Article

Differences between clinical “snap-shot” and “real-life” assessments of lumbar spine alignment and motion-What is the “real” lumbar lordosis of a human being?

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

The individual lumbar lordosis and lumbar motion have been identified to play an important role in pathogenesis of low back pain and are essential references for preoperative planning and postoperative evaluation. The clinical “gold-standard” for measuring lumbar lordosis and its motion are radiological “snap-shots” taken while standing and during upper-body flexion and extension. The extent to which these clinically assessed values characterise lumbar alignment and its motion in daily life merits discussion.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... However, these concepts of spinopelvic alignment do not take into account both short-and long-term variations in the sagittal spinal profile [22]. Some authors therefore recommend a closer look at the anatomical aspect of the pelvis, which is considered to be the socket of the vertebral column architecture [13,14]. ...
... Restoration of the sagittal profile is directly related to the improvement of pain and function after spine surgery for various disease states [30,31]. However, it has been discussed that the spinal profile, and thus the functional spinopelvic parameters, are highly variable, and changes both in the short term during daily activities and in the long term due to degeneration are possible [22]. In particular, constant anatomical parameters of the pelvis have been focused on mitigating the influence of functional changes in spinopelvic parameters. ...
Article
Full-text available
Functional spinopelvic parameters are crucial for describing spinal alignment (SA), but this is susceptible to variation. Anatomically fixed pelvic shape is defined by the parameters pelvic radius (PR), pelvic incidence (PI), and sacral table angle (STA). In patients with lumbosacral transitional vertebrae (LSTV), the spinopelvic alignment may be altered by changes of these parameters and influences of SA. There have been no reports studying the relation between LSTV, four (4 LV) and six (6 LV) lumbar vertebrae, and fixed anatomical spinopelvic parameters. A retrospective analysis of 819 abdomen–pelvis CT scans was performed, identifying 53 patients with LSTV. In a matched-pair analysis, we analyzed the influence of LSTV and the subgroups 4 LV (n = 9) and 6 LV (n = 11) on PR, PI, and STA. LSTV were classified according to Castellvi classification. In patients with 6 LV, measurement points at the superior endplates of S1 and S2 were compared. The prevalence of LSTV was 6.5% (53/819), 6 LV was 1.3% (11/819), and 4 LV was 1.1% (9/819) in our study population. PI significantly increased (p < 0.001), STA significantly decreased (p < 0.001), and PR (p = 0.051) did not differ significantly in the LSTV group (n = 53). Similar findings were observed in the 4 LV subgroup, with an increase in PI (p < 0.021), decrease in STA (p < 0.011), and no significant difference in PR (p < 0.678). The same results were obtained in the 6 LV subgroup at measuring point S2 (true S1) PI (p = 0.010), STA (p = 0.004), and PR (p = 0.859), but not at measuring point S1 (true L6). Patients with LSTV, 4 LV, and 6 LV showed significant differences in PI and STA compared to the matched control group. PR showed no significant differences. The altered spinopelvic anatomy in LSTV patients need to be reflected in preoperative planning rebalancing the sagittal SA.
... In addition to walking, activities in forward bent postures, including upper body flexion and weight lifting are among the most frequently performed daily activities. Our previous 24-h in vivo measurements on the lumbar spinal alignment during daily life revealed that humans spend approximately 90% of the day in forward bent postures with a lordosis that is at least 5°less than in standing (Dreischarf et al., 2016a). Moreover, the mean daily lumbar lordosis was 8°, which is significantly lower than that recorded during regular short-term measurements in upright standing of 33° (Dreischarf et al., 2016a). ...
... Our previous 24-h in vivo measurements on the lumbar spinal alignment during daily life revealed that humans spend approximately 90% of the day in forward bent postures with a lordosis that is at least 5°less than in standing (Dreischarf et al., 2016a). Moreover, the mean daily lumbar lordosis was 8°, which is significantly lower than that recorded during regular short-term measurements in upright standing of 33° (Dreischarf et al., 2016a). A possible explanation for the lower daily lordosis angle could be the current dominance of sitting postures (Matthews et al., 2008). ...
Article
Long-term measurements on the lumbar spinal alignment during daily life revealed that humans spent 90% of the day in a forward bent posture. Compared to standing, this posture leads to a substantial increase in spinal loading. The lumbar spine and pelvis, however, contribute differently to the total amount of flexion, which could possibly indicate a different timing of maximum loads in both structures during flexion. This study aimed to evaluate the in vivo implant forces in the hip and lumbar spine during activities in forward bent postures. This work utilized data collected in earlier in vivo measurements on patients either with telemeterized hip endoprostheses (HE) or vertebral body replacements (VBR). The following activities were investigated: standing, upper body flexion with and without weights in the hands using different lifting techniques (straight and bent knees). The maximum resultant forces in VBR were considerably lower than in HE. Increases in flexion inclinations caused direct increases of the resultant forces within VBR, followed by a plateau or even a decrease of the force until maximum inclination. The resultant force in HE displayed an almost continuous increase until the maximum inclination. This general curve behavior resulted in different HE-VBR load ratios, which were affected by lifting additional weights or different lifting techniques. The results emphasize that maximum loads in the spine, in contrast to the hip, do not necessarily occur at maximum upper body flexion as normally expected, rather already at intermediate flexion angles in VBR patients. The results form the basis for more detailed insilico analyzes.
... [1][2][3] On this basis, Roussouly et al 2 defined 4 different sagittal profile types and suggested related patterns of degeneration; however, this definition did not consider the high extent of spinal flexibility. 4 Furthermore, the degenerative process itself changes spinal alignment significantly. For degenerative pathologies such as spinal canal stenosis, this influence has been well described. ...
... Because in the normal healthy population, the spinal profile is highly variable and changes frequently during daily activities, the suggestion by Roussouly et al 2 that degeneration patterns can be linked to single sagittal snapshots of this flexible and variable organ has been met with criticism. 4 Therefore, a link to a fundamental spinal constant-the pelvis-seems crucial for predicting spinal loads and potentially spinal degeneration patterns. Information able to predict how pelvic shapes contribute to degeneration would have a direct impact not only on screening and prevention but also on conservative and surgical treatment planning. ...
Article
Study design: Retrospective cohort study. Objective: The objective was to prove the association between anatomic pelvis parameters and specific types of lumbar spinal degeneration. Summary of background data: Different spinopelvic sagittal profile types are suggested to be associated with specific degenerative lumbar spine pathologies. Because pelvic morphology plays a key role defining the spinal shape as well as its load and function it thereby potentially predisposes the development of spinal degeneration. Materials and methods: Patients with symptomatic lumbar spinal degeneration who were surgically treated in 2 spine departments from March 2011 until August 2016 were included in this retrospective analysis. Single-level degenerative pathologies were classified as lumbar disc herniation (LDH), degenerative disc disease (DDD), lumbar spinal stenosis (LSS), and degenerative spondylolisthesis (DSPL). The constant anatomic pelvic parameters pelvic incidence (PI), pelvic radius (PR), and sacral table angle (STA) were assessed in lateral radiographs of the lumbar spine and compared between the pathologies. Results: In total, 249 patients were assigned to the LDH (n=73), DDD (n=67), LSS (n=42), and DSPL (n=67) groups. Group comparisons revealed significant differences in the anatomic pelvic parameters PR (LDH, 139.5±10.8 mm; DDD, 135.9±14.0 mm; LSS, 127.8±14.3 mm; DSPL, 135.8±12.7 mm; P<0.001), PI (LDH, 53.1±10.0 degrees; DDD, 50.0±9.9 degrees; LSS, 54.5±9.6 degrees; DSPL, 57.1±10.8 degrees; P=0.001), and STA (LDH, 95.3±12.7 degrees; DDD, 105.4±9.0 degrees; LSS, 105.9±11.5 degrees; DSPL, 98.6±9.5 degrees; P<0.001). Post hoc tests indicated significant differences between the PR of the LSS group and that of all other subgroups (P<0.012), the PI of the DDD group and that of DSPL (P<0.001), and the STA of the LDH/DSPL groups and that of the LSS/DDD group (P<0.005). Conclusions: We found all the constant anatomic parameters to be specific for distinct types of degeneration, suggesting pelvis shape is a predisposing factor for their development. Level of evidence: Level III.
... Ethnicity, age, gender, obesity, posture, activity, muscular strength and flexibility of the spine and lower limbs; all these factors may influence the angle of the lordosis, where some studies did not find any correlation between age, gender and LSA [9]. ...
... To begin with, there is evidence that the females have greater lumbar lordosis according to the literature [9], [16], [17]. Moreover, in this study there is a significant difference between the LSA of male and female, possibly because females have a larger sacral slope than males [18]. ...
Article
Full-text available
Background: Lumbar lordosis is an essential postural element that has gained the interest of both clinicians and researchers for several years. It is the inward curvature made by the wedging of the vertebrae of the lumbar spine. Since there is paucity of data on the lumbar lordosis in the Lebanese population, most of the data used in clinical practice to classify hypo- and hyper-lordosis are based on studies from other races. Aim: To identify the normal LSA in a Lebanese population, then see if there is a difference between the races and determine if this angle is affected by the gender or age. Methods: A retrospective study established to measure lumbar lordosis using LSA technique. Lateral supine lumbosacral radiographs of 128 Lebanese subjects, aged between 19 and 84 years, were analyzed. Statistical analysis was done using SPSS version 20.0. Results: The mean value (SD) of LSA was 38.980 (+9.90) with a min 15.70 and max 64.20. A significant difference was found between LSA and gender. However, there was no significant variation between this angle and age. Conclusion: The mean value of this angle 38.980 (+9.90) may form a reference for the Lebanese population. The study demonstrated that lumbar lordosis is affected by race and gender, with females having a greater LSA than males. Whereas the latter was not affected by age. Keywords: Lumbar lordosis, Lebanese population, lumbosacral angle, radiography.
... Additionally, cross-sectional studies, like the present one, could be vulnerable to reverse causality, with the cause-and-e®ect direction of e®ect between posture and all other variables di±cult to establish with certainty. 52 Also, signi¯cant di®erences have been identi¯ed between the average 24h lumbar lordosis measurement and static measurement in standing, 53 perhaps denoting the nonfunctional nature of static measurements followed in this study. ...
Article
Full-text available
Background: Various factors, inherited and acquired, are associated with habitual spinal postures. Objective: The purpose of this study was to identify the relationships between trunk muscle endurance, anthropometry and physical activity/inactivity and the sagittal standing lumbopelvic posture in pain-free young participants. Methods: In this study, 112 healthy young adults (66 females), with median (IQR) age of 20 years (18.2-22 years), without low back pain, injury or trauma were included. Lumbar curve (LC) and sacral slope (SS) angles were measured in standing with a mobile phone application (iHandy level). Anthropometric, physical activity/inactivity levels (leisure-time sport involvement and sitting hours/day) and abdominal (plank prone bridge test) and paraspinal (Sorensen test) isometric muscle endurance measures were collected. Results: LC and SS angles correlated significantly ( r = 0 . 80 , p < 0 . 001 ). Statistically significant differences for both LC ( p = 0 . 023 ) and SS ( p = 0 . 013 ) angles were identified between the male and female participants. A significant negative correlation was identified between the abdominal endurance time and LC ( r =- 0 . 27 , p = 0 . 004 ); however, the power of this result (56%) was not sufficiently high. The correlation between abdominal endurance and SS was non-significant ( r =- 0 . 17 , p = 0 . 08 ). In addition, no significant associations were identified between either of the sagittal lumbopelvic angles (LC-SS) in standing and the participants' body mass index (BMI), paraspinal endurance, leisure-time sport involvement or sitting hours/day. Conclusion: The potential role of preventive exercise in controlling lumbar lordosis via enhancement of the abdominal muscle endurance characteristics requires further confirmation. A subsequent study, performed in a larger population of more diverse occupational involvement and leisure-time physical activity levels, is proposed.
... To investigate the effect of age, a longitudinal study within the same cohort with a long-term follow-up is considered to be more powerful (Adams et al., 1999). While we only included studies assessing static postures or the RoM, future work should also aim to evaluate thoracic kinematics during functional tasks (e.g., walking, respiration, sit-to-stand and lifting) or in daily life under a more natural environment as performed in our previous study for the lumbar shape and kinematics (Dreischarf et al., 2016), which might provide a closer reference to the thoracic pathological status. ...
Article
A comprehensive knowledge of the thoracic shape and kinematics is essential for effective risk prevention, diagnose and proper management of thoracic disorders and assessment of treatment or rehabilitation strategies as well as for in silico and in vitro models for realistic applications of boundary conditions. After an extensive search of the existing literature, this study summarizes 45 studies on in vivo thoracic kyphosis and kinematics and creates a systematic and detailed database. The thoracic kyphosis over T1–12 determined using non-radiological devices (34°) was relatively less than measured using radiological devices (40°) during standing. The majority of kinematical measurements are based on non-radiological devices. The thoracic range of motion (RoM) was greatest during axial rotation (40°), followed by lateral bending (26°), and flexion (21°) when determined using non-radiological devices during standing. The smallest RoM was identified during extension (13°). The lower thoracic level (T8–12) contributed more to the RoM than the upper (T1–4) and middle (T4–8) levels during flexion and lateral bending. During axial rotation and extension, the middle level (T4–8) contributed the most. Coupled motion was evident, mostly during lateral bending and axial rotation. With aging, the thoracic kyphosis increased by about 3° per decade, whereas the RoM decreased by about 5° per decade for all load directions. These changes with aging mainly occurred in the lower region (T6–12). The influence of sex on thoracic kyphosis and the RoM has been described as partly contradictory. Obesity was found to decrease the thoracic RoM. Studies comparing standing, sitting and lying reported the effect of posture as significant.
... Furthermore, discrepancies between standing during physical examination and daily life measurements might imply a substantially different loading of certain spinal structures. Own preliminary studies on 208 asymptomatic subjects revealed for the first time that the actual sagittal alignment and motion of the lumbar spine throughout the entire day differ significantly from their corresponding values in clinical short-term assessment [25]. In particular, the mean LL during the day was significantly smaller than that during the short-term measurements. ...
Article
Background context: Sacral slope and lumbar lordosis have been studied extensively in recent years via x-ray examinations and strongly correlate with each other. This raises firstly the question of the reproducibility of this correlation in multiple standing phases and secondly whether this correlation can be achieved using non-radiological measurement tools. Purpose: This study aimed to (1) determine the extent to which the back-shape measurements correspond to the correlations between the sacral slope and lumbar lordosis found in previous radiologic investigations, (2) identify a possible effect of age and gender on this correlation and (3) evaluate the extent to which this correlation is affected by repeated standing phases. Study design/sample: Observational cohort study. Patient sample: 410 asymptomatic subjects (non-athletes), 21 asymptomatic soccer players (athletes), and 176 low back pain patients were included. Outcome measures: The correlation between sacrum orientation (SO) and lumbar lordosis (LL) was determined in six repetitive upright standing postures. Methods: A non-invasive strain-gauge based measuring system was used. Results: Back-shape measurements yielded a similar correlation to that measured in previous x-ray examinations. Coefficient of determination (R2) between SO and LL ranged between: 0.76 and 0.79 for the asymptomatic cohort. Athletes showed the strongest correlation (0.76≤R2≤0.84). For low back pain patients, the correlation substantially decreased (0.18≤R2≤0.39). R2 was not strongly affected by repeated standing phases. Conclusions: The correlation between SO and LL can be assessed by surface measurements of the back-shape and is not influenced by natural variations in the standing posture.
... The current study builds upon this prior work by accurately estimating lumbar loads during dynamic ROM trials, using kinematic motion capture data measured with a skin-mounted marker set that includes tracking of the trunk, pelvis and lower limbs. Despite the inherent complexity involved in tracking the trunk (Dreischarf et al., 2016;Leardini et al., 2009;Zemp et al., 2014), this model accurately represents spinal loading tracking a three degree-of-freedom trunk segment, while revealing Fig. 6. Average model activations (grey shaded) versus measured EMG activity (black) for participants with an amputation (four males, one female). ...
Article
Low back mechanics are important to quantify to study injury, pain and disability. As in vivo forces are difficult to measure directly, modeling approaches are commonly used to estimate these forces. Validation of model estimates is critical to gain confidence in modeling results across populations of interest, such as people with lower-limb amputation. Motion capture, ground reaction force and electromyographic data were collected from ten participants without an amputation (five male/five female) and five participants with a unilateral transtibial amputation (four male/one female) during trunk-pelvis range of motion trials in flexion/extension, lateral bending and axial rotation. A musculoskeletal model with a detailed lumbar spine and the legs including 294 muscles was used to predict L4-L5 loading and muscle activations using static optimization. Model estimates of L4-L5 intervertebral joint loading were compared to measured intradiscal pressures from the literature and muscle activations were compared to electromyographic signals. Model loading estimates were only significantly different from experimental measurements during trunk extension for males without an amputation and for people with an amputation, which may suggest a greater portion of L4-L5 axial load transfer through the facet joints, as facet loads are not captured by intradiscal pressure transducers. Pressure estimates between the model and previous work were not significantly different for flexion, lateral bending or axial rotation. Timing of model-estimated muscle activations compared well with electromyographic activity of the lumbar paraspinals and upper erector spinae. Validated estimates of low back loading can increase the applicability of musculoskeletal models to clinical diagnosis and treatment.
... However, spinal curvature was prescribed in the model as a function of trunk-pelvis motion, which cannot capture the variability in spinal curvature (Leardini et al., 2011). Higher resolution spinal tracking technology (e.g., Dreischarf et al., 2016a) would be valuable for better modeling vertebral kinematics (Azari et al., 2017;Bruno et al., 2015). Higher resolution modeling may also help in quantifying load sharing between the facet joints and intervertebral disc. ...
Article
People with a transtibial amputation have numerous secondary health conditions, including an increased prevalence of low back pain. This increased prevalence may be partially explained by altered low back biomechanics during movement. The purpose of this study was to compare trunk kinematics and L4-L5 lumbar loads in people with and without a transtibial amputation during sit-to-stand. Motion capture, ground reaction force and electromyographic data were collected from eight people with a unilateral transtibial amputation and eight people without an amputation during five self-paced sit-to-stand motions. A musculoskeletal model of the torso, lumbar spine, pelvis, lower limbs, and 294 muscles was used in a static optimization framework to quantify L4-L5 loads, low back muscle forces, and trunk kinematics. Participants with an amputation had greater peak and average L4-L5 loading in compression compared to control participants, with peak loading occurring shortly after liftoff from the chair. At the instant of peak loading, participants with an amputation had significantly greater segmental trunk lateral bending and trunk-pelvis axial rotation toward the intact side, and significantly greater segmental trunk axial rotation toward the prosthetic side compared to control participants. Participants with an amputation also had greater peak frontal plane and transverse plane segmental trunk angular velocity. The postural differences observed in people with a transtibial amputation were consistent with their ground reaction force asymmetry. The cumulative effects of the altered movement strategy used by people with an amputation may result in an increased risk for low back pain development over time.
... Therefore, novel non-radiological techniques that can evaluate the spinal profile during regular daily life should be implemented in routine clinical practice. In a recent study on 208 asymptomatic subjects, we determined the shape of the lumbar spine over a period of 24 hours using a non-invasive measurement tool [52]. The mean lumbar lordosis was subsequently compared with the lordosis achieved during standing for short term, similar to radiological assessment. ...
Article
Full-text available
Correction of the overall coronal and/or sagittal plane deformities is one of the main predictors of successful spinal surgery. In routine clinical practice, spinal alignment is assessed using several spinal and pelvic parameters, such as pelvic incidence and tilt, sacral slope, lumbar lordosis, thoracic kyphosis, and sagittal vertical axis. Standard values have been defined for all these parameters, and the formulas of correction have been set for determining the surgical strategy. However, several factors can potentially bias these formulas. First, all standard values are measured using conventional plain radiographs and are, therefore, prone to bias. The radiologist, measuring surgeon, and patient are possible confounding influencing factors. Second, spino-pelvic compensatory effects and biomechanically relevant structures for the patient's posture, including ligaments, tendons, and muscles, have received minimal consideration in the literature. Therefore, even in cases of appropriately planned deformity correction surgeries, complications, revision rates, and surgical outcomes significantly vary. This study aimed to illustrate the current clinical weaknesses of the assessment of spinal alignment and the importance of holistically approaching the musculoskeletal system for any spinal deformity surgery. We believe that our detailed insights regarding spinal, sagittal, and coronal alignments as well as the considerations of an individual's spinal balance will contribute toward improvement in routine patient care.
... Exclusion criteria were back pain, neck pain or pain in the upper limbs (shoulders, arms, lower-arms, hands) in the preceding month; surgery of the pelvis or spinal column; scoliosis; systemic or degenerative disease; body mass index (BMI) greater than 26 kg 2 /m,; one positive response to the Physical Activity Readiness Questionnaire (Thomas et al., 1992); history of neurological diseases or deficits not related to back pain (e.g., stroke, peripheral neuropathies, balance deficits); pregnancy; claustrophobia. Exclusion criteria related to BMI and the Physical Activity Readiness Questionnaire were to ensure a high correlation between the shape of the back and that of the spine (Dreischarf et al., 2016) and to eliminate those likely to have heart problems, respectively. Most participants were recruited through physical therapy and kinesiology departments of University of Montreal to increase the likelihood of participants having good motor control abilities. ...
Article
Background: Lumbar spine stability is regularly studied by positioning different loads at different heights and distance and measuring trunk muscle activation changes. Some of these studies have reported sex differences, but this needs to be revisited while controlling for confounding factors. Method: 20 males and 20 females sustained three static standing postures, with various loads (0, 5 and 10% of body weight), to evaluate the effect of height and distance. Activation of 12 trunk muscles was recorded with surface electromyography (EMG). Results: Females activated their external obliques a little more than males, with increases ranging between 1.5 and 2.3% of maximal voluntary activation (MVA), which corresponds to strong effect sizes (Cohen's d ranging between 0.86 and 1.13). However, the significant Sex × Height, Sex × Distance and Sex × Load interactions observed for different trunk muscles led to small differential effects (≤1% MVA). Increasing load height slightly increased and decreased back and abdominal muscle activation, respectively, generally by less than 1% MVA. Conclusion: The higher activation of the external obliques observed in females might be of clinical value, relative to the required overall trunk muscle activation (5%), to preserve lumbar stability. Other effects were negligible.
... However, the reported measurements in the existing literature show considerable differences because of several factors. In a normal population, age and sex caused temporal and spatial variation in LL (Damasceno et al., 2006;González-Sánchez et al., 2014;Kobayashi et al., 2004;Koumantakis et al., 2016;Krejčí and Gallo, 2016;Milne and Lauder, 1974;Norton et al., 2004;Parkinson et al., 2013;Vialle et al., 2005;Youdas et al., 1996;Zhu et al., 2014) and the RoM (Burton and Tillotson, 1988;Consmüller et al., 2012;Dopf et al., 1994;Dreischarf et al., 2016;Fitzgerald, 1983;Goldberg and Chiarello, 2001;Hindle et al., 1990;Ignasiak et al., 2017;Kasukawa et al., 2017;Kienbacher et al., 2015;Kuo et al., 2009;Moll and Wright, 1971;Pries et al., 2015;Sung and Kim, 2011;Uluçam and Cigali, 2009), whereas other studies did not find any significant differences in LL (Boulay et al., 2006;Endo et al., 2012;Janssen et al., 2009;Jean, 2014;Lee et al., 2011;Mehta et al., 2016;Singh et al., 2010;Tüzün et al., 1999) or RoM (Wong et al., 2004) due to age or sex. This poses a major difficulty for clinicians in defining what is a normal LL or RoM for different age groups and sex to be able to differentiate what is dysfunctional spinal motion. ...
Article
Lumbar lordosis (LL) and the range of motion (RoM) are important physiological measurements when initiating any diagnosis and treatment plan for patients with low back pain. Numerous studies reported differences in LL and the RoM due to age and sex. However, these findings remain contradictory. A systematic review and meta-analysis were performed to synthesize mean values and the differences in LL and the RoM because of age and sex. The quality assessment tool for quantitative studies was applied to assess the methodological quality of the studies included. We identified 2372 papers through electronic (2309) and physical (63) searches. We assessed 218 full-text studies reporting measurements of LL or the RoM. In total, 65 studies were included, and a normative database for LL and the RoM is provided as supplementary material. Among these, 11 were included in the meta-analysis. LL and the RoM displayed non-monotonic variations with significant age and sex differences. Young females showed a significantly greater LL and the range of extension (RoE), whereas young males exhibited a greater range of flexion (RoF). Sex differences in the range of lateral bending (RoLB) were small but were significant for the axial rotation (RoAR). For the RoF, RoE and RoLB, differences because of age were significant among most of the age groups in both sexes, whereas for the RoAR, differences were significant only between the 20s vs the 30s-40s (males) and 40s vs 50s (females). Significant differences because of age/sex were identified. However, the age-dependent reduction in LL and the RoM was non-monotonic and differed in both sexes. These findings will help to better distinguish between functional deficits caused by spinal disorders and natural factors/conditions related to age and sex.
... These findings cautioned against the risk of misinterpretation of radiological results, wrong diagnoses, or even unnecessary surgeries. Moreover, Dreischarf et al. (2016) reported that the lumbar lordosis (LL) measured via back shape during an upright standing posture (33°) differed significantly from average lordosis measured over a period of 24 h (8°). These results indicate that one single static standing posture examined in a clinical X-ray might not be representative of the spinal shape in daily life. ...
Article
Background: Currently, an upright standing posture is normally adopted for evaluations of spinal alignment, which is however sensitive to posture variations. Thus, finding a reproducible reference is essential. This study aimed to evaluate the reproducibility of standing and sitting postures at different arm positions in five consecutive repetitions. Methods: 22 asymptomatic subjects (11 males; 11 females) aged 20-35 years were included. Subjects were repeatedly asked to adopt different arm positions in standing and sitting. The absolute reposition errors of lumbar lordosis and sacral orientation between two consecutive repetitions were assessed with a non-radiological back measurement system. Findings: During standing at the relaxed arm position, the median absolute reposition errors of lumbar lordosis and sacral orientation were 1.14° (range 0.23°-3.80°) and 0.92° (range 0.17°-3.27°), respectively, which increased to 1.75° (range 0.21-4.97°) and 1.36° (range 0.35°-4.08°) during sitting (P < 0.01). The absolute reposition error of lumbar lordosis was non-significantly lower at the relaxed and clasped arm positions than at other arm positions. Between the first two repetitions, the absolute reposition errors of both, lumbar lordosis and sacral orientation, were greater than between the remaining two consecutive repetitions (P < 0.01). Both during standing and sitting, lumbar lordosis was smallest when hands holding two bars (P < 0.05). Interpretation: Sitting showed a worse reproducibility than standing. When assessing sagittal spinal balance, the clasped arm position during standing is recommended and an initial trial can help to reduce inception irreproducibility.
... Thereby, while inertial measurement unit (IMU)-based systems are known to be affected by drift errors when collecting data over longer time periods (Bergamini et al., 2014), strain gauge sensor-based systems such as the Epionics SPINE system might be more appropriate for measuring spinal motion during daily activities. With the capacity of collecting spinal motion data for up to 24 hours, the system was previously used to investigate lumbar spine alignment and motion over the course of a full day (Dreischarf et al., 2016;Rohlmann et al., 2014). Moreover, its easy-to-apply design facilitates data collections in large cohorts (Consmüller et al., 2012b;Consmüller et al., 2014;Dreischarf et al., 2014;Pries et al., 2015;Schmidt et al., 2018a;Schmidt et al., 2018b). ...
Preprint
Quantifying spinal motion during functional activities may contribute to a better understanding of common pathologies such as spinal disorders. Therefore, the current study aimed at the comparative evaluation of the Epionics SPINE system, a portable and cost-effective device for measuring sagittal lumbar movement during functional activities. Twenty healthy participants were therefore evaluated with the Epionics SPINE and a Vicon motion analysis system in two identical separate research visits. They performed the following activities: standing, sitting, chair rising, box lifting, walking, running and a counter movement jump (CMJ). Sagittal plane lumbar spine angles were extracted as continuous values as well as average and range of motion (ROM) parameters. Agreement between the systems was evaluated using Bland-Altman analyses, whereas within- and between-session reliability were assessed using intraclass correlation coefficients (ICC) and minimal detectable changes (MDC). The analysis showed excellent agreement between the systems for chair rising, box lifting and CMJ with a systematic underestimation of lumbar lordosis angles during walking and running. Reliability was moderate to high for all continuous and discrete parameters (ICC>=0.62), except for ROM during running (ICC=0.29). MDC values were generally below 15{\deg}, except for CMJ (peak values up to 20{\deg} within and 25{\deg} between the sessions). The Epionics SPINE system performed similarly to a Vicon motion capture system for measuring lumbar lordosis angles during functional activities and showed high consistency within and between measurement sessions. These findings can serve researchers and clinicians as a bench mark for future investigations using the system in populations with spinal pathologies.
... Thereby, while inertial measurement unit (IMU)-based systems are known to be affected by drift errors when collecting data over longer time periods (Bergamini et al., 2014), strain gauge sensor-based systems such as the Epionics SPINE system might be more appropriate for measuring lumbar back motion during daily activities. With the capacity of collecting motion data for up to 24 h, this system was previously used to investigate lumbar back alignment and motion over the course of a full day (Dreischarf et al., 2016;Rohlmann et al., 2014). Moreover, its easy-to-apply design facilitates data collections in large cohorts (Consmüller et al., 2012b;Consmüller et al., 2014;Dreischarf et al., 2014;Pries et al., 2015;Schmidt et al., 2018aSchmidt et al., , 2018b. ...
Article
Quantifying lumbar back motion during functional activities in real-life environments may contribute to a better understanding of common pathologies such as spinal disorders. The current study therefore aimed at the comparative evaluation of the Epionics SPINE system, a portable device for measuring sagittal lumbar back motion during functional activities. Twenty healthy participants were therefore evaluated with the Epionics SPINE and a Vicon motion capture system in two identical separate research visits. They performed the following activities: standing, sitting, chair rising, box lifting, walking, running and a counter movement jump (CMJ). Lumbar lordosis angles were extracted as continuous values as well as average and range of motion (ROM) parameters. Agreement between the systems was evaluated using Bland-Altman analyses, whereas within- and between-session reliability were assessed using intraclass correlation coefficients (ICC) and minimal detectable changes (MDC). The analysis showed excellent agreement between the systems for chair rising, box lifting and CMJ with a systematic underestimation of lumbar lordosis angles during walking and running. Reliability was moderate to high for all continuous and discrete parameters (ICC ≥ 0.62), except for ROM during running (ICC = 0.29). MDC values were generally below 15°, except for CMJ (peak values up to 20° within and 25° between the sessions). The Epionics SPINE system performed similarly to a Vicon motion capture system for measuring lumbar lordosis angles during functional activities and showed high consistency within and between measurement sessions. These findings can serve researchers and clinicians as a bench mark for future investigations using the system in populations with spinal pathologies.
... For patient presentations in which radiographs are appropriate, Cobb-angle 24 measurements are widely seen as the gold standard. [25][26][27][28][29][30][31][32] In the most common version of the analysis, a line is drawn on a lateral lumbar radiograph, through the superior endplate of the first lumbar vertebra, and a second line is then drawn parallel to the superior endplate of the sacral base or the inferior endplate of the lowest lumbar segment (Fig 1B). 25,27,33,34 Perpendiculars are then created, and the angle at the intersection is measured (Fig 1B). ...
Article
Objective The purpose of this study was to compare 2 alternative methods, the radiologic Harrison Posterior Tangent Method (HPTM) and the nonradiologic Spinal Mouse (SM), to the Cobb angle for measuring lumbar lordosis. Methods Sixteen participants with previously existing lateral lumbopelvic radiographs underwent nonradiographic lordosis assessment with a Spinal Mouse. Then 2 investigators analyzed each radiograph twice using the Harrison Posterior Tangent Method and Cobb angle. Correlations were analyzed between HPTM, the Cobb angle, and SM using the Spearman rank correlation coefficient; intraexaminer and interexaminer agreement were analyzed for HPTM and the Cobb angle using intraclass correlation coefficients. Results The HPTM correlated highly with the Cobb angle (Spearman ρ = 0.936, P < .001); SM had moderate to strong correlations with the Cobb angle (ρ = 0.737, P = .002) and HPTM (ρ = 0.707, P = .003). Intraexaminer and interexaminer agreement for the Cobb angle and HPTM were excellent (all intraclass correlation coefficients > 0.90). One participant had slight kyphosis according to HPTM and SM analyses (which consider the entire lumbar region), whereas the Cobb angle, based only on L1 and L5, reported mild lordosis for that participant. Conclusion In this sample, HPTM measurements showed high correlation with the commonly used Cobb angle, but this method requires more time and effort, and normal values have not been established. The SM may be an alternative when radiographs are inappropriate, but it measures soft tissue contours rather than lordosis itself.
... Portable solutions based on strain-gauge sensors that can be used without supervision have the advantage of monitoring the spinal motion in an unobtrusive manner [22,23]. Usually, an accelerometer is also needed to determine the orientation of the sensor while considering Earth's gravitational field. ...
Article
Full-text available
This paper presents a mathematical model that can be used to virtually reconstruct the posture of the human spine. By using orientation angles from a wearable monitoring system based on inertial sensors, the model calculates and represents the curvature of the spine. Several hypotheses are taken into consideration to increase the model precision. An estimation of the postures that can be calculated is also presented. A non-invasive solution to identify the human back shape can help reducing the time needed for medical rehabilitation sessions. Moreover, it prevents future problems caused by poor posture.
Article
Die axiale Spondyloarthritis (axSpA) ist eine chronisch entzündliche Erkrankung der Wirbelsäule, die langfristig mit einem Verlust körperlicher Funktionen, der Beweglichkeit und der aufrechten Haltung einhergehen kann. Bisher gängige Methoden zur Messung der Beweglichkeit basieren zum einen auf subjektiver Patientenwahrnehmung, wobei verschiedene Funktionen durch standardisierte Fragebögen (BASFI) semiquantitativ erfasst werden, und zum anderen werden im Rahmen einer körperlichen Untersuchung verschiedene Bewegungsbereiche v. a. des Achsenskeletts vermessen (BASMI). Vor Kurzem kam der erste Test hinzu, mit dem die Durchführung und Geschwindigkeit bestimmter Aufgaben erfasst werden kann (ASPI). Da diese Tests nur begrenzt verlässlich und reproduzierbar sind, wäre ein objektiverer Test wünschenswert. In der hier berichteten Studie wurde die Mobilität der Wirbelsäule (WS) von Patienten mit axSpA mit dem Epionics SPINE-Gerät (ES) quantitativ untersucht und anhand der OMERACT(outcome measures in rheumatology)-Kriterien evaluiert. Das Gerät misst verschiedene Bewegungsmuster der Wirbelsäule anhand elektronischer Sensoren automatisiert, das schließt die Geschwindigkeit der Bewegungsdurchführung ein. Als Kontrollen dienten Patienten mit Rückenschmerzen anderer Genese und Menschen ohne Rückenschmerzen. Die mit ES erhobenen Messungen unterschieden sich zwischen den Gruppen und korrelierten mit den BASMI-Werten (r =0,53–0,82, alle p = <0,03). Röntgenologische axSpA-Patienten hatten zudem eine eingeschränktere und langsamere Beweglichkeit als die mit nr-axSpA. Insgesamt sprechen die Ergebnisse dieser Arbeit dafür, dass Messungen mit dem ES ein valides und objektives Messverfahren der Wirbelsäulenbeweglichkeit für axSpA-Patienten darstellen.
Article
Full-text available
The understanding of the individual shape and mobility of the lumbar spine are key factors for the prevention and treatment of low back pain. The influence of age and sex on the total lumbar lordosis and the range of motion as well as on different lumbar sub-regions (lower, middle and upper lordosis) in asymptomatic subjects still merits discussion, since it is essential for patient-specific treatment and evidence-based distinction between painful degenerative pathologies and asymptomatic aging. A novel non-invasive measuring system was used to assess the total and local lumbar shape and its mobility of 323 asymptomatic volunteers (age: 20-75 yrs; BMI <26.0 kg/m2; males/females: 139/184). The lumbar lordosis for standing and the range of motion for maximal upper body flexion (RoF) and extension (RoE) were determined. The total lordosis was significantly reduced by approximately 20%, the RoF by 12% and the RoE by 31% in the oldest (>50 yrs) compared to the youngest age cohort (20-29 yrs). Locally, these decreases mostly occurred in the middle part of the lordosis and less towards the lumbo-sacral and thoraco-lumbar transitions. The sex only affected the RoE. During aging, the lower lumbar spine retains its lordosis and mobility, whereas the middle part flattens and becomes less mobile. These findings lay the ground for a better understanding of the incidence of level- and age-dependent spinal disorders, and may have important implications for the clinical long-term success of different surgical interventions.
Article
Full-text available
The measure of radiographic pelvic and spinal parameters for sagittal balance analysis has gained importance in reconstructive surgery of the spine and particularly in degenerative spinal diseases (DSD). Fusion in the lumbar spine may result in loss of lumbar lordosis (LL), with possible compensatory mechanisms: decreased sacral slope (SS), increased pelvic tilt (PT) and decreased thoracic kyphosis (TK). An increase in PT after surgery is correlated with postoperative back pain. A decreased SS and/or abnormal sagittal vertical axis (SVA) after fusion have a higher risk of adjacent segment degeneration. High pelvic incidence (PI) increases the risk of sagittal imbalance after spine fusion and is a predictive factor for degenerative spondylolisthesis. Restoration of a normal PT after surgery is correlated with good clinical outcome. Therefore, there is a need for comparative prospective studies that include pre- and postoperative spinopelvic parameters and compare complication rate, degree of disability, pain and quality of life.
Article
Full-text available
Background: Non-fatal health outcomes from diseases and injuries are a crucial consideration in the promotion and monitoring of individual and population health. The Global Burden of Disease (GBD) studies done in 1990 and 2000 have been the only studies to quantify non-fatal health outcomes across an exhaustive set of disorders at the global and regional level. Neither effort quantified uncertainty in prevalence or years lived with disability (YLDs). Methods: Of the 291 diseases and injuries in the GBD cause list, 289 cause disability. For 1160 sequelae of the 289 diseases and injuries, we undertook a systematic analysis of prevalence, incidence, remission, duration, and excess mortality. Sources included published studies, case notification, population-based cancer registries, other disease registries, antenatal clinic serosurveillance, hospital discharge data, ambulatory care data, household surveys, other surveys, and cohort studies. For most sequelae, we used a Bayesian meta-regression method, DisMod-MR, designed to address key limitations in descriptive epidemiological data, including missing data, inconsistency, and large methodological variation between data sources. For some disorders, we used natural history models, geospatial models, back-calculation models (models calculating incidence from population mortality rates and case fatality), or registration completeness models (models adjusting for incomplete registration with health-system access and other covariates). Disability weights for 220 unique health states were used to capture the severity of health loss. YLDs by cause at age, sex, country, and year levels were adjusted for comorbidity with simulation methods. We included uncertainty estimates at all stages of the analysis. Findings: Global prevalence for all ages combined in 2010 across the 1160 sequelae ranged from fewer than one case per 1 million people to 350 000 cases per 1 million people. Prevalence and severity of health loss were weakly correlated (correlation coefficient -0·37). In 2010, there were 777 million YLDs from all causes, up from 583 million in 1990. The main contributors to global YLDs were mental and behavioural disorders, musculoskeletal disorders, and diabetes or endocrine diseases. The leading specific causes of YLDs were much the same in 2010 as they were in 1990: low back pain, major depressive disorder, iron-deficiency anaemia, neck pain, chronic obstructive pulmonary disease, anxiety disorders, migraine, diabetes, and falls. Age-specific prevalence of YLDs increased with age in all regions and has decreased slightly from 1990 to 2010. Regional patterns of the leading causes of YLDs were more similar compared with years of life lost due to premature mortality. Neglected tropical diseases, HIV/AIDS, tuberculosis, malaria, and anaemia were important causes of YLDs in sub-Saharan Africa. Conclusions: Rates of YLDs per 100 000 people have remained largely constant over time but rise steadily with age. Population growth and ageing have increased YLD numbers and crude rates over the past two decades. Prevalences of the most common causes of YLDs, such as mental and behavioural disorders and musculoskeletal disorders, have not decreased. Health systems will need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality. Quantification of the burden of non-fatal health outcomes will be crucial to understand how well health systems are responding to these challenges. Effective and affordable strategies to deal with this rising burden are an urgent priority for health systems in most parts of the world. Funding: Bill & Melinda Gates Foundation.
Article
Full-text available
The diagnosis of low back pain pathology is generally based upon invasive image-based assessment of structural pathology, but is limited in methods to evaluate function. The accurate and robust measurement of dynamic function may assist in the diagnosis and monitoring of therapy success. Epionics SPINE is an advanced strain-gauge measurement technology, based on the two sensor strips SpineDMS system, which allows the non-invasive assessment of lumbar and thoraco-lumbar motion for periods of up to 24 h. The aim of this study was to examine the reliability of Epionics SPINE and to collect and compare normative data for the characterisation of spinal motion in healthy subjects. Furthermore, the identification of parameters that influence lumbar range of motion (RoM) was targeted. Spinal shape was measured using Epionics SPINE in 30 asymptomatic volunteers during upright standing, as well as maximum flexion and extension, to check intra-rater reliability. Furthermore, back shape was assessed throughout repeated maximum flexion and extension movements in 429 asymptomatic volunteers in order to collect normative data of the lordosis angle and RoM in different gender and age classes. The lordosis angle during standing in the healthy collective measured with Epionics SPINE was 32.4° ± 9.7°. Relative to this standing position, the average maximum flexion angle was 50.8° ± 10.9° and the average extension angle 25.0° ± 11.5°. Comparisons with X-ray and Spinal Mouse data demonstrated good agreement in static positions. Age played a larger role than gender in influencing lumbar posture and RoM. The Epionics SPINE system allows the practical and reliable dynamic assessment of lumbar spine shape and RoM, and may therefore provide a clinical solution for the evaluation of lower back pain as well as therapy monitoring.
Chapter
Full-text available
Improving knowledge among health workers at all levels about musculoskeletal conditions is important for early diagnosis and intervention, as is the provision of access to specialist services, such as orthopedic surgery. Simple programs that emphasize the importance of obesity and lack of exercise as predictors of poor musculoskeletal outcomes are low cost, but their implementation and their influence on health outcomes need to be assessed in properly conducted studies. Medications—particularly analgesic and anti-inflammatory drugs for arthritis and pain and vitamin D and calcium supplementation to prevent OP—need to be widely available. Exciting advances in the treatment of inflammatory forms of arthritis with biologics need to be evaluated from an economic perspective, particularly in developing nations, where the risk of exacerbating underlining infections such as tuberculosis is much higher than in developed countries. Currently, biologic agents are not cost-effective in developing countries, but they may be in the future. Access to hip and knee replacements, probably the most cost-effective surgical intervention available, is important but depends on the availability of a qualified staff. Musculoskeletal diseases will continue to present a challenge to the health systems of both developing and developed countries, but as we solve some of the issues related to communicable diseases, the hope is that more resources will become available for tackling the burgeoning epidemic of noncommunicable disease, including musculoskeletal conditions.
Article
Full-text available
Several attempts have been made to measure the segmental range of motion in the lumbar spine during flexion-extension with the purpose of gathering additional data for the diagnosis of instability. The previous studies were performed in vitro or in vivo during active motion. The aim of this study was to obtain normal values of passively performed segmental motions. Forty-one healthy adults were examined by means of functional radiographs during flexion-extension and lateral bending. A graphic construction method and a computer-assisted method were used to measure rotations. Comparing with recent in vivo studies, the values obtained for normal angles of rotation were predominately larger. This might be due to the passive examination used in the study. The graphic construction method and computer-assisted method techniques are equally reliable, but the computer-assisted method method yields other important kinematic data, such as translations. It is proposed that passive motion be applied during functional examination of patients with suspected instabilities. However, the large variation of rotational values between individuals in the normal population may limit the clinical usefulness of functional lumbar analysis using this parameter. Future studies should explore the clinical relevance of determining altered segmental mobility in low-back pain patients.
Article
Full-text available
Pelvis and spinal curves were studied with an angular parameter typical of pelvis morphology: pelvic incidence. A significant chain of correlations between positional pelvic and spinal parameters and incidence is known. This study investigated standards of incidence and a predictive equation of lordosis from selective pelvic and spinal individual parameters. One hundred and forty nine (78 men and 71 women) healthy adults, aged 19–50 years, with no spinal disorders, were included and had a full-spine lateral X-ray in a standardised upright position. Computerised technology was used for the measurement of angular parameters. Mean-deviation section of each parameter and Pearson correlation test were calculated. A multivariate selection algorithm was running with the lordosis (predicted variable) and the other spinal and pelvic parameters (predictor variables), to determine the best sets of predictors to include in the model. A low incidence (62°) increased sacral-slope and the lordosis is more pronounced. Lordosis predictive equation is based on incidence, kyphosis, sacral-slope and ±T9 tilt. The confidence limits and the residuals (the difference between measured and predicted lordosis) assessed the predicted lordosis accuracy of the model: respectively, ±1.65 and 2.41° with the 4-item model; ±1.73 and 3.62° with the 3-item model. The ability of the functional spine-pelvis unit to search for a sagittal balance depended both on the incidence and on the variation section of the other positional parameters. Incidence gave an adaptation potential at two levels of positional compensation: overlying state (kyphosis, T9 tilt), underlying state (sacral slope, pelvic tilt). The biomechanical and clinical conditions of the standing posture (as in scoliosis, low back pain, spondylisthesis, spine surgery, obesity and postural impairments) can be studied by comparing the measured lordosis with the predicted lordosis.
Article
Full-text available
Sedentary behaviors are linked to adverse health outcomes, but the total amount of time spent in these behaviors in the United States has not been objectively quantified. The authors evaluated participants from the 2003–2004 National Health and Nutrition Examination Survey aged ≥6 years who wore an activity monitor for up to 7 days. Among 6,329 participants with at least one 10-hour day of monitor wear, the average monitor-wearing time was 13.9 hours/day (standard deviation, 1.9). Overall, participants spent 54.9% of their monitored time, or 7.7 hours/day, in sedentary behaviors. The most sedentary groups in the United States were older adolescents and adults aged ≥60 years, and they spent about 60% of their waking time in sedentary pursuits. Females were more sedentary than males before age 30 years, but this pattern was reversed after age 60 years. Mexican-American adults were significantly less sedentary than other US adults, and White and Black females were similarly sedentary after age 12 years. These data provide the first objective measure of the amount of time spent in sedentary behavior in the US population and indicate that Americans spend the majority of their time in behaviors that expend very little energy.
Article
The relation of the pelvis to the spine has previously been overlooked as a contributor to sagittal balance. However, it is now recognized that spinopelvic alignment is important to maintain an energy-efficient posture in normal and disease states. The pelvis is characterized by an important anatomic landmark, the pelvic incidence (PI). The PI does not change after adolescence, and it directly influences pelvic alignment, including the parameters of pelvic tilt (PT) and sacral slope (SS) (PI = PT 1 SS), overall sagittal spinal balance, and lumbar lordosis. In the setting of an elevated PI, the spineadapts with increased lumbar lordosis. To prevent or limit sagittal imbalance, the spine may also compensate with increased PT or pelvic retroversion to attempt to maintain anupright posture. Abnormal spinopelvic parameters contribute to multiple spinal conditions including isthmic spondylolysis, degenerative spondylolisthesis, deformity, and impact outcome after spinal fusion. Sagittal balance, pelvic incidence, and all spinopelvic parameters are easily and reliably measured on standing, full-spine (lateral) radiographs, and it is essential to accurately assess and measure these sagittal values to understand their potential role in the disease process, and to promote spinopelvic balance at surgery. In this article, we provide a comprehensive review of the literature regarding the implications of abnormal spinopelvic parameters and discuss surgical strategies for correction of sagittal balance. Additionally, the authors rate and critique the quality of the literature cited in a systematic review approach to give the reader an estimate of the veracity of the conclusions reached from these reports.
Article
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.
Article
Several variables can have effect on sagittal balance. The changes that occur between standing and sitting have been inadequately studied, especially in the, pediatric population. Preoperative sagittal radiographs were obtained in both standing and sitting positions for 26 patients with idiopathic scoliosis before spinal fusion and instrumentation. Standard measurements of thoracic kyphosis, lumbar lordosis, sacral slope (SS), pelvic incidence, pelvic tilt, and lumbar intervertebral angles were, recorded. Differences were compared between positions using 2-sided paired t tests. When moving from standing to a seated position, the spine loses 5-degree thoracic kyphosis (P=0.007), 29-degree lumbar lordosis (P<0.0001), and the sacrum rotates 20 degrees (P<0.0001) to a more vertical position. The greatest change in sitting sagittal balance occurs due to increased pelvic tilt with decreased SS. The next greatest change is increased forward flexion of the lowest 2 lumbar vertebrae, 6.5 degrees between L4-L5 (P<0.0001) and 5.9 degrees between L5-S1 (P<0.0001). Flexion occurs throughout the lumbar spine but its magnitude decreases in the more proximal lumbar segments, 1.6 degrees between L1-L2 (P=0.028). The sagittal vertical axis also moves more anterior by 44 mm (P<0.0001). Sitting significantly straightens the spine with decreases of thoracic kyphosis, lumbar lordosis, and SS. The majority of the changes occur in the lumbar spine and pelvis. As humans spend much of their time sitting, this difference should be considered when spinal instrumentation is performed. These findings may be important to those who only sit, especially when instrumentation is extended to the pelvis. Level II-retrospective prognostic study.
Article
A technique for measuring the curvature of the lumbar spine is described and evaluated. Two small electronic inclinometers are attached to the skin overlying the spinous processes of L1 and S1. The signal from these inclinometers is stored and then processed to give a record of lumbar curvature against time. Tests showed that recordings from the inclinometers were reproducible and correlated well (r=0.91) with flexion angles measured from X-rays. The dynamic response of the system was good enough to measure lumbar curvature during typical bending and lifting movements.
Article
Study design: Retrospective analysis of clinical and radiologic data of a prospective cohort study. Objective: To research the clinical differences after lumbar total disk replacement (TDR) with respect to the preoperative global and the adaptation at the local sagittal profile (SP) of the spine. Summary of background data: It was suggested that facet loads and degeneration are dependent on epidemiologically defined types of SP. Moreover, the success of TDR was related to segmental facet joint loads. The influences of the preoperative SP or of the changes of the local SP after TDR on the clinical outcome after TDR remain unclear. Methods: Fifty-two patients included in a prospective cohort study regarding lumbar single-level TDR L4/5 (n=22) or L5/S1 (n=30) because of degenerative disk disease (Modic ≤2 degrees) were clinically (visual analog scale for back, leg, and overall pain; Oswestry Disability Index) and radiologically (extension-flexion radiographs, plain-spine, and whole-spine lateral radiographs in upright standing position) reevaluated after a minimum follow-up of 24 (24-69) months. On the basis of preoperative plain radiographs in upright standing position, patients were retrospectively assigned to 4 groups according to the individual sagittal profile type (SPT). In patients with persistent back pain, a facet infiltration at the index level was performed. Results: For all patients, an SPT could be defined. Global SP did not change compared with the preoperative state. All groups improved clinically over follow-up. At the last follow-up, types 1 and 4 demonstrated significantly inferior scores for pain and function. TDR-induced changes at the superior adjacent segment and the posterior disk height at the index level were also correlated to inferior clinical results. Infiltration test was positive in type 1-4: 67%, 40%, 33%, and 75%, respectively, of the symptomatic patients. Conclusions: We suggest SPTs 1 and 4 to represent a contraindication for lumbar TDR of levels L4/5 or L5/S1. Local adaptation in the adjacent segment to TDR may influence the clinical outcome as well.
Article
The differences in sagittal spino-pelvic alignment between adults with chronic low back pain (LBP) and the normal population are still poorly understood. In particular, it is still unknown if particular patterns of sagittal spino-pelvic alignment are more prevalent in chronic LBP. The current study helps to better understand the relationship between sagittal alignment and low back pain. To compare the sagittal spino-pelvic alignment of patients with chronic LBP with a cohort of asymptomatic adults. Sagittal spino-pelvic alignment was evaluated in prospective cohorts of 198 patients with chronic LBP and 709 normal subjects. The two cohorts were compared with respect to the sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL), lumbar tilt (LT), lordotic levels, thoracic kyphosis (TK), thoracic tilt (TT), kyphotic levels, and lumbosacral joint angle (LSA). Correlations between parameters were also assessed. Sagittal spino-pelvic alignment is significantly different in chronic LBP with respect to SS, PI, LT, lordotic levels, TK, TT and LSA, but not PT, LL, and kyphotic levels. Correlations between parameters were similar for the two cohorts. As compared to normal adults, a greater proportion of patients with LBP presented low SS and LL associated with a small PI, while a greater proportion of normal subjects presented normal or high SS associated with normal or high PI. Sagittal spino-pelvic alignment was different between patients with chronic LBP and controls. In particular, there was a greater proportion of chronic LBP patients with low SS, low LL and small PI, suggesting the relationship between this specific pattern and the presence of chronic LBP.
Article
Chronic lower back pain is a potentially incapacitating condition associated with disc degeneration. Although therapy is primarily pharmaceutical, surgery comprising arthrodesis constitutes an alternative. Anterior intersomatic lumbar arthrodesis (ALIF, anterior interbody lumbar fusion) is the reference approach, although total disc arthroplasty may also be undertaken. Analysis of pelvic and spinal parameters provides the best indication of sagittal balance. Materials and methods This was a prospective study in a continuous series of 99 patients presenting chronic lower back pain due to disc disease. Pelvic incidence, sacral slope, pelvic tilt, spino-sacral angle (SSA) and the four back types in the Roussouly classification were studied in radiographs of the whole spine under load using an EOS imaging system. Results The pre-operative SSA value for the study population was 126.09° ± 8.45° and the mean spine tilt angle was 90° compared with 95° in healthy subjects. Following surgery, the SSA was considerably increased in the discal arthroplasty, resulting in a significantly more balanced spinal position. In the group of patients undergoing arthrodesis using the ALIF technique, no such significant improvement was found despite the use of a lordosis cage. We showed that in cases of low pelvic incidence, it was necessary to maintain a Roussouly type 1 or 2 back without increasing lordosis. The results demonstrated the value of L4–L5 disc prostheses in these subjects. L5–S1 arthrodesis seemed a more suitable approach for treating patients with elevated sacral slope (back type 3 or 4). This new type of analysis of sagittal parameters should be performed prior to all surgical procedures involving lumbar prostheses.
Article
Prospective study of normal sagittal global spinal balance in the Caucasian adult population. To document values for parameters of global spinal balance in 709 asymptomatic adults without spinal pathology. Previous studies have investigated sagittal spinal balance in the normal population, but there is still a need for a large prospective database with normative values on the basis of gender and age. Spinosacral angle (SSA), spinal tilt (ST), and C7 translation ratio were evaluated in 709 asymptomatic adults (354 males and 355 females). Position of C7 plumbline relative to sacrum and hip axis (HA) was also assessed. Comparisons on the basis of gender were performed using analyses of covariance with age as covariate. Relationships between parameters and age were assessed using Spearman's coefficients. Mean SSA, ST, and C7 translation ratio were respectively 130.4° ± 8.1°, 90.8° ± 3.4°, and 0.1° ± 1.9°. Mean ± 2 standard deviations were respectively 110° to 150° for SSA and 85° to 100° for ST. Mean SSA and ST were higher in females but by less than 2°. C7 plumbline was behind the HA in 86% of subjects. Correlations between global balance and age were small (-0.1 ≤ r ≤ 0.1), with only 1 correlation reaching statistical significance (SSA vs. age; r = -0.1), reflecting a slight tendency for SSA to decrease with age. There was no relationship between ST and age. Asymptomatic adults tend to stand with a stable global balance and it is expected that 95% of normal adults have an SSA and ST between 110° to 150° and 85° to 100°, respectively. C7 plumbline in front of the HA is not necessarily associated with a spinal pathology. Results suggest that in adults, anterior displacement of C7 plumbline with respect to sacrum cannot be attributed solely to aging and should raise a suspicion for the risk of developing spinal pathology.
Article
Low back pain can be exacerbated by poor posture, particularly over extended stationary periods such as when sitting or standing. The repetitive determination of back shape could allow an ongoing assessment of subject specific posture to better understand the mechanisms of back pain. The portable measurement system SpineDMS(©) allows the dynamic, extended assessment of back shape in six segments of the lumbar and lower thoracic spine. The objective of this study was to assess the accuracy and repeatability of the system to determine its applicability for assessing back shape in patients. To assess the accuracy and repeatability of angle measurements, six SpineDMS(©) sensor strips (three systems) were repeatedly bent taut over a range of defined arcs. Measurements of spinal curvature were additionally conducted in 10 volunteers who performed flexion and extension exercises, with all results compared against reference marker data. The measurement sensors had a high accuracy and excellent repeatability (mean intraclass correlation coefficient (ICC) >0.98), with test-retest reliability ICCs of >0.98. Measurements in volunteers showed that SpineDMS(©) was capable of detecting the shape and movement of the human back. This study showed that SpineDMS(©) could be deployed as a reliable diagnostic tool for back posture, as well as movements in the sagittal plane.
Article
Lumbar spinal flexion and extension motion was measured radiographically and from the back surface curvature in 42 patients with low-back pain to determine whether the surface measurements provided accurate measurement of the total lumbar spinal motion and its distribution by vertebral level. Also, a biomechanical model of motion of the lumbar spine was used to predict the changes in the back surface as a function of varying amount of flexion and extension at the intervertebral articulations. Surface measurements provided reasonably accurate (+/- 11.2 degrees or +/- 25.5%) measurement of the total lumbar motion with a correlation coefficient of 0.58 between surface and radiographic measures. However, there was a poor correlation (varying between -.08 and .54 at different levels) between segmental motion measured radiographically and at the surface. Detection of the most mobile and least mobile intervertebral levels was done successfully by the surface curvature method in no more cases than would be expected by chance. Measurements of intersegmental motion are inherently error prone since they involve calculating differences between small angles which in turn are difficult to measure accurately. Surface measurements based on changes in back curvature are further complicated since the back surface has a variable relationship with spine shape and accurate measurement of curvature is very difficult.
Article
A surveyor's flexicurve has been used to measure kyphosis and lordosis in a cross-sectional study of men and women aged 20–90 years. No age effect was found in men aged 20–59 years or in women aged 20–49 years. Linear regressions showed an increase in kyphosis with age in older men and women. Various indices were examined to test their suitability as estimates of kyphosis. Lordosis was absent in an increasingly large proportion of men and women as age rose above 60 years. Das Kurvenbiegungsmass eines Landvermessers wurde benützt um Kyphosis und Lordosis zu messen im Studium eines Querschittes von Männern und Frauen im Alter von 20 bis 90 Jahren. Es wurde gefunden, dass Alter keine Auswirkungen verursachte auf Männer im Alter von 20–59 Jahren und auf Frauen im Alter von 20–49 Jahren. Lineare Regressionen zeigten ein Ansteigen von Kyphosis mit dem Alter in älteren Männern und Frauen. Verschiedene Anzeichen wurden studiert um ihre Eignung als Kyphosis-Einschätzungen zu prüfen. Lordosis war bei Männern und Frauen nicht vorhanden in steigender grosser Proportion mit steigendem Alter über 60 Jahre. Un curvimètre d'enquéte a été utilisé pour mesurer la cyphose et la lordose, lors d'une enquéte transversale portant sur des hommes et des femmes de 20 à 90 ans. Aucune influence de l'áge n'a été décelée pour les hommes de 20 à 59 ans, et les femmes de 20 à 49 ans. Chez les hommes et les femmes plus ágés, il existe une liaison linéaire positive entre l'áge et la cyphose. Plusieurs indices ont été essayés pour évaluer la cyphose. La lordose est absente dans des fractions de plus en plus importantes des populations masculine et féminine examinées lorsque l'áge augmente au delà de 60 ans.
Article
Biplanar radiography was used to assess the normal three-dimensional movements of the lumbar spine in the erect posture in a group of asymptomatic volunteers. The primary movements investigated were flexion and extension, while the three-dimensional analysis also measured any associated coupled lateral bends and axial rotations. The results showed that each intervertebral joint had a total range of flexion and extension of approximately 14 degrees, the lower levels moving slightly more than the upper levels. All the intervertebral joints had more movement in flexion than extension from the upright position, except for the L5/S1 joint, which showed no consistent pattern, some subjects extending more than flexing. Coupled movements of 4 degrees or more in flexion and 3 degrees or more in extension were shown to be abnormal.
Article
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. 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. Previous studies of sagittal alignment have focused on adolescent and young adult populations before the onset of degenerative changes that may affect sagittal alignment. Radiographic measurements were collected and subjected to statistical analysis. 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. 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.
Article
The CA-6000 Spine Motion Analyzer was used to measure the lumbar spine's range of motion (ROM). One hundred and four asymptomatic volunteers were examined to obtain normal values for flexion/extension, lateral bending, and axial rotation. A detailed error analysis was conducted to investigate the inter- and intraobserver reliability of the measurement equipment, the differences between passive and active examination, the effects of stretching exercises before examination, and the diurnal changes related to lumbar spine ROM. Subjects were divided into groups by age and gender. Values for each group were compared with respect to age and gender. The measurements were found to be consistent and repeatable. Stretching exercises were observed to increase ROM. Passive examination was recommended to achieve maximum ROM. ROM was observed to increase during the course of the day. A normative database was established showing significantly decreased motion as age increased, but no gender differences were discovered. The validity of the axial rotation values due to fixation difficulties is questioned.
Article
This paper proposes an anatomical parameter, the pelvic incidence, as the key factor for managing the spinal balance. Pelvic and spinal sagittal parameters were investigated for normal and scoliotic adult subjects. The relation between pelvic orientation, and spinal sagittal balance was examined by statistical analysis. A close relationship was observed, for both normal and scoliotic subjects, between the anatomical parameter of pelvic incidence and the sacral slope, which strongly determines lumbar lordosis. Taking into account the Cobb angle and the apical vertebral rotation confers a three-dimensional aspect to this chain of relations between pelvis and spine. A predictive equation of lordosis is postulated. The pelvic incidence appears to be the main axis of the sagittal balance of the spine. It controls spinal curves in accordance with the adaptability of the other parameters.
Article
We conducted intradiscal pressure measurements with one volunteer performing various activities normally found in daily life, sports, and spinal therapy. The goal of this study was to measure intradiscal pressure to complement earlier data from Nachemson with dynamic and long-term measurements over a broad range of activities. Loading of the spine still is not well understood. The most important in vivo data are from pioneering intradiscal pressure measurements recorded by Nachemson during the 1960s. Since that time, there have been few data to corroborate or dispute those findings. Under sterile surgical conditions, a pressure transducer with a diameter of 1.5 mm was implanted in the nucleus pulposus of a nondegenerated L4-L5 disc of a male volunteer 45-years-old and weighing 70 kg. Pressure was recorded with a telemetry system during a period of approximately 24 hours for various lying positions; sitting positions in a chair, in an armchair, and on a pezziball (ergonomic sitting ball); during sneezing, laughing, walking, jogging, stair climbing, load lifting during hydration over 7 hours of sleeping, and others. The following values and more were measured: lying prone, 0.1 MPa; lying laterally, 0.12 MPa; relaxed standing, 0.5 MPa; standing flexed forward, 1.1 MPa; sitting unsupported, 0.46 MPa; sitting with maximum flexion, 0.83 MPa; nonchalant sitting, 0.3 MPa; and lifting a 20-kg weight with round flexed back, 2.3 MPa; with flexed knees, 1.7 MPa; and close to the body, 1.1 MPa. During the night, pressure increased from 0.1 to 0.24 MPa. Good correlation was found with Nachemson's data during many exercises, with the exception of the comparison of standing and sitting or of the various lying positions. Notwithstanding the limitations related to the single-subject design of this study, these differences may be explained by the different transducers used. It can be cautiously concluded that the intradiscal pressure during sitting may in fact be less than that in erect standing, that muscle activity increases pressure, that constantly changing position is important to promote flow of fluid (nutrition) to the disc, and that many of the physiotherapy methods studied are valid, but a number of them should be re-evaluated.
Article
The relationship between the degree of lumbar lordosis and chronic low back pain (LBP) has long been speculated. It is postulated that prolonged sitting and sedentary lifestyle might change the degree of lumbar lordosis and cause LBP. The purpose of this study was to determine the effects of lifestyle, exercise, work setting, work intensity, and other demographic factors such as age, height, weight, and gender on the degree of lumbar lordosis and occurrence of LBP. Eight hundred forty subjects between ages 20 and 65 years were equally categorized into four groups: normal male, normal female, males with LBP, and females with LBP. A questionnaire was used to obtain information about the subject's lifestyle, work setting, level of exercise, and work-related physical activity. A flexible ruler was used to measure lumbar lordosis in all subjects. The average degree of lumbar lordosis for all subjects was 37 degrees +/- 13 degrees. Females had greater lumbar lordosis (42 degrees +/- 15 degrees ) than males did (32 degrees +/- 10 degrees ). There was no significant difference in the degree of lumbar lordosis in subjects with different lifestyle (p = 0.97), level of physical activity (p = 0.36), work setting (p = 0.5), and with or without LBP (p = 0.28). The degree of lumbar lordosis was positively related with the number of pregnancies (p = 0.04, r = 0.25), age (p = 0.02, r = 0.1) and height (p = 0.0001, r = 0.31) and negatively related with weight (p = 0.04, r = 0.06) of the subjects. The likelihood of developing LBP was significantly higher in the subjects who had high work-related physical activity (p = 0.03) and those who exercised less often (p = 0.008). We found no significant relationship between LBP occurrence and the degree of lumbar lordosis (p = 0.68), work setting (p = 0.15), height (p = 0.08), weight (p =0.06), and age (p = 0.67) of the subjects. The degree of lumbar lordosis was not different between normal subjects and those with LBP. Lumbar lordosis was not affected by lifestyle, level of physical activity, or type of work setting. Although these factors have not been found to affect the degree of lumbar lordosis, some affected the occurrence of LBP. This finding indicates that the effect of these factors on LBP involves mechanisms other than changing the degree of lumbar lordosis.
Article
A prospective radiographic study of 160 volunteers without symptoms of spinal disease was conducted. The objective of this study was to describe, quantify, and classify common variations in the sagittal alignment of the spine, sacrum, and pelvis. Previous publications have documented the high degree of variability in the sagittal alignment of the spine. Other studies have suggested that specific changes in alignment and the characteristics of the lumbar lordosis are responsible for degenerative changes and symptomatic back pain. In the course of this study, anteroposterior and lateral radiographs of 160 volunteers in a standardized standing position were taken. A custom computer application was used to analyze the alignment of the spine and pelvis on the lateral radiographs. A four-part classification scheme of sagittal morphology was used to classify each patient. Reciprocal relationships between the orientation of the sacrum, the sacral slope, the pelvic incidence, and the characteristics of the lumbar lordosis were evident. The global lordotic curvature, lordosis tilt angle, position of the apex, and number or lordotic vertebrae were determined by the angle of the superior endplate of S1 with respect to the horizontal axis. Understanding the patterns of variation in sagittal alignment may help to discover the association between spinal balance and the development of degenerative changes in the spine.
Article
There is an increasing recognition of the clinical importance of the sagittal plane alignment of the spine. A prospective study of several radiographic parameters of the sagittal profile of the spine was conducted to determine the physiological values of these parameters, to calculate the variations of these parameters according to epidemiological and morphological data, and to study the relationships among all of these parameters. Sagittal radiographs of the head, spine, and pelvis of 300 asymptomatic volunteers, made with the subject standing, were evaluated. The following parameters were measured: lumbar lordosis, thoracic kyphosis, T9 sagittal offset, sacral slope, pelvic incidence, pelvic tilt, intervertebral angulation, and vertebral wedging angle from T9 to S1. The radiographs were digitized, and all measurements were performed with use of a software program. Two different analyses, a descriptive analysis characterizing these parameters and a multivariate analysis, were performed in order to study the relationships among all of them. The mean values (and standard deviations) were 60 degrees 10 degrees for maximum lumbar lordosis, 41 degrees +/- 8.4 degrees for sacral slope, 13 degrees +/- 6 degrees for pelvic tilt, 55 degrees +/-10.6 degrees for pelvic incidence, and 10.3 degrees +/- 3.1 degrees for T9 sagittal offset. A strong correlation was found between the sacral slope and the pelvic incidence (r = 0.8); between maximum lumbar lordosis and sacral slope (r = 0.86); between pelvic incidence and pelvic tilt (r = 0.66); between maximum lumbar lordosis and pelvic incidence, pelvic tilt, and maximum thoracic kyphosis (r = 0.9); and, finally, between pelvic incidence and T9 sagittal offset, sacral slope, pelvic tilt, maximum lumbar lordosis, and thoracic kyphosis (r = 0.98). The T9 sagittal offset, reflecting the sagittal balance of the spine, was dependent on three separate factors: a linear combination of the pelvic incidence, maximum lumbar lordosis, and sacral slope; the pelvic tilt; and the thoracic kyphosis. This description of the physiological spinal sagittal balance should serve as a baseline in the evaluation of pathological conditions associated with abnormal angular parameter values. Before a patient with spinal sagittal imbalance is treated, the reciprocal balance between various spinal angular parameters needs to be taken into account. The correlations between angular parameters may also be useful in calculating the corrections to be obtained during treatment.
Article
To evaluate the validity and reliability of the Spinal Mouse model to assess lumbar spine flexion. For the validity study, patients with low-back pain underwent radiography to produce 2 lateral radiographs, first from the neutral position, and then with full trunk flexion. The correlation between mobility as assessed by radiography and the Spinal Mouse were evaluated by use of Spearman's correlation coefficient (SCC) for segmental mobility (L1-L2, L2-L3, L3-L4, L4-L5 and L5-S1) and global mobility (L1-L5 and L1-S1). Reliability was studied in healthy volunteers by the intraclass correlation coefficient (ICC). A total of 20 patients (8 women) aged 41.6+/-8.6 (range 24-63), were included in the validity study. The SCC between radiography and Spinal Mouse measures were 0.55; 0.64; 0.69; 0.54; 0.19; 0.7; and 0.86 for flexion mobility of the L1-L2, L2-L3, L3-L4, L4-L5, L5-S1, L1-L5 and L1-S1, respectively. A total of 45 subjects aged 24.2+/-3.7 (range 20-29) were included for the reliability study. For intrarater reliability, the ICC was 0.84; 0.89; 0.96; 0.97; 0.63; 0.95 and 0.83 for the L1-L2, L2-L3, L3-L4, L4-L5, L5-S1, L5-S1, L1-L5 and L1-S1, respectively. For interrater reliability, the ICC was 0.75; 0.81; 0.79; 0.60; 0.83; 0.85, respectively. The Spinal Mouse has acceptable metrological properties to assess segmental and global lumbar mobility during trunk flexion. Its metrological properties are not acceptable to assess mobility of L5-S1.