The importance of proximal femoral angle on sagittal balance and quality of life in children and adolescents with high-grade lumbosacral spondylolisthesis

Is sagittal spinopelvic alignment a cause of low back pain in pediatric spine pathologies? A review

Purpose

Altered spinopelvic morphology is observed in many spine pathologies occurring during growth. The aim of the study is to better understand the sagittal compensatory mechanisms and their possible influence on the occurrence of pain in selected pediatric spine pathologies.

Methods

A bibliographic search in the PubMed database included articles published between September 1965 and July 2023. The keywords contained in the search were "spondylolysis," "spondylolisthesis," "scoliosis," "kypho," "sagittal," "pediatric," "child," "adolescent," "grow," "development," and "pain."

Results

The largest diversity in sagittal alignment patterns was reported in idiopathic scoliosis, with global flattening of the spine being the most common. Kyphotic deformations occurring during growth are characterized by structural thoracic or thoracolumbar kyphosis compensated by lumbar hyperlordosis and lower pelvic incidence. Whereas in spondylolisthesis, altered morphology of the spinopelvic junction with high values of pelvic incidence is observed. Pain does not seem to be related to sagittal alignment in idiopathic scoliosis. In Scheuermann disease, it is localized at the apex of the deformity and is associated with the curve pattern, whereas in spondylolisthesis, sagittal alignment correlates with pain scores only in high-grade slips.

Conclusion

Most of the patients with spine disorders that occurred during growth present a clinically balanced posture in the sagittal plane. It suggests that compensatory mechanisms before achieving skeletal maturity are really significant. A comprehension of sagittal alignment in spine deformities and its relationship to pain is essential for the proper assessment and treatment of these disorders.

The role of femoral obliquity angle and T1 pelvic angle in predicting quality of life after spinal surgery in adult spinal deformities

BACKGROUND

Adult spinal deformities (ASD) represent a growing clinical condition related to chronic pain, disability and reduction in quality of life (QoL). A strong correlation among spinal alignment, spinopelvic parameters and QoL after spinal fusion surgery in ASD patients was thoroughly investigated over the last decade, However, only few studies focused on the relationship between lumbo-pelvic-femoral parameters - such as Femoral Obliquity Angle (FOA), T1 Pelvic Angle (TPA) and QoL.

METHODS

Radiological and clinical data from 43 patients surgically treated with thoracolumbar posterior spinal fusion for ASD between 2015 and 2018 were retrospectively analyzed. The primary outcomes were the correlation between preoperative spino-pelvic-femoral parameters and postoperative clinical, functional outcomes and QoL. Secondary outcomes were: changes in sagittal radiographic parameters spino-pelvic-femoral, clinical and functional outcomes and the rate of complications after surgery.

RESULTS

Using Spearman's rank correlation coefficients, spinopelvic femoral parameters (FOA, TPA, pre and post-operative) are directly statistically correlated to the quality of life (ODI, SRS-22, pre and post-operative; > 0,6 strong correlation, p <  0.05). Stratifying the patients according pre preoperative FOA value (High FOA ≥ 10 and Normal/Low FOA <  10), those belonging to the first group showed worse clinical (VAS: 5.2 +/- 1.4 vs 2.9 +/- 0.8) and functional outcomes (ODI: 35.6+/- 6.8 vs 23.2 +/- 6.5) after 2 years of follow-up and a greater number of mechanical complications (57.9% vs 8.3% p <  0.0021).

CONCLUSION

Based on our results, preoperative FOA and TPA could be important prognostic parameters for predicting disability and quality of life after spinal surgery in ASD patients and early indicators of possible spinal sagittal malalignment. FOA and TPA, like other and better known spinopelvic parameters, should always be considered when planning corrective surgery in ASD patients.

The effect of pedicle subtraction osteotomy for the correction of severe Scheuermann thoracolumbar kyphosis on sagittal spinopelvic alignment

Purpose

To analyze how pedicle subtraction osteotomy (PSO) treatment of severe Scheuermann thoracolumbar kyphosis (STLK) using pedicle screw instrumentation affects sagittal spinopelvic parameters.

Background

The medical literature on the post-surgical effects of treatments such as Ponte osteotomy is limited, but suggests few effects on spinopelvic profiles. Currently, there is no research regarding changes in sagittal spinopelvic alignment upon PSO treatment in STLK patients.

Methods

We performed a retrospective study on 11 patients with severe STLK. These patients underwent posterior-only correction surgeries with PSO and pedicle screw instrumentation between 2012 to 2017 in a single institute. Patients were measured for the following spinopelvic parameters: global kyphosis (GK), thoracic kyphosis (TK), thoracolumbar kyphosis (TL), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tile (PT), sacral slope (SS), and administered a Scoliosis Research Society-22 questionnaire (SRS-22) pre-operation, post-operation and at final follow-up.

Results

GK improved from a median of 74.1° to 40.0° after surgery, achieving a correction rate of 48.8% with a median correction loss of 0.8°. TK, TL and LL all showed significant difference (P < 0.05) and SVA improved 22.7 (11.6, 30.9) mm post operation. No significant difference was found in pelvic parameters (PI, PT, SS, all P < 0.05). The absolute value of LL- PI significantly improved from a median of 26.5° pre-operation to 6.1° at the final follow-up. 72.7% in this series showed an evident trend of thoracic and lumbar apices migrating closer to ideal physiological segments after surgery. Self-reported scores of pain, self-image, and mental health from SRS-22 revealed significant improvement at final follow-up (all P < 0.05).

Conclusions

PSO treatment of severe STLK with pedicle screw instrumentation can improve spine alignment and help obtain a proper alignment of the spine and the pelvis.

Adult spinal deformity and its relationship with hip range of motion: a cohort study of community-dwelling females

BACKGROUND CONTEXT

Adult spinal deformity affects lower extremity alignment with compensation in joint range of motion (ROM) and alignment of the hip.

PURPOSE

To investigate the relationship between sagittal spinopelvic alignment and the ROM of the hip joint and the femoral oblique angle (FOA).

STUDY DESIGN

Cross-sectional, observational cohort study of community-dwelling Japanese women.

METHODS

The study group included 158 women, enrolled in our ongoing prospective cohort study, with upright spine radiographs and physical measurements obtained for all participants. Radiographic spinopelvic parameters included measurement of thoracic kyphosis, lumbar lordosis (LL), sagittal vertical axis (SVA), sacral slope, pelvic incidence, and pelvic tilt (PT). FOA parameters were measured on hip radiographs and hip ROM included external and internal rotation and extension. The association between spinopelvic parameters, the FOA, and hip joint ROM was evaluated using Spearman's correlation analysis.

RESULTS

External rotation of the hip was correlated with LL (R=0.179, p=.024), PT (R=-0.273, p=.001) and SVA (R=-0.215, p=.007), with the FOA being correlated with the SVA (R=0.502, p<.001).

CONCLUSIONS

The decrease in hip external rotation with adult spinal deformity might reflect a structural modification in spinopelvic alignment. An increase in FOA was associated with an increase in SVA, indicative of a sagittal malalignment in the decompensated phase of adult spinal deformity.

The impact of surgical reduction of high-grade lumbosacral spondylolisthesis on proximal femoral angle and quality of life

BACKGOUND CONTEXT

Abnormal proximal femoral angle (PFA) was recently found to be associated with deteriorating sagittal balance and quality of life (QoL) in high-grade spondylolisthesis (HGS). However, the influence of PFA on the QoL of patients undergoing surgery remains unknown.

PURPOSE

This study compares the pre- and postoperative measurements of sagittal balance including PFA in patients with lumbosacral HGS after surgery. It also determines if PFA is a radiographic parameter that is associated with QoL in patients undergoing surgery.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

Thirty-three patients (mean age 15.6 ± 3.0 years) operated for L5-S1 HGS between July 2002 and April 2015. Thirteen had in situ fusion and 20 had reduction to a low-grade slip.

OUTCOME MEASURES

The outcome measures included PFA and QoL scores measured from the Scoliosis Research Society SRS-30 QoL questionnaire.

METHODS

The minimum follow-up was 2 years. PFA and QoL were compared pre- and postoperatively. Statistical analysis used nonparametric Mann-Whitney and Wilcoxon Signed Rank tests, Chi-square tests to compare proportions, and bivariate correlations with Spearman's coefficients.

RESULTS

A decreasing PFA correlated with less pain (r = -0.56, p = .010), improved function (r = -0.51, p = .022) and better self-image (r = -0.46, p = .044) postreduction. Reduction decreased PFA by 5.1° (p = .002), whereas in situ fusion did not alter PFA significantly. Patients with normal preoperative PFA had similar postoperative QoL regardless of the type of surgery, except for self-image, which improved further with reduction (3.73 ± 0.49 to 4.26 ± 0.58, p = .015). Patients with abnormal preoperative PFA tended to have a higher QoL in all domains after reduction.

CONCLUSION

Decreasing PFA correlates with less pain, better function and self-image. Reduction of HGS decreases PFA. Reduction also relates to a better postoperative QoL when the preoperative PFA is abnormal. When the preoperative PFA is normal, in situ fusion is equivalent to reduction except for self-image, which is better improved after reduction.

Self-Image and Health-Related Quality of Life Three Decades After Fusion In Situ for High-Grade Isthmic Spondylolisthesis

STUDY DESIGN

Observational study.

OBJECTIVES

To evaluate self-image after in situ fusion for high-grade isthmic spondylolisthesis.

SUMMARY OF BACKGROUND DATA

Certain clinical findings such as short trunk or waistline skin folds are often seen in high-grade spondylolisthesis. Since treatment with spinal fusion in situ does not address appearance, self-image and also health-related quality of life might be negatively affected in the short-term as well as the long-term perspective. This observational study evaluated health-related quality of life outcome including self-image three decades after in situ fusion for high-grade isthmic spondylolisthesis in relation to healthy controls.

METHODS

Thirty-eight of 39 consecutive patients, fused in situ for high-grade isthmic spondylolisthesis at a young age, completed the Scoliosis Research Society (SRS)-22r questionnaire 28-41 years after surgery. The results were compared with the results of an age- and gender-matched control group.

RESULTS

We found that the SRS-22r self-image domain scores were statistically significantly lower in patients than in controls whereas the pain and mental health scores were similar in patients and controls. Also, the SRS-22r function domain scores were statistically significantly lower in patients but the difference in means was small. We found no correlation between severity of slip and SRS-22r outcome.

CONCLUSIONS

In situ fusion for high-grade isthmic spondylolisthesis is a safe treatment option in the long term from a function and pain perspective, but the results of our study suggest that self-image is negatively affected long into adult life.

LEVEL OF EVIDENCE

Level IV.