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Abstract

Lumbar lordosis is a key postural component that has interested both clinicians and researchers for many years. Despite its wide use in assessing postural abnormalities, there remain many unanswered questions regarding lumbar lordosis measurements. Therefore, in this article we reviewed different factors associated with the lordosis angle based on existing literature and determined normal values of lordosis. We reviewed more than 120 articles that measure and describe the different factors associated with the lumbar lordosis angle. Because of a variety of factors influencing the evaluation of lumbar lordosis such as how to position the patient and the number of vertebrae included in the calculation, we recommend establishing a uniform method of evaluating the lordosis angle. Based on our review, it seems that the optimal position for radiologic measurement of lordosis is standing with arms supported while shoulders are flexed at a 30° angle. There is evidence that many factors, such as age, gender, body mass index, ethnicity, and sport, may affect the lordosis angle, making it difficult to determine uniform normal values. Normal lordosis should be determined based on the specific characteristics of each individual; we therefore presented normal lordosis values for different groups/populations. There is also evidence that the lumbar lordosis angle is positively and significantly associated with spondylolysis and isthmic spondylolisthesis. However, no association has been found with other spinal degenerative features. Inconclusive evidence exists for association between lordosis and low back pain. Additional studies are needed to evaluate these associations. The optimal lordotic range remains unknown and may be related to a variety of individual factors such as weight, activity, muscular strength, and flexibility of the spine and lower extremities.

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... Most cases of LBP are due to herniated discs, 98% of which occur in the L4-5 disc [2]. Lumbar lordosis, a key role in maintaining sagittal balance, is a notable factor affecting LBP [12]. It has been suggested that flattening and loss of the normal lumbar lordosis angle is an important clinical sign of back problems [12]. ...
... Lumbar lordosis, a key role in maintaining sagittal balance, is a notable factor affecting LBP [12]. It has been suggested that flattening and loss of the normal lumbar lordosis angle is an important clinical sign of back problems [12]. Almost 40% of overall lordosis is contributed by the last lumbar segment, L5, while only 5% is contributed by the L1 segment [13]. ...
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Background: The axial (horizontal) traction approach has been traditionally used for treatment of low back pain-related spinal disorders such as nuclear protrusion, primary posterolateral root pain, and lower thoracic disc herniation; however, it is known to have some technical limitations due to reductions of the spinal curve. Lumbar lordosis plays a pivotal function in maintaining sagittal balance. Recently, vertical traction and combination traction have been attracting attention due to improving therapeutic outcomes, although evidence of their clinical application is rare; therefore, this study was conducted to investigate the mechanical changes of lumbar intervertebral space, lordotic angle, and the central spinal canal area through vertical traction treatment using a spinal massage device in healthy participants. Methods: In total, 10 healthy subjects with no musculoskeletal disorders and no physical activity restrictions participated. The participants lay on the experimental device (CGM MB-1901) in supine extended posture and vertical traction force was applied in a posterior-to-anterior direction on the L3-4 and L4-5 lumbar sections at level 1 (baseline) and level 9 (traction mode). Magnetic resonance (MR) images were recorded directly under traction mode using the MRI scanner. The height values of the intervertebral space (anterior, center, and posterior parts) and lordosis angle of the L3-4 and L4-5 sections were measured using Image J software and the central spinal canal area (L4-5) was observed through superimposition method using the MR images. All measurement and image analyses were conducted by 2 experienced radiologists under a single-blinded method. Results: The average height values of the intervertebral space under traction mode were significantly increased in both L3-4 and L4-5 sections compared to baseline, particularly in the anterior and central parts but not in the posterior part. Cobb's angle also showed significant increases in both L3-4 and L4-5 sections compared to baseline (p < 0.001). The central spinal canal area showed a slightly expanded feature in traction mode. Conclusions: In this pilot experiment, posterior-to-anterior vertical traction on L3-4 and L4-5 sections using a spinal massage device caused positive and significant changes based on increases of the intervertebral space height, lumbar lordosis angle, and central spinal canal area compared to the baseline condition. Our results are expected to be useful as underlying data for the clinical application of vertical traction.
... Cobb's method is widely used to measure spinal curvature deviations in radiographic evaluations [11,12]. However it is also questioned since it can present measurement errors caused by difficulty to visualize and identify the vertebras [17], problems with the characterization of the curves [16,18], and a lack of consensus concerning the values of the curvatures [8,17]. ...
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Introduction. This study aimed to propose a categorization of body postures and to provide indexes/scores for the postural patterns. Methods. The body posture of the 3 spinal regions in 180 asymptomatic young people, mean age: 16.1 (0.77) years, was evaluated quantitatively in the sagittal plane (cinemetry and the curvature index). The same images were presented to experts who, by way of qualitative analyses, provided the postural diagnosis of each curvature for all of the young people. individuals with the same postural patterns were grouped together and the qualitative data were crossed with the quantitative values. Thus, scores were attributed to normal curvature, tendencies, and deviations. The one-way ANoVA test for independent samples was used to compare the patterns and the Bonferroni post-hoc test served to analyse effects between neighbouring changes. The mean difference and the 95% confidence interval were also calculated to compare the patterns. An alpha level of 5% was adopted for all analyses. The sensitivity, specificity, positive and negative likelihood ratios, and the predictive value for the suggested reference intervals were calculated to determine the diagnostic accuracy. Results. Significantly different scores were attributed to the postural pattern curves: 0: curve inversion; 0.1-10: rectification; 10.1-11: tendency for rectification; 11.1-14: normal; 14.1-15: tendency for hyperlordosis/hyperkyphosis; > 15: hyperlordosis/hyperkyphosis. The scores presented great discriminatory capacity and diagnostic accuracy among the postural patterns. Conclusions. This categorization could aid researchers and health professionals in evaluating postural deviations.
... Failure to maintain normal LL may also increase the incidence of facet arthritis [16]. If the LL is small, this increases the risk of sagittal imbalance after surgery and is a predictor of ASD [17], which is similar to our findings. Thus, restoration of the physiological curvature of the lumbar spine is very important in improving patient quality of life and preventing postoperative complications. ...
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Background: Symptomatic adjacent segment disease (ASDis) is a major complication following spinal fusion. Sagittal spinopelvic imbalance may contribute to the development of ASDis. However, the exact ideal correction of lumbar lordosis (LL) is unknown for different ages of people to prevent ASDis. The purpose of this study was to estimate the ideal correction of LL required to prevent symptomatic ASDis requiring revision surgery in patients of various ages, and to determine the radiographic risk factors for ASDis. Methods: 468 patients who underwent lumbar fusion between January 2014 and December 2016, were enrolled in the present study. The patients were classified into the ASDis and N-ASD group. These two matched groups were compared regarding surgery-related factors and radiographic features. Multivariate logistic regression analysis was used to evaluate the risk factors for ASDis. Results: Sixty-two patients (13.25%) underwent reoperation for ASDis during a mean follow-up duration of 38.07 months. Receiver operating characteristic curve analysis showed that the postoperative LL - preoperative LL (△LL) cutoff value was 11.7°for the development of ASDis. Logistic regression analysis revealed that the risk factors for symptomatic ASDis were a smaller LL angle, △LL > 12°, and PI-LL > 10° (p < 0.05). For patients > 60 years, the incidence of ASDis was higher in patients with a LL correction of ≥10° and a lumbar-pelvic mismatch (PI-LL) of > 20°. Conclusions: The significant predictors of the occurrence of ASDis were a smaller LL angle, △LL > 12°, and PI-LL > 10°. However, in patients older than 60 years, the incidence of ASDis after lumbar fusion was higher in those with a LL correction of ≥10° and PI-LL of > 20°. More attention should be paid to patient age and the angle of correction of LL before lumbar fusion.
... The most common practice is to do a standing X-ray with the patient's arms supported on a bar in front of him/her and then measuring the Cobb's angle between the superior end plate of the first lumbar vertebra and the superior end plate of the sacrum. [46] Norms Normal ranges for lordosis have been investigated in several studies and, as in the case of kyphosis, a wide range has been reported ( Table 4). [37] Propst-Proctor and Bleck [41] reported a range of 50° -60°. ...
Article
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Spinal deformities are common in people with cerebral palsy (CP), and there is a concern of an increase during the adult ageing period. There is especially a worry about the increase of scoliosis, thoracic hyperkyphosis, lumbar hyperlordosis, spondylolysis and spondylolisthesis incidence, though supporting literature is lacking. Therefore, the aim of this narrative review is to provide a scientific overview of how spinal curvatures should be measured, what the norm values are and the incidence in people with CP, as well as a description of the risk factors and the treatment regimens for these spinal abnormalities. This review can be used as a guideline relevant for a range of clinicians, including orthopaedic and neurosurgeons, radiologists, physiotherapists, and biokineticists, as well as academics.
... Some of these changes, including a considerable increase in abdominal volume, breast volume, and ligamentous laxity due to hormonal actions [1], lead to increased mobility of the pelvic segment and peripheral joints [2,3] and contribute to postural adaptations to maintain sagittal balance and better joint load distributions [4]. The lumbopelvic complex plays an essential role in maintaining vertical posture [5]. Its stability is aimed at bearing physical loading without uncontrolled displacements to damaged structures and preventing pain due to structural changes [6]. ...
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Pregnancy induces numerous modifications in the musculoskeletal system of the female body. Since one of the essential roles of the lumbopelvic structure is to support mechanical loads in the upright position, this study was designed to simulate the response of this complex to the growing foetus in pregnant women. The authors hypothesized that posture (i.e., lordosis and muscle involvement) under pregnancy conditions might be adjusted to minimize the demands of the obstetrical load. The analysis of the load on the musculoskeletal system during gestation was made based on numerical simulations carried out in the AnyBody Modeling System. The pregnancyrelated adjustments such as increased pelvic anteversion and increased lumbar lordosis enhance the reduction of muscle activation (e.g., erector spinae, transversus abdominis or iliopsoas), muscle fatigue and spinal load (reaction force). The results may help develop antenatal exercise programs targeting core strength and pelvic stability.
... The most common practice is to do a standing X-ray with the patient's arms supported on a bar in front of him/her and then measuring the Cobb's angle between the superior end plate of the first lumbar vertebra and the superior end plate of the sacrum. [46] Norms Normal ranges for lordosis have been investigated in several studies and, as in the case of kyphosis, a wide range has been reported ( Table 4). [37] Propst-Proctor and Bleck [41] reported a range of 50° -60°. ...
Article
Full-text available
Spinal deformities are common in people with cerebral palsy (CP), and there is a concern of an increase during the adult ageing period. There is especially a worry about the increase of scoliosis, thoracic hyperkyphosis, lumbar hyperlordosis, spondylolysis and spondylolisthesis incidence, though supporting literature is lacking. Therefore, the aim of this narrative review is to provide a scientific overview of how spinal curvatures should be measured, what the norm values are and the incidence in people with CP, as well as a description of the risk factors and the treatment regimens for these spinal abnormalities. This review can be used as a guideline relevant for a range of clinicians, including orthopaedic and neurosurgeons, radiologists, physiotherapists, and biokineticists, as well as academics.
... For instance, the fact that thoracic kyphosis lies between 20-45 • has been suggested by Mejia, et al. [25]. Been and Kalichman [26] have reported a normal range of 30-80 • for lumbar lordosis. The apex of the curvature is defined as the farthest point of a vertebra from the C7 plump line. ...
Article
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This paper presents a study on form-finding of four-stage class one self-equilibrated spine biotensegrity models. Advantageous features such as slenderness and natural curvature of the human spine, as well as the stabilizing network that consists of the spinal column and muscles, were modeled and incorporated in the mathematical formulation of the spine biotensegrity models. Form-finding analysis, which involved determination of independent self-equilibrium stress modes using generalized inverse and their linear combination, was carried out. Form-finding strategy for searching the self-equilibrated models was studied through two approaches: application of various combinations of (1) twist angles and (2) nodal coordinates. A total of three configurations of the spine biotensegrity models with different sizes of triangular cell were successfully established for the first time in this study. All members in the spine biotensegrity models satisfied the assumption of linear elastic material behavior. With the established spine biotensegrity model, the advantageous characteristics of flexibility and versatility of movement can be further studied for potential application in deployable structures and flexible arm in the robotic industry.
... This area is exposed to many dangers and anomalies due to the weight-bearing related to the upper body [7]. This can lead to many problems, including stress focus on specific vertebral structures, lower back pain, and the disorders of postural stability and patient function [8]. During the period before and after puberty, the body posture undergoes significant changes to achieve a new balance. ...
Article
Purpose: Lumbar hyperlordosis is one of the main physical abnormalities that occur in the lumbopelvic region and affect the body movement system in daily life. This condition can also lead to chronic injuries and pain. The present study aimed to investigate the ability of the nine-test screening battery to predict the incidence of lumbar hyperlordosis in adolescent boys. Methods: This causal study described and analyzed the data with a cross-sectional design. In this regard, 60 adolescents (age range: 13 to 15 years) were selected. After the initial assessments, they were assigned into two groups: the lumbar hyperlordosis group (n=31) and the normal lordosis group (n=29). The angle of lumbar lordosis curvature and functional movements were measured using a flexible ruler and the nine-test screening battery instruction, respectively. The obtained data were analyzed using the logistic regression test at a significance level of 0.05, in SPSS v. 24. Results: The examination of the coefficients of predictive variables showed that the Wald test is statistically significant for deep squat (P=0.023) and straight leg raise (P=0.033). Also, these variables significantly contribute to the predictability of the model and the likelihood of lumbar hyperlordosis. Conclusion: Based on the results, the nine-test screening battery can predict the occurrence of lumbar hyperlordosis in adolescent boys through the components of deep squat and straight leg raise.
... Researchers, over a period of time have developed association with altered spinal alignment with lumbago [12,26], and have emphasized on its restoration for adequate spinal balance [15,45,59]. Identification of these measurements is an extremely important pre-operative procedure to restore the normal lordosis enabling posture correction and spinal balance restoration. ...
Article
Assessment of medical images and diagnostic decision making of lumbar associated diseases by clinicians is invariably subjective, time consuming and challenging task. Presently, clinicians make use of either manual or semi-automated computer-aided tools to make relevant measurements for adding vote of confidence to their grading and evaluation. Lacking reliability and offering substantive dissimilarity once performed by different clinicians, these methods complicate the evaluation process. In an effort to support the decision making process of clinicians, in this paper we present a lumbar assessment framework with autonomous extraction of spinal measurements. Furthermore, an effort is made to address the challenges faced by clinicians while assessing disorders including spondylolisthesis and assessment of lumbar lordosis (LL) by proposing novel disease classification methodologies. For spondylolisthesis classification, we achieved an accuracy of 89% by using angular deviation metric whereas, 93% accuracy for determining adequacy/inadequacy in LL assessment through computation of area within enclosed lumbar curve region. Our framework involves semantic segmentation of vertebral bodies (VBs) using ResNet-UNet where we achieved DSC of 0.97 and IoU of 0.86. Subsequently, we achieved a statistically significant correlation coefficient R and encouraging mean absolute error (MAE) with clinicians’ grading for measurements involving lumbar lordotic angle (LLA), lumbosacral angle (LSA), VB dimensions and lumbar height. In addition to this, we have publicly released the dataset with all the clinicians markings at https://data.mendeley.com/datasets/k3b363f3vz/2.
... Hyperkyphosis is characterized by Cobb angle greater than 40 degrees as seen in the sagittal plane (9). Using the Cobb's method and by measurement of the region between the superior endplate of the L1 to the superior endplate of the S1, it was determined that an optimal lordosis angle ranged from 30 degrees up to even 80 degrees (11). ...
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The aim of the research was to contribute to better understanding of the correlation between postural disorders and muscle power in primary school children. The sample of respondents consisted of 1,120 children, aged 7 to 12 years (549 boys and 571 girls) from the territory of the municipality of Knjaževac. In the assessment of the spinal column status, the device "Spinal Mouse" (Switzerland) was used, while in the analysis of the status of the feet, the podoscope "Pedic" (Hungary) was used. A handheld dynamometer "Lafayette" (USA) and tensiometric force platform "Vernier Force Plate" (USA) were used in the analysis of muscle power. Spinal column and feet status were measured in the static condition, with children being in the upright standing position. Muscle power status was measured in both static (a clinician was applying muscle force to the dominant upper extremity of a child trying to overcome or "break" the child's muscle resistance) and dynamic conditions (Counter Movement Jump). Descriptive statistics and correlation analysis were used in data processing by the means of the SPSS software version 24. Results revealed poor postural and muscle power status, and correlations suggesting to possible kinetic chain reaction causing the disruption of the normal postural status in primary school children. Determined postural disorders are characterized by the early functional stage that can be reduced by appropriate corrective exercise programme application and augmented level of proper physical activity. Those programmes and activities are being guided and implemented by physicians and PE teachers in the municipality of Knjaževac.
Article
Objective: The purpose of this study was to investigate the effect of posterior pelvic tilt taping (PPTT) on lumbar lordosis, pain, disability, and abdominal muscle thickness in individuals with nonspecific chronic low back pain with hyperlordosis. Methods: A prospective, single-group, repeated-measures design was conducted with 31 individuals with nonspecific chronic low back pain (16 men, 15 women) with hyperlordosis (mean ± SD = 59.3° ± 2.9°). Participants’ mean age, pain, disability, and lumbar lordosis were, respectively, 35.7 ± 9.9 years, 5.1 ± 1.3, 26.8 ± 11.5, and 59.3° ± 2.9°. The thickness of the abdominal muscles on both sides was measured in the crook lying position by ultrasound imaging. PPTT was performed on both sides. Pain intensity, functional disability, lumbar lordosis angle, and abdominal muscle thickness were measured before PPTT (W0), 1 week after PPTT (W1), and 1 week after PPTT removal (W2). Results: Analysis revealed significant reductions in lumbar lordosis, pain, and disability, and increased abdominal muscle thickness, at W1 and W2 compared with W0 (P < .001). There were no significant differences in lumbar lordosis or abdominal muscle thickness between W1 and W2. Conclusion: The current study showed in a small group of participants that 1 week of PPTT may improve lumbar lordosis, pain, disability, and abdominal muscle thickness in individuals with nonspecific chronic low back pain with hyperlordosis. Key Indexing Terms: Athletic TapeChronic PainLordosisMuscle ThicknessUltrasonography
Article
Resumen Antecedentes y objetivo Actualmente, se considera la radiografía como la prueba estándar para medir la lordosis lumbar; sin embargo, requiere de una preparación especial y, además, existe el riesgo de exposición a radiación ionizante la cual es nociva para la salud. El costo en los equipos utilizados y la exposición a la radiación son factores que limitan la aplicación de este tipo de pruebas diagnósticas. La fotogrametría es capaz de identificar las particularidades de la postura corporal que permiten reconocer ángulos como el de la lordosis lumbar. Se hace necesario ampliar el conocimiento acerca de la fiabilidad a partir de estándares que proporcionen al profesional en fisioterapia protocolos con medidas reproducibles que le faciliten la toma de decisiones relacionadas con esta condición. Por lo tanto, el objetivo de este estudio es determinar la fiabilidad inter-evaluador de tres formas de fotogrametría para medir la lordosis lumbar en personas con dolor lumbar no específico. Metodología Se realizó un análisis de lordosis lumbar mediante dos programas (Kinovea y ADiBAS Posture) a una muestra de 26 personas con dolor lumbar. Se empleó Kinovea para la evaluación en 2D por medio del test de flechas y el ángulo lordótico. ADiBAS Posture se utilizó para calcular la lordosis en 3D. Tres evaluadores hicieron medidas a partir de las fotografías, usando tres protocolos de medición definidos para el estudio. Resultados El análisis llevado a cabo a través de ADiBAS Posture presenta un coeficiente de correlación intraclase (CCI) muy bueno, mientras que el test de flechas y ángulo lordótico resultaron tener CCI buenos. Por otra parte, la prueba de ángulo lordótico presentó diferencias significativas mientras que el de flechas y el análisis efectuado en 3D no presentaron diferencias significativas (p > 0,05). Conclusiones El análisis en 3D y el test de flechas para determinar la lordosis lumbar son pruebas con un nivel de fiabilidad muy bueno.
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Background Spondylolysis and undiagnosed mechanical low back pain (UMLBP) are the main causes of low back pain (LBP) in adolescent athletes. No studies have evaluated the difference in clinical and radiographic factors between these 2 conditions. Furthermore, it remains unclear which adolescent athletes with LBP should undergo advanced imaging examination for spondylolysis. Purpose To compare the clinical and radiographic factors of adolescent athletes with spondylolysis and UMLBP who did not have neurological symptoms or findings before magnetic resonance imaging (MRI) evaluation and to determine the predictors of spondylolysis findings on MRI. Study Design Cohort study, Level of evidence, 3. Methods The study population included 122 adolescent athletes aged 11 to 18 years who had LBP without neurological symptoms or findings and who underwent MRI. Of these participants, 75 were ultimately diagnosed with spondylolysis, and 47 were diagnosed with UMLBP. Clinical factors and the following radiographic parameters were compared between the 2 groups: spina bifida occulta, lumbar lordosis (LL) angle, and the ratio of the interfacet distance of L1 to that of L5 (L1:L5 ratio, %). A logistic regression analysis was performed to evaluate independent predictors of spondylolysis on MRI scans. Results Significantly more athletes with spondylolysis were male (82.7% vs 48.9%; P < .001), had a greater LL angle (22.8° ± 8.1° vs 19.3° ± 8.5°; P = .02), and had a higher L1:L5 ratio (67.4% ± 6.3% vs 63.4% ± 6.6%; P = .001) versus athletes with UMLBP. A multivariate analysis revealed that male sex (odds ratio [OR], 4.66; P < .001) and an L1:L5 ratio of >65% (OR, 3.48; P = .003) were independent predictors of positive findings of spondylolysis on MRI scans. Conclusion The study findings indicated that sex and the L1:L5 ratio are important indicators for whether to perform MRI as an advanced imaging examination for adolescent athletes with LBP who have no neurological symptoms and findings.
Chapter
Lumbar spinal MRI has the advantage of providing a wealth of visible structures. The assessment of its signal intensities, however, can be challenging. This chapter supplies a systematic guide to assess lumbar spinal MRI scans. Furthermore, it gives an overview of signal intensities of diverse physiological and pathological entities.
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Objectives: To evaluate the comparison between lordotic and non-lordotic transforaminal lumbar interbody fusion (TLIF) cages in degenerative lumbar spine surgery and analyze radiological as well as clinical outcome parameters in long-term follow up. Methods: In a retrospective study design, we compared 37 patients with non-lordotic cage (NL-group) and 40 with a 5° lordotic cage (L-group) implanted mono- or bi-segmental in TLIF-technique from 2013 to 2016 and analyzed radiological parameters of pre- and postoperative (Lumbar lordosis (LL), segmental lordosis (SL), and pelvic tilt (PT), as well as clinical parameters in a follow-up physical examination using the Oswestry disability index (ODI), Roland-Morris Score (RMS), and visual analog scale (VAS). Results: Surgery was mainly performed in lower lumbar spine with a peak in L4/5 (mono-segmental) and L4 to S1 (bi-segmental), long-term follow-up was on average 4 years postoperative. According to the literature, we found significantly better results in radiological outcome in the L-group compared to the NL-group: LL increased 6° in L-group (51° preoperative to 57° postoperative) and decreased 1° in NL-group (50° to 49° (P < 0.001). Regarding SL, we found an increase of 5° in L-group (13° to 18°) and no difference in NL-group (15°)(P < 0.001). In PT, we found a clear benefit with a decrease of 2° in L-group (21° to 19°) and no difference in NL-group (P = 0.008). In direct group comparison, ODI in NL-group was 23% vs 28% in L-group (P = 0.25), RMS in NL-group was 8 points vs 9 points in L-group (P = 0.48), and VAS was in NL-group 2.7 vs 3.2 in L-group (P = 0.27) without significant differences. However, the clinical outcome in multivariate analysis indicated a significant multivariate influence across ODI and RMS of BMI (Wilks λ = 0.57, F [4, 44] = 3.61, P = 0.012) and preoperative SS (Wilks λ = 0.66, F [4, 44] = 2.54, P = 0.048). Age, gender, cage type and postoperative PT had no significant influence (P > 0.05). Intraoperatively, we saw three dura injuries that could be sutured without problems and had no consequences for the patient. In the follow-up, we did not find any material-related problems, such as broken screws or cage loosening, also no pseudarthrosis. Conclusion: In conclusion, we think it's not cage design but other influenceable factors such as correct indication and adequate decompression that lead to surgical success and the minimal difference in the LL therefore seemed to be of subordinate importance.
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Background: Bilateral decompression via unilateral approach (BDUA) is an effective surgical approach for treating lumbar degenerative diseases. However, no studies of prognosis, especially the recovery of the soft tissue, have reported using BDUA in an elderly population. The aims of these research were to investigate the early efficacy of the bilateral decompression via unilateral approach versus conventional approach transforaminal lumbar interbody fusion (TLIF) for the treatment of lumbar degenerative disc disease in the patients over 65 years of age, especially in the perioperative factors and the recovery of the soft tissue. Methods: The clinical data from 61 aging patients with lumbar degenerative disease who received surgical treatment were retrospectively analyzed. 31 cases who received the lumbar interbody fusion surgery with bilateral decompression via unilateral approach (BDUA) were compared with 30 cases who received conventional approach transforaminal lumbar interbody fusion. The radiographic parameters were measured using X-ray including lumbar lordosis angle and fusion rate. Japanese Orthopedic Association (JOA), Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores were used to evaluate the clinical outcomes at different time points. Fatty degeneration ratio and area of muscle/vertebral body were used to detect recovery of soft tissue. Results: The BDUA approach group was found to have significantly less intraoperative blood loss(p < 0.05) and postoperative drainage(p < 0.05) compared to conventional approach transforaminal lumbar interbody fusion group. Symptoms of spinal canal stenosis and nerve compression were significantly relieved postoperatively, as compared with the preoperative state. However, the opposite side had a lower rate of fatty degeneration (9.42 ± 3.17%) comparing to decompression side (11.68 ± 3.08%) (P < 0.05) six months after surgery in the BDUA group. While there were no significant differences (P > 0.05) in two sides of conventional transforaminal lumbar interbody fusion approach group six months after surgery. Conclusions: Bilateral decompression via unilateral approach (BDUA) is able to reduce the intraoperative and postoperative body fluid loss in the elderly. The opposite side of decompression in BDUA shows less fatty degeneration in 6 months, which indicates better recovery of the soft tissue of the aging patients.
Article
In humans and known fossil hominins, lumbar lordosis is produced by vertebral body wedging and other bony and soft tissue features such as the shape of the intervertebral discs. Current techniques for quantifying the wedging of vertebral bodies are limited in utility, especially when analyzing incomplete fossil material. Here, we introduce a 3D method to quantify vertebral body wedging angles that yields the angles between two “best fit” planes in the software GeoMagic Wrap (3D Systems). To test that this new method is repeatable with existing methods, we measure the wedging of 320 lumbar vertebrae representing 64 modern human individuals. For each vertebra, wedging angles were calculated from linear measurements taken with calipers and compared with estimates generated from the 3D best fit plane method. We also apply the 3D plane method to fossil hominin lumbar vertebrae, including newly described lumbar vertebrae of Homo naledi, the majority of which do not preserve the four landmarks necessary to calculate wedging angles using the traditional approach. The results of the two methods are highly and significantly correlated (r2 = 0.98, p < 0.0001). The 3D plane method was successfully applied to nearly all of the fossil hominin specimens included in the study. The new 3D plane method introduced here is repeatable with the traditional linear measurement method and allows for the estimation of wedging angles in incomplete material. When applied to Homo naledi lumbar vertebrae, similarities to other fossil hominins and modern humans are found.
Article
Aims: This study aimed to investigate the relationship between lumbar lordosis angle (LLA) and trunk functions, sitting balance, functional independence, and lesion level in children with spina bifida (SB). Methods: Thirty children with SB were included. LLA was measured with a flexible ruler. The Pediatric Functional Reach Test (PRT), Trunk Impairment Scale (TIS), Functional Independence Measure for Children (WeeFIM), and International Myelodysplasia Study Group Criteria were used to evaluate sitting balance, trunk functions, functional independence, and motor lesion level respectively. The correlations were performed by using Spearman’s correlation test. Results: There were significant correlations between the LLA and PRT, TIS, and WeeFIM results. Also, a significant correlation was found between the LLA and lesion level (p < .05). Conclusions: The development of the LLA in the normal range should be supported in rehabilitation approaches aiming to increase sitting balance, functional independence, and trunk functions in children with SB.Abbreviations: SB: Spina Bifida; LLA: Lumbar Lordosis Angle; MMS: Meningomyelocele; WeeFIM: Functional Independence Measure for Children; TIS: Trunk Impairment Scale; PRT: Pediatric Functional Reach Test
Article
Lumbo-pelvic parameters in the sagittal plane are normally measured from lateral radiographs obtained at a single time point during upright standing with arms held forward to expose anatomical bony structures. However, the human trunk naturally sways during still standing, which potentially alters the targeted parameters. We therefore aimed to investigate the effect of postural sway on lumbo-pelvic parameters during still standing at different arm positions. A non-radiological back measurement device was used to determine the absolute changes of back lordosis and sacral orientation during one-minute still standing while participants (10 males and 10 females without low back pain) held their arms at eight different positions. When the arms were freely hanging down at both sides, males displayed median values of 25.2° (range: 15.6–45.0°) and 7.4° (range: 2.0–26.7°) for back lordosis and sacral orientation, which were smaller than those of 33.1° (range: 11.9–41.9°) and 16.1° (range: 0.8–22.8°) for females, respectively (P < 0.05). At the same arm position, the median values were 2.7° (range: 1.3–5.2°) and 2.9° (range: 1.6–4.5°) for change of back lordosis and change of sacral orientation, respectively. Sex displayed no significant influence for both measures. Different arm positions non-significantly affected the change of back lordosis. When hands rested on horizontal bars, the change of sacral orientation was significantly less than during other arm positions (P < 0.05). Hence, back lordosis and sacral orientation inherently change during still standing, independently of sex and arm position, which could compromise the reliability of measurements at a single time point. When categorizing subjects into groups with normal or abnormal lumbo-pelvic balance, this variability should be taken into consideration.
Article
Objective: The purpose of this study was to investigate differences in regional lumbar lordosis (RLL) and global lumbar lordosis (GLL) angle during slumped sitting and upright sitting among three global subgroups. Methods: A total of 48 young asymptomatic volunteers stood in a comfortable posture, sat upright, and sat in a slumped position for 5 seconds, with inertial measurement units attached to the T10, L3, and S2 vertebrae. According to standing measurement, the participants were categorized into flat-back (GLL < 20∘), normal lordosis (20∘⩽ GLL < 30∘), and hyper-lordosis (30∘⩽ GLL < 40∘) groups. Results: Both the GLL and RLL in the flat-back group were reduced lumbar lordosis in the upright sitting posture and increased lumbar kyphosis in the slumped sitting postures compared to the other groups (p< 0.05), but the range of motion during the transition from upright sitting to slumped sitting was lower than that of the normal and hyper-lordosis groups (p< 0.05). GLL in standing was a moderate correlation with GLL and RLL during upright sitting (p< 0.05). However, there was a strong correlation between GLL and RLL kinematics during upright and slumped sitting (p< 0.05). Conclusions: Flat-back posture is a potential source of low back pain during both upright and slumped sitting compared to the normal and hyper-lordosis groups. Posture measurements in a standing and sitting position conducted to assess lordosis should consider the relationship between GLL and RLL.
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Despite the growing use of computed tomography (CT) and magnetic resonance imaging (MRI) in the study of spinal disorders, radiography still plays an important role in many conditions affecting the spine. However, the study and interpretation of spine radiograph is receiving less attention and radiologists are increasingly unfamiliar with the typical findings in normal and pathologic conditions of the spine. The aim of this article is to review the radiologic indications of radiograph in different pathologic conditions that affect the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumour disorders, as well as their main radiographic manifestations.
Article
Pathologies of the hip, spine and the lower extremity are often concomitant due to their three-dimensional anatomic and physiological interrelation. The real challenge lies in defining which of the pathologies is most relevant for the patient in terms of clinical symptoms and which organ should be treated first. The purpose of this review article is two-fold: Firstly, to explain the treatment dilemma of hip-spine syndrome to the treating physician. Secondly, to highlight the significance of spinal pathology in this context.
Article
Study design: A cross-sectional study on a randomly selected prospective cohort of patients presenting to a single tertiary spine center. Objective: The aim of this study was to describe the clinical and radiographic parameters of patients with S- and C-shaped thoracolumbar sagittal spinal profiles, and to identify predictors of these profiles in a natural, relaxed sitting posture. Summary of background data: Sagittal realignment in adult spinal deformity surgery has to consider the sitting profile to minimize the risks of junctional failure. Persistence of an S-shaped sagittal profile in the natural, relaxed sitting posture may reflect a lesser need to accommodate for this posture during surgical realignment. Methods: Consecutive patients with low back pain underwent whole body anteroposterior and lateral radiographs in both standing and sitting. Baseline clinical data of patients and radiographic parameters of both standing and sitting sagittal profiles were compared using χ, unpaired t tests, and Wilcoxon rank-sum test. Subsequently, using stepwise multivariate logistic regression analysis, predictors of S-shaped curves were identified while adjusting for confounders. Results: Of the 120 patients included, 54.2% had S-shaped curves when sitting. The most common diagnoses were lumbar spondylosis (26.7%) and degenerative spondylolisthesis (26.7%). When comparing between patients with S- and C-shaped spines in the sitting posture, only diagnoses of degenerative spondylolisthesis (odds ratio [OR], 5.44; P = 0.01) and degenerative scoliosis (OR, 2.00; P = 0.039), and pelvic incidence (PI) >52.5° (OR, 5.48; P = 0.008), were predictive of an S-shaped sitting sagittal spinal alignment on multivariate analysis. Conclusion: Stiffer lumbar curves (e.g., patients with degenerative spondylolisthesis and degenerative scoliosis) or those who have a predilection for an S-shaped standing sagittal profile when sitting (e.g., high PI) may be more amenable to fusion in accordance with previously studied sagittal realignment targets. In contrast, more flexible curves may benefit from less aggressive lordotic realignment to prevent potential junctional failures. Level of evidence: 3.
Article
Objective The purpose of this study was to compare 2 alternative methods, the radiologic Harrison Posterior Tangent Method (HPTM) and the nonradiologic Spinal Mouse (SM), to the Cobb angle for measuring lumbar lordosis. Methods Sixteen participants with previously existing lateral lumbopelvic radiographs underwent nonradiographic lordosis assessment with a Spinal Mouse. Then 2 investigators analyzed each radiograph twice using the Harrison Posterior Tangent Method and Cobb angle. Correlations were analyzed between HPTM, the Cobb angle, and SM using the Spearman rank correlation coefficient; intraexaminer and interexaminer agreement were analyzed for HPTM and the Cobb angle using intraclass correlation coefficients. Results The HPTM correlated highly with the Cobb angle (Spearman ρ = 0.936, P < .001); SM had moderate to strong correlations with the Cobb angle (ρ = 0.737, P = .002) and HPTM (ρ = 0.707, P = .003). Intraexaminer and interexaminer agreement for the Cobb angle and HPTM were excellent (all intraclass correlation coefficients > 0.90). One participant had slight kyphosis according to HPTM and SM analyses (which consider the entire lumbar region), whereas the Cobb angle, based only on L1 and L5, reported mild lordosis for that participant. Conclusion In this sample, HPTM measurements showed high correlation with the commonly used Cobb angle, but this method requires more time and effort, and normal values have not been established. The SM may be an alternative when radiographs are inappropriate, but it measures soft tissue contours rather than lordosis itself.
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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.
Article
Background Movement and posture are commonly believed to relate to non‐specific low back pain (NSLBP). While people with NSLBP appear to move and posture themselves differently from those without NSLBP, changes in movement and posture infrequently relate to improvements in NSLBP when analysed at a group‐level. Additionally, little is known about how movement or posture change when clinical outcome improves. Methods Within‐person relationships were investigated using a replicated, repeated measures, single‐case design in 12 people with persistent, disabling NSLBP. Individually relevant movement and posture were captured using wearable sensors on up to 20 occasions over a 22‐week period (5‐week baseline, 12‐week physiotherapy‐led intervention, 5‐week follow‐up), while pain and activity limitation were collected concomitantly. A series of cross‐correlation analyses estimated the presence, strength, and direction of relationships. Results Many participants (n=10/12) had strong (e.g. r=0.91, p=<0.001) relationships between changes in movement or posture and changes in pain and activity limitation, while some showed no strong association. Where relationships were observed, clinical improvement predominantly (93% or 57/61 relationships) related to increased spinal movement range and velocity during forward bending and lifting, reduced lumbar muscle EMG activity at maximum voluntary flexion, and increased posterior‐pelvic‐tilt during sitting and standing. Conclusion Within‐person changes to individually relevant movement and posture appear to often relate to clinical outcome, but not always. When changes were related, movement and posture appear to return towards being ‘less protective’, however causal directions remain unknown. Important activities, movements, and postural parameters varied across the participants, highlighting the potential importance of individualised management.
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Background Implementation of best-practice care for patients with low back pain (LBP) is an important issue. Physiotherapists’ who hold unhelpful beliefs are less likely to adhere to guidelines and may negatively influence their patients’ beliefs. Pre-registration education is critical in moving towards a biopsychosocial model of care. This study aimed to investigate the changes in 2nd year physiotherapy students’ beliefs about LBP after a module on spinal pain management and determine whether these changes were maintained at the end of academic training. Methods During three consecutive calendar years, this longitudinal cohort study assessed physiotherapy students’ beliefs with the Back Pain Attitudes Questionnaires (Back-PAQ) in their 1st year, before and after their 2nd year spinal management learning module, and at the end of academic training (3rd year). Unpaired t-tests were conducted to explore changes in Back-PAQ score. Results The mean response rate after the spinal management module was 90% (128/143 students). The mean (± SD) Back-PAQ score was 87.73 (± 14.21) before and 60.79 (± 11.44) after the module, representing a mean difference of − 26.95 (95%CI − 30.09 to − 23.80, p < 0.001). Beliefs were further improved at the end of 3rd year (− 7.16, 95%CI − 10.50 to − 3.81, p < 0.001). Conclusions A spinal management learning module considerably improved physiotherapy students’ beliefs about back pain. Specifically, unhelpful beliefs about the back being vulnerable and in need of protection were substantially decreased after the module. Improvements were maintained at the end of academic training one-year later. Future research should investigate whether modifying students’ beliefs leads to improved clinical practice in their first years of practice.
Article
Background: The Movement System Impairment (MSI) model is useful for identifying spine-hip mobility and motor control deficits that may contribute to low back pain (LBP). While previous studies have found differences in global spine-hip movement impairments between lumbar MSI subgroups, no studies have compared segmental spine movement impairments between these subgroups. Therefore, the purpose of this study is to analyze segmental lumbar mobility in participants with LBP and a lumbar flexion- or extension-based MSI. Methods: Forty participants with subacute-chronic LBP were placed into one of three age groups (< 35, 35-54, or > 54 years-old) and then classified into a flexion- or extension-based MSI sub-group. Segmental lumbar range of motion (ROM) was measured in degrees using a skin-surface device. Total lumbar and segmental flexion and extension ROM of L1-L2 to L5-S1 was compared between MSI sub-groups for each age group using separate two-way ANOVAs. Results: Significant main effects were found for the independent variables of MSI subgroup and age. Participants in all three age groups with a flexion-based MSI displayed significantly less lumbar extension (-0.6∘) at L4-5 as compared to participants with an extension-based MSI (-2.1∘), p= 0.03. In addition, lumbar total and segmental ROM was significantly less for older individuals in both subgroups. Conclusions: Individuals with LBP may demonstrate a pattern of lumbar segmental hypomobility in the opposite direction of their MSI. Future studies may investigate the added value of direction-specific spinal mobilization to a program of MSI-based exercise.
Article
Objective The purpose of this study was to assess the association between hip flexor length and pelvic tilt or lumbar lordosis by quantifying the effect of stretching on pelvic tilt and lumbar lordosis. Methods We quantified pelvic tilt and lumbar lordosis before and after a single session of passive hip flexor stretching in a sample of 23 male participants. Changes in hip flexor length were also characterized, using a Thomas test protocol to measure passive hip extension in supine lying. We investigated both the mean effect of the stretching protocol and potential correlations between changes in passive hip extension and changes in pelvic tilt or lumbar lordosis. Results Following the stretching protocol, there was a mean increase of 2.6° (P < .001) in passive hip extension and a corresponding mean reduction of 1.2° (P < .001) in anterior pelvic tilt. However, there was no change in lumbar lordosis, nor were there any meaningful correlations between change in passive hip extension and change in pelvic tilt or lumbar lordosis. Conclusion The results suggest that hip muscle stretching may lead to immediate reductions in pelvic tilt during relaxed standing. Such stretching programs could play an important role in interventions designed to improve standing postural alignment.
Article
Study design: Retrospective cohort study. Objective: The purpose of this study was to compare segmental and regional radiographic parameters between anterior interbody fusion (ALIF) and posterior interbody fusion (TLIF) for treatment of L5-S1 isthmic spondylolisthesis, and to assess for changes in these parameters over time. Secondarily, we sought to compare clinical outcomes via patient-reported outcome measures (PROMs) between techniques and within groups over time. Summary of background data: Isthmic spondylolistheses are frequently treated with interbody fusion via ALIF or TLIF approaches. Robust comparisons of radiographic and clinical outcomes are lacking. Methods: We reviewed pre- and postoperative radiographs as well as Patient-Reported Outcomes Measurement Information System (PROMIS) elements for patients who received L5-S1 interbody fusions for isthmic spondylolisthesis in the Mass General Brigham (MGB) health system (2016-2020). Intraclass correlation testing was used for reliability assessments; Mann-Whitney U tests and Sign tests were employed for intercohort and intracohort comparative analyses, respectively. Results: ALIFs generated greater segmental and L4-S1 lordosis than TLIF, both at first postoperative visit (mean 26 days [SE = 4]; 11.3° vs. 1.3°, P < 0.001; 6.2° vs. 0.3°, P = 0.005) and at final follow-up (mean 410 days [SE = 45]; 9.6° vs. 0.2°, P < 0.001; 7.9° vs. 2.1°, P = 0.005). ALIF also demonstrated greater increase in disc height than TLIF at first (9.6 vs. 5.5 mm, P < 0.001) and final follow-up (8.7 vs. 3.6 mm, P < 0.001). Disc height was maintained in the ALIF group but decreased over time in the TLIF cohort (ALIF 9.6 vs. 8.7 mm, P = 0.1; TLIF 5.5 vs. 3.6 mm, P < 0.001). Both groups demonstrated improvements in Pain Intensity and Pain Interference scores; ALIF patients also improved in Physical Function and Global Health - Physical domains. Conclusion: ALIF generates greater segmental lordosis, regional lordosis, and restoration of disc height compared to TLIF for treatment of isthmic spondylolisthesis. Additionally, ALIF patients demonstrate significant improvements across more PROMs domains relative to TLIF patients.Level of Evidence: III.
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Gestation increases the biomechanical loading of lower extremities. Gestational loading may influence anthropometrics of articular surfaces in similar means as bone diaphyseal properties. This study aimed to investigate whether gravidity (i.e. number of pregnancies) and parity (i.e. number of deliveries) is associated with knee breadth among middle-aged women. The study sample comprised 815 women from the Northern Finland Birth Cohort 1966. The median parity count of our sample was 2 and the median gravidity count 3. At the age of 46, questionnaires were used to enquire gravidity and parity, and posteroanterior knee radiographs were used to obtain two knee breadth parameters (tibial plateau mediolateral breadth (TPML) and femoral condylar mediolateral breadth (FCML)) as representatives of articular size. The associations of gravidity and parity with knee breadth were analyzed using general linear models with adjustments for height, weight, leisure-time physical activity, smoking, and education years. Individuals with osteoarthritic changes were excluded from our sample. The mean TPML in our sample was 70.3 mm and the mean FCML 71.6 mm respectively. In the fully adjusted models, gravidity and parity showed positive associations with knee breadth. Each pregnancy was associated with 0.11–0.14% larger knee breath (p < 0.05), and each delivery accounted for an increase of 0.20% in knee breadth (p < 0.01). Between-group comparisons showed that multiparous women had 0.68–1.01% larger knee breath than nulli- and primiparous women (p < 0.05). Pregnancies and deliveries seem to increase the mediolateral breadth of the knee. This increase is potentially associated with increased biomechanical loadings during gestation.
Article
In 1923, Sir Arthur Keith proposed that many common back problems are due to the stresses caused by our evolutionarily novel form of locomotion, bipedalism. In this article, we introduce an updated version of Keith’s hypothesis with a focus on acquired spinal conditions. We begin by outlining the main ways in which the human spine differs from those of our closest living relatives, the great apes. We then review evidence suggesting there is a link between spinal and vertebral shape on the one hand and acquired spinal conditions on the other. Next, we discuss recent studies that not only indicate that two common acquired spinal conditions—intervertebral disc herniation and spondylolysis—are associated with vertebral shape, but also suggest that the pathology-prone vertebral shapes can be understood in terms of the shift from quadrupedalism to bipedalism in the course of human evolution. Subsequently, we place the aforementioned findings under an umbrella hypothesis, which we call the “Evolutionary Shape Hypothesis.” This hypothesis contends that individuals differ in their propensity to develop different acquired spinal conditions because of differences in vertebral shape that relate to the evolutionary history of our species. We end the article with some possible directions for future research.
Article
Background: Spinal deformation during surgical intervention (caused by patient positioning and/or correction of malalignment) confounds conventional navigation due to assumptions of rigid transformation. Moreover, the ability to accurately quantify spinal alignment in the operating room would provide assessment of the surgical product via metrics that correlate with clinical outcome. Purpose: A method for deformable 3D-2D registration of preoperative CT to intraoperative long-length tomosynthesis images is reported for accurate 3D evaluation of device placement in the presence of spinal deformation and automated evaluation of global spinal alignment (GSA). Methods: Long-length tomosynthesis ("Long Film", LF) images were acquired using an O-arm™ imaging system (Medtronic, Minneapolis USA). A deformable 3D-2D patient registration was developed using multi-scale masking (proceeding from the full-length image to local subvolumes about each vertebra) to transform vertebral labels and planning information from preoperative CT to the LF images. Automatic measurement of GSA [Main Thoracic Kyphosis (MThK) and Lumbar Lordosis (LL)] was obtained using a spline fit to registered labels. The "Known-Component Registration" (KC-Reg) method for device registration was adapted to the multi-scale process for 3D device localization from orthogonal LF images. The multi-scale framework was evaluated using a deformable spine phantom in which pedicle screws were inserted, and deformations were induced over a range in LL ∼25-80°. Further validation was carried out in a cadaver study with implanted pedicle screws and a similar range of spinal deformation. The accuracy of patient and device registration was evaluated in terms of 3D translational error and target registration error (TRE), respectively, and the accuracy of automatic GSA measurements were compared to manual annotation. Results: Phantom studies demonstrated accurate registration via the multi-scale framework for all vertebral levels in both the neutral and deformed spine: median (interquartile range, IQR) patient registration error was 1.1 mm (0.7-1.9 mm IQR). Automatic measures of MThK and LL agreed with manual delineation within -1.1° ± 2.2° and 0.7° ± 2.0° (mean and standard deviation), respectively. Device registration error was 0.7 mm (0.4-1.0 mm IQR) at the screw tip and 0.9° (1.0°-1.5°) about the screw trajectory. Deformable 3D-2D registration significantly outperformed conventional rigid registration (p < 0.05), which exhibited device registration error of 2.1 mm (0.8-4.1 mm) and 4.1° (1.2°-9.5°). Cadaver studies verified performance under realistic conditions, demonstrating patient registration error of 1.6 mm (0.9-2.1 mm); MThK within -4.2° ± 6.8° and LL within 1.7° ± 3.5°; and device registration error of 0.8 mm (0.5-1.9 mm) and 0.7° (0.4°-1.2°) for the multi-scale deformable method, compared to 2.5 mm (1.0-7.9 mm) and 2.3° (1.6°-8.1°) for rigid registration (p < 0.05). Conclusion: The deformable 3D-2D registration framework leverages long-length intraoperative imaging to achieve accurate patient and device registration over extended lengths of the spine (up to 64 cm) even with strong anatomical deformation. The method offers a new means for quantitative validation of spinal correction (intraoperative GSA measurement) and 3D verification of device placement in comparison to preoperative images and planning data. This article is protected by copyright. All rights reserved.
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Résumé Introduction L’objectif de cette étude était d’évaluer la relation entre port de chaussures à talons et lombalgie chez les femmes libanaises dont la profession nécessite une station debout prolongée. Matériel et méthodes Un questionnaire en ligne a été réalisé au moyen de Surveymonkey.com et envoyé par WhatsApp du 10 avril au 7 mai 2019 à 237 femmes qui travaillaient dans des écoles, universités et agences de travail. Résultats Un total de 47 % des femmes qui ont répondu restaient debout en moyenne 6 h par jour, 51,9 % portaient des chaussures à talons, 49,8 % étaient lombalgiques, 30 % gardaient leurs chaussures à talons malgré la douleur; 50,6 % portaient des talons de 1 à 4 cm de hauteur; 50,2 % les portaient pour des raisons esthétiques. Discussion Dans la population étudiée, il n’y avait pas de relation statistiquement significative entre la lombalgie et le port de chaussures à talons, chaussures considérées comme plus élégantes. D’ailleurs la hauteur de talon conseillée est de 4 cm pour relâcher la chaîne musculaire postérieure. Au-delà de 7 cm, les blessures musculosquelettiques augmentent, ainsi que le risque de chute. Conclusion Il serait intéressant qu’une étude de corrélation plus poussée définisse mieux la relation entre types de chaussures à talons et lombalgie. Niveau de preuve 5.
Article
Study design: Retrospective study. Objectives: The traditional PLIF is routinely utilized in severe lumbar spinal stenosis to relief the nerve compression. Nevertheless, the removal of posterior tension-band structure and the denervation and atrophy of the paraspinal muscle affect the clinical efficacy. Therefore, unilateral modified PLIF combined with contralateral fenestration was performed to overcome above-mentioned drawbacks. Methods: 32 modified PLIF and 33 traditional PLIF cases were retrospectively included. Operation time, length of stay (LOS) and blood loss were recorded. VAS of low back pain and leg pain, ODI and Sf-36 score including physical function and body pain were assessed. Fusion rate, lumbar lordosis (LL), intervertebral angle (IVA) and intervertebral height index (IHI) were evaluated radiologically. Results: Modified group possessed less blood loss, shorter operation time and less LOS. Compared with traditional group, the VAS of back pain was lower at 6 months postoperatively ( P < .05) and the ODI score was lower at 3 months postoperatively ( P < .05) in modified group. Modified group exhibited better physical function 3 months postoperatively and lower body pain 6 months postoperatively in Sf-36 score ( P < .05). No statistic difference in LL, IVA, IHI and fusion rate were observed between both groups. Conclusions: Our modified PLIF combining with contralateral fenestration procedure exhibited particular advantages in comparison to traditional PLIF. The preservation of posterior tension-band structure facilitates to less low back pain, low complication rate and early functional recovery.
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Abstract Background Postural rehabilitation plays an important role in the treatment of non-specific low back pain. Although pelvic inclination has been widely used to improve lumbar lordosis, the effect of cervical anterior inclination on lumbar lordosis in young and older adults in sitting and standing posture is still unclear. This preliminary study was designed to examine the influence of changing the cervical anterior angle on the lumbar lordosis angle, through alterations of the head position under the natural sitting and standing conditions, aiming to provide a basis for establishing a new postural rehabilitation strategy. Methods Thirty-six young (24.0 ± 2.2 years, 14 females and 22 males) and 38 older (68.4 ± 5.9 years, 36 females and 2 males) healthy adults participated in this study. The four spinal regional angles—cervical anterior angle, thoracic kyphosis angle, lumbar lordosis angle, and pelvic forward inclination angle, were measured in standing and relaxed sitting postures to determine the effects of a postural cueing for the head and neck posture, “inclining head backward and performing chin tuck,” on lumbar lordosis angle. Results In the standing posture, the pelvic forward inclination angle in the older adult group was significantly smaller (P
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Objective Spinopelvic alignment is increasingly considered as an essential factor for maintaining an energy-efficient posture in individuals with normal or pathological status. Although several previous studies have shown that changes in the sagittal spinopelvic alignment may occur in patients undergoing total hip arthroplasty (THA), no review of this area has been completed so far. Thus, the objective of this scoping review was to summarize the evidence investigating changes in spinopelvic alignment and low back pain (LBP) following THA. Data sources We adhered to the established methodology for scoping reviews. Four electronic databases were systematically searched from inception-December 31, 2021. Study selection We selected prospective or retrospective observational or intervention studies that included patients with THA. Data extraction Data extraction and levels of evidence were independently performed using standardized checklists. Data synthesis A total of 45 papers were included in this scoping review, involving 5185 participants with THA. Pelvic tilt was the most common parameter measured in the eligible studies ( n = 26). The results were not consistent across all studies; however, it was demonstrated that the distribution of pelvic tilt following THA had a range of 25° posterior to 20° anterior. Moreover, decreased sacral slope and lower pelvic incidence were associated with increased risk of dislocation in patients with THA. Lumbar spine scoliosis did not change significantly after THA in patients with bilateral hip osteoarthritis (5.50°(1.16°) vs. 3.73°(1.16°); P -value = 0.29). Finally, one study indicated that LBP improvement was not correlated with postoperative changes in spinopelvic alignment parameters. Several methodological issues were addressed in this study, including no sample size calculation and no type-I error adjustment for outcome multiplicity. Conclusions Changes in spinopelvic alignment may occur after THA and may improve with time. Patients with a THA dislocation usually show abnormal spinopelvic alignment compared to patients without a THA dislocation. LBP usually improves markedly over time following THA.
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Lumbar lordosis is a key adaptation to bipedal locomotion in the human lineage. Dorsoventral spinal curvatures enable the body's center of mass to be positioned above the hip, knee, and ankle joints, and minimize the muscular effort required for postural control and locomotion. Previous studies have suggested that Neandertals had less lordotic (ventrally convex) lumbar columns than modern humans, which contributed to historical perceptions of postural and locomotor differences between the two groups. Quantifying lower back curvature in extinct hominins is entirely reliant upon bony correlates of overall lordosis, since the latter is significantly influenced by soft tissue structures (e.g. intervertebral discs). Here, we investigate sexual dimorphism, ancestry, and lifestyle effects on lumbar vertebral body wedging and inferior articular facet angulation, two features previously shown to be significantly correlated with overall lordosis in living individuals, in a large sample of modern humans and Neandertals. Our results demonstrate significant differences between postindustrial cadaveric remains and archaeological samples of people that lived preindustrial lifestyles. We suggest these differences are related to activity and other aspects of lifestyle rather than innate population (ancestry) differences. Neandertal bony correlates of lumbar lordosis are significantly different from all human samples except preindustrial males. Therefore, although Neandertals demonstrate more bony kyphotic wedging than most modern humans, we cast doubt on proposed locomotor and postural differences between the two lineages based on inferred lumbar lordosis (or lack thereof), and we recommend future research compare fossils to modern humans from varied populations and not just recent, postindustrial samples.
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Degenerative changes of the spine can cause spinal misalignment, with part of the spine arching beyond normal limits or moving in an incorrect direction, potentially resulting in back pain and significantly limiting a person’s mobility. The most important parameters related to spinal misalignment include pelvic incidence, pelvic tilt, lumbar lordosis, thoracic kyphosis, and cervical lordosis. As a general rule, alignment of the spine for diagnosis and surgical treatment is estimated based on geometrical parameters measured manually by experienced doctors. However, these measurements consume the time and effort of experts to perform repetitive tasks that could be automated, especially with the powerful support of current artificial intelligence techniques. This paper focuses on creation of a decentralized convolutional neural network to precisely measure 12 spinal alignment parameters. Specifically, this method is based on detecting regions of interest with its dimensions that decrease by three orders of magnitude to focus on the necessary region to provide the output as key points. Using these key points, parameters representing spinal alignment are calculated. The quality of the method’s performance, which is the consistency of the measurement results with manual measurement, is validated by 30 test cases and shows 10 of 12 parameters with a correlation coefficient > 0.8, with pelvic tilt having the smallest absolute deviation of 1.156°.
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Excessive or incorrect loading of lumbar spinal structures is commonly assumed as one of the factors to accelerate degenerative processes, which may lead to lower back pain. Accordingly, the mechanics of the spine under medical conditions, such as scoliosis or spondylolisthesis, is well-investigated. Treatments via both conventional therapy and surgical methods alike aim at restoring a “healthy” (or at least pain-free) load distribution. Yet, surprisingly little is known about the inter-subject variability of load bearings within a “healthy” lumbar spine. Hence, we utilized computer tomography data from 28 trauma-room patients, whose lumbar spines showed no visible sign of degeneration, to construct simplified multi-body simulation models. The subject-specific geometries, measured by the corresponding lumbar lordosis (LL) between the endplates of vertebra L1 and the sacrum, served as ceteris paribus condition in a standardized forward dynamic compression procedure. Further, the influence of stimulating muscles from the M. multifidus group was assessed. For the range of available LL from 28 to 66°, changes in compressive and shear forces, bending moments, as well as facet joint forces between adjacent vertebrae were calculated. While compressive forces tended to decrease with increasing LL, facet forces were tendentiously increasing. Shear forces decreased between more cranial vertebrae and increased between more caudal ones, while bending moments remained constant. Our results suggest that there exist significant, LL-dependent variations in the loading of “healthy” spinal structures, which should be considered when striving for individually appropriate therapeutic measures.
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Study design: Prospective cohort study. Objective: To assess the differences in the clinical and radiological outcomes between oblique lateral interbody fusion (OLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). Summary of background data: Nowadays, there is still a controversy regarding whether OLIF is superior to MI-TLIF in the management of degenerative lumbar disease. Methods: Between August 3, 2019 and February 3, 2020, 137 patients were assigned to OLIF or MI-TLIF at their request and the surgeon's discretion: 71 in the OLIF group and 66 in the MI-TLIF group. The perioperative data, patient-reported outcomes, radiographic outcomes, and complications were compared between the two groups. Results: The OLIF group showed shorter operation time (110.5 vs.183.8 minutes, P < 0.001), lesser estimated blood loss (123.1 vs. 232.0 mL, P < 0.001), shorter length of hospital stay (5.5 vs. 6.7 days, P < 0.001), and lower serum creatine kinase (CK) (1 day postoperatively) (376.0 vs. 541.8 IU/L, P < 0.01) than that of MI-TLIF group. Both groups showed no significant differences in the visual analog scale (VAS) scores of lower back and leg pain and the Oswestry Disability Index (ODI) scores preoperatively and at 1, 3, and 12 months postoperatively, respectively (P > 0.05). Compared with the MI-TLIF group, the OLIF group showed better restoration of disc height (DH) (4.7/4.6/4.7 vs. 3.7/3.7/3.7 mm, P < 0.01) and lumbar lordosis angle (LLA) (10.5°/10.8°/11.1° vs. 5.8°/5.7°/5.3°, P < 0.001), but not the value of segmental lordosis angle (SLA) (P > 0.05) at 1 day, 1 month, and 1 year postoperatively, respectively. The complication rate of OLIF was higher than that of MI-TLIF (29.4% vs. 9.7%, P < 0.01). Conclusion: Compared with MI-TLIF, OLIF showed similar results in terms of patient-reported outcomes, restoration of SLA and fusion rate, and superior results with respect to restoration of DH and LLA, operation time, estimated blood loss, length of hospital stay, and serum CK levels (1 day postoperatively). Even though the complication rate of OLIF is higher than that of MI-TLIF, it does not bring persistent and substantial damage to the patients.Level of Evidence: 3.
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Introduction The prevalence of acetabular retroversion is sparsely investigated. It may be associated with increased anterior pelvic tilt. The purpose of this study was to investigate whether patients with symptomatic and radiographically verified acetabular retroversion demonstrated increased anterior pelvic tilt compared to a control group, and furthermore to evaluate the prevalence of acetabular retroversion in the general population. Methods Anteroposterior pelvic radiographs in standing position of 111 patients with acetabular retroversion prior to anteverting periacetabular osteotomy (PAO) and 132 matched controls from the general Danish population were assessed. Pelvic tilt was assessed by the sacrococcygeal joint–symphysis distance and pelvic-tilt-ratio. Acetabular retroversion was defined as positive cross-over sign and posterior wall sign. Prior to assessments, interrater reliability analysis was performed. Measurements were agreed by two independent assessors. A nonparametric regression model was used to test between-group differences in median pelvic tilt. The prevalence was calculated as the ratio of subjects and hips with acetabular retroversion, respectively. Results The patient group had significantly larger median anterior pelvic tilt of 14.3 mm in sacrococcygeal joint–symphysis distance and −0.08 in pelvic-tilt-ratio, compared to controls. The prevalence of subjects in the general population with either unilateral or bilateral acetabular retroversion was 24% and 18% for all hips. Conclusion Our data demonstrated that patients with symptomatic acetabular retroversion have increased anterior pelvic tilt compared to the general population. Radiographic sign of acetabular retroversion was highly prevalent in the general population. Implication for practice Increased anterior pelvic tilt should be considered when diagnosing and treating patients with hip pain, as symptoms may be related to the functional position of the pelvis and not necessarily solely come from the radiographic verified acetabular retroversion.
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Objective: The prevalence of Marfan syndrome (MFS) is estimated to be 1 in 10,000 to 15,000 individuals, but the phenotype of MFS may not be apparent and hence its diagnosis may not be considered by clinicians. Furthermore, the effects of MFS on the lungs and breathing are underrecognized despite the high morbidity that can occur. The objective of this Narrative Review is to delineate the molecular consequences of a defective fibrillin-1 protein and the skeletal and lung abnormalities in MFS that may contribute to respiratory compromise. It is important for clinicians to be cognizant of these MFS-associated respiratory conditions, and a contemporaneous review is needed. Background: MFS is an autosomal dominant, connective tissue disorder caused by mutations in the FIBRILLIN-1 (FBN1) gene, resulting in abnormal elastic fibers as well as increased tissue availability of transforming growth factor-beta (TGFβ), both of which lead to the protean clinical abnormalities. While these clinical characteristics are most often recognized in the cardiovascular, skeletal, and ocular systems, MFS may also cause significant impairment on the lungs and breathing. Methods: We searched PubMed for the key words of "Marfan syndrome," "pectus excavatum," and "scoliosis" with that of "lung disease," "breathing", or "respiratory disease." The bibliographies of identified articles were further searched for relevant articles not previously identified. Each relevant article was reviewed by one or more of the authors and a narrative review was composed. Conclusions: Though the classic manifestations of MFS are cardiovascular, skeletal, and ocular, FBN1 gene mutation can induce a variety of effects on the respiratory system, inducing substantial morbidity and potentially increased mortality. These respiratory effects may include chest wall and spinal deformities, emphysema, pneumothorax, sleep apnea, and potentially increased incidence of asthma, bronchiectasis, and interstitial lung disease. Further research into approaches to prevent respiratory complications is needed, but improved recognition of the respiratory complications of MFS is necessary before this research is likely to occur.
Article
Objective: To investigate whether lumbar lordosis (LL) and lumbar segmental lordosis (LSL) are related to sex, age, low back pain (LBP), and lumbar disc space narrowing (DSN). Methods: A total of 569 farmers were recruited. In lateral spine radiograph, LL (L1-L5) and LSL (L1, L2, L3, L4, and L5) were measured using Cobb's method. The differences in LSL values (ΔLSL) according to the presence or absence of a DSN were calculated as LSLDSN - LSLnoDSN for each DSN level. Results: In male, the lateral spine radiograph showed significantly greater L4-LSL and L5-LSL and smaller L1-LSL and L2-LSL compared to female. LLs in the 50-59 and ≥60 years age groups were significantly smaller compared to those in the <50 years age group. In subjects with LBP, LL and L4-LSL were significantly smaller than in those without. The ΔLSLs at the disc level with DSN showed the greatest decrease: L1-ΔLSL (Δ-3.99°), L2-ΔLSL (Δ-3.31°), L3-ΔLSL (Δ-2.87°), L4-ΔLSL (Δ-3.31°), and L5-ΔLSL (Δ-4.44°) in L1/2, L2/3, L3/4, L4/5, and L5/S1 DSN, respectively. Conversely, distant ΔLSLs were inversely increased: L1-LSL (Δ0.75°) with L4/5 DSN and L2-LSL (Δ0.94°) with L5/S1 DSN. Conclusion: Sagittal plane alignment was significantly associated with sex, age, LBP, and DSN. LSLs around the levels of DSN were decreased, and there was compensational increase of LSL distant to the DSN to maintain the overall LL.
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Athletes have higher thoracic and lumbar curvature in standing than the reference values of the non-athletic population. The sagittal integral morphotype method (SIM) assessment has not previously been applied to competitive amateur athletes (CAA). The propose of the present study was to determine the SIM of CAA treated at a sports-medicine center and to identify spinal misalignments associated with recurrent low back pain (LBP). An observational analysis was developed to describe the SIM in 94 CAA. The thoracic and lumbar curvatures of the CAA were measured in standing, sitting, and trunk forward flexion. Association analysis (Pearson’s chi-square and Cramér’s V tests) was then performed to identify the SIM misalignments associated with LBP. Effect size was analyzed based on Hedges’ g. The most common thoracic SIMs in CAA were total hyperkyphosis (male = 59.02%; female = 42.42%) and static hyperkyphosis (male = 11.48%; female = 6.06%). Hyperlordotic attitude (female = 30.30%; male = 4.92%), static-functional hyperkyphosis (male = 16.39%; female = 3.03%), and structured hyperlordosis (female = 21.21%; male = 1.64%) were the most common lumbar SIMs. Hyperlordotic attitude, static functional lumbar hyperkyphosis, and structured hyperlordosis were associated with LBP in male and female athletes.
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Many recent studies have focused on the functional and clinical importance of cervical lordosis. However, there is little accurate knowledge of the anatomical parameters that constitute cervical lordosis (i.e., the sagittal wedging angles of intervertebral discs and vertebral bodies) and their associations with age and sex. Standing lateral cervical radiographs of 1020 subjects (424 males, 596 females) with a mean age of 36.6 ± 17.0 years (range: 7–95 years) were evaluated retrospectively. Cervical lordosis, the sum of intervertebral disc wedging angles from C2/C3 to C6/C7 and the sum of vertebral body wedging angles from C3 to C7 were measured. The sum of intervertebral disc wedging and the sum of vertebral body wedging were 20.6 ± 14.7° and − 12.8 ± 10.3°, respectively. The sum of intervertebral disc wedging increased significantly with age and was significantly greater in males than females, whereas there was no sex-related difference in the sum of vertebral body wedging. The sum of intervertebral disc wedging was negatively correlated with sum of vertebral body wedging. Wedging of discs contributed to C2-C7 cervical lordosis more significantly than wedging of vertebral bodies. There were moderate positive correlations between cervical lordosis and intervertebral disc wedging angles at C3/C4, C4/C5 and C5/C6; weak correlations were observed at C2/C3 and C6/C7. This study constitutes the largest currently available analysis comprehensively documenting the anatomical characteristics of sagittal wedging of intervertebral discs and vertebral bodies in the cervical spine. The findings could improve understanding of the internal architecture of cervical lordosis among clinicians. This article is protected by copyright. All rights reserved.
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Aim: Spinal cord injury (SCI)-related flaccid paralysis may result in a debilitating hyperlordosis associated with a progressive hip flexion contracture. The aim of this study was to evaluate the correction of hip flexion contractures and lumbar hyperlordosis in paraplegic patients that had a history of spinal cord injuries. Methods: A retrospective review was performed on 29 hips of 15 consecutive patients who underwent corrective surgeries for severe hip flexion deformity from 2006 to 2018. The mean age at surgery was 10.1 years (2.7 to 15.8), and the mean follow-up was 68 months (7 to 143). Relevant medical, surgical, and postoperative information was collected from the medical records and radiographs. Results: Improvements were seen in the mean hip flexion contracture ( p < 0.001) with 100% hip correction at surgery and 92.1% at the latest follow-up. Mean lumbar lordosis decreased ( p = 0.029) while the mean Cobb angle increased ( p = 0.001) at the latest follow up. Functional score subdomains of the Spinal Cord Independence Measure, Functional Independence Measure, and modified Barthel activities of daily living (ADL) scores remained the same at the final follow-up. Conclusion: For paraplegic SCI patients, we found an association between treating the hip flexion contracture and indirect correction of their lumbar hyperlordosis. We recommend the surgeon carefully examine the hip pathology when managing SCI-related spinal deformities, especially increased lumbar lordosis.
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Background: Adjacent segment degeneration (ASD) is a frequent complication following vertebral fusion procedures and is defined as the condition where patients recover after the initial procedure but develop compatible symptoms with radiological injuries in the segments adjacent to the fused ones at a later stage. The objective of the study was to describe the frequency and analysis of ASD related signs following a lumbar fusion procedure. Methods: Observational descriptive retrospective study on patients with degenerative or instability conditions, operated on by posterolateral or circumferential lumbar fusion procedure. Pedicle screws, interbody peek cages (polyether-ether-ketone) and autologous bone graft were used. Clinical (pain and disability) and radiological (instability, rotation, disc height loss, radiological degeneration evaluated by X-ray and MR) variables were analysed. Results: Postoperative disc height loss was observed in 159 free discs among 112 patients (42.6%) (95% CI: 36.4-48.8%). Anterior or posterior slippage (anterolisthesis or retrolisthesis) at the end of the follow-up period was observed in 33 patients (12.5%). Upper segment rotation increased in the postoperative period in 36 patients (13.6%). Radiological disc degeneration was observed in 107 discs among 72 patients, being more frequent in the immediate upper disc with grade 2 and 3 changes at the end of follow-up in 48 discs from 35 patients (13.6%) (95% CI: 13.4-23.1%). Radiological ASD signs were observed in 151 patients (57.4%; 95% CI: 51.2-63.6%) and 53 of them (20.2%; 95% CI: 15.1-25.2%) who also showed clinical ASD symptoms (clinical and radiological ASD). Degeneration changes with degrees IV and V shown by a preoperative and magnetic resonance (MR) study at end of the follow-up period performed in 73 patients (27.7%), were observed in 46 discs among 32 patients (43.8%) (95% CI: 31.8-55.9%). Conclusions: Radiological ASD signs evaluated in every free disc following a lumbar fusion procedure are observed with a variable frequency. All free discs after fusion were assessed as they could indicate mechanisms of compensation of lordosis loss and should be taken into consideration in a prospective revision surgery.
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Background/Aims Hyperlordosis is associated with shortened hip flexor muscles, causing low back pain. The aim of this study was to investigate the effects of hip flexor stretching with and without abdominal exercises in individuals with hyperlordosis. Methods A total of 30 participants with hyperlordosis, aged between 20 and 30 years, were divided into three groups. Participants in the hold-relax group performed hold-relax stretching for 10 seconds, five repetitions, on both legs. Participants in the abdominal hollowing group performed hold-relax stretching and added an abdominal hollowing exercise for 10 seconds a repetition, 10 repetitions a set for three sets. Participants in the curl-up group performed hold-relax stretching and then performed curl-up exercises for 10 repetitions a set for three sets. The angle of lumbar lordosis, hip muscle length (degrees), percentage of maximum voluntary contraction of transversus abdominis and internal abdominal oblique, external abdominal oblique, rectus abdominis, lumbar erector spinae and multifidus muscles were investigated at pre-test, post-test and followed up 3 days after the end of the intervention. Results Significant within-group differences were found in the angle of lumbar lordosis for all groups (P<0.05), muscle length of hip flexor, and percentage of maximum voluntary contraction of the lumbar erector spinae and multifidus muscles in the curl-up group (P<0.05). The significant difference between pre-test and follow up in the hold-relax group and curl-up group reflects the retention of at least 3 days. Conclusions Hold-relax stretching can reduce the angle of lumbar lordosis and increase hip muscle length. In the curl-up group, the lumbar erector spinae and multifidus muscles decreased. Therefore, performing curl-up exercises after hold-relax stretching is recommended to decrease the angle of lumbar lordosis and percentage of maximum voluntary contraction of lumbar erector spinae and multifidus muscles.
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Lumbar lordosis is a key element of the upright posture, being interpreted as a consequence of bipedal locomotion. There is consensus that the generic modern human pattern of metameric vertebral body wedging is sexually dimorphic in modern humans. However, recently published studies have compared this pattern with other hominins, such as Neanderthals. These tried to establish whether the (male) Neanderthal lumbar vertebrae express a pattern that falls within or outside the range of modern human males. In the present study, data collected by 3D landmarks of the lumbar vertebrae of modern humans from different geographic regions and Neanderthals (Ntotal = 505 individual vertebrae) are used to clarify this problem, observing a similarity of the generic human pattern but with some interspecific differences in the pattern in the upper and lower lumbar vertebrae. Thus, the vertebral bodies L1-L3 of Neanderthals are more ventrally-wedged than in male modern humans, whilst the L4-L5 vertebral bodies of Neanderthal show a more progressive increase of dorsal wedging than in modern human males. The obtained results support modularity of the lumbar spine with different patterns in its upper and lower parts, and add that human geographic variability must be taken into account when carrying out comparisons of Neanderthals and modern humans. Our findings make clear the need to investigate this matter in more detail including complementary methods. Finally, key issues concerning the choice of measurement are discussed and recommendations made about how much inference can be made about complex systems such as the lumbar spine based on single linear measurements.
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Study Design: Sixty radiographs were measured on two separate occasions by three physicians using four different techniques to evaluate the reliability and reproducibility of the measurement of lumbar lordosis. Objective: To evaluate clinical methods of measuring lumbar lordosis, determining intraobserver and interobserver reliability. Summary of Background Data: Several different methods are used to measure lumbar lordosis. The reliability and reproducibility of these has not been well studied. Methods: Sixty lateral full spine radiographs were obtained, labeled, and the lumbar lordosis measured independently by three practitioners who routinely perform these measurements. Four measurement techniques were used. These included measurements from the inferior endplate of T12 to the superior endplate of S1; the superior endplate of L1 to the superior endplate of S1; the inferior endplate of T12 to the inferior endplate of L5; and the superior endplate of L1 to the inferior endplate of L5. The measurements then were repeated after relabeling. Results: Intraobserver reliability coefficients ranged from 0.83 to 0.92, indicating excellent reproducibility. Ninety‐two percent of repeat measures were within 10°. High overall and pairwise agreement among the three observers also was present; the interobserver reliability coefficients ranged from 0.81 to 0.92. Conclusions: The measurement of lumbar lordosis is reproducible and reliable if the technique is specified and one accepts 10° as acceptable variation. Factors that affect the reproducibility of measurement include end vertebra selection (especially with transitional segments) and vertebral endplate architecture.
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OBJETIVO: Os autores discutem a correlação existente entre a cifose torácica aumentada, em pacientes portadores de Dorso Curvo Postural (DCP) ou Doença de Scheuermann (DS), e a contratura dos músculos isquiotibiais. Esta relação é pouco estudada na literatura. MÉTODOS: No período de junho a dezembro de 2003, foram analisados 38 pacientes. Dentre os pacientes, 26 (68,4 %) eram do sexo masculino e 12 (31,6%) do sexo feminino. A idade mínima foi de 10 anos e a máxima de 20 anos, com média de 15,36. Encontramos 20 (52,6%) pacientes portadores de Doença de Scheuermann e 18 (47,4%) com Dorso Curvo Postural. RESULTADOS: De todos os 38 pacientes estudados, 32 (84,2%) apresentaram contratura dos isquiotibiais, o que foi estatisticamente significante (p<0,001). Analisando apenas pacientes com DS encontramos 85% de contratura e 83,3% nos com DCP. CONCLUSÃO: Não houve diferença estatística, da porcentagem de contratura dos isquiotibiais na DS em relação ao DCP (p=0,61).
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The consensus of the normal magnitude of lumbosacral curve has not been achieved. The Cobb's angle cannot depict the whole contour of this curve. For practical applications, a clearer image of these curves and their aging changes should be further investigated. This study aimed to provide a more consolidate concept of normal lumbosacral curves for clinician through a computerized reconstruction method. Standing lateral radiographs of lumbosacral spine in 82 normal adults were used for reconstructing the sagittal lumbosacral curves. The geometric characteristics of these curves according to the gender and age groups were studied. Using standing lateral radiographs, reconstruction of the lumbosacral curves was performed through digitization, programming and computation. These curves and related parameters were normalized and averaged for analyzing the differences of gender and age. The most anteriorward and horizontal vertebrae usually occurred on the L4 and L3 in any gender and age groups. The sacral inclination angle did not change obviously with the increasing ages. A tendency of L1 shifting backward was noted in the age groups of 40 to 60 and above 60 years old. The sagittal lumbosacral curves can be easily reconstructed by digitizing lateral radiographs, The aging changes of lumbosacral curves could be qualitatively described as the flattening of lower lumbar curve and the rearward inclination of upper lumbar curve. The changes occurred obviously above 40 years old. Although individual variations existed, the aging changes and the geometric characteristics such as the most anteriorward or horizontal vertebrae could be used as an important guideline during therapy or surgical correction.
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BACKGROUND: Postural abnormalities are often found in children. At this stage of life, posture undergoes many adjustments and adaptations due to body changes. Objective: To qualitatively identify the postural abnormalities which occur most frequently among children aged OBJECTIVE: Reven and ten years, comparing boys and girls, and to evaluate these subjects' lumbar flexibility. METHODS: One hundred and ninety-one children were photographed in the sagittal and frontal planes. The variables analyzed were: ankle (valgus and varus), tibiotarsal angle (opened and closed), knee (hyperextension and semiflexion, valgus and varus), pelvis (anteversion and retroversion; lateral pelvic inclination), trunk (antepulsion and retropulsion), lumbar spine (hyperlordosis and rectification), thoracic spine (hyperkyphosis and rectification), cervical spine (hyperlordosis and rectification), scoliosis, shoulder (imbalance and protraction), scapula (winged, abducted and adducted) and head (tilt and protraction). The lumbar flexibility was assessed using Schöber's index. RESULTS: The boys had greater incidence of winged scapula, shoulder imbalance, protraction of shoulders and head and cervical hyperlordosis than the girls did. Conversely, the girls had greater incidence of head tilt and larger Schöber index values. CONCLUSIONS: There were abnormalities in children's postural development that are probably related to muscle, skeletal and flexibility differences between the genders. These differences may influence each child's postural pattern during growth.
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Change in lumbar lordosis was measured in patients that had undergone posterolateral lumbar fusions using transpedicular instrumentation. The biomechanical effects of postoperative lumbar malalignment were measured in cadaveric specimens. To determine the extent of postoperative lumbar sagittal malalignment caused by an intraoperative kneeling position with 90 degrees of hip and knee flexion, and to assess its effect on the mechanical loading of the instrumented and adjacent segments. The importance of maintaining the baseline lumbar lordosis after surgery has been stressed in the literature. However, there are few objective data to evaluate whether postoperative hypolordosis in the instrumented segments can increase the likelihood of junctional breakdown. Segmental lordosis was measured on preoperative standing, intraoperative prone, and postoperative standing radiographs. In human cadaveric spines, a lordosis loss of up to 8 degrees was created across L4-S1 using calibrated transpedicular devices. Specimens were tested in extension and under axial loading in the upright posture. In patients who underwent L4-S1 fusions, the lordosis within the fusion decreased by 10 degrees intraoperatively and after surgery. Postoperative lordosis in the proximal (L2-L3 and L3-L4) segments increased by 2 degrees each, as compared with the preoperative measures. Hypolordosis in the instrumented segments increased the load across the posterior transpedicular devices, the posterior shear force, and the lamina strain at the adjacent level. Hypolordosis in the instrumented segments caused increased loading of the posterior column of the adjacent segments. These biomechanical effects may explain the degenerative changes at the junctional level that have been observed as long-term consequences of lumbar fusion.
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The purpose of the first part of the study was to establish the variability of repeated measurements in different measuring conditions. In the second part, we performed in a large number of patients, a measurement of thoracic kyphosis and lumbar lordosis and compared them to age, gender, and level of nourishment. In the first part, measurements were performed on a plastic model of the back of a patient with a rigid and a normal spine. In the second part, 250 patients participated in the study (126 men and 124 women). For measuring spinal curvatures we used an apparatus for laser triangulation constructed at the Faculty of Mechanical Engineering, University of Ljubljana. A comparison of 30 repeated measurements was shown as the average value±2 SD which included 95% of the results. Thirty repeated readings of one 3D measurement: thoracic kyphosis 41.2°±0.6°, lumbar lordosis 4.4°±1.2°; 30 measurements on a plastic model: thoracic kyphosis 36.8°±1.2°, lumbar lordosis 30.9°±2.0°; 30 measurements on a patient with a rigid spine: thoracic kyphosis 41.5°±2.4°, lumbar lordosis 4.0°±1.8°; 30 measurements on a patient with a normal spine: thoracic kyphosis 48.8°±7.4°, lumbar lordosis 21.1°±4.4°. The average size of thoracic kyphosis in 250 patients was 46.8° (SD 10.1°) and lumbar lordosis 31.7° (SD 12.5°). The angle size was statistically significantly correlated to gender (increased thoracic kyphosis and lumbar lordosis in women) and body mass index (increased thoracic kyphosis and lumbar lordosis in more nourished patients). Age was not significantly correlated to the observed angles. During measurements of the spinal angles it was important to pay attention to relaxation and the patient's position as well as to perform more measurements providing the average value. The age and the level of nourishment influence the size of the sagittal spinal angles. In the observed sample the effect of age was not confirmed.
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A prospective study conducted on several roentgenographic parameters of the standing sagittal profile of the spine in an asymptomatic Greek population. To perform segmental analysis of the sagittal plane alignment of the normal thoracic, lumbar, and lumbosacral spines and to compare the findings with those derived from similar populations. Until recently, little attention has been paid to the sagittal segmental alignment of the spine, and there are only a few studies (in French and American populations) in which radiographic analysis of sagittal spinal alignment is investigated. Ninety-nine consecutive asymptomatic Greek volunteers (38 men, 61 women), an average age of 52.7 +/- 15 years old (range, 20-79 years), were included in this prospective study, on the basis of several inclusion criteria. These volunteers were divided into six distinct age groups. The radiologic parameters, which were measured (by Cobb's method) on the lateral standing roentgenograms of the whole spine were: thoracic kyphosis (T4-T12), lumbar lordosis (L1-L5), total lumbar lordosis (T12-S1), distal lumbar lordosis (L4-S1), sacral inclination (measured from the line drawn parallel along the back of the proximal sacrum and the vertical line), pelvic tilting, vertebral body inclination, and relative segmental inclination between pairs of adjacent vertebrae. Thoracic kyphosis and lumbar lordosis (T12-S1, L1-L5) were not gender related. Thoracic kyphosis increased with age (P < 0.001), the lumbar spine (L1-L5) gradually became less lordotic as the thoracic kyphosis increased (P < 0.003), and total lumbar lordosis was not age related. Sacral inclination correlated strongly with both thoracic kyphosis (P < 0.002) and L1-L5 lordosis (P < 0.001). Pelvic tilting correlated strongly with L1-L5 lordosis (P < 0.0075), but did not correlate with thoracic kyphosis and age. Vertebral body inclination showed a narrow variability in T6-T12 and in L4 and a wide variability in T4, T5, L1-L3, and S1. Distal lumbar lordosis represents the 68.6% of the total lumbar lordosis. In the results of this study, a reliable table of reference for roentgenographic parameters in the sagittal plane of the spine was established in an asymptomatic Greek population. The parameters are similar to those used in previous studies. Thus, these data should be considered in preoperative planning and postoperative evaluation of achieved correction during restoration procedures of the spine in the sagittal plane.
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The objective is to evaluate the geometric parameters of vertebral bodies and intervertebral discs in spinal segments adjacent to spondylolysis and spondylolisthesis. This pilot cross-sectional study was an ancillary project to the Framingham Heart Study. The presence of spondylolysis and spondylolisthesis as well as measurements of spinal geometry were identified on CT imaging of 188 individuals. Spinal geometry measurements included lordosis angle, wedging of each lumbar vertebra and intervertebral disc. Last measurements were used to calculate ΣB, the sum of the lumbar L1-L5 body wedge angles; and ΣD, the sum of the lumbar L1-L5 intervertebral disc angles. Using Wilcoxon-Mann-Whitney test we compared the geometric parameters between individuals with no pathology and ones with spondylolysis (with no listhesis) at L5 vertebra, ones with isthmic spondylolisthesis at L5-S1 level, and ones with degenerative spondylolisthesis at L5-S1 level. Spinal geometry in individuals with spondylolysis or listhesis at L5 shows three major patterns: In spondylolysis without listhesis, spinal morphology is similar to that of healthy individuals; In isthmic spondylolisthesis there is high lordosis angle, high L5 vertebral body wedging and very high L4-5 disc wedging; In degenerative spondylolisthesis, spinal morphology shows more lordotic wedging of the L5 vertebral body, and less lordotic wedging of intervertebral discs. In conclusion, there are unique geometrical features of the vertebrae and discs in spondylolysis or listhesis. These findings need to be reproduced in larger scale study.
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The sagittal orientation and osteoarthritis of facet joints, paravertebral muscular dystrophy and loss of ligament strength represent mechanical factors leading to degenerative spondylolisthesis. The importance of sagittal spinopelvic imbalance has been described for the developmental spondylolisthesis with isthmic lysis. However, it remains unclear if these mechanisms play a role in the pathogenesis of degenerative spondylolisthesis. The purpose of this study was to analyze the sagittal spinopelvic alignment, the body mass index (BMI) and facet joint degeneration in degenerative spondylolisthesis. A group of 49 patients with L4-L5 degenerative spondylolisthesis (12 males, 37 females, average age 65.9 years) was compared to a reference group of 77 patients with low back pain without spondylolisthesis (41 males, 36 females, average age 65.5 years). The patient's height and weight were assessed to calculate the BMI. The following parameters were measured on lateral lumbar radiographs in standing position: L1-S1 lordosis, segmental lordosis from L1-L2 to L5-S1, pelvic tilt, pelvic incidence and sacral slope. The sagittal orientation and the presence of osteoarthritis of the facet joints were determined from transversal plane computed tomography (CT). The average BMI was significantly higher (P=0.030) in the spondylolisthesis group compared to the reference group (28.2 vs. 24.8) and 71.4% of the spondylolisthesis patients had a BMI>25. The radiographic analysis showed a significant increase of the following parameters in spondylolisthesis: pelvic tilt (25.6° vs. 21.0°; P=0.046), sacral slope (42.3° vs. 33.4°; P=0.002), pelvic incidence (66.2° vs. 54.2°; P=0.001), L1-S1 lordosis (57.2° vs. 49.6°; P=0.045). The segmental lumbar lordosis was significantly higher (P<0.05) at L1-L2 and L2-L3 in spondylolisthesis. The CT analysis of L4-L5 facet joints showed a sagittal orientation in the spondylolisthesis group (36.5° vs. 44.4°; P=0.001). The anatomic orientation of the pelvis with a high incidence and sacral slope seems to represent a predisposing factor for degenerative spondylolisthesis. Although the L1-S1 lordosis keeps comparable to the reference group, the increase of pelvic tilt suggests a posterior tilt of the pelvis as a compensation mechanism in patients with high pelvic incidence. The detailed analysis of segmental lordosis revealed that the lordosis increased at the levels above the spondylolisthesis, which might subsequently increase posterior stress on facet joints. The association of overweight and a relatively vertical inclination of the S1 endplate is predisposing for an anterior translation of L4 on L5. Furthermore, the sagittally oriented facet joints do not retain this anterior vertebral displacement.
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The impact of sagittal plane alignment on the treatment of spinal disorders is of critical importance. A failure to recognise malalignment in this plane can have significant consequences for the patient not only in terms of pain and deformity, but also social interaction due to deficient forward gaze. A good understanding of the principles of sagittal balance is vital to achieve optimum outcomes when treating spinal disorders. Even when addressing problems in the coronal plane, an awareness of sagittal balance is necessary to avoid future complications. The normal spine has lordotic curves in the cephalad and caudal regions with a kyphotic curve in between. Overall, there is a positive correlation between thoracic kyphosis and lumbar lordosis. There are variations on the degree of normal curvature but nevertheless this shape allows equal distribution of forces across the spinal column. It is the disruption of this equilibrium by pathological processes or, as in most cases, ageing that results in deformity. This leads to adaptive changes in the pelvis and lower limbs. The effects of limb alignment on spinal posture are well documented. We now also know that changes in pelvic posture also affect spinal alignment. Sagittal malalignment presents as an exaggeration or deficiency of normal lordosis or kyphosis. Most cases seen in clinical practise are due to kyphotic deformity secondary to inflammatory, degenerative or post-traumatic disorders. They may also be secondary to infection or tumours. There is usually pain and functional disability along with concerns about self-image and social interaction due to inability to maintain a horizontal gaze. The resultant pelvic and lower limb posture is an attempt to restore normal alignment. Addressing this complex problem requires detailed expertise and awareness of the potential pitfalls surrounding its treatment.
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We studied the lumbar spines of 117 adults (39 women and 78 men) with spondylolysis unrelated to low back pain using multidetector computed tomography (CT). Of the 117 subjects with spondylolysis, including five with multiple-level spondylolysis, there were 124 vertebrae with spondylolysis. In adult lumbar spines with unilateral spondylolysis, there was no significant difference between the incidence of spondylolisthesis in female and male subjects. However, in those with bilateral spondylolysis, there was a significantly higher incidence of spondylolisthesis in female subjects (90.9%) than in males (66.2%). Furthermore, females with bilateral spondylolysis had significant more slippage than males. Lumbar index and lumbar lordosis were not significantly different between male and female subjects, and did not significantly correlate with slippage. In conclusion, to treat acute spondylolysis in adolescents, it is important to obtain bony union at least unilaterally, especially in female subjects, to prevent further slippage.
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Careful review of published evidence has led to the postulate that the degree of lumbar lordosis may possibly influence the development and progression of spinal osteoarthritis, just as misalignment does in other joints. Spinal degeneration can ensue from the asymmetrical distribution of loads. The resultant lesions lead to a domino- like breakdown of the normal morphology, degenerative instability and deviation from the correct configuration. The aim of this study is to investigate whether a relationship exists between the sagittal alignment of the lumbar spine, as it is expressed by lordosis, and the presence of radiographic osteoarthritis. 112 female subjects, aged 40-72 years, were examined in the Outpatients Department of the Orthopedics' Clinic, University Hospital of Heraklion, Crete. Lumbar radiographs were examined on two separate occasions, independently, by two of the authors for the presence of osteoarthritis. Lordosis was measured from the top of L1 to the bottom of L5 as well as from the top of L1 to the top of S1. Furthermore, the angle between the bottom of L5 to the top of S1 was also measured. 49 women were diagnosed with radiographic osteoarthritis of the lumbar spine, while 63 women had no evidence of osteoarthritis and served as controls. The two groups were matched for age and body build, as it is expressed by BMI. No statistically significant differences were found in the lordotic angles between the two groups There is no difference in lordosis between those affected with lumbar spine osteoarthritis and those who are disease free. It appears that osteoarthritis is not associated with the degree of lumbar lordosis.
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Study Design. A radiographic evaluation of 100 adult volunteers over age 40 and without a history of significant spinal abnormality was done to determine indices of sagittal spinal alignment. Objectives. To determine the sagittal contours of the spine in a population of adults older than previously reported in the literature and to correlate age and overall sagittal balance to other measures of segmental spinal alignment. Summary of Background Data. Previous studies of sagittal alignment have focused on adolescent and young adult populations before the onset of degenerative changes that may affect sagittal alignment. Methods. Radiographic measurements were collected and subjected to statistical analysis. Results. Mean sagittal vertical axis fell 3.2 +/- 3.2 cm behind the front of the sacrum. Total lumbar lordosis (T12-S1) averaged -64[degrees] +/- 10[degrees]. Lordosis increased incrementally with distal progression through the lumbar spine. Lordosis at L5-S1 and the position of the apices of the thoracic and lumbar curves were most closely correlated to sagittal vertical axis. Increasing age correlated to a more forward sagittal vertical axis with loss of distal lumbar lordosis but without an increase in thoracic or thoracolumbar kyphosis. Conclusions. The majority of asymptomatic individuals are able to maintain their sagittal alignment despite advancing age. Loss of distal lumbar lordosis is most responsible for sagittal imbalance in those individuals who do not maintain sagittal alignment. Spinal fusion for deformity should take into account the anticipated loss of lordosis that may occur with age.
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Study of twenty skeletons and two hundred patients with degenerative spondylolisthesis established that it occurred four times more frequently in females, six to nine times more frequently at the interspace between the fourth and fifth lumbar vertebrae than at adjoining levels, three times more frequently in blacks than in whites, and four times more frequently when the fifth lumbar vertebra was sacralized. It did not occur before the fifth decade or in conjunction with spina bifida or isthmic spondylolisthesis. The slipping occurs as a result of degenerative disease of the articular processes, but it never exceeds 30%. When symptoms are severe and unrelieved by conservative treatment (10 per cent of our patients), decompression laminectomy and excision of the medial portion of the articular processes affords relief of pain. The predisposing factor is a straight, stable lumbosacral joint which puts abnormal stress on the intervertebral joint between the fourth and fifth lumbar vertebrae, leading to decompensation of disc and ligaments, hypermobility, and degeneration of the articular processes allowing forward slipping.
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This large treatise (1209 pages) can be considered the most complete textbook of clinical anatomy available today. The text in the book is aided by outstanding figures from the 11 editions of John C. Boileau Grant's classical anatomical atlases. These are very capably re-edited and supplemented by hundreds of creative and illuminating anatomical and clinically relevant art produced by Dr Anne M. R. Agur.
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The fascicular anatomy of the psoas major was determined by dissection in three cadavers. Its actions on the lumbar spine in the sagittal plane were modelled on erect, flexion, and extension radiographs of ten adult males. Calculations revealed that psoas exerts only very small moments that tend to extend the upper lumbar spine and to flex the lower lumbar spine, but at maximum contraction the psoas exerts severe compression forces on the lumbar segments, and large shear forces.
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Purposes of study: Most studies published on sagittal spinal balance have focused on the cervical, thoracic, lumbar and sacral spine without evaluating its relationship to the pelvis and femoral heads. Measures of sagittal balance of 148 asymptomatic volunteers from two countries have been studied. The purpose of this study was to evaluate the relationship between the measures of pelvic equilibrium and lumbar lordosis. Methods used: Volunteers were required to have had no previous spinal surgery, no low back pain, no lower limb length inequality and no scoliotic deformity. A 72-inch, standing lateral X-ray of the spine, pelvis and proximal femurs of each subject was obtained while the subject stood on a force plate, in a standardized position, knees in extension. The force plate provided the ground coordinates of the central axis of gravity (CAG). Each X-ray was digitized, and morphological and positional data of spine and pelvis were measured using custom software. Spinal measures collected included thoracic kyphosis and lumbar lordosis. Pelvic angles measured included one constant shape parameter, pelvic incidence (PI: angle between the line uniting the middle of the femoral heads and the middle of the sacral end plate and the perpendicular to the sacral end in its middle) and two positional parameters: sacral slope (SS: angle between the sacral end and horizontal) and pelvic tilt (PT: angle between the line uniting the middle of the femoral heads and middle of the sacral end and vertical). These three parameters are related in that PI=PT+SS. of findings: Distance between the CAG and the center of the femoral heads (femoral gravity offset) averaged 10.0 mm posterior. The anatomic parameter, PI, varied from 30.7 to 89.8 degrees (mean, 52.2 degrees; SD, 8.2 degrees). The average lumbar lordosis was 44.6 degrees. The average thoracic kyphosis was 47.4 degrees. We found a statistical correlation between PI and lumbar lordosis (r=0.60, p<.01) and between sacral inclination and lumbar lordosis (r=0.67, p<.01). Relationship between findings and existing knowledge: There have been no other studies correlating the gravity line with sagittal plane indexes. Overall significance of findings: The spine and pelvis balance around the hip axis in order to position the CAG over the femoral heads. Spinal–pelvic sagittal balance in normals is a combination between spinal and pelvic shape parameters. The pelvic shape, quantified by PI, determines the position of the sacrum, and in this way the magnitude of lumbar lordosis. PT controls the position of CAG. Sagittal balance of the spine seems to be linked to the pelvic shape. The relationship between the femoral heads and the sacrum indexed with the PI correlates generally well with the lumbar lordosis. An adverse relationship between PI and lumbar lordosis could be a factor in producing low back pain. Disclosures: No disclosures. Conflict of interest: No conflicts.
Article
OBJECTIVE: To evaluate peripheral joint laxity during pregnancy and to correlate changes with serum cortisol, estradiol, progesterone, and relaxin. METHODS: Forty-six women with first-trimester singleton gestations consented to participate in this longitudinal observational study. Bilateral wrist laxity measurements (flexion-extension and medial-lateral deviation) were made using a clinical goniometer, and serum levels of cortisol, estradiol, progesterone, and relaxin were determined during each trimester of pregnancy and postpartum. Patients were also screened for subjective joint complaints. Statistical analysis included Student t test, analysis of variance, and linear regression analysis. RESULTS: Eleven women (24%) were excluded from the study after spontaneous first-trimester pregnancy loss. Fifty-four percent (19 of 35) demonstrated increased laxity (10% or higher) in either wrist from the first to the third trimester. Although serum levels of cortisol, estradiol, progesterone, and relaxin were significantly elevated during pregnancy, no significant differences in these levels were noted between those who became lax during gestation and those who did not. Linear regression analysis of wrist joint laxity and level of serum estradiol, progesterone, and relaxin demonstrated no significant correlation. Wrist flexion-extension laxity, however, did significantly correlate with level of maternal cortisol (r = 0.18, P = .03). Fifty-seven percent of women developed subjective joint pain during pregnancy, which was not associated with increased joint laxity, but was associated with significantly increased levels of estradiol and progesterone. CONCLUSION: Peripheral joint laxity increases during pregnancy; however, these changes do not correlate well with maternal estradiol, progesterone, or relaxin levels. (C) 2003 by The American College of Obstetricians and Gynecologists.
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Diminished spinal mobility and altered posture with ageing may be normal or due to decreasing activity levels or gender differences. We investigated the effect of gender and physical activity on lumbar mobility and lordosis in well elderly men and women. Additionally we examined the data by ethnicity. Forty-one subjects (70.5 years ± 5.3) from two senior centers all exhibited a low physical activity score. Caucasians exhibited 6.45° more lumbar flexion than African Americans. Males averaged 6.45° less lordosis than females. African American women demonstrated a moderate inverse relationship between lordosis and lumbar flexion. Women had more lumbar flexion than men did and Caucasians had more lumbar flexion than African Americans. In the elderly, ethnic and gender-related differences may exist in lumbar spine mobility and spinal posture.
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Objective: The aim of this study was to determine the reliability and validity of the AutoCAD software method in lumbar lordosis measurement. Methods: Fifty healthy volunteers with a mean age of 23 ± 1.80 years were enrolled. A lumbar lateral radiograph was taken on all participants, and the lordosis was measured according to the Cobb method. Afterward, the lumbar lordosis degree was measured via AutoCAD software and flexible ruler methods. The current study is accomplished in 2 parts: intratester and intertester evaluations of reliability as well as the validity of the flexible ruler and software methods. Results: Based on the intraclass correlation coefficient, AutoCAD's reliability and validity in measuring lumbar lordosis were 0.984 and 0.962, respectively. Conclusions: AutoCAD showed to be a reliable and valid method to measure lordosis. It is suggested that this method may replace those that are costly and involve health risks, such as radiography, in evaluating lumbar lordosis.
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A postmortem material of lumbar spines from individuals aged 0–25 years was studied. Spines from newborn mature or premature infants were generally straight or kyphotic above a well marked lumbo-sacral angle. The development of the lordosis takes place during the first 3 years after birth and commences before the children start to sit, stand or walk. Children who never assume the erect position develop a lumbar lordosis to the same degree and at the same time as other children. Growth retardation gives a delay in the emergence of the lumbar lordosis.Ein Postmortalmaterial von lumbalen Wirbelsulen von Individuen im Alter von 0–25 Jahren wurde studiert. Die Wirbelsulen von Neugeborenen, maturen oder prmaturen Kindern, waren gewhnlich gerade oder kyphotisch ber einem gut markierten lumbosacralen Winkel. Die Entwicklung der Lordose findet whrend der ersten 3 Jahre nach der Geburt statt und beginnt, bevor die Kinder zu sitzen, gehen oder stehen anfangen. Kinder, die niemals die aufrechte Stellung erreichen, entwickeln eine lumbale Lordose von demselben Grad und zu derselben Zeit wie andere Kinder. Wachstumshemmung gibt einen Aufschub des Auftretens der lumbalen Lordose.Nous avons examin des colonnes vertbrales, excises d'individus morts entre l'ge de 0 25 ans. Les colonnes vertbrales de prmaturs ou de nouveau-ns taient pour la plupart droites ou cyphotiques au-dessus d'un angle sacro-vertbral nettement marqu. La lordose dbute avant que l'enfant commence s'asseoir, se mettre debout ou marcher, et se dveloppe au cours des trois premires annes postnatales. Les enfants qui n'adoptent jamais la position verticale dveloppent une lordose lombaire au mme degr et en mme temps que les autres enfants. La croissance retarde fait que la lordose lombaire apparat plus tard que normalement.
Article
Psoas muscle (PM) function with regard to the lumbar spine (LS) is disputed. Electromyographic studies attribute to the PM a possible role as stabilizer. Anatomical textbooks describe the PM as an LS flexor, but not a stabilizer. According to more recent anatomical studies, the PM does not act on the LS, because it tends to pull the LS into more lordosis by simultaneously flexing the lower and extending the upper region, but due to the short moment arms of its fascicles, this would require maximal muscular effort and would expose the LS motion segments to dangerous compression and shear. The findings of the present study indicate that the described opposite action of the PM on upper and lower LS regions, performed passively and requiring minimal muscular effort, may serve to stabilize the LS in an upright stance. It was demonstrated that a vertically placed elastic metal strip, modelled into a lordotic configuration to imitate the LS, will be brought into more lordosis, with maintenance of vertical position, if a string fastened at its upper end is pulled downward in a very specific direction. Conversely, any increase of lordosis of the strip brought about by vertical downward pushing of its top, will be stabilized by tightening the pulling string in the same specific direction. As this direction corresponded with the psoas orientation, the experiments show that the PM probably functions as a stabilizer of the lordotic LS in an upright stance by adapting the state of contraction of each of its fascicles to the momentary degree of lordosis imposed by factors outside the LS, such as general posture, general muscle activity and weight bearing. The presence of multiple PM fascicles, all of about equal length, and attaching to all LS levels, facilitates this function.
Article
In elite climbers, the development of "climber's back" has often been subjectively referred to. However no scientific proof is present. In a cross-sectional cohort study, the spines of 80 healthy asymptomatic male sport climbers were examined. The performance-oriented sport climbers (SC) trained regularly (9.8 +/- 4.3 hr/wk) and had a mean climbing ability of 9.7 +/- 0.6; the 34 recreational climbers (control group) (RC) climbed less frequently (3.4 +/- 2.0 hr/wk) and had a mean climbing ability of 6.0 +/- 0.9. Measurement of the sagittal thoracolumbar spine was performed using the "SpinalMouse". The kyphosis angle in the erect posture was significantly greater in SC verses the RC. The lordosis angle was also greater in SC versus RC but did not reach significance. No significant differences were found in flexion and extension. Further evaluation of the SC group was carried out by subdividing them to a moderate group (SC-moderate) (n = 17) and top-level group SC-top level) (n = 29). Here the kyphosis angle was significantly greater in SC-top-level than in SC-moderate. The results demonstrated that "climber's back" was characterized by an increased thoracic kyphosis, increased lumbar lordosis, and was probably influenced by shortened pectoralis muscles. The climbing ability level was strongly correlated to the postural adaptations.
Article
Few studies have directly evaluated the association of lumbar lordosis and segmental wedging of the vertebral bodies and intervertebral discs with the prevalence of spinal degenerative features. To evaluate the association of computed tomography (CT)-evaluated lumbar lordosis as well as segmental wedging of the vertebral bodies and that of the intervertebral discs with various spinal degenerative features. This cross-sectional study was a nested project to the Framingham Heart Study. A random consecutive subset of 191 participants chosen from the 3,590 participants enrolled in the Framingham Heart Study who underwent multidetector CT to assess aortic calcification. Dichotomous variables indicating the presence of intervertebral disc narrowing, facet joint osteoarthritis, spondylolysis, spondylolisthesis and spinal stenosis, and density (in Hounsfield units) of multifidus and erector spinae muscles were evaluated on supine CT, as well as the lordosis angle (LA) and the wedging of the vertebral bodies and intervertebral discs. The sum of vertebral bodies wedging (ΣB) and sum of intervertebral discs wedging (ΣD) were used in the analyses. Mean values (±standard deviation [SD]) of LA, ΣB, and ΣD were calculated in males and females and compared using the t test. Mean values (±SD) of LA, ΣB, and ΣD in four age groups (<40, 40-49, 50-59, and 60+ years) were calculated. We tested the linear relationship between LA, ΣB, and ΣD and age groups. We evaluated the association between each spinal degenerative feature and LA, ΣB, and ΣD using multiple logistic regression analysis where studied degenerative features were the dependent variable and all LA, ΣB, and ΣD (separately) as well as age, sex, and body mass index were independent predictors. Lordosis angle was slightly lower than the normal range for standing individuals, and no difference was found between males and females (p=.4107). However, the sex differences in sum of vertebral bodies wedging (ΣB) and sum of intervertebral discs wedging (ΣD) were statistically significant (.0001 and .001, respectively). Females exhibit more dorsal wedging of the vertebral bodies and less dorsal wedging of the intervertebral discs than do males. All these parameters showed no association (p>.05) with increasing age. Lordosis angle showed statistically significant association with the presence of spondylolysis (odds ratio [95% confidence interval]: 1.08 [1.02-1.14]) and with the density of multifidus (1.06 [1.01-1.11]) as well as a marginally significant association with isthmic spondylolisthesis (1.07 [1.00-1.14]). ΣB showed a positive association with degenerative spondylolisthesis and disc narrowing (1.14 [1.06-1.23] and 1.04 [1.00-1.08], correspondingly), whereas ΣD showed a negative one (0.93 [0.87-0.98] and 0.93 [0.89-0.97], correspondingly). Significant associations were found between lumbar lordosis evaluated in supine position and segmental wedging of the vertebral bodies and intervertebral discs and the prevalence of spondylolysis and spondylolisthesis. Additional studies are needed to evaluate the association between spondylolysis, isthmic and degenerative spondylolisthesis and vertebral and disc wedging at the segmental level.
Article
Prospective radiographic study. To investigate the feasibility of controlling quality of reconstructed sagittal balance for sagittal imbalance. Patients with sagittal imbalance cannot walk or stand erect without overwork of musculature because of compromised biomechanical advantage. The result is muscle fatigue and activity-related pain. During reconstructive surgery, restoration of optimal sagittal balance is crucial for obtaining satisfactory clinical results. However, there is no way to control quality of reconstructed sagittal balance before or during surgery. A method was developed to determine the lumbosacral curve in a way that theoretically would bring sagittal balance to an ideal state by calculation and simulation for each patient before surgery and then template rods of the curve and a blueprint were made accordingly for operative procedures. Ninety-four consecutive patients with sagittal imbalance due to lumbar kyphosis were treated for intractable pain and then followed up for a mean of 4.3 years. Radiographs were analyzed before surgery, 2 months after surgery, and at most recent follow-up. The mean estimated values of L1-S1 lordosis, sacral inclination angle, sacrofemoral distance, and distribution of L1-S1 lordosis at the closing-opening wedge osteotomy site and L4-S1 segments were 30.8°, 24.6°, 0 mm, 16.1% (-5°), and 62% (-19°), respectively. The mean reconstructed values were 41.1°, 23.3°, 3.9 mm, 41% (-17°), and 46% (-19°), respectively. There were significant differences between estimated and reconstructed values of L1-S1 lordosis and the percentage of distributions; however, there was no significant difference between the estimated and reconstructed magnitude of L4-S1 lordosis, sacral inclination angle, and sacrofemoral distance. A properly oriented pelvis can be brought nearly directly above the hip axis. The mean sagittal global balance, represented by the distance between the vertical line through the hip axis and sacral promontory, improved from 61.4 mm before surgery to 3.9 mm 2 months after surgery, and 1.3 mm at final follow-up. Normal sagittal global balance was reconstructed and maintained. The mean sagittal spinal balance measured as the horizontal distance between the C7 sagittal plumb line and the posterior superior corner of S1 improved from 97.4 mm before surgery to 11 mm 2 months after surgery. However, there was significant loss of sagittal spinal balance to 25.4 mm at the fi nal visit. Normal sagittal spinal balance was reconstructed and appeared to be maintained. The magnitude of T1-T12 kyphosis compensated from 13° before surgery to 25.2° 2 months after surgery and 34.5° at fi nal follow-up. Quality control of the reconstructed sagittal balance for sagittal imbalance is possible. Correctly orienting the pelvis, reconstructed by the restoration of enough L1-S1 lordosis with adequate distribution at L4-S1 segments, is a matter of critical importance for optimizing reconstructed sagittal balance. The correctly oriented pelvis can be determined before surgery. Preventing junctional fracture and persistent rehabilitation of surgically injured lumbar extensor musculature are crucial for maintaining the reconstructed sagittal balance.