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Lumbar lordosis
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.
... A recent systematic review (24) found an effect of sex on lumbar lordosis and lumbar RoM, but noted that the studies available for synthesis were limited and more evidence was needed. Considering the importance of lumbar lordosis in spinal loading (11,16,25) and its possible association with low-back pain and spondylolysis (26,27) an assessment of lumbo-pelvic kinematics in a large number of healthy participants and patients with low-back pain may be of clinical relevance. ...
... Sex-specific differences in sacral shape and orientation (74) or hamstring flexibility (75) might affect the lumbo-pelvic kinematics resulting in a higher pelvic angle in females. It has been argued that in female participants lower muscular strength capacities (76)(77)(78)(79) and sex-specific characteristics in muscle morphology (80,81) may also affect lumbar lordosis and pelvic inclination (26). However, several studies failed to support a relationship between trunk muscle strength, lumbar lordosis and pelvic inclination (56,82,83) suggesting that muscle strength may not be the reason for the sex-specific higher lumbar lordosis. ...
Background
Trunk posture and lumbo-pelvic coordination can influence spinal loading and are commonly used as clinical measures in the diagnosis and management of low-back pain and injury risk. However, sex and pain specific characteristics have rarely been investigated in a large cohort of both healthy individuals and low-back pain patients. It has also been suggested that the motor control of trunk stability and trunk movement variability is altered in individuals with low-back pain, with possible implications for pain progression. Nonetheless, clear links to low-back pain are currently lacking.
Objective
To investigate trunk posture, lumbo-pelvic coordination, trunk dynamic stability and trunk movement variability in an adequately large cohort of individuals with low-back pain and asymptomatic controls and to explore specific effects of sex, pain intensity and pain chronicity.
Methods
We measured lumbo-pelvic kinematics during trunk flexion and trunk dynamic stability and movement variability during a cyclic pointing task in 306 adults (156 females) aged between 18 and 64 years, reporting either no low-back pain or pain in the lumbar area of the trunk. Participants were grouped based on their characteristic pain intensity as asymptomatic (ASY, N = 53), low to medium pain (LMP, N = 185) or medium to high pain (MHP, N = 68). Participants with low-back pain that persisted for 12 weeks or longer were categorized as chronic (N = 104). Data were analyzed using linear mixed models in the style of a two way anova.
Results
Female participants showed a higher range of motion in both the trunk and pelvis during trunk flexion, as well as an increased lumbar lordosis in standing attributed to a higher pelvic angle that persisted throughout the entire trunk flexion movement, resulting in a longer duration of lumbar lordosis. The intensity and chronicity of the pain had a negligible effect on trunk posture and the lumbo-pelvic coordination. Pain chronicity had an effect on trunk dynamic stability (i.e., increased trunk instability), while no effects of sex and pain intensity were detected in trunk dynamic stability and movement variability.
Conclusions
Low-back pain intensity and chronicity was not associated with lumbo-pelvic posture and kinematics, indicating that lumbo-pelvic posture and kinematics during a trunk flexion movement have limited practicality in the clinical diagnosis and management of low-back pain. On the other hand, the increased local instability of the trunk during the cyclic coordination task studied indicates control errors in the regulation of trunk movement in participants with chronic low-back pain and could be considered a useful diagnostic tool in chronic low-back pain.
... The normal values for cervical lordosis and thoracic kyphosis range between 20 • and 40 • [63][64][65][66]. Lumbar lordosis is considered normal between 20 • and 45 • [67]. In the pelvis, the reference considers the positioning of the ASIS and PSIS in the same plane, corresponding to zero degrees [68]. ...
... However, we found the result regarding lumbar lordosis in the control group to be unusual, as lumbar hyperlordosis is also reported in the literature as prevalent [17,18]. On the other hand, several authors note that the values corresponding to an adequate curvature are controversial, that the ideal range of lordosis remains unknown, and that it may be related to a variety of individual factors, such as weight, activity level, muscle strength, and flexibility of the spine and lower limbs [67,78]. Therefore, the normative values we considered may not be the most suitable for identifying lumbar curvature. ...
Background: Postural changes are considered a public health issue and have gathered significant interest in both research and clinical practice. Aims: To evaluate the effectiveness of Global Postural Reeducation (GPR) in improving postural changes and postural stability in healthy young adults. Additionally, this study aims to identify the main postural changes in the sample population. Methods: A longitudinal study was conducted with a sample of students (n = 38) from the 2nd and 3rd years of undergraduate programs at Coimbra Health School, divided into an experimental group (EG) with 20 subjects and a control group (CG) with 18 subjects. The EG underwent a GPR intervention, while the CG received no intervention. Postural changes were assessed using a 3D motion analysis system (Qualisys), and stabilometry was evaluated using a Bertec force platform. Results: At baseline (T0), the groups were homogeneous regarding sample characterization variables, as well as postural and stabilometric variables (p > 0.05). After four weeks of the intervention (T1), no significant differences were observed between the EG and CG for any of the variables studied (p > 0.05). However, within-group analysis for the experimental group revealed a significant difference (p = 0.04) in anterior-posterior velocity, indicating a reduction in this parameter from T0 to T1. In the control group, a significant difference was observed (p = 0.03) in the left knee valgus, indicating a reduction in valgus alignment. Conclusions: GPR does not appear to be effective in improving postural changes or center of pressure displacement in healthy young students.
... The lumbosacral joint is the transition area from the lumbar spine to the sacral spine. In this location, the curvature of the vertebra changes to the sacral kyphosis (backward curvature) from the lumbar lordosis (forward curvature) [5,6]. It is the key area that helps in the transfer of weight from the vertebral column to the pelvis and lower limb. ...
... The predictive simulation of the active hybrid FE-MB MLS model was divided into the following six phases, of which [i], [iii], [iv], and [v] were optional depending on the scenario and physical activity: We defined the resulting orientation of the dynamic vertebrae after the spinal settling phase [ii] as the stable, upright reference posture (in the following also abbreviated as standing) with a lumbar lordosis of 52 • (COBB angle [79] in between L1 and S1). After reaching a static target posture in [vi], the biomechanical model responses extracted from the MLS model included intradiscal pressure (IDP), intra-abdominal pressure (IAP), range of motion (ROM), intervertebral displacement, and muscle force. ...
Knowledge of realistic loads is crucial in the engineering design process of medical devices and for assessing their interaction with the spinal system. Depending on the type of modeling, current numerical spine models generally either neglect the active musculature or oversimplify the passive structural function of the spine. However, the internal loading conditions of the spine are complex and greatly influenced by muscle forces. It is often unclear whether the assumptions made provide realistic results. To improve the prediction of realistic loading conditions in both conservative and surgical treatments, we modified a previously validated forward dynamic musculoskeletal model of the intact lumbosacral spine with a muscle-driven approach in three scenarios. These exploratory treatment scenarios included an extensible lumbar orthosis and spinal instrumentations. The latter comprised bisegmental internal spinal fixation, as well as monosegmental lumbar fusion using an expandable interbody cage with supplementary posterior fixation. The biomechanical model responses, including internal loads on spinal instrumentation, influences on adjacent segments, and effects on abdominal soft tissue, correlated closely with available in vivo data. The muscle forces contributing to spinal movement and stabilization were also reliably predicted. This new type of modeling enables the biomechanical study of the interactions between active and passive spinal structures and technical systems. It is, therefore, preferable in the design of medical devices and for more realistically assessing treatment outcomes.
... Lumbar lordosis was assessed using a standard lumbar lateral radiograph by calculating the angle formed between the tangents of the upper endplates of the L1 and S1 vertebrae (12) (Figure 2A). ...
Purpose
This study aims to investigate how aspirin influences lumbar degeneration by analyzing the effect of aspirin on patients with low back pain (LBP) and concurrent atherosclerosis.
Methods
Using 1:1 nearest neighbor matching based on propensity score matching (PSM), 73 patients who regularly took aspirin were assigned to the aspirin group, while another 73 patients who did not take aspirin formed the control group. Radiographs were used to measure lumbar lordosis (LL) and intervertebral height index (IHI). Subcutaneous fat tissue thickness (SFTT), paravertebral muscle fat infiltration area (%FIA), cartilage endplate (CEP) Modic changes, and modified Pfirrmann grading scores were performed based on lumbar MRI.
Results
After PSM analysis, confounders between the aspirin and control groups were balanced. A total of 73 pairs of patients were analyzed in this study. The aspirin group showed lower SFTT(L1/2) and a reduced incidence of CEP Modic changes, compared to the control group (both P < 0.05). Additionally, the %FIA and Pfirrmann scores were lower in the aspirin group, particularly in the upper lumbar spine (both P < 0.05). No significant differences were observed in LL and IHI between the aspirin and control groups.
Conclusion
In summary, conservative treatment with aspirin protects against upper lumbar spine degeneration, although its effect on the lower lumbar spine is less pronounced.
... Previous research has emphasized the link between pelvic tilt and lumbar lordosis [33,34], showing that pelvic anteversion increases the sacral slope, which, in turn, heightens lumbar lordosis [35,36]. This increased curvature exerts greater compressive forces on the posterior vertebral structures, potentially exacerbating LBP [37,38]. Therefore, this study aims to investigate the effects of inverted drop soles (insoles) on sagittal posture, such as the kinematic parameters of the lower limbs (i.e., trunk, hip, and knee angles) and lower back (i.e., spinal curvature angles), as well as EMG activities (i.e., rectus abdominis and rectus femoris). ...
Maintaining proper posture is essential for preventing musculoskeletal disorders and reducing injury risks. This study investigates the impact of insoles with ankle dorsiflexion (inverted drop sole) on sagittal posture, spinal curvatures, and core muscle activation. Methods: Fifty-five participants (29 men, 26 women; aged 20–70 years) were evaluated in two conditions: barefoot and with insoles incorporating an inverted drop sole. Kinematic data of trunk, hip, and knee angles, along with spinal curvatures (dorsal kyphosis, lumbar lordosis, and sacral slope), were collected using the Simi Aktysis 3D system and the Medi Mouse IDIAG 360®. The electromyographic (EMG) activity of the rectus abdominis and rectus femoris muscles was analyzed using the Bioplux® device. Statistical analyses were conducted using Wilcoxon tests (W) for non-parametric data and Student’s t-tests (T) for parametric data with significance set at p < 0.05. For parametric data, effect size (ES) was used to assess the magnitude of differences based on the Cohen scale. For nonparametric data, the rank biserial correlation (rB) was used, considered an ES equivalent to the correlation coefficient. Results: Significant differences were observed between the barefoot and insole conditions for trunk and knee angles (p = 0.009 and p < 0.001, respectively) with moderate and large magnitude of difference (rB = −0.41 and rB = −0.96, respectively). No significant change in hip angle (p = 0.162) was observed. Spinal curvatures, including dorsal kyphosis, lumbar lordosis, and sacral slope, significantly decreased (p < 0.001), with a large magnitude of difference for dorsal kyphosis, lumbar lordosis, and sacral scope (rB = 0.71, rB = −0.94 and ES = 0.54, respectively). EMG analysis revealed the increased activation of the rectus abdominis and rectus femoris muscles (p < 0.001), with a large magnitude of difference both the rectus abdominis and rectus femoris (rB = −0.82, and ES = −0.82, respectively). Conclusions: Insoles with ankle dorsiflexion significantly improve sagittal posture by reducing spinal curvatures and enhancing core muscle activation. These findings suggest that dorsiflexion technology in footwear may serve as a non-invasive strategy for improving posture, preventing musculoskeletal disorders, and managing low back pain.
... In general, it is typically quantified by measuring the angle between the upper endplate of the L1 vertebra and the lower endplate of the L5 vertebra. [15][16][17] In contrast, in this study, the limited imaging availability of the lower lumbar spine led to the adoption of the AVD/AT and PAD/AT ratios at L1 and L3 as surrogate markers. Given that Nissen fundoplication targets the upper abdomen, these metrics are considered effective indicators of lordosis and, by extension, the dimensions of the abdominal cavity. ...
Background: Laparoscopic fundoplication is commonly performed in patients with neurological impairment. However, these patients often have spinal deformities that can complicate achieving a clear surgical view. This study aimed to identify factors associated with poor visibility in pediatric laparoscopic fundoplication.
Methods: Operative videos, medical records, and radiographs of patients who underwent laparoscopic fundoplication between 2015 and 2023 were retrospectively reviewed. The videos were reviewed by two pediatric surgeons and classified into good or poor visibility groups. Age, sex, height, weight, history of abdominal surgery, lordosis, operative time, blood loss, and intraoperative complications were compared between the two groups. Lordosis was evaluated using the sagittal view of computed tomography images, and the anterior vertebral depth and abdominal thickness were measured to calculate the ratio.
Results: Forty-one patients were included in this study. Based on the video review, the patients were classified into good (20 patients) and poor (21 patients) visibility groups. The median age, height, and weight were 6 years, 110 cm, and 16.1 kg, respectively. In the poor visibility group, 23.8% of patients had a history of abdominal surgery (P = .048). Additionally, the anterior vertebral depth to abdominal thickness ratios at the first and third lumbar vertebrae were significantly lower in the poor visibility group (P = .016 and P = .0018, respectively). There were no significant differences in the operative time, blood loss, or intraoperative complications between the two groups.
Conclusions: Lordosis and a history of abdominal surgery may be risk factors for poor visibility in pediatric laparoscopic fundoplication.
... From a structural perspective, the angle of lumbar lordosis is determined by the shape of the lumbar vertebrae and the height of the intervertebral disks. A thinner dorsal vertebral wedge leads to a more fixed angle in lordosis, whereas a thinner anterior vertebral wedge reverses the lordosis, leading to a fixed position moving into a more neutral or kyphotic position [49,50]). While maintaining lumbar lordosis is recommended, health and fitness professionals should guide older individuals to perform the back squat while maintaining the most comfortable, symptom-free, neutral spine position. ...
Background/Objectives: Falls pose a significant health risk for older adults, often due to balance disorders and decreased mobility. Methods: The ability to perform sit-to-stand transfers, which involve squatting, is crucial for daily independence. Incorporating squats into exercise routines can enhance lower body strength, reduce fall risk, and improve overall quality of life. Results: While the back squat is beneficial, proper form is essential to avoid biomechanical errors, like lumbar hyperlordosis and knee valgus. Conclusions: Health and fitness professionals, such as physical therapists and/or clinical exercise physiologists, should carefully guide older adults in performing the back squat, addressing any functional deficits, and ensuring proper technique to minimize the risk of injury and maximize the benefits.
... In particular, because humans are adapted to walk long distances often while carrying loads, as well as dig, climb and do other activities that require significant back muscle activity and spinal loading, the mismatch hypothesis predicts the human spine may be poorly adapted to experiencing only low levels of spinal loading and back muscle activation and thus developing weak back muscles with low endurance that are poor at stabilizing the spine, increasing risk of injury and back pain [7]. Back muscles are like guy wires providing the majority of support to the spine [119][120][121], so according to this reasoning features of the human spine thought to predispose humans to back pain, such as a longer lumbar region featuring a ventral curvature, known as lordosis [122][123][124][125][126], may only become problematic in the presence of weak, fatigable back muscles that are unable to generate appropriate levels of force to stabilize the spine [7]. ...
Over the course of the physical activity transition, machines have largely replaced skeletal muscle as the source of work for locomotion and other forms of occupational physical activity in industrial environments. To better characterize this transition and its effect on back muscles and the spine, we tested to what extent typical occupational activities of rural subsistence farmers demand higher magnitudes and increased variability of back muscle activity and spinal loading compared to occupational activities of urban office workers in Rwanda, and whether these differences were associated with back muscle endurance, the dominant risk factor for back pain. Using electromyography, inertial measurement units, and OpenSim musculoskeletal modeling, we measured back muscle activity and spinal loading continuously while participants performed occupational activities for one hour. We measured back muscle endurance using electromyography median frequency analysis. During occupational work, subsistence farmers activate their back muscles and load their spines at 390% higher magnitudes and with 193% greater variability than office workers. Partial correlations accounting for body mass show magnitude and variability response variables are positively associated with back muscle endurance (R = 0.39–0.90 [P < 0.001–0.210] and R = 0.54–0.72 [P = 0.007–0.071], respectively). Body mass is negatively correlated with back muscle endurance (R = -0.60, P = 0.031), suggesting higher back muscle endurance may be also partly attributable to having lower body mass. Because higher back muscle endurance is a major factor that prevents back pain, these results reinforce evidence that under-activating back muscles and under-loading spines at work increases vulnerability to back pain and may be an evolutionary mismatch. As sedentary occupations become more common, there is a need to study the extent to which occupational and leisure time physical activities that increase back muscle endurance helps prevent back pain.
... It is noteworthy, however, that individual genetic predispositions constrain these mechanisms. Concurrently, the anatomical characteristics of the spine are susceptible to alterations stemming from discopathy, with a pronounced interrelationship between the two phenomena [13][14][15][16][17]. This condition introduces several biomechanical deficiencies, culminating in aberrant body postures during mechanical activity, constrained balance capabilities, and restricted individual joint mobility [18]. ...
Background: Physiological curvature changes of the lumbar spine and disc herniation can cause abnormal biomechanical responses of the lumbar spine. Finite element (FE) studies on special weightlifter models are limited, yet understanding stress in damaged lumbar spines is crucial for preventing and rehabilitating lumbar diseases. This study analyzes the biomechanical responses of a weightlifter with lumbar straightening and L4-L5 disc herniation during symmetric bending and lifting to optimize training and rehabilitation. Methods: Based on the weightlifter’s computed tomography (CT) data, an FE lumbar spine model (L1-L5) was established. The model included normal intervertebral discs (IVDs), vertebral endplates, ligaments, and a degenerated L4-L5 disc. The bending angle was set to 45°, and weights of 15 kg, 20 kg, and 25 kg were used. The flexion moment for lifting these weights was theoretically calculated. The model was tilted at 45° in Abaqus 2021 (Dassault Systèmes Simulia Corp., Johnston, RI, USA), with L5 constrained in all six degrees of freedom. A vertical load equivalent to the weightlifter’s body mass and the calculated flexion moments were applied to L1 to simulate the weightlifter’s bending and lifting behavior. Biomechanical responses within the lumbar spine were then analyzed. Results: The displacement and range of motion (ROM) of the lumbar spine were similar under all three loading conditions. The flexion degree increased with the load, while extension remained unchanged. Right-side movement and bending showed minimal change, with slightly more right rotation. Stress distribution trends were similar across loads, primarily concentrated in the vertebral body, increasing with load. Maximum stress occurred at the anterior inferior margin of L5, with significant stress at the posterior joints, ligaments, and spinous processes. The posterior L5 and margins of L1 and L5 experienced high stress. The degenerated L4-L5 IVD showed stress concentration on its edges, with significant stress also on L3-L4 IVD. Stress distribution in the lumbar spine was uneven. Conclusions: Our findings highlight the impact on spinal biomechanics and suggest reducing anisotropic loading and being cautious of loaded flexion positions affecting posterior joints, IVDs, and vertebrae. This study offers valuable insights for the rehabilitation and treatment of similar patients.
... Deviations from the normal lumbar lordotic curvature can lead to various musculoskeletal issues, impacting an individual's quality of life. (1,2) Lumbar hyperlordosis is a condition characterized by an excessive inward curvature of the lumbar spine, leading to an exaggerated arching of the lower back. This abnormal posture can result in various biomechanical and structural changes throughout the lumbar region, affecting not only the alignment of the vertebrae but also the surrounding soft tissues, including the muscles and fascia. ...
Background: Lumbar hyperlordosis is the most prevalent musculoskeletal postural deformity. Maintenance of normal limits of lumbar lordosis is necessary for obtaining an ideal posture. Literature suggests that poor posture results in fascial restriction in which the fascia reorganizes in response to tension. Gross myofascial release (MFR) combined with posterior pelvic tilting exercises proved to be beneficial in improving the lumbar range of motion. Three-dimensional (3D) MFR is a novel approach toward reducing fascial restrictions. However, the literature determining the effects of 3D MFR is still emerging. Aim: To determine the effect of 3D MFR on a lumbar lordosis angle and lumbar range of motion, in individuals with asymptomatic hyperlordosis. Method: Participants (n = 30) with hyperlordosis were randomly assigned to either the experimental group receiving 3D MFR (n = 15) or the control group (n = 15) that received sham 3D MFR for six sessions (3 alternate days for 2 weeks). The outcomes were assessed at day 1 and day 6. Lumbar range of motion was assessed using modified-modified Schober’s test and the lumbar lordosis angle was measured using x-ray and flexicurve. Results: There was significant decrease (p = 0.0001) in the lumbar lordosis angle, increase in the lumbar flexion (p = 0.0001), and decrease in the extension (p = 0.0011) range of motion in the experimental group when compared to the control group. Conclusion: Lumbar lordosis decreased and the lumbar range of motion increased in the experimental group only with 3D MFR and not with sham 3D MFR. Hence, 3D MFR is an effective method in the correction of lumbar hyperlordosis and improving the lumbar range. Clinical Trial Registry of India (CTRI) trial number CTRI/2023/03/050340.
... The lumbar lordosis is often one of the most relevant parameters in the study of the sagittal plane of the spine, and its normal range can vary in each individual, generally in relation to sacral slope or pelvic incidence [1,2]. Additionally, the sagittal curvatures of the vertebral column (i.e., lumbar and cervical lordosis, and thoracic and sacral kyphosis) have a relationship of interdependence [3,4]. ...
Highlighting the crucial role of monitoring and quantifying lumbopelvic rhythm for spinal curvature, the Ergotex IMU, a portable, lightweight, cost-effective, and energy-efficient technology, has been specifically designed for the pelvic and lumbar area. This study investigates the concurrent validity of the Ergotex device in measuring sagittal pelvic tilt angle. We utilized an observational, repeated measures design with healthy adult males (mean age: 39.3 ± 7.6 y, body mass: 82.2 ± 13.0 kg, body height: 179 ± 8 cm), comparing Ergotex with a 3D optical tracking system. Participants performed pelvic tilt movements in anterior, neutral, and posterior conditions. Statistical analysis included paired samples t-tests, Bland–Altman plots, and regression analysis. The findings show minimal systematic error (0.08° overall) and high agreement between the Ergotex and optical tracking, with most data points falling within limits of agreement of Bland–Altman plots (around ±2°). Significant differences were observed only in the anterior condition (0.35°, p < 0.05), with trivial effect sizes (ES = 0.08), indicating that these differences may not be clinically meaningful. The high Pearson’s correlation coefficients across conditions underscore a robust linear relationship between devices (r > 0.9 for all conditions). Regression analysis showed a standard error of estimate (SEE) of 1.1° with small effect (standardized SEE < 0.26 for all conditions), meaning that the expected average deviation from the true value is around 1°. These findings validate the Ergotex as an effective, portable, and cost-efficient tool for assessing sagittal pelvic tilt, with practical implications in clinical and sports settings where traditional methods might be impractical or costly.
... The RA, EO, and IO muscles, attached to the pelvis and ribs, contribute to trunk flexion through co-contraction, while trunk rotation is achieved through the co-contraction of the EO and IO muscles [5,39,40]. The abdominal muscles can influence lumbar lordosis by altering the position of the pelvis, and strong abdominal muscles can induce a posterior tilt of the pelvis, potentially reducing lumbar lordosis [41][42][43][44]. ...
Background and Objectives: Abdominal muscle exercises with limb movements are more effective for trunk stabilization than traditional exercises involving trunk flexion alone. This study examined the effects of abdominal exercises incorporating sprinter pattern and crunch exercises on changes in the lordotic curve and abdominal muscle activation in individuals with low back pain caused by hyperlordosis resulting from weak abdominal muscles. Materials and Methods: In this single-blind, randomized controlled trial, a total of 40 participants with hyperlordosis were recruited and randomly assigned to perform either sprinter-pattern abdominal exercises or crunch exercises. The participants assigned to each group performed three sets of ten abdominal exercises. The lumbar lordotic angle (LLA) and sacrohorizontal angle (SHA) were assessed prior to and following the intervention, whereas abdominal muscle activity was gauged throughout the intervention period. Changes in the LLA and SHA were measured by radiography. Abdominal muscle activity was measured using electromyography. Results: The LLA and SHA decreased significantly in both groups (p < 0.001), while the sprinter-pattern exercise group showed a statistically significant decrease compared to the crunch exercise group (p < 0.001). In the activity of the abdominal muscles, there was no significant difference in the rectus abdominis muscle between the two groups (p > 0.005). However, a significant difference between the external and internal oblique muscles was observed, and the activities of both muscles were significantly higher in the sprinter-pattern exercise group than in the crunch exercise group (p < 0.005). Conclusions: Abdominal exercise using a sprinter pattern may be effective in reducing lumbar lordosis by strengthening the abdominal muscles in patients with hyperlordosis.
Study aim: Dynamic knee valgus is one of the most common reasons for knee instability during functional activities in sports. Lumbar hyperlordosis, as an abnormal posture, is associated with decreased knee stability due to altered neuromuscular function of the lower limb muscles. This study aimed to investigate the impact of lumbar hyperlordosis on dynamic knee valgus during single-leg jump landing and squat in male college football players.
Materials and methods: Thirty male college athletes (15 with and 15 without lumbar hyperlordosis) participated in this study. Dynamic knee valgus was measured using a motion analysis system during single-leg jump landing and squat (descending phase). The independent samples t-test was used to compare the means between the groups (α=0.05).
Results: Athletes with lumbar hyperlordosis exhibited significantly greater knee valgus during both tasks.
Conclusions: Increased dynamic knee valgus angle in athletes with lumbar hyperlordosis may contribute to decreased knee stability and increased injury risk. Coaches and athletes should implement corrective strategies and exercises to prevent injuries associated with dynamic knee valgus in athletes with lumbar hyperlordosis.
The main objective of this study was to analyze the effect of a resistance training program using outdoor fitness equipment (OFE) on sagittal spine disposition and pelvic tilt in middle-aged and older adults. One hundred and twenty-eight middle-aged and older adults were randomly assigned to the training (TG) or control group (CG). The TG trained for 8 weeks, with 2 weekly sessions of one hour of resistance circuit training with OFE. Before and after the intervention, the sagittal spine disposition and pelvic tilt in the relaxed standing and sitting positions were analyzed. The results showed that the TG obtained a significant reduction (p < 0.001) in all the curvatures of the sagittal spine disposition and pelvic tilt in the standing position after the intervention, in contrast to the CG, which only showed a significant reduction in pelvic tilt (p = 0.005). Regarding the sitting position, only the TG presented a significant decrease in lumbar lordosis (p < 0.001). In conclusion, resistance training with OFE may be useful in improving sagittal spine disposition in middle-aged and older adults. Given the availability of free OFE in parks, the present research provides elders with an accessible and effective training program to curb the effects of ageing on the sagittal spine disposition.
Study Design
Observational—ecologic study.
Introduction
Spine and pelvis undergo modifications in alignment so that the individual can maintain an orthostatic position, but to date there is no evidence as to the contribution of each lumbar segment and the change that occurs in them when moving from orthostasis to supine position.
Objective
To identify the difference in the contribution of the lumbar segments and pelvis to the formation of lumbar lordosis in both positions (orthostasis and supine) and how each one alters in this change.
Summary of Background Data
lumbar lordosis adapts to the individual’s body position and can be physiological or pathologic.
Materials and Methods
Retrospective cohort study that included 174 patients: the segments total lumbar lordosis (LL), L1–L4, L4–S1, L4–L5, L5–S1, and sacral slope were measured on x-rays (orthostasis) and MRI (supine). We obtained the mean values, correlations and models proposed for the relationship between the values found.
Results
The SS, LL, L1–L4, L4–S1, and L4–L5 had their angular value reduced, and L5–S1 had its contribution to lordosis significantly increased when lying down. Moderate and strong correlations were obtained between SS × LL, L1–L4 and L4–S1, and between LL versus L1–L4 and L4–S1 in both positions. When using linear regression, proposed models were obtained with a high coefficient of determination between LL versus SS, L1–L4 and L4–S1 in orthostasis, for the same measurements and SS versus L4–S1 in supine, as well as for lordosis when comparing the 2 positions.
Conclusions
The L5–S1 segment has no change in angular value when lying in supine and is thus the largest contributor to lordosis in supine. L1–L4 increases its angular value when standing in orthostasis, the position in which it is the greatest contributor to lordosis.
Low back pain (LBP) development has been associated with increased hip muscle co-activation and lumbar lordosis during standing in previously asymptomatic individuals. It is commonly advised to use footrests to relieve LBP. The impact of adjusting arm position on lumbar biomechanics can also be impressive. This study aimed to compare the effects of normalized footrest height and changing arm position on Gluteus medius (GMed) muscle activity, lumbar lordosis, and pain intensity. Twenty-four female pain developers (PDs) were recruited, identified by a > 10 mm increase on the visual analog scale (VAS) during prolonged standing. Electromyography (EMG) recorded GMed activity, and photogrammetry measured lumbar lordosis at time points over one hour-standing. The first group (A) used the footrest intermittently, while the second group (B) additionally changed their arm positions. These variables were analyzed using repeated measures (between/within) ANOVA. No significant interaction was observed between the groups in right and left GMed co-contraction index (CCI) (p = 0.14). However, both groups exhibited a significant decrease in CCI during prolonged standing (time * condition: p = 0.003). Additionally, Group B consistently demonstrated lower overall levels of co-contraction across time (p = 0.01). An approximate 6-degree reduction in lumbar lordosis was observed after prolonged standing with both interventions (group A and group B; p = 0.008 and p = 0.01, respectively), although no significant differences in lumbar lordosis were detected between the groups. Lumbar discomfort increased over time; however, the interventions significantly alleviated this discomfort after the intervention time point. Notably, group B reported lower pain intensity compared to group A (p = 0.007). Applying these interventions in the workplace could be beneficial to reduce discomfort for individuals who stand for long periods of time. Further research is needed to optimize these strategies and assess long-term benefits.
In the clinical care of people with disproportionate short stature, healthcare practitioners need to accurately collect anthropometric measurements over time, including height, weight, head circumference, and lengths of affected limb and body segments. Accurate anthropometric measurements are important for diagnostic evaluation, tracking growth, measuring response to pharmacologic therapies or surgeries, and monitoring for potential complications. However, for this clinical population, anthropometric measurements may need to be adjusted or modified to accommodate characteristics such as body disproportions, joint contractures, long bone deformities, spinal deformities, or muscle hypotonia. This article provides guidance for key anthropometric measurements in children and adults with disproportionate short stature, with a focus on people with achondroplasia. The measurements described in this article and illustrated in the infographics can be performed without expensive specialized equipment and are suitable for a variety of clinical settings.
Aims
The development of lumbar lordosis has been traditionally examined using angular measurements of the spine to reflect its shape. While studies agree regarding the increase in the angles during growth, the growth rate is understudied, and sexual dimorphism is debated. In this study, we used a novel method to estimate the shape of the lumbar curve (LC) using the landmark-based geometric morphometric method to explore changes in LC during growth, examine the effect of size and sex on LC shape, and examine the associations between angular measurements and shape.
Methods
The study population included 258 children aged between 0 and 20 years (divided into five age groups) who underwent a CT scan between the years 2009 and 2019. The landmark-based geometric morphometric method was used to capture the LC shape in a sagittal view. Additionally, the lordosis was measured via Cobb and sacral slope angles. Multivariate and univariate statistical analyses were carried out to examine differences in shape between males and females and between the age groups.
Results
The overall shape of the LC overlapped between males and females in most age groups, except for the nine- to 12-year age group. However, size did not affect LC shape. LC shape changed significantly during growth from straight to curved, reaching its mature shape earlier in females. This corresponded with the results obtained by the lordosis and sacral slope angles. A significant positive correlation was found between the LC shape and angles, although the angles demonstrated poor distinction between age groups, as opposed to the LC shape.
Conclusion
New insights into LC shape development were achieved using the geometrical morphometric method. The LC shape was sex-independent in most age groups. However, the LC reached its mature shape earlier in females than males. The method and data of this study are beneficial for future studies examining aetiological factors for spinal pathologies and maldevelopment.
Cite this article: Bone Joint Res 2025;14(1):58–68.
Background and Aims Hyperlordosis is one of the deformities in the lumbar spine, which causes changes in the forward center of gravity and increases the movement of the pelvis. It also changes the stability of the trunk, lumbo-pelvic-hip core complex, and lower limbs. This study aims to compare the changes in the center of pressure (COP) and the time to stabilization (TTS) in male football players with and without hyperlordosis during a single-leg jump-landing task. Methods This is a causal-comparative study with a cross-sectional design, conducted on 28 male football players (14 with hyperlordosis and 14 without hyperlordosis), with a mean age of 24±2.42 years, a mean height of 178±6.06 cm and a mean weight of 72±4.93 kg. First, the Sargent jump test was taken to determine their maximum vertical jump. Then, they were asked to jump with two legs and a half maximum vertical jumping height and land on the force plate with the dominant leg. The independent t-test analysis was used to analyze the data in SPSS software, version 23. Results A significant difference in the COP fluctuations in the mediolateral (ML) direction (P=0.015), the maximum and minimum COP displacements in the ML direction (P=0.021, P=0.001), the TTS in the ML direction, and the total TTS (P=0.001), was observed between two groups, but no significant difference was found in the amount of COP variability in the anterior-posterior (AP) and ML directions, the amount of COP fluctuations in the AP direction, the minimum and maximum COP displacements in the AP direction, and the TTS in the AP and vertical directions (P>0.05). Conclusion It seems that changes in the sagittal plane in the area of the lumbar spine and pelvis cause instability and loss of balance in the frontal plane in the lower limbs. Therefore, football players with hyperlordosis should pay more attention to the changes in the proximal region to prevent instability and injury in the lower limb.
Purpose: To evaluate the reliability and validity of spinal alignment measurements in the raised arm standing posture using a smartphone app.
Background: An inclinometer is a reliable tool for measuring spinal alignment. Measurement of static standing posture spinal curvature angles using smartphone inclinometer applications has been investigated in the lumbar spine but has not been reported for the thoracic spine. However, the sacral vertebrae were used as the reference point for the measurement of the lumbar spine, and the method of palpation of the sacral vertebrae was unclear. No measurement methods, including inclinometers, have been found for upper limb elevation.
Methods: Thoracic kyphosis and lumbar lordosis angles were measured in 18 healthy young adults (mean age: 21.0 ± 3.5). Measurements were taken in the raised standing posture. The points of measurement included angle α at the thoracic spine (T)1/2, angle β at the T12/lumbar spine (L)1, and angle γ at the L4/L5 spinous processes. The thoracic kyphosis angle was calculated as the sum of α and β, while the lumbar lordosis angle was the sum of β and γ. Two raters measured these angles twice using the same smartphones. Inter-rater reliability was assessed using intraclass correlation coefficients (ICC 2.1), and measurement precision was determined by calculating MDC95 from the ICC values. Validity was also carried out on 12 healthy young adults (age: 20.8 ± 4.0 years). The measurement points were the same as described above, and two types of measurements were taken with a smartphone and an inclinometer; the results of the two types of measurements were used to determine the relationship using Pearson's correlation coefficient.
Results: During upper limb raising, the smartphone’s ICC (95% confidence interval) was 0.92 (0.81-0.97) for thoracic kyphosis and 0.90 (0.74-0.96) for lumbar lordosis. The MDC95 values indicated acceptable precision, with 7.00° for thoracic kyphosis and 9.95° for lumbar lordosis. All correlation coefficients between inclinometers and smartphones were above 0.9 for both the thoracic and lumbar spines.
Conclusions: Measuring spinal alignment angles using a smartphone inclinometer app in the raised standing posture demonstrates good reliability for inter-rater comparisons. It was also good with regard to validity.
Disc herniation is defined as focal or localized displacement of disc material beyond the margins of the intervertebral space. The incidence of disc herniation has been constantly increasing, with the disease affecting between 60 and 90% of the population aged between 30 and 50 years. The research objective was to achieve, apply and highlight the efficiency of a therapeutic program, based on osteopathic and physical therapy techniques, in the treatment and prophylaxis of recurrent lumbar disc herniation. For evaluation, we used: the MRI, the Lasegue test and the “The Oswestry Disability Index” questionnaire. The intervention involved the application of two sessions of osteopathic and physical therapy treatment weekly, for a period of 4 months. The results obtained at the final examination show a decrease in the size of the disc herniation, an improvement of the symptoms and an improvement in the daily functional activities. The analysis and interpretation of the obtained results underline that the application of a rehabilitation programme consisting of osteopathic and physical therapy techniques, can be effective in the treatment of recurrent lumbar disc herniation.
Purpose
To investigate positional lumbar changes by weight-bearing MRI in low back pain (LBP) patients with hypermobile joints (Beighton score ≥ 4).
Methods
Patients referred to weight-bearing MRI went through a clinical examination, including Beighton’s test, answered back pain-related questionnaires, and were hereafter imaged in supine and standing in a 0.25-T MRI unit. All MRI exams were evaluated for degenerative findings i.e., herniations, disc degeneration, spinal stenosis, disc degeneration, and spondylolisthesis. Subsequently, the lumbar lordosis angle, the sacral angle, and all spondylolisthesis’ slippages were measured for both positions.
Results
Of 257 LBP patients, Beighton score ≥ 4 were seen in 48 patients, and these included more females (81.3% vs. 51.7%), younger patients (mean difference [MD]: −8.1 years), and had less degenerated lumbar discs (sum-score MD: −0.9). No difference between groups in degenerative MRI findings was found, although, a non-significant tendency (p = 0.072) to a higher number of anterolisthesis in the hypermobile patients. The hypermobile patients had a greater lordosis angle both during supine and standing and a greater sacral angle in supine, however, changes in the angles between supine and standing were without difference between groups. A sensitivity analysis adjusted for gender and age confirmed these findings.
Conclusion
Hypermobility in LBP patients was associated with being female, younger, having increased lumbar lordosis both during standing and in supine, however, was not associated with increased back pain, anterolisthesis grade or more severe lumbar changes between positions.
Amaç: Transtibial (TTA) ve Transfemoral (TFA) amputelerde görülen statik postural adaptasyonları ve submaksimal egzersizin postür ile bel ağrısı üzerine etkisini değerlendirmek ve karşılaştırmaktır. Gereç ve Yöntem: Prospektif olarak yapılan araştırmaya, tek taraflı transtibial (n:14; yaş:36,36±12,15 yıl) ve transfemoral (n:15; yaş:27,36±7,60 yıl) ampütasyona sahip erkek olgular dahil edilmiştir. Postüral parametrelerin ölçümü ayakta serbest duruş ile her iki ekstremiteye eşit ağırlık verilmiş duruş pozisyonunda, ADIBAS Posture (Physical TECH, Barselona, İspanya) ile elde edilen görüntülerin analizi yoluyla gerçekleştirilmiştir. Submaksimal egzersiz amacıyla 6 Dakika Yürüme Testi yapılmış; tüm değerlendirmeler submaksimal egzersiz sonrasında tekrar edilmiştir. Bel bölgesi ağrısı Wong-Baker Ağrı Skalası ile değerlendirilmiştir. Bulgular: TTA grupta, submaksimal egzersiz öncesinde, serbest duruşta elde edilen sağlıklı ve ampute taraf lordoz açısı arasındaki fark anlamlı bulunmuştur (p:0,019). Submaksimal egzersizi takiben Spina İliaca Posterior Superior düzlem açısı iki duruş pozisyonu arasında anlamlı düzeyde farklılık göstermiştir (p:0,041). TFA grupta, submaksimal egzersiz öncesinde, omuz düzlem açısı duruş pozisyonları arasında anlamlı fark göstermiştir (p:0,015) ve bu durum egzersizi takiben devam etmiştir (p:0,003). Egzersiz sırasında katedilen mesafe TTA’lar lehine yüksek bulunmuştur (p<0,001). Ağrı submaksimal egzersizi takiben her iki grupta da anlamlı düzeyde artmıştır (p<0.05). Sonuç: Çalışmanın sonuçları amputasyon seviyesinin statik postural adaptasyonların gelişiminde ayırt edici bir etkiye sahip olmadığını göstermiştir. Benzer şekilde, submaksimal egzersizin postür ve bel ağrısı üzerine etkisinin amputasyon seviyesinden etkilenmediği tespit edilmiştir. Erken dönem rehabilitasyon uygulamaları ile postüral adaptasyonların ve bel ağrısının semptom şiddeti düşürülebilir hatta önlenebilir.
Background: Low back pain (LBP) is a common health condition with an estimated prevalence of 42-83% in India. Clinicians usually measure lumbar lordotic angle (LLA) and lumbosacral angle (LSA) in sagittal radiographs even though the normal range of lordosis has not yet been agreed upon. Hence, the radiographic measurement of these angles needs to be re-evaluated. We aimed to study the difference in LLA and LSA in those with and without non-specific acute LBP and to analyze the correlation and association of confounding factors like age, gender, BMI, and pain severity with LLA and LSA.
Methods: LLA and LSA in those with and those without non-specific acute LBP in 200 individuals were recorded and analyzed statistically.
Results: In age, gender, and BMI-matched groups, the LSA in the cases group (34.44 ± 5.93) was significantly less than in controls (36.9 ± 6.8) (p = 0.007). LLA in the non-specific acute LBP group (50.51 ± 8.78) and those without non-specific acute LBP (50.05 ± 9.86) was statistically similar (p = 0.727). LSA was significantly less in patients than in healthy subjects. Both LLA and LSA were not associated withback pain and showed a weak or very weak correlation with age, gender, BMI, and severity of pain in both groups.
Conclusion: Lumbar lordosis didn’t show any association or correlation with age, gender, BMI, and VAS in non-specific acute LBP patients. Hence, measuring LSA and LLA in sagittal radiographs does not provide any additional information regarding the cause of pain in non-specific acute LBP patients.
Background
A healthy lower back is essential for optimal spinal function and overall wellness. Magnetic resonance imaging (MRI) has become the gold standard in assessing lumbar spine disease. This article aims to evaluate the precision and efficacy of the lumbar offset distance (LOD) as a novel MRI parameter designed to determine the lumbar spine alignment. normally measured as we compared it to a new parameter based on length.
Materials and Methods
Supine sagittal magnetic resonance images of 101 patients who underwent lumbar spine MRI scans were analyzed. We focused on L1–L5 lumbar lordosis angle (LLA) and LOD to assess lumbar spine alignment. Diagnostic cutoff values for LOD measurements were determined, and their diagnostic accuracies were evaluated.
Results
The normal LLA in our dataset was 23°–45°, and the normal LOD was 5–15 mm. Using linear regression, the range of 6–14 mm correlates to the LLA range of 20°–45°, which would define the standard lumbar offset as normal between 6 and 14 mm. Hence, lumbar hypolordosis was defined as <6 mm, and lumbar hyperlordosis was defined as more than 14 mm. Our study showed a good correlation between the LOD and LLA and is particularly useful in identifying cases of normal lumbar lordosis, hypolordosis, and hyperlordosis.
Conclusion
Linear measurements show good diagnostic accuracy of LOD in evaluating lumbar spinal alignment, including normal alignment, hypolordosis, and hyperlordosis.
Background
In order to restore the individual's health in lumbar stabilization surgeries, it is aimed to bring the sagittal alignment closer to normal values, to eliminate the findings, and thus to increase the quality of life of the individual by reducing the disability level. The aim of this study is to measure the effects of lumbar region stabilization surgeries performed in our clinic on some angular values in the spine, disability and quality of life. Preoperative (preop) and postoperative (postop) radiographs of 30 individuals over the age of 40 who applied to our clinic with various lumbar region complaints and underwent lumbar stabilization surgery between the years 2020–2022 were taken. Lumbar lordosis, pelvic tilt, sacral slope and pelvic inclination angles were measured from the images obtained. The Visual Analog Scale was used to measure the pain of individuals, the Oswestry Disability Index to measure the disability level, and the Nottingham Health Profile questionnaire to measure the quality of life. Preop and postop data were analyzed with the SPSS 23.0 program and p < 0.05 was considered significant.
Results
The lumbar lordosis angles of individuals who underwent lumbar stabilization surgery approached normal values and the difference between preop–postop lumbar lordosis angle averages was significant ( p < 0.05); It was observed that the harmony between the lumbar lordosis and pelvic inclination angles increased, the pain decreased and the difference between preop–postop pain values was significant ( p < 0.05), disability levels decreased and quality of life increased.
Conclusions
The decrease in the level of disability and the increase in the quality of life seen in individuals who underwent lumbar stabilization surgery were associated with the decrease in pain; The changes in angular values are considered to be clinically significant.
Background
Lumbar puncture is challenging for patients with scoliosis. Previous ultrasound-assisted techniques for lumbar puncture used the angle of the probe as the needle trajectory; however, reproducing the angle is difficult and increases the number of needle manipulations. In response, we developed a technique that eliminated both the craniocaudal and lateromedial angulation of the needle trajectory to overall improve this technique. We assessed the feasibility and safety of this method in patients with scoliosis and identify factors related to difficult lumbar puncture.
Methods
Patients with spinal muscular atrophy and scoliosis who were referred to the anesthesia department for intrathecal nusinersen administrations were included. With a novel approach that utilized patient position and geometry, lumbar puncture was performed under ultrasound guidance. Success rates, performance times and adverse events were recorded. Clinical-demographic and spinal radiographic data pertaining to difficult procedures were analyzed.
Results
Success was achieved in all 260 (100%) lumbar punctures for 44 patients, with first pass and first attempt success rates of 70% (183/260) and 87% (226/260), respectively. Adverse events were infrequent and benign. Higher BMI, greater skin dural sac depth and smaller interlaminar size might be associated with greater difficulty in lumbar puncture.
Conclusions
The novel ultrasound-assisted horizontal and perpendicular interlaminar needle trajectory approach is an effective and safe method for lumbar puncture in patients with spinal deformities. This method can be reliably performed at the bedside and avoids other more typical and complex imaging such as computed tomography guided procedure.
Thoracolumbar fractures represent a broad category of relatively common injuries, which range from an incidental radiographic finding to an unstable pattern with profound neurologic compromise. There are many nuances to patient management that must be addressed including ensuring the patient is appropriately stabilized in the emergency department, relevant imaging is ordered, and an understanding of the fracture to ensure the patient receives the appropriate management for his/her injury. In cases of operatively managed cases, there are a multitude of management strategies that a provider can utilize, ranging from minimally invasive to open circumferential treatment, each with their own risk profiles.
Study Design
Retrospective Cohort Study.
Objective
The purpose of this study was to determine if muscle mass and quality of the lumbar paraspinal muscles was associated with improvements in lumbar lordosis and other sagittal parameters after isolated posterior lumbar decompression surgery for lumbar spinal stenosis.
Summary of Background Data
Over time, either due to degenerative changes or other spinal conditions, individuals may develop sagittal imbalance. In patients with lumbar spinal stenosis, sagittal imbalance can further exacerbate symptoms of pain and radiculopathy. Sarcopenia of paraspinal muscles has been implicated in previous spine research as a variable with influence on surgical outcomes.
Methods
Sagittal parameters were measured on preoperative and postoperative lateral lumbar radiographs and included lumbar lordosis (LL), sacral slope (SS), and pelvic tilt (PT). Preoperative MRI images were evaluated at the base of the L4 vertebral body to assess muscles mass of the psoas muscle and paravertebral muscles (PVM) and Goutallier grade of the PVM. Patients were divided into 3 muscle size groups based on PVM normalized for body size (PVM/BMI): Group A (smallest), Group B, and Group C (largest).
Results
Patients in Group C had greater LL preoperatively (51.5° vs. 47.9° vs. 43.2, P =0.005) and postoperatively (52.2° vs. 48.9° vs. 45.7°, P =0.043). There was no significant difference in the ∆LL values between groups ( P >0.05). Patients in Group C had larger SS preoperatively (35.2° vs. 32.1° vs. 30.0°, P =0.010) and postoperatively (36.1° vs. 33.0° vs. 31.7°, P =0.030). Regression analysis showed that PVM/BMI was a significant predictor of LL preoperatively ( P =0.039) and postoperatively ( P =0.031), as well as SS preoperatively ( P =0.001) and postoperatively ( P <0.001).
Conclusion
Muscle mass of the paravertebral muscles significantly impacts lumbar lordosis and sacral slope in patients with lumbar spinal stenosis before and after posterior lumbar decompression. These findings highlight a need to address risk factors for poor muscle quality in patients with sagittal imbalance.
Background
Hyperlordosis is an excessive inward curvature of the lumbar spine that affects spinal function. The aim of this study was to compare the effects of core stability exercises (CSE), Whole-Body Electromyostimulation (WB-EMS), and CSE Plus on the Lumbar lordosis angle and dynamic balance in sedentary people with hyperlordosis.
Methods
In a parallel randomized controlled trial study, seventy five untrained male adults with hyperlordosis, recruited from clinics of sports medicine and corrective exercise centers in Tehran, were randomly assigned to four groups: CSE (n = 19), WB-EMS (n = 18), CSE Plus (n = 18), and control Group (CG) (n = 20). The CSE group performed Core stability exercises, the WB-EMS group followed a Whole-body electromyostimulation combined training protocol, and the CSE Plus group engaged in a combined program protocol (CSE with the WB-EMS vest), and the control group only participated in activities of daily living. Anthropometric parameters and outcomes, including the lordosis angle and dynamic balance, were assessed before and after a six-week training program. A flexible ruler was used to measure the angle of lordosis, and the Y balance test was employed to evaluate the dynamic balance.
Results
The results indicated that the lordosis angle improved in both the CSE and CSE Plus groups compared to the CG in the post-test (P = 0.017, P = 0.024). However, there were no significant differences observed between the other group pairs. Additionally, a significant difference in dynamic balance was found between the CSE Plus group and the CG in the post-test (P = 0.001), while no significant differences were observed between the other group pairs. Furthermore, within-group test results demonstrated that lumbar lordosis angle and dynamic balance variables significantly improved in the post-test compared to the pre-test stage (P < 0.05).
Conclusions
The two CSE and CSE Plus training protocols are effective as training methods for correcting certain parameters and physical deformities, including lumbar lordosis. Furthermore, the CSE Plus group demonstrated a positive impact on improving dynamic balance. Consequently, it is highly recommended that individuals with hyperlordosis can benefit from the exercises of the present study, especially CSE Plus exercises along with other rehabilitation exercises.
Trial registration
The trial was registered at Thai Clinical Trials Registry (TCTR20221004011, registration date: 04/10/2022).
Study Design
Systematic review and meta-analysis.
Objective
This study aims to assess the effectiveness of lumbar segmental stabilization exercises (LSSE) in managing spondylolysis and spondylolisthesis
Summary of Background Data
Spondylolysis and spondylolisthesis are spinal disorders associated with lumbar segmental instability. LSSE have shown positive effects in treating these conditions; however, systematic reviews and meta-analyses are lacking.
Methods
A systematic search adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including studies from the inception of the databases used up to January 2024, was conducted. Disability improvement and pain intensity change were the primary and secondary outcomes, respectively, standardized using Hedges’ g. Eligible articles underwent independent scrutiny by two authors, who also performed data extraction and quality assessment. Data pooling was accomplished using a random-effects model.
Results
In total, five randomized controlled trials comprising 198 participants were included, revealing a trend effect toward disability improvement in the LSSE group (Hedges’ g =−0.598, 95% CI=−1.211 to 0.016, P =0.056, I ² =75.447%). When the LSSE was administered as a single treatment, disability improvement became significant (Hedges’ g =−1.325, 95% CI=−2.598 to −0.053, P =0.041, I ² =80.020%). No significant effect of LSSE on pain reduction was observed (Hedges’ g =−0.496, 95% CI=−1.082 to 0.090, P =0.097, I ² =73.935%).
Conclusion
In summary, our meta-analysis suggests that LSSE can potentially improve disability, especially when used as a single treatment. LSSE appears more beneficial in reducing disability than alleviating pain. Future research on different patient groups is needed to understand comprehensively LSSE’s effects on other musculoskeletal disorders.
Background
Investigations regarding the role of high-heeled shoes in the alteration of the spinopelvic profile attempted to identify a correlation with pain in the lower back. Conclusions from these studies, however, are controversial. In authors knowledge no studies were carried out to investigate the effect of heels on male population, which has been overlooked due to gender-related customs.
Research question
What is the immediate effect of the height of heels on the sagittal back profile (trunk inclination (TI), pelvic inclination, lordotic lumbar angle (ITL-ILS), kyphotic dorsal angle, lumbar arrow, and cervical arrow) in females and males, not used to wearing high-heeled shoes?
Methods
One hundred healthy young adult subjects were enrolled. Three were excluded. The remaining 97 subjects (48 female and 49 male) underwent a three-dimensional analysis of the posterior surface of the trunk, using rasterstereography. The spinopelvic profile in the barefoot condition, and with the heel raised by 3 and 7 cm, was recorded. To evaluate the reproducibility of the measure, the neutral evaluation was repeated twice in 23 subjects (13 males, 10 females).
Results
The change of heel height did not show statistically significant differences for any of the variables used; instead, significant differences were found stratifying the results according to the sex of the subjects tested. Test-retest evaluation in the neutral condition showed no significant differences using the Student's t-test (p > 0.05). Repeatability was excellent and significant for all data used (minimum TI r = 0.85, maximum ITL-ILS r = 0.97).
Significance
Studying the effect of heels on the spino-pelvic profile also in the male population is crucial for promoting gender-inclusive healthcare, enhancing occupational health practices and developing possible preventive measures. Nevertheless, in the sample of females and males evaluated in this study, the different heights of heel lift did not immediately induce significant changes in pelvis and spine posture. If there is therefore a correlation between low-back pain and the use of heels, it should not reasonably be sought in the immediate change of the spino-pelvic profile caused by raising the heels. However, the variables analyzed differed according to sex.
This study aimed to compare the long-term effects of flexion- and extension-based lumbar exercises on chronic axial low back pain (LBP). This was a 1-year follow-up of a prospective, assessor-blind, randomized controlled trial. Patients with axial LBP (intensity ≥ 5/10) for > 6 months allocated to the flexion or extension exercise group. Patients underwent four sessions of a supervised treatment program and were required to perform their assigned exercises daily at home. Clinical outcomes were obtained at baseline, 1, 3, 6 months, and 1-year. A total of 56 patients (age, 54.3 years) were included, with 27 and 29 in the flexion and extension groups, respectively. Baseline pain and functional scales were similar between both groups. The mean (± standard deviation) baseline average back pain was 6.00 ± 1.00 and 5.83 ± 1.20 in the flexion and extension groups, respectively. At 1-year, the average pain was 3.78 ± 1.40 and 2.26 ± 2.62 (mean between-group difference, 1.52; 95% confidence interval 0.56–2.47; p = 0.002), favoring extension exercise. The extension group tended to have more improvements in current pain, least pain, and pain interference than the flexion group at 1-year. However, there was no group difference in worst pain and functional scales. In this controlled trial involving patients with chronic axial LBP, extension-based lumbar exercise was more effective in reducing pain than flexion-based exercises at 1-year, advocating lumbar extension movement pattern as a component for therapeutic exercise for chronic LBP.
Clinical Trial Registration No.: NCT02938689 (Registered on www.clinicaltrial.gov; first registration date was 19/10/2016).
Objective
The aim of this study was to identify clinical phenotypes using sensor-based measures of posture and movement, pain behavior, and psychological factors in Hispanic/Latino people with chronic low back pain (CLBP).
Methods
Baseline measures from an ongoing clinical trial were analyzed for 81 Hispanic/Latino people with CLBP. Low back posture and movement were measured using commercial sensors during in-person testing and 8 hours of ecological monitoring. Magnitude, frequency, and duration of lumbar movements, sitting and standing postures were measured. Movement-evoked pain was assessed during in-person movement testing. Psychological measures included the Pain Catastrophizing Scale and the Fear Avoidance Beliefs Questionnaire. Random forest analysis was conducted to generate 2 groups and identify important variables that distinguish groups. Group differences in demographics, pain, psychological, and posture and movement variables were examined using t tests and chi-square analyses.
Results
Two subgroups of Hispanic/Latino people with CLBP were identified with minimal error (7.4% misclassification [“out-of-bag” error]). Ecological posture and movement measures best distinguished groups, although most movement-evoked pain and psychological measures did not. Group 1 had greater height and weight, lower movement frequency, more time in sitting, and less time in standing. Group 2 had a greater proportion of women than men, longer LBP duration, higher movement frequency, more time in standing, and less time in sitting.
Conclusions
Two distinct clinical phenotypes of Hispanic/Latino people with CLBP were identified. One group was distinguished by greater height and weight and more sedentary posture and movement behavior; the second group had more women, longer duration of LBP, higher lumbar spine movement frequency, and longer duration of standing postures.
Impact
Ecological measures of posture and movement are important for identifying 2 clinical phenotypes in Hispanic/Latino people with CLBP and may provide a basis for a more personalized plan of care.
Lay Summary
Wearable sensors were used to measure low back posture and movement in Hispanic/Latino people with chronic low back pain. These posture and movement measures helped to identify 2 different clinical subgroups that will give physical therapists more information to better personalize treatment for chronic low back pain in Hispanic/Latino patients.
Background
Postoperative low back pain (LBP) following total hip arthroplasty (THA) is classified as secondary hip-spine syndrome. The purpose of this study was to explore the correlations between cup orientation of THA and postoperative LBP in patients with osteonecrosis of the femoral head (ONFH).
Methods
A retrospective cohort study included 364 ONFH patients who underwent bilateral THA between January 2011 and December 2020. Among them, 53 patients (14.6%) experienced postoperative LBP at the end of follow-up and were designated as pain group (PG). A control group (CG) consisting of 106 patients with similar age, sex, and body mass index (BMI) to those in the PG was selected. Postoperative LBP in the PG was assessed using the visual analogue scale (VAS). Demographic data, clinical information, and radiographic criteria were evaluated as potential predictors of LBP.
Results
Patients in PG (mean age, 47.3 years [range, 27 to 75 years]; 42 [79%] male) had a mean VAS score of 4.6 (range, 1 to 9) compared with 0 for the patients in CG (mean age, 47.6 years [range, 19 to 77 years]; 84 [79%] male). There were no significant differences in clinical data between the two groups (p > 0.05). Preoperative radiographic variables also showed no significant differences between the PG and CG (p > 0.05). However, the postoperative inclination, anteversion, and standing ante-inclination (AI) were significantly lower in the PG compared to the CG, whereas the sitting and standing sacral slope (SS) were significantly higher (p < 0.05). Moreover, the variations in standing AI, standing and sitting pelvic tilt (PT) were significantly lower in the PG compared to the CG, while the variations in standing and sitting SS and lumbar lordosis (LL) were significantly higher (p < 0.05). The variation in standing AI in the PG showed a significantly correlation with the variation of standing SS, standing PT, and LL (p < 0.05).
Conclusion
Postoperative LBP in ONFH patients after bilateral THA is significantly associated with the intraoperative cup orientation. The variation in standing AI is correlated with the variations in standing SS, standing PT, and LL, potentially contributing to the development of postoperative LBP.
Background
Lumbar stiffness leads to greater hip dependance to achieve sagittal motion and increases instability after total hip arthroplasty (THA). We aimed to determine parameters that influence lumbar stiffness amongst patients with hip pathology. We hypothesized that modifiable (degenerative changes, spinal canal stenosis, facet orientation) and non‐modifiable factors (muscle condition) would be associated with lumbar spine stiffness.
Methods
In this retrospective case‐cohort study from a tertiary referral center, consecutive patients presenting at a hip specialist clinic underwent standing and deep‐seated radiographic assessment to measure lumbar lordosis (∆LL) (stiffness: ∆LL<20°), hip flexion (∆PFA: pelvic‐femoral angle) and degree of degenerative‐disc‐disease (DDD) (facet osteoarthritis, disc height, endplate proliferative changes). Of these, 65 patients were selected with previous lumbar spine Magnetic Resonance Imaging (MRI), allowing to determine lumbar facet orientation, spinal canal stenosis (Schizas classification) and flexor‐ and extensor‐ muscle atrophy (Goutallier classification).
Results
Mean ∆LL was 45° (range: 11°‐72°) and 4 patients (6%) exhibited spine stiffness. Patients with multilevel DDD (n=22) had less ∆LL than those with no/single level (n=43) DDD [34° (range: 11°‐53°) vs. 51° (21°‐72°); p<0.001]. Number of DDD levels correlated strongly with ∆LL (rho=‐0.642; p<0.001). Spinal stiffness was only seen in patients with ≥4 DDD‐levels. There was no correlation between ∆LL and facet orientation (p>0.05). ∆LL correlated strongly with extensor atrophy at L3‐L4 (rho=‐0.473), L4‐L5 (rho=‐0.520) and L5‐S1 (rho=‐0.473), and poorly with flexors at L4‐L5 (rho=‐0.134) and L5‐S1 (rho=‐0.227).
Conclusion
Lumbar stiffness is dependent on modifiable‐ (muscle atrophy) and non‐modifiable‐ (extend of DDD) factors. This can guide non‐operative management of hip pathology, emphasizing relevance of core muscle rehabilitation to improve posture and stiffness. Identification ≥4 DDD‐levels should alert surgeons of increased THA instability‐risk.
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Background
Although oblique lumbar interbody fusion (OLIF) has produced good results for lumbar degenerative diseases (LDDs), its efficacy vis-a-vis posterior lumbar interbody fusion (PLIF) remains controversial. This meta-analysis aimed to compare the clinical efficacy of OLIF and PLIF for the treatment of LDDs.
Methods
A comprehensive assessment of the literature was conducted, and the quality of retrieved studies was assessed using the Newcastle–Ottawa Scale. Clinical parameters included the visual analog scale (VAS), and Oswestry Disability Index (ODI) for pain, disability, and functional levels. Statistical analysis related to operative time, intraoperative bleeding, length of hospital stay, lumbar lordosis angle, postoperative disc height, and complication rates was performed. The PROSPERO number for the present systematic review is CRD42023406695.
Results
In total, 574 patients (287 for OLIF, 287 for PLIF) from eight studies were included. The combined mean postoperative difference in ODI and lumbar VAS scores was − 1.22 and − 0.43, respectively. In postoperative disc, height between OLIF and PLIF was 2.05. The combined advantage ratio of the total surgical complication rate and the mean difference in lumbar lordosis angle between OLIF and PLIF were 0.46 and 1.72, respectively. The combined mean difference in intraoperative blood loss and postoperative hospital stay between OLIF and PLIF was − 128.67 and − 2.32, respectively.
Conclusion
Both the OLIF and PLIF interventions showed good clinical efficacy for LDDs. However, OLIF demonstrated a superior advantage in terms of intraoperative bleeding, hospital stay, degree of postoperative disc height recovery, and postoperative complication rate.
Trial design
This study investigated the effect of adding abdominal bracing to spinal stability exercise in patients with chronic low back pain (CLBP). This prospective, randomized pilot study included 67 patients and was conducted at the sports medicine center of a single hospital.
Methods
The abdominal bracing group (ABBG) underwent spinal stability exercise with abdominal bracing (N = 33), comprising 50 minutes training twice a week for 24 weeks. The control group performed only spinal stability exercise (N = 34) for 50 minutes twice a week for 24 weeks. The ABBG received abdominal bracing training at each session and applied abdominal bracing during the spinal stability exercise. The lumbar lordosis angle (LLA) and spine extensor muscle strength were measured. Spinal flexion angles were measured every 12° from 0° to 72°. The visual analog scale score and Oswestry disability index were measured before treatment and at 12 and 24 weeks after treatment.
Results
The LLA increased over time in both the groups but was not significantly different between the groups. Spine extensor strength was improved over time in both the groups, and an interactive effect was observed at a spinal flexion angle of 60° and 72°. Pain and function were also improved over time in both the groups, but the effect was stronger in the ABBG than in the control group. In patients with CLBP, spinal stability exercise changed the LLA.
Conclusions
Although adding abdominal bracing to spinal stability exercise did not affect the changes in the LLA, abdominal bracing improved the spinal extensor strength, pain, and function in patients with CLBP. Therefore, it is recommended to add abdominal bracing to spinal stability exercise to maintain the lordosis angle and to improve CLBP symptoms.
Introductionː Football soccer practice involves considerable risks of lesions, making it difficult to strike a balance between adequate preparation and the demand imposed on athletes. A high incidence of postural disorders among adolescents leads to questions about the influence of sports activity on the athletes' posture and sagittal balance.
Methodsː A cross-sectional study was conducted from panoramic spine radiographs of 110 professional Brazilian football (soccer) players. They were male and aged between 20 and 30 years. Measurements of pelvic incidence, pelvic tilt (PT), sacral slope, sagittal vertical axis (SVA), and lumbar lordosis were obtained by using the Surgimap software. Measurement values were compared with the Brazilian literature data. Lordosis type was categorized according to the classification of Roussouly et al., and the presence of spondylolysis and spondylolisthesis was analyzed.
Resultsː Findings indicated that (1) among 110 radiographs analyzed, 104 had appropriate measurement quality; (2) values compared with the Brazilian mean demonstrated that PT and SVA were statistically lower in professional players (P = 0.013 and P = 0.037, respectively); (3) according to Roussouly et al. most participants presented Type 3 lordosis (54.8%), followed by Type 4 (26.9%); (4) eight athletes (7.7%) had spondylolysis, and among them, seven (6.7%) had spondylolisthesis.
Conclusionsː Significant differences in PT and SVA were found in professional athletes. The most common type of lordosis was the same as that found in the general population (Type 3), and the incidence of spondylolysis and spondylolisthesis was higher than that found in the general population, but lower than that found in football (soccer) players.
Purpose
The aim of this study; evaluate lumbar lordosis (LL) in symptomatic individuals with six different techniques and to examine the techniques comparatively. Thus, to provide an overview of lumbal lordosis and techniques.
Methods
Cobb L1-L5, Cobb L1-S1, Posterior Tangent, tangential radiologic assessment of lumbar lordosis (TRALL), vertebral centroid measurement of lumbar lordosis (CLL) and Risser Ferguson measurement techniques were used to assess LL from radiographs of 175 symptomatic adults. Correlations between techniques and relationship between the measurements obtained, gender and age were analyzed. Also ınterclass correlation (ICC) analyzed. Bland–Altman plots were performed to compare the techniques with Cobb.
Results
ICC for all methods were greater than 0.96. For each method, no difference in LL was observed with respect to gender or age (p > 0.05). High positive correlation was observed between the Risser Ferguson, Posterior Tangent, Cobb L1-L5, Cobb L1-S1 and CLL techniques (p < 0.001), and moderate positive correlation between TRALL and all other techniques (p < 0.001).
Conclusion
In this study, it was found that the mean lumbar lordosis values of symptomatic participants were lower than most of the other asymptomatic studies in the literature and there was no significant difference in lumbar lordosis values in terms of gender and age in symptomatic individuals. Based on statistical findings, Risser Ferguson can be used to assess LL. These results and the data obtained as a result of the comparative examination of techniques according to age groups and gender will benefit clinicians and those working in the field by providing a better understanding LL.
Objective
the aim of the current study was to compare the lower limb muscle activation pattern in soccer players with and without lumbar hyperlordosis during single-leg squat performance.
Methods
thirty male collegiate soccer players (15 with and 15 without lumbar hyperlordosis) performed the SLS task. Surface EMG was used to record the activation of eleven lower limb muscles. The activation of these muscles reduces to 100 points during the SLS cycle, where 50% demonstrates the maximum knee flexion, and 0% and 99% demonstrate the maximum knee extension.
Results
soccer players with lumbar hyperlordosis had higher muscle activation than those with normal lumbar lordosis in gluteus maximus, biceps femoris, and medial gastrocnemius. By contrast, they had lower gluteus medius, vastus medialis oblique, rectus femoris, soleus, and medial gastrocnemius (only in the final ascent phase of the SLS) muscle activity than the normal group during the SLS.
Conclusion
this alteration may negatively affect targeted muscle performance during the SLS. Subsequent study is required to specify whether such an alteration in the lower limb muscle could be accompanied by injury in soccer players and change in their athletic performance.
Background
Because of the association of lumbar lordosis with some clinical conditions such as low back pain, the chiropractic field has emphasized the significance of evaluating the lumbar lordotic status, by measuring Cobb's angle, regarded as the radiological gold standard, for the assessment of lumbar lordosis, on lateral radiographs. However, research has shown that this technique has some considerable drawbacks, mostly in terms of low accuracy and high variability between clinicians when compared with other radiological modalities. The main objective was to compare the diagnostic accuracy of newly established radiological measurements with one of Cobb's angle methods, for the characterization of lumbar lordosis status in a sample of Lebanese patients aged 15 and above.
Material and methods
This retrospective single-center study consisted of measuring Cobb's L1-S1 and Cobb's L1-L5 angles, along with the novel established measurements which are the derivative and the normalized surface area, on 134 lateral radiographs of the lumbar spine of Lebanese patients aged fifteen years old and above, gotten from the Radiology department at Zahra'a’s Hospital in Beirut, performed by two observers using MATLAB. Inter-rater agreement was assessed by calculating the Intra-class correlation coefficients. Spearman correlation was analyzed between both Cobb's angle methods and with the derivative and normalized area respectively. 54 patients of the sample were diagnosed by two radiologists, according to their LL status. ROC curve analysis was performed to compare the diagnostic accuracy of the four techniques used. Data were analyzed with IBM SPSS Statistics 23.0 (NY, USA); P < 0.05 was considered statistically significant.
Results
According to the ROC curve analysis the new methods, which are the derivative and the normalized surface area, displayed lower diagnostic accuracy (AUCderivative = 0.818 and 0.677, AUCsurface area = 0.796 and 0.828) than Cobb's L1-L5 (AUCL1-L5 = 0.924 and 0.929 values) and L1-S1 (AUCL1-S1 = 0.971 and 0.955) angles, in the characterization of hypo and hyperlordotic patients, respectively, in our Lebanese sample consisting of patients aged 15 and above, because of their lower area under the curve's values compared to the traditional Cobb's techniques. The Cobb's L1-S1 has shown to have the highest diagnostic accuracy among the four methods to characterize normal patients from hypo and hyperlordotic ones, by referring to its highest area under the curve's values. However, the sensitivity of Cobb's L1-L5 angle in characterizing hyperlordotic patients was similar to the one of the normalized surface area with a value of 100%.
Conclusion: among the four modalities, the new methods didn't show a better diagnostic accuracy compared to the traditional modalities. Cobb's L1-S1 displayed the highest diagnostic accuracy despite its drawbacks. Further prospective studies are needed to validate the cut-offs obtained for Cobb's L1-S1 angle in our sample.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
This study is a repeated measures design to measure the lumbar spine response to typical school backpack loads in healthy children. The lumbar spine in this setting was measured for the first time by an upright magnetic resonance imaging (MRI) scanner.
The purpose of this study is to measure the lumbar spine response to typical school backpack loads in healthy children. We hypothesize that backpack loads significantly increase disc compression and lumbar curvature.
Children commonly carry school backpacks of 10% to 22% bodyweight. Despite growing concern among parents about safety, there are no imaging studies which describe the effect of backpack loads on the spine in children.
Three boys and 5 girls, age 11 +/- 2 years (mean +/- SD) underwent T2 weighted sagittal and coronal MRI scans of the lumbar spine while standing. Scans were repeated with 4, 8, and 12 kg backpack loads, which represented approximately 10%, 20%, and 30% body weight for our sample. Main outcome measures were disc compression, defined as post- minus preloading disc height, and lumbar asymmetry, defined as the coronal Cobb angle between the superior endplates of S1 and L1.
Increasing backpack loads significantly compressed lumbar disc heights measured in the midline sagittal plane (P < 0.05, repeated-measures analysis of variance [ANOVA]). Lumbar asymmetry was: 2.23 degrees +/- 1.07 degrees standing, 5.46 degrees +/- 2.50 degrees with 4 kg, 9.18 degrees +/- 2.25 degrees with 8 kg, and 5.68 degrees +/- 1.76 degrees with 12 kg (mean +/- SE). Backpack loads significantly increased lumbar asymmetry (P < 0.03, one-way ANOVA). Four of the 8 subjects had Cobb angles greater than 10 degrees during 8-kg backpack loads. Using a visual-analogue scale to rate their pain (0-no pain, 10-worst pain imaginable), subjects reported significant increases in back pain associated with backpack loads of 4, 8, and 12 kg (P < 0.001, 1-way ANOVA).
Backpack loads are responsible for a significant amount of back pain in children, which in part, may be due to changes in lumbar disc height or curvature. This is the first upright MRI study to document reduced disc height and greater lumbar asymmetry for common backpack loads in children.
Few studies have investigated the factors related to the disability and physical function in degenerative lumbar spondylolisthesis using axially loaded magnetic resonance imaging (MRI). Therefore, we aimed to investigate the effect of axial loading on the morphology of the spine and the spinal canal in patients with degenerative spondylolisthesis of L4-5 and to correlate morphologic changes to their disability and physical functions. From March 2003 to January 2004, 32 consecutive cases (26 females, 6 males) with degenerative L4-5 spondylolisthesis, grade 1-2, intermittent claudication, and low back pain without sciatica were included in this study. All patients underwent unloaded and axially loaded MRI of the lumbo-sacral spine in supine position to elucidate the morphological findings and to measure the parameters of MRI, including disc height (DH), sagittal translation (ST), segmental angulation (SA), dural sac cross-sectional area (DCSA) at L4-5, and lumbar lordotic angles (LLA) at L1-5 between the unloaded and axially loaded condition. Each patient's disability was evaluated by the Oswestry Disability Index (ODI) questionnaire, and physical functioning (PF) was evaluated by the Physical Function scale proposed by Stucki et al. (Spine 21:796-803, 1996). Three patients were excluded due to the presence of neurologic symptoms found with the axially loaded MRI. Finally, a total of 29 (5 males, 24 females) consecutive patients were included in this study. Comparisons and correlations were done to determine which parameters were critical to the patient's disability and PF. The morphologies of the lumbar spine changed after axially loaded MRI. In six of our patients, we observed adjacent segment degeneration (4 L3-L4 and 2 L5-S1) coexisting with degenerative spondylolisthesis of L4-L5 under axially loaded MRI. The mean values of the SA under pre-load and post-load were 7.14 degrees and 5.90 degrees at L4-L5 (listhetic level), respectively. The mean values of the LLA under pre-load and post-load were 37.03 degrees and 39.28 degrees , respectively. There were significant correlations only between the ODI, PF, and the difference of SA, and between PF and the post-loaded LLA. The changes in SA (L4-L5) during axial loading were well correlated to the ODI and PF scores. In addition, the LLA (L1-L5) under axial loading was well correlated to the PF of patients with degenerative L4-L5 spondylolisthesis. We suggest that the angular instability of the intervertebral disc may play a more important role than neurological compression in the pathogenesis of disability in degenerative lumbar spondylolisthesis.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
To identify distinct age-related trajectory classes of body mass index (BMI) z-scores from childhood to adolescence, and to examine the association of these trajectories with measures of standing sagittal spinal alignment at 14 years of age.
Adolescents participating in the Western Australian Pregnancy Cohort (Raine) Study contributed data to the study (n=1 373). Age- and gender-specific z-scores for BMI were obtained from height and weight at the ages of 3, 5, 10 and 14 years. Latent class group analysis was used to identify six distinct trajectory classes of BMI z-score. At the age of 14 years, adolescents were categorised into one of four subgroups of sagittal spinal posture using k-means cluster analysis of photographic measures of lumbar lordosis, thoracic kyphosis and trunk sway. Regression modeling was used to assess the relationship between postural angles and subgroups, and different BMI trajectory classes, adjusting for gender.
Six trajectory classes of BMI z-score were estimated: Very Low (4%), Low (24%), Average (34%), Ascending (6%), Moderate High (26%) and Very High (6%). The proportions of postural subgroups at age 14 were; Neutral (29%), Flat (22%), Sway (27%) and Hyperlordotic (22%). BMI trajectory class was strongly associated with postural subgroup, with significantly higher proportions of adolescents in the Very High, High and Ascending BMI trajectory classes displaying a Hyperlordotic or Sway posture than a Neutral posture at age 14.
This prospective study provides evidence that childhood obesity, and how it develops, is associated with standing sagittal postural alignment in adolescence.
Current concepts review.
Outline the basic principles in the evaluation and treatment of adult spinal deformity patients with a focus on goals to achieve during surgical realignment surgery.
Proper global alignment of the spine is critical in maintaining standing posture and balance in an efficient and pain-free manner. Outcomes data demonstrate the clinical effect of spinopelvic malalignment and form a basis for realignment strategies.
Correlation between certain radiographic parameters and patient self-reported pain and disability has been established. Using normative values for several important spinopelvic parameters (including sagittal vertical axis, pelvic tilt, and lumbar lordosis), spinopelvic radiographic realignment objectives were identified as a tool for clinical application. Because of the complex relationship between the spine and the pelvis in maintaining posture and the wide range of "normal" values for the associated parameters, a focus on global alignment, with proportionality of individual parameters to each other, was pursued to provide clinical relevance to planning realignment for deformity across a range of clinical cases.
Good clinical outcome requires achieving proper spinopelvic alignment in the treatment of adult spinal deformity. Although variations in pelvic morphology exist, a framework has been established to determine ideal values for regional and global parameter in an individualized patient approach. When planning realignment surgery for adult spinal deformity, restoring low sagittal vertical axis and pelvic tilt values are critical goals, and should be combined with proportional lumbar lordosis to pelvic incidence.
To evaluate the lumbar lordosis, lumbosacral angle, lumbosacral disc angle, lumbosacral lordosis angle, intervertebral disc angles and heights, interpedicular distances, sagittal canal diameters and the lumbar gravity line (selected radiographic parameters) in young to middle aged Indian females in Durban. To determine any association between the selected radiographic parameters and the age of the subjects, weight, height and body mass index of the subjects, occupation, smoking, previous pregnancy and leg length inequality (selected anthropometric and demographic factors). Methods: Sixty healthy, asymptomatic, young to middle aged, Indian females were recruited for this study. All subjects underwent a case history, a physical examination and radiographic evaluation (AP and lateral views) of the lumbar spine. SPSS version 15.0 (SPSS Inc., Chicago, Ill, USA) was used to analyze the data. Results: The mean (± SD) of the lumbar lordosis, lumbosacral angle, lumbosacral disc angle and lumbosacral lordosis angle was 49º (± 6º), 39º (± 8º), 12º (± 5º) and 143.2º (± 5º) respectively. For the lumbar intervertebral disc angles at L1-L2, L2-L3, L3-L4, L4-L5 and L5- S1 levels, the mean (± SD) was 6º (± 2º), 8º (± 2º), 10º (± 3º), 12º (± 4º) and 12º (± 5º) respectively. The anterior and posterior intervertebral disc heights at the respective vertebral levels were: L1-L2: anterior: 8 mm (± 2), posterior 5 mm (± 2); L2-L3: anterior: 10 mm (± 2), posterior 5 mm (± 2); L3-L4: anterior: 12 mm (± 2), posterior 5 mm (± 2); L4-L5: anterior: 14 mm (± 3), posterior 5 mm (± 2) and L5-S1: anterior: 13 mm (± 4), posterior 6 mm (± 2). The mean (± SD) of the interpedicular distance at the L1, L2, L3, L4 and L5 vertebral levels was 23 mm (± 2), 24 mm (± 2), 25 mm (± 2), 27 mm (± 2) and 31 mm (± 3) respectively. For the sagittal canal diameter at the L1, L2, L3, L4 and L5 vertebral levels, the mean (± SD) was 20 mm (± 5), 21 mm (± 3), 21 mm (± 3), 21 mm (± 3) and 19 mm (± 3) respectively. The lumbar gravity line intersected the sacrum in 67.3% of the subjects. In 29.1% of the subjects, the lumbar gravity line passed anterior to the sacrum while in 3.6% of the subjects, it passed posterior to the sacrum. iv A significant association was found between lumbar lordosis and the height of the subjects in this study (p = 0.004). A decrease in the intervertebral disc height at L5-S1 was associated with smoking (p = 0.005). A decrease in the intervertebral disc height at L4-L5 was associated with previous pregnancy (p = 0.016). Body mass index of 26–30 kg.m-2 was significantly associated with an increase in the intervertebral disc angles at L3-L4 (p = 0.028) and L4-L5 (p = 0.031). A decrease in the L5-S1 intervertebral disc angle was also significantly associated with smoking (p = 0.023). There was a significant association between previous pregnancy and an increase in the intervertebral disc angle at L3-L4 (p = 0.016). A significant association was found between the age of the subjects and the L5-S1 intervertebral disc angle (p = 0.007). Specifically it was the 23–27 year group and 33–37 year group who were significantly different from each other (p = 0.033). Conclusion: Similarities and differences were found in the mean values of the radiographic parameters measured in this study and those reported in the literature. A number of the selected anthropometric and demographic factors were associated with some of the lumbar radiographic parameters. Further studies are required to establish the clinical significance of these findings. Thesis (M.Tech.: Chiropractic)-Durban University of Technology, 2008
A retrospective cohort study of the relationship between the structures that form the lumbar spine in humans.
To investigate the relationship between the segmental wedging of the vertebral bodies and that of the intervertebral discs, and between the overall lordosis angle and each of the 5 lumbar segments.
Little attention has been paid to the internal relationship between the structures that form the lumbar spine. Understanding these relationships is instrumental to our ability to restore and rehabilitate the lordotic curvature.
Lateral radiographs of 101 adult lumbar spines were examined in patients at spinal clinics. The patients had no history of spinal surgery and no radiographic abnormality. The radiologic parameters are the lordosis angle (LA), the body wedge angle (B), the total segmental angle (S), and the intervertebral disc angle (D). Measurements B, S, and D were taken for each of the 5 lumbar segments. Measurements B and D were used to calculate ΣB, the sum of the B, and ΣD, the sum of the D.
The LA correlates with the sum of the vertebral body angles and with the sum of the intervertebral disc angles. Vertebral body wedging is negatively correlated with intervertebral disc wedging. The middle 3 lumbar segments are moderately-to-poorly correlated, among themselves and with the LA, while the upper and lower lumbar segments are poorly correlated with the LA and not correlated with any lumbar segment.
Three parts of the lumbar lordosis were identified: the upper part, formed by the first lumbar segment; the middle part, formed by the middle 3 segments; and the lower part, formed by the fifth lumbar segment. The statistical study shows an inverse relationship between vertebral body and intervertebral disc wedging.
Concurrent validity between postural indices obtained from digital photographs (two-dimensional [2D]), surface topography imaging (three-dimensional [3D]), and radiographs.
To assess the validity of a quantitative clinical postural assessment tool of the trunk based on photographs (2D) as compared to a surface topography system (3D) as well as indices calculated from radiographs.
To monitor progression of scoliosis or change in posture over time in young persons with idiopathic scoliosis (IS), noninvasive and nonionizing methods are recommended. In a clinical setting, posture can be quite easily assessed by calculating key postural indices from photographs.
Quantitative postural indices of 70 subjects aged 10 to 20 years old with IS (Cobb angle, 15 degrees -60 degrees) were measured from photographs and from 3D trunk surface images taken in the standing position. Shoulder, scapula, trunk list, pelvis, scoliosis, and waist angles indices were calculated with specially designed software. Frontal and sagittal Cobb angles and trunk list were also calculated on radiographs. The Pearson correlation coefficients (r) was used to estimate concurrent validity of the 2D clinical postural tool of the trunk with indices extracted from the 3D system and with those obtained from radiographs.
The correlation between 2D and 3D indices was good to excellent for shoulder, pelvis, trunk list, and thoracic scoliosis (0.81>r<0.97; P<0.01) but fair to moderate for thoracic kyphosis, lumbar lordosis, and thoracolumbar or lumbar scoliosis (0.30>r<0.56; P<0.05). The correlation between 2D and radiograph spinal indices was fair to good (-0.33 to -0.80 with Cobb angles and 0.76 for trunk list; P<0.05).
This tool will facilitate clinical practice by monitoring trunk posture among persons with IS. Further, it may contribute to a reduction in the use of radiographs to monitor scoliosis progression.
Case-control observational study.
Determination of dimensional changes in the lumbar spines of athletes between supine and stand-up position in MRI, concerning the lordosis, spinal canal cross-sectional area (SCCA), dural sac cross-sectional area (DSCA), sagittal dural sac diameter (SDSD), the lateral recess and the neural foramina.
The development of positional MRI allows the examination of spine segments under a true weight-bearing situation.
About 35 athletes (20m/15f, Ø: 28a) were examined using a 0.25 T open MRI-Scanner (G-Scan, ESAOTE, Italy). In all cases, axial and sagittal SE-T1 + SSE-T2 images were recorded in supine and true standing position. All measurements were performed using MEDIMAGE software (Vepro AG, Germany). The blinded measurements were performed 3 times by 2 independent examiners. Sagittal images were used to determine the lordosis and the narrowing of the left/right foramen at all levels between L1/2 and L5/S1. Axial images were used to determine the SDSD, the SCCA and the DSCA at L3/4, L4/5, L5/S1, and narrowing of the left/right recessus lateralis of L4, L5 and S1.
The lordosis showed a significant increase of 6.3 degrees (14%) from supine to true standing position (P < 0.001). The SDSD is significantly smaller in true standing position, than in supine position at the level of L3/4 and L4/5 (P < 0.001). Narrowing of the foramen occurred in true standing position in 13.4% at L4/L5 and in 26.7% at level L5/S1. No significant differences were observed at the recessus lateralis, the SCCA and the DSCA.
The measurement method in supine and true standing position is excellent for depicting the anatomical regions relevant for spinal canal stenosis in healthy individuals. Measuring the lumbar lordosis angle in both positions is an important requirement for interpreting the relevant anatomical regions. Of particular importance here is the DSCA and the SDSD.
Cross-sectional study of total sagittal spinal alignment in lumbar spinal canal stenosis (LCS) patients with and without intermittent claudication.
To evaluate total sagittal spinal alignment in LCS.
The sagittal spinal alignment is an important factor in the management of lumbar degenerative diseases and lower back pain. Patients with LCS accompanied by intermittent claudication adopt a forward-bending posture during walking. However, few studies have quantitatively assessed the abnormal posture in LCS in relation to clinical symptoms.
This study analyzed 93 patients with LCS. They were divided into two groups according to the presence of neurogenic intermittent claudication; patients of the Claudicant group had intermittent claudication of the cauda equina (n = 53; mean age, 66.7) and those of the Nerve root group had no claudication (n = 40; mean age, 67.0). The following parameters were measured on the lateral whole-spine standing radiographs: the distance between the C7 plumb line and the posterior superior corner on the superior margin of S1 (sagittal vertical axis), the angle between the superior margin of the first lumbar vertebra and the first sacral vertebra (L1S1), lumbar lordotic angle, pelvic tilting angle (PA), and pelvic morphologic angle (PRS1).
The sagittal vertical axis of the Claudicant group (57.6 +/- 37.5 mm) was significantly larger than that of the Nerve root group (40.3 +/- 42.3 mm) and was larger in both groups compared with the standard values. Lumbar lordotic angle was smaller (18.8 degrees +/- 13.2 degrees ) and pelvic tilting angle was larger (27.2 degrees +/- 8.3 degrees ) in patients with the Claudicant group than those with the Nerve root group (22.4 degrees +/- 14.0 degrees and 22.7 degrees +/- 7.2 degrees , respectively).
Patients of the Claudicant group exhibited forward bending of the trunk and pelvis backtilt, compared with those of the Nerve root group.
A retrospective review of clinical and radiographic data from a multicenter adolescent idiopathic scoliosis (AIS) database. OBJECTIVE.: The purpose of this study was to perform a comprehensive radiographic evaluation of the differences in pelvic parameters between 2 groups (white and black) in a scoliotic population.
Increasingly, the importance of spinopelvic alignment and balance is appreciated as a major factor in the energy-efficient posture of the individual in the normal and diseased states. Pelvic incidence (PI) determines the lordosis of the patient and equations defining the interplay of pelvic parameters, lordosis, and kyphosis have been developed to guide surgical decision-making for spinal deformity. PI and thoracic lordosis have been previously shown to be increased in the AIS population.
Data were obtained from a prospective multicenter AIS database from a total of 1658 patients. We evaluated the 2 largest racial subsets in our database. We identified 421 whites and 115 black patients who met inclusion criteria. The parameters evaluated on preoperative full-length coronal and lateral radiographs were PI, sacral slope (SS), pelvic tilt, lumbar lordosis (LL), thoracic kyphosis, sagittal Cobb angle, and the shift of the sagittal C7 plumb line.
Age, gender, major and minor cobb angles were similar in the 2 groups. PI, pelvic tilt, and LL were found to be significantly greater in the black group when compared with the white group (black: 56.0, 13.9, and -63.6 vs. white: 52.5, 10.8, and -59.1).
In our study, significant differences were found in 3 of the 6 sagittal plane parameters between the 2 groups. With a larger PI, a larger LL is required in order maintain a neutral sagittal balance. Our results suggest that race may influence an individual's natural spinopelvic alignment, and serves as a reminder when planning surgical reconstruction for spinal deformity.
Sitting has been identified as a cause of mechanical low back pain. The purpose of this study was to use plain film x-rays to measure lumbar spine and pelvic posture differences between standing and sitting.
Eight male subjects were radiographed standing and sitting in an automobile seat. Measures of lumbar lordosis, intervertebral disk angles, lumbosacral angle, lumbosacral lordosis, and sacral tilt were completed. One-way analysis of variance (alpha = .05) was conducted on the variables stated above. A Bland-Altman analysis was conducted to assess agreement and repeatability of the lumbar lordosis angle using 2 raters.
Lumbar lordosis values in standing (average, 63 degrees +/- 15 degrees ) and sacral inclination (average, 43 degrees +/- 10 degrees ) decreased by 43 degrees and 44 degrees , respectively, in sitting. Intervertebral joint angles in sitting underwent substantial flexion (L1/L2-5 degrees [+/-3 degrees ], L2/L3-7 degrees [+/-3 degrees ], L3/L4-8 degrees [+/-3 degrees ], L4/L5-13 degrees [+/-3 degrees ], and L5/S1-4 degrees [+/-10 degrees ]). Measures of lumbar lordosis; intervertebral disk angles between L2/L3, L3/L4, and L4/L5; lumbosacral lordosis; lumbosacral angle; and sacral tilt were significantly decreased between standing and sitting (P < .001). Intervertebral disk angle between L5/S1 was not significantly different. Analysis using the Bland-Altman technique found good agreement and stable repeatability of measures with no statistical significant differences between or within raters (R1, P = .8474; R2, P = .4402; and R-R2, P = .8691).
The significant differences in lumbar and pelvic measures from standing to sitting further emphasize the range of motion experienced at vertebral levels in sitting. Based on the results of this study, interventions to return motion segments to a less flexed posture should be investigated because they may play a role in preventing injury and low back pain.
For about half of all pregnant women, low-back pain is inevitable. Physicians who can specify what type of back pain the patient has - lumbar, sacroiliac, or nocturnal - can institute targeted treatment that addresses the relevant pathophysiology. Acetaminophen and certain modalities such as icing the area are the basis of acute treatment in conjunction with ergonomic adaptation and a good low-back exercise program. This will help decrease stress on the low back, making back pain less likely. Before a woman becomes pregnant, encouraging her to become fit and resolving existing back problems is the key to back pain prevention.
The attainment of upright posture, with its requisite lumbar lordosis, was a major turning point in human evolution. Nonhuman primates have small lordosis angles, whereas the human spine exhibits distinct lumbar lordosis (30 degrees -80 degrees ). We assume the lumbar spine of the pronograde ancestors of modern humans was like those of extant nonhuman primates, but which spinal components changed in the transition from small lordosis angles to large ones is not fully understood.
We wished to determine the relative contribution of vertebral bodies and intervertebral discs to lordosis angles in extant primates and humans.
We measured the lordosis, intervertebral disc, and vertebral body angles of 100 modern humans (orthograde primates) and 56 macaques (pronograde primates) on lateral radiographs of the lumbar spine (humans-standing, macaques-side-lying).
The humans exhibited larger lordosis angles (51 degrees ) and vertebral body wedging (5 degrees ) than did the macaques (15 degrees and -25 degrees , respectively). The differences in wedging of the intervertebral discs, however, were much less pronounced (46 degrees versus 40 degrees ).
These observations suggest the transition from pronograde to orthograde posture (ie, the lordosis angle) resulted mainly from an increase in vertebral body wedging and only in small part from the increase in wedging of the intervertebral discs.
Prospective nonscoliotic cohort evaluation of the effects of various positions for obtaining standing lateral thoracolumbar radiographs.
The purpose of this study was to compare the effects of various upper extremity positions on thoracolumbar sagittal spinal alignment.
The standing position used to capture a lateral plane radiograph can have marked effects on measurements of sagittal spinal alignment and may compound the variability between measurements from successive radiographs.
Twenty-two healthy female adolescents performed 3 repeated trials of 4 standing positions in a motion analysis laboratory. The positions included: (1) relaxed standing with arms at sides (CONTROL), (2) standing with fists overlying ipsilateral clavicles (CLAVICLE), (3) active shoulder flexion to 30 degrees with elbows extended (30 ACTIVE), and (4) passive shoulder flexion to 30 degrees with hand supports (30 PASSIVE). Sagittal alignment of the spine was described by kyphosis, lordosis, and the sagittal vertical axis (SVA), all of which were measured from the positions of reflective markers attached to the surface of the back and pelvis. Differences between alignment measures obtained for each of the 3 radiographic positions relative to the functional position (CONTROL) were calculated. Mean differences were then compared between positions using repeated measures ANOVAs (alpha = 0.05).
Relative to the CONTROL position, all other positions resulted in negative shifts in SVA (range = -1.1 cm- -4.6 cm), decreased kyphosis (range = -1 degrees- -3 degrees), and increased lordosis (4 degrees for all positions). The shift in the SVA with the 30 PASSIVE position was significantly less than the other 2 positions (P < 0.05) and demonstrated the least variability.
Standing with the hands supported while flexing the shoulders 30 degrees during positioning for lateral spinopelvic radiographic acquisition resulted in an SVA and measures of sagittal plane curvature that were comparable with a functional standing position with arms at the side. This seems to be the best way to move the arms anterior to the spine with the least effect on overall sagittal balance.
A age- and sex-matched case-control radiographic study.
To identify the predisposing factors of degenerative spondylolisthesis (DS).
None of the radiologic methods for predicting the development of DS are very reliable or readily accessible. The methods commonly used are computed tomography or magnetic resonance imaging.
Data were gathered retrospectively on middle-aged women with degenerative lumbar spondylolisthesis.
The most common slipped vertebra was L4 (63.64%) and the second was L5 (13.64%). Most parameters, including the disc height, body height, and angle measurements, for the case group tended to be lower than the control group, whereas the transverse process were larger than control group. The differences in disc height, lumbar index (LI), sacral inclination angle (SIA), sacral horizontal angle (SHA), and transverse process between the 2 groups were statistically significant (P < 0.05). Multivariate logistic regression analysis confirmed that anterior inferior disc height (DHIA) and LI were independent variables of predisposing factor to DS and both could explain a 50% variation of DS. Further analysis of the different levels of spondylolisthesis (L4 on L5 vs. L5 on S1 DS) revealed that there was a significant difference in the width of L5 transverse process in L4 on L5 spondylolisthesis (P = 0.03) but insignificant on disc height (P = 0.86).
There are 2 independent predictors of DS, decreased anterior disc height and increased lumbar index. The iliolumbar ligament also contributes to the stability of lumbosacral junction, especially in L5 on S1 DS.