7.2 –17.2± 5.6 –17.8± 5.9
RRA
L5–S1
(°) –26.6±10.3 –31.7±10.7 –38.1± 8.8
ARA
L1–L5
b
(°) –36.8±13.8 –38.6±12.3 –31.2±15.4
ARA
T12–S1
(°) –67.4±15.5 –70.7±14.0 –65.0±15.0
a
Relative rotation angle formed by posterior tangents (segmental
angle)
b
Absolute rotation angle (sum of RRAs). Negative values indicate
extension
Table 3 Rotational changes of the thoracic kyphosis for 20 nor-
mal subjects during anterior and posterior translations (±Tz) of the
thoracic cage (mean±SD)
Measure +Tz Neutral –Tz
H/L
a
of T1–T12 0.970 0.953 0.940
Cobb
T1–T12
(°) 31.5±14.2 47.5±10.4 57.5±12.3
Cobb
T2–T11
(°) 29.7±14.5 43.0±10.9 50.2±14.4
RRA
T1–T2
(°) 0.8± 7.8 –0.1± 4.8 1.0± 6.7
RRA
T2–T3
(°) 4.5± 5.5 3.6± 4.5 5.3± 5.5
RRA
T3–T4
(°) 2.7± 6.2 5.5± 5.2 4.4± 3.7
RRA
T4–T5
(°) 5.2± 5.3 6.2± 4.2 6.5± 5.2
RRA
T5–T6
(°) 4.6± 4.3 6.3± 4.1 5.5± 5.1
RRA
T6–T7
(°) 5.8± 4.3 6.9± 3.1 7.8± 3.6
RRA
T7–T8
(°) 3.6± 3.6 5.9± 4.4 6.4± 4.0
RRA
T8–T9
(°) 3.3± 3.6 4.3± 3.5 5.7± 3.9
RRA
T9–T10
(°) 2.1± 3.7 2.5± 3.3 3.4± 3.8
RRA
T10–T11
(°) 0.7± 4.9 3.1± 3.4 6.4± 3.3
RRA
T11–T12
(°) –0.7± 4.0 2.2± 4.2 3.5± 3.3
ARA
T1–T12
(°) 32.7±14.8 46.3±11.6 55.7±12.9
ARA
T2–T11
(°) 32.6±13.6 44.1±11.5 51.2±12.4
ARA
T3–T10
(°) 27.4±11.4 37.4±12.2 39.6±11.3
a
Height/length ratio; length along the posterior longitudinal liga-
ment from T1 to T12
Fig.3A–C Anterior/posterior translations of the thoracic cage cre-
ated changes in thoracic kyphosis. Hypokyphosis (A) was found in
anterior translation. Hyperkyphosis was observed in subjects in
posterior translated posture (C) as compared with a neutral posture
(B). The average total change in the Cobb angle at T1–T12 was
26° from the posterior to anterior translated positions. The length
of the spine (L) is the arc length along the posterior longitudinal
ligament from T1 to T12. The height-to-length index increased in
anterior translation posture (mean H
A
/L=0.97), indicating straight-
ening in the anterior translated posture. The height-to-length index
decreased in posterior translation (mean H
P
/L=0.94)
Comparing horizontal displacement of T12 to the fe-
mur head, the range of motion was approximately 85 mm
forward and 73 mm backward translational movement on
the radiographs, but this was dependent on the initial start-
ing posture. Using similar triangles to eliminate projec-
tion distortion, we estimated these distances to be anterior
77 mm and posterior 66 mm in the live subjects.
Concerning the change in thoracic kyphosis, in Table 3,
the findings indicate that the lower thoracic region
(T8–T12) accounts for 13.6° of this change, or 60%; this is
probably related to the floating or incomplete rib arrange-
ment in this region. This finding is unique, as these values
are unlike those reported for thoracic coupling during flex-
ion/extension (±Rx) of the rib cage [39].
In regard to the lumbar lordosis, the opposite exten-
sion/flexion movements above and below the lumbar curve
apex (L4) during anterior/posterior translations of the tho-
racic cage (Table 2) are similar to Penning’s cervical find-
ings in head protrusion/retraction [29, 30]. An “S” shape
was noted in the sagittal lumbar spine during posterior
thoracic cage translation (Fig.4). However, even though
the opposite extension/flexion coupling was observed in
the lumbar segments, the opposite “S” shape was not ob-
served during anterior translation of the thoracic cage. This
is because of the deeper lordosis at L4-L5-S1 in the nor-
mal elliptical shape [7, 14].
Recently, Kiefer et al. [15] reported the importance of
keeping T1, T12 and S1 vertically aligned in the sagittal
plane to minimize muscle forces and moments in upright
neutral posture. For these reasons, we measured thoracic
cage translations as horizontal displacements of T12 to
S1, while keeping T1 vertically aligned with T12. During
thoracic Tz translations, subjects had a mean flexion/ex-
tension of less than 4.2° at T1–T12, indicating that these
endpoints remained vertically aligned (Table 1). However,
Kiefer et al. [15] modeled T1–T12 as one rigid body and
the large changes in thoracic kyphosis reported here, es-
pecially in the lower thoracic region (total change in Cobb
angle of 26° at T1–T12 in Table 3) indicate that the rigid-
ity of the thoracic cage needs to be re-evaluated. Perhaps
only the thoracic kyphosis from T1 to T10 should be mod-
eled as a rigid body.
There are limitations inherent in the present study. First,
we utilized only 20 normal subjects; however, the major-
ity of range of motion and spinal coupling pattern reports
have utilized a similar number of subjects [8, 9, 28]. Sec-
ondly, our subjects were healthy, pain-free volunteers;
therefore, it is unknown how spinal disorders will affect
or change the results of the present study. Third, and most
important, there are different ways in which the anterior/
posterior thoracic translation could have been carried out.
Because we desired to simulate (as close as possible) a
real life situation in upright stance, we did not constrain
the pelvis. We wished to see any compensatory pelvic
movements. Lastly, some of our subjects needed feedback
to keep this sagittal plane translation a pure movement,
and a supervisor was therefore used to give subjects visual
feedback about the verticality of the thoracic cage. This
could have influenced the movements in the ribcage in an
unknown way. However, since the subjects’ muscles were
actively controlling the movement (no external loads were
used), we feel that the movement is as close to a real life
situation as possible.
The decreased range of movement or flexibility in pos-
terior thoracic cage translation in our subjects is consis-
tent with findings in cadavers subjected to anterior and
posterior shear loads [20, 35]. This is probably related to
the reduced range of motion of the thoraco-lumbar spine
in extension compared to flexion.
Recently, there have been a multitude of studies de-
scribing the normal ranges and segmental contributions of
the thoracic kyphosis, lumbar lordosis, and pelvic tilt an-
gle [13, 36, 37]. According to the findings of the present
study, differences in the magnitude and direction of tho-
racic z-axis translation postures in different individuals
may be one of the causes of the variances in sagittal plane
thoracic and lumbar curvatures. Many studies utilizing a
type of a sagittal plane plumb line analysis to measure
spinal balance of the thorax relative to the pelvis have de-
scribed a wide range of values [13, 36, 37]. However,
these vertical plumb lines cannot distinguish between tho-
racic cage flexion, extension, anterior translation, poste-
rior translation, pelvic flexion and extension nor combina-
tions of the above postures. To ensure that the subjects in
the current study were not adding excessive flexion/exten-
sion of the thoracic cage to the desired anterior/posterior
translations, lines through the centroids of T1 and T12
and T2 and T11 were compared to the true vertical.
Additionally, several surgical outcome studies have
identified loss of the distal lumbar lordosis and decreased
sacral tilt (extension) as risk factors for post-surgical low
291
Fig.4 Three configurations of the lumbar curvature and pelvic tilt
are illustrated: A anterior thoracic translation (+Tz), B neutral pos-
ture, and C posterior thoracic translation (–Tz). In anterior transla-
tion (A), the pelvis flexes on the femur heads, the Ferguson’s
sacral base angle increases, while the upper lumbars extend and
the lower lumbars flex compared to the neutral posture. In poste-
rior translation (C), the pelvis extends on the femur heads, the
sacral base becomes more horizontal, and the lumbar curve be-
comes an “S” shape as the upper lumbars flex (T12–L2), while the
lower lumbars extend
back pain [17, 18, 22]. As our present study demonstrates
that posterior translations of the thorax reduces lumbar
lordosis (6°–8°) and pelvic and sacral tilt (16°–13°), tho-
racic sagittal plane translations merit clinical evaluation
as one of the corrective procedures in combating thora-
columbar spinal pain, impairment, and deformity.
It is interesting to speculate about the relevance of an-
terior translated thoracic postures to spinal disorders such
as thoracic scoliosis, Scheuermann’s kyphosis, and lum-
bar spondylolisthesis. Concerning scoliosis of the thoracic
region, several studies indicate that the thoracic kyphosis
must decrease or become lordotic in order for the coronal
plane curvature to progress [4, 5, 12]. In a few of our sub-
jects, the thoracic kyphosis dramatically straightened dur-
ing anterior thoracic translation. In this anterior translated
position, the application of compressive loads or lateral
moment loads to the thoracic spine may be a risk factor
for the development of or increase in the magnitude of
curvature.
Conversely, posterior translation increased the thoracic
kyphosis by 10° and could be one of the mechanical factors
associated with the onset or progression of syndromes asso-
ciated with an increased thoracic cage kyphosis (Scheuer-
mann’s kyphosis, osteoporosis, compression fractures, and
decreased rib mobility). In support of this idea, Lowe and
Kasten [21] reported that 31 out of 32 of their patients
with
Scheuermann’s disease had an average increased pos
terior
translation of 7.3 cm compared to normal sagittal balance.
Diagnostic thoracic sagittal plane translation studies
could be made a part of the clinical evaluation and reha-
bilitative exercises in the management of increased or de-
creased lumbar lordosis and thoracic kyphosis. In such
cases, no emphasis would need to be placed on pelvic tilt-
ing or thoracic cage flexion/extension movements. Cur-
rently, this idea is not in the armamentarium of teaching
or clinical practice.
Conclusions
This study is the first to report ranges of motion and spinal
coupling for anterior/posterior translations of the thoracic
cage. Large changes (26°) in kyphosis occur in anterior/
posterior translation of the thoracic cage (60% of this be-
ing at T8–T12); the thoracic kyphosis straightens in ante-
rior translation and increases in posterior translation. The
pelvis tilts forward in anterior thoracic cage translations,
while the lower lumbars flex and the upper lumbars ex-
tend. The pelvis extends backwards in posterior thoracic
cage translations, the lower lumbars extend and the upper
lumbars flex, creating an “S” configuration. In the future,
thoracic cage sagittal plane translations may lead to an in-
creased understanding of physical medicine and rehabili-
tation for sagittal plane deformities of these regions.
Acknowledgements We acknowledge the support given by CBP
Nonprofit Inc. We thank Dr. Phillip Paulk, Stockbridge, Georgia,
for taking 60 X-rays, Dr. Sanghak O. Harrison, CBP Nonprofit,
Inc., for the art work, Dr. Burt Holland, Temple University, for sta-
tistical analysis, and Brittany Adkins for modeling.
292
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... For this reason, a non-parametric correlation test (Spearman's rank correlation) rather than a common Pearson's correlation analysis was conducted to measure rank correlation between the thoracic RoM and Cobb angle. Third, although the Cobb method is the most frequent approach to the evaluation of the spinal curves [22][23][24][25][26][27][28][29][30][31] and is also widely recognized as the gold-standard approach in clinical applications [20,21,32], some have questioned its validity due to inherent errors in identi cation of the vertebral mid-plane slopes and in using 2D measurements rather than 3D ones [24]. Other methods for radiologic assessment of the spinal curvatures have been suggested [33]; however, the Cobb angle remains the clinical standard technique [20]. ...
... Unlike RoM, normal thoracic kyphosis has been extensively measured using both radiographic and skinbased methods [10,17,[22][23][24][25][26][27][28][29][30][31][32], and a wide range of data have been reported ( Figure 4). The normal thoracic kyphosis is accepted in the range of 20 to 50 [22]. ...
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Previous studies have measured thoracic range of motion (RoM) using either skin-mounted devices or supine CT-imaging and have reported quite different RoMs. Given the inherent shortcomings of measurements of vertebrae movements from the overlying skin, the present study aims to measure normal RoM of the thoracic spine in the sagittal plane using the upright digital radiography. Lateral radiographs of the thoracic spine were acquired from eight asymptomatic male subjects in upright standing and full forward flexion using a mobile U-arm digital radiographic system. Total (T1-T12), upper (T1-T6), and lower (T6-T12) thoracic RoMs were measured. A throughout comparison with available skin-based measurements in the literature was carried out. Mean of total (T1-T12) thoracic RoM was 22.5° (SD 4.1°), most of which was generated by the lower (T6-T12) as compared to upper (T1-T6) thoracic spine (15.5° versus 7.1°, p<0.001). These RoMs were within the lower range of data previously reported by other skin-based approaches. While skin-based measurements suffer from the inter sensor-skin-vertebra movements and supine imaging techniques do not allow maximal trunk flexion, standing radiography remains as the gold-standard technique. Evaluation of thoracic spine RoM has implications in both patient discrimination for diagnosis and in biomechanical models for estimation of spinal loads.
... Harrison et al. presented an important paper on TL spinal coupling that occurs with a posteriorly translated thoracic posture 29) . They determined, that as compared to an ideal neutral position, when a subject posteriorly translated their thorax the lumbar spine changes from the normal neutral elliptical configuration to an S-shape, where the lower lumbar spine hyperextends, and the upper lumbar and TL spine flexes 29) . ...
... Harrison et al. presented an important paper on TL spinal coupling that occurs with a posteriorly translated thoracic posture 29) . They determined, that as compared to an ideal neutral position, when a subject posteriorly translated their thorax the lumbar spine changes from the normal neutral elliptical configuration to an S-shape, where the lower lumbar spine hyperextends, and the upper lumbar and TL spine flexes 29) . The sacral base angle also reduces as the pelvis is rotated posteriorly. ...
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Purpose] To present the structural improvement of an excessive junctional thoracolumbar kyphosis and related biomechanical parameters in an adolescent. [Participant and Methods] A 16 year old female presented with chronic back pains. Radiographic assessment revealed excessive posterior sagittal balance and thoracolumbar kyphosis and reduced lumbar lordosis and sacral inclination. Chiropractic BioPhysics ® technique including mirror image ® , anterior thoracic translation and thoracolumbar hyperextension traction was performed as well as spinal manipulation and postural exercises over an 8-week period. [Results] After 24 in-office treatments and a daily home program the patient reported a minimization of back pains and a better mood. Follow-up X-rays demonstrated a 48 mm reduction of posterior sagittal balance, a 22° reduction of thoracolumbar kyphosis, an 11° increase in lumbar lordosis, and a 10° increase in sacral inclination. [Conclusion] This is the first case documenting the non-surgical reduction of excessive thoracolumbar junctional kyphosis and related biomechanical parameters in an adolescent. Precise analysis of radiologic assessment for adolescents presenting with back pains is advised and are safe for the screening of postural disorders. There is a growing evidence base for the Chiropractic BioPhysics ® technique approach in the correction of lumbar spine disorders; more research is encouraged to further evaluate this unique treatment.
... For the thoracic kyphosis assessment, most studies assessed the angle from the superior endplate of the T1 vertebrae and inferior endplate of the T12 vertebrae. 28,36,41,45 For the frequency values for lumbar lordosis, studies that calculated the angle from the superior endplate of L1 and inferior endplate of L5 3,28,38,43,44 and studies that calculated from the superior endplate of L1 and superior of L5 43-45 were considered. It was not possible to establish frequency values for percentiles of photogrammetric studies because of the divergence of procedures and angle calculation between the studies found. ...
... Moreover, in this present review, 15 studies were found which used the radiographic method to assess the curvature angles, and 5 of them showed mean values over 60°. 35,36,38,42,46 According to Cobb (apud Moe 17 ), this population would be hyperlordotic. On the other hand, Endo et al 40 and Ghandihari et al 45 presented a population with lumbar rectification when following Cobb's classification. ...
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... Postural rotations and translations as described by Harrison (Figures 2 and 3) are understood as 'main motions' and the corresponding spinal displacements to accommodate the postural positions are termed 'coupled motions' [2,3,[35][36][37][38]. In CBP, a considerable clinical significance is placed on the correlation between the patient's three-dimensional postural presentation (posture displacement in terms of rotations and translations) and the two-dimensional X-ray coupled motion (spinal rotations and translations) [2,3,38]. ...
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... However, radiography is considered the gold standard for the quantification of spine angles from calculations, with reference to the vertebrae visible on the radiographic examination [29]. The commonly used method is the Cobb angle, used to measure frontal deformity by the intersection of a straight line drawn from the endplate of a vertebra and a straight line drawn from the endplate of another vertebra of reference [30,31]. In mastectomised patients, where there may be adjuvant treatments involving radiation, biophotogrammetry is a simple and easy-to-apply alternative, with a low cost of clinical application, ease of photo interpretation, high precision and facile reproduction of results [19] with an objective and quantitative analysis. ...
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... Lumbar spine hyperlordosis is associated with LBP and facet arthrosis 10) . Biomechanically it is also associated with a forward postural sagittal balance and increased pelvic tilt (sacral base angle) 11) . In asymptomatic and normally postured subjects, this postural subluxation pattern can easily be reproduced by anteriorly translating the thoracic cage over the pelvis. ...
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This paper describes a technique for analyzing movement of the cervical spine. The method consists of superimposition of two films representing the cervical spine in the end positions of the movement under investigation (e.g., flexion and extension). From tracings of selected structures, movement is represented in the form of movement diagrams. Knowledge of cervical spine dynamics is helpful in understanding muscle and ligament function as well as the shape of components in various postures.
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Nineteen fresh, intact lumbar intervertebral joints (two vertebrae and the intervening joint) from twelve spines were loaded in a materials testing machine to determine their mechanical behavior. The loads applied were pure axial compression and complex loading conditions simulating physiological states. The measurements made included vertical load deflection, disc bulge, and strains in both the anterior and the lateral aspects of the vertebral body and in one lamina. The results showed that the posterior elements transmit considerable force during quasistatic complex loading, particularly in extension and frontal shear. When a healthy specimen is subjected to complex loading, "yielding or failure" occurs in the vertebral body and not in the annulus fibrosus of the disc.
Article
Removal of the posterior elements will allow increased correction of axial deformity, in scoliosis. The clinician may take advantage of the creep and relaxation characteristic of the tissues to improve efficiency of correction. Axial loading has been shown theoretically to be more efficient for the more severe curves, (greater than 53 degrees) and transverse loading more efficient for the less severe curves (less than 53 degrees). Combined loading is always more efficient than either type alone. The Milwaukee brace can be just as effective as a cast in resisting deforming forces in scoliosis. Removal of axillary supports or thoracic pads or not wearing the brace when recumbent reduces the effectiveness of the Milwaukee brace. The strength of the thoracid lamina is a limiting factor in the amount of forces that may be applied to correct the deformity; 30 kilopond (65.8 lb) is the upper limit of this force. Coughing or buckling can apply dangerously high forces with the Harrington rod. Greater surgace contact of the hook to the lamina and small increments between notches on the rod may increase the tolerance limits of the system. Compression rods on the convex side probably add little or no correctional value. The Dwyer technique is biomechanically sound and effective and has the additional advantage of applying asymmetrical loads to the epiphyseal plates.