Correlations between the sagittal plane parameters of the spine and pelvis and lumbar disc degeneration

Intradiscal vacuum phenomenon matches lumbar spine degeneration patterns in an ageing population

PURPOSE

Intra-Discal Vacuum phenomenon (IDVP) is well-recognised, yet poorly visualised and poorly understood radiological finding in disc degeneration, particularly with regard to its role in spinal alignment. CT analysis of the lumbar spine in an aging population aims to identify patterns associated with IDVP including lumbopelvic morphology and associated spinal diagnoses.

METHODS

An analysis was performed of an over-60s population sample of 2020 unrelated abdominal CT scans, without acute spinal presentations. Spinal analysis included sagittal lumbopelvic reconstructions to assess for IDVP and pelvic incidence (PI). Subjects with degenerative pathologies, including previous vertebral fractures, auto-fusion, transitional vertebrae, and listhesis, were also selected out and analysed separately.

RESULTS

The prevalence of lumbar spine IDVP was 50.3% (955/1898) and increased with age (125 exclusions). This increased in severity towards the lumbosacral junction (L1L2 8.3%, L2L3 10.9%, L3L4 11.5%, L4L5 23.9%, and L5S1 46.3%). A lower PI yielded a higher incidence of IDVP, particularly at L5S1 (p < 0.01). A total of 292 patients had IDVP with additional degenerative pathologies, which were more likely to occur at the level of isthmic spondylolisthesis, adjacent to a previous fracture or suprajacent to a lumbosacral transitional vertebra (p < 0.05).

CONCLUSIONS

This study identified the prevalence and severity of IDVP in an aging population. Sagittal patterns that influence the pattern of IVDP, such as pelvic incidence and degenerative pathologies, provide novel insights into the function of aging spines.

Does the Extent of Rod Bending and Actual Lumbar Lordosis Mismatch Affect Quality of Life?

BACKGROUND

To evaluate any mismatch between rod bending and actual lordosis during posterior lumbar instrumentation and its effects on the quality of life (QOL) of patients.

METHODS

Patient records for posterior lumbar fusion in 2018-2023 were retrospectively reviewed. The radiologic parameters consisted of pelvic incidence, sacral slope, L1S1 lumbar lordosis, lumbosacral angle, the distance between the posterior wall of the vertebra and the rod, lordosis of the rod. The postoperative QOL of patients was assessed using Oswestry Disability Index. The patients were grouped postoperative into Group-1 (minimal/moderate disability) and Group-2 (severe disability/crippled/bed bound).

RESULTS

Total of 133 patients were included; 99 women, 34 men. The difference was significant for patients with diabetes to be presented in the more disabled Group-2. The distance between the posterior vertebral wall and the rod was found to be short in Group-2. Preoperative and postoperative sagittal lumbar Cobb angles were significantly higher in Group-2. The changing degree of pain was found to score high in Group-2. The postoperative visual analog scale was high in Group-2. The difference between the preoperative and postoperative lumbar sagittal Cobb and rod Cobb-angles was found to be high in Group-2.

CONCLUSIONS

The results of our study confirm the importance of considering the preoperative actual lumbar lordosis during bending and maintaining it as much as possible. To our knowledge, this is the first study that evaluated the effect of rod bending on quality of life (QOL) and supports that this might be affected in case of any mismatches.

Mechanism exploration of Osteoking in the treatment of lumbar disc herniation based on network pharmacology and molecular docking

OBJECTIVE

Lumbar disc herniation (LDH) is a common spinal surgical disease. Low back and leg pain caused by LDH is the main factor leading to functional disability, which has caused a serious burden to patients and society. Osteoking can delay the progression of osteoporosis and osteoarthritis, and even has a significant effect on the prevention of deep vein thrombosis after fracture surgery. In recent years, it has been gradually used in the treatment of LDH and has received significant results. However, the underlying mechanism remains unclear. The aim of this study was to predict the mechanism of Osteoking in the treatment of LDH through network pharmacology and verify it by molecular docking method.

METHODS

The TCMSP database was used to collect the relevant active components and targets of Osteoking, while the GeneCards, OMIM and DisGeNET databases were utilized to collect the relevant disease targets of LDH. The Venny 2.1.0 software was employed to obtain the intersecting gene targets of Osteoking and LDH. PPI network construction and core target selection were performed using Cytoscape 3.9.0 software. The Metascape database was used for GO and KEGG enrichment analysis of the relevant targets. Finally, molecular docking was conducted using AutoDock software.

RESULTS

The study identified 116 potential targets and 26 core targets for the treatment of LDH with Osteoking. Pathways in cancer, Alzheimer's disease, microRNAs in cancer and the IL-17 signalling pathway were among the main involved signalling pathways. Molecular docking results demonstrated that the key targets AKT1, IL-6, ALB, TNF and IL-1β exhibited relatively stable binding activities with the main active components of Osteoking.

CONCLUSIONS

Osteoking can alleviate the symptoms of lumbar disc herniation through the modulation of multiple targets and signalling pathways.

[Sagittal Profi le of the Spine in Patients after Lumbar Stabilisation Surgeries]

PURPOSE OF THE STUDY

Spine stabilization surgery is nowadays one of the most common spinal surgical procedures. Spinopelvic alignment is considered to be an important factor impacting the patients' preoperative diffi culties as well as the outcome of surgery. In our study, the outcomes of stabilization surgeries in patients with lumbar spine disorders were evaluated - especially in those with stenosis and spondylolisthesis, in whom the importance of sagittal parameters were assessed with respect to the patients' clinical outcomes and diffi culties.

MATERIAL AND METHODS

The study included 50 patients with lumbar spine disorders who had undergone a spine stabilization surgery for a degenerative disease - lumbar spinal stenosis, spondylolisthesis between 2015 and 2017. Spino-pelvic radiological parameters and clinical parameters were evaluated using the nonparametric Kruskal-Wallis, Mann-Whitney, and Wilcoxon tests.

RESULTS

In 38 of 50 patients, who at the end of the follow-up period did not have the PI-LL (pelvic incidence-lumbar lordosis) mismatch, i.e. PI-LL was ≤10°, a statistically signifi cant difference in pelvic tilt (p=0.049) and sagittal vertical axis (p<0.001) was reported, which was not the case in the remaining patients of the study population. Claudication and OSWESTRY (ODI) showed no statistically signifi cant difference. We have also compared the differences in the number of fused vertebrae and type of stabilization. A signifi cant change was seen in the claudication parameter at 12 and 24 months after surgery (p=0.007, p=0.005), with better outcomes achieved by 360° lumbar fusion compared to posterior lumbar fusion. The improvement of VAS and ODI scores in both the groups over time (from 6.1 to 3.6 or from 6.3 to 3.5 in VAS and from 62 to 32, or from 62 to 30 in ODI) was also statistically signifi cant (p<0.001 in both groups), while when comparing the groups against each other it was statistically insignifi cant.

DISCUSSION

The authors confi rmed signifi cant improvement in the studied clinical parameters in all groups of patients (VAS, ODI, claudication), which is consistent with the results of recently published papers. The authors also established the correlation between different radiological parameters in the studied groups. The results do not confi rm the importance of the length or type of instrumentation for the clinical outcomes. This is consistent with the fi ndings of other published manuscripts. The authors failed to confi rm a signifi cant change in clinical parameters in dependence on the matching relationship between the pelvic incidence and lumbar lordosis.

CONCLUSIONS

Proper spinopelvic balance in patients after spinal surgery is a very important indicator of postoperative development and condition, but our cohort showed no statistically signifi cant difference in the clinical outcomes of patients whose postoperative sagittal parameters were unsatisfactory.

KEY WORDS

sagittal profi le, spine stabilization, pelvic tilt, pelvic incidence, sagittal vertical axis, SVA.

Lack of correlation between hip osteoarthritis and anatomical spinopelvic parameters obtained in supine position on MRI

PURPOSE

Hip osteoarthritis (HOA) is known to have a multifactorial pathogenesis. Recent studies suggest that spinopelvic alignment may represent an important additional pathogenic abnormality resulting in HOA. This study aims to assess the correlation between spinopelvic parameters (pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) and lumbar lordosis (LL)) obtained in the supine position on MRI and HOA, lateral center edge (LCE) angle, and patient reported back pain.

METHODS

Asymptomatic participants from the whole-body MRI cohort (FF4) from the cross-sectional case-control "Cooperative Health Research in the Region of Augsburg" study (KORA) were included. Whole-body MRI was performed in a standardized fashion in each case, on which hip osteoarthritis (HOA), anatomical spinopelvic parameters and lateral center edge angle were measured. Presence of back pain was assessed using a standardized questionnaire. Correlations were estimated by logistic regression models providing odds ratio.

RESULTS

Among 340 subjects (mean age 56.3 ± 9.3 years; 56.5% male), HOA was present in 89.1% (male: 87.0%, female: 91.7%, p = 0.17). The LCE angle was 30.0° ± 5.5 (men: 29.8° ± 5.9; women: 30.1° ± 5.1; p = 0.696). Mean PI was 54.0° ± 11.3°, PT was 13.7° ± 5.9°, SS was 40.3° ± 8.8° (significantly smaller in women p<0.05) and LL was 36.4° ± 9.6° (significantly greater in women p<0.05). None of the spinopelvic parameters correlated significantly with hip osteoarthritis or LCE angle. HOA was not correlated with back pain.

CONCLUSION

Spinopelvic parameters as measured in the supine position on MRI, do not correlate with hip osteoarthritis or lateral center edge angle.

Prediction of lumbar disc herniation resorption in symptomatic patients: a prospective, multi-imaging and clinical phenotype study

BACKGROUND CONTEXT

Symptomatic lumbar disc herniations (LDH) are very common. LDH resorption may occur by a "self-healing" process, however this phenomenon remains poorly understood. By most guidelines, if LDH remains symptomatic after 3 months and conservative management fails, surgical intervention may be an option.

PURPOSE

The following prospective study aimed to identify determinants that may predict early versus late LDH resorption.

STUDY DESIGN/SETTING

Prospective study with patients recruited at a single center.

PATIENT SAMPLE

Ninety-three consecutive patients diagnosed with acute symptomatic LDH were included in this study (n=23 early resorption and n=67 late resorption groups) with a mean age of 48.7±11.9 years.

OUTCOMES MEASURE

Baseline assessment of patient demographics (eg, smoking status, height, weight, etc.), herniation characteristics (eg, the initial level of herniation, the direction of herniation, prevalence of multiple herniations, etc.) and MRI phenotypes (eg, Modic changes, end plate abnormalities, disc degeneration, vertebral body dimensions, etc.) were collected for further analysis. Lumbar MRIs were performed approximately every 3 months for 1 year from time of enrollment to assess disc integrity.

METHODS

All patients were managed similarly. LDH resorption was classified as early (<3 months) or late (>3 months). A prediction model of pretreatment factors was constructed.

RESULTS

No significant differences were noted between groups at any time-point (p>.05). Patients in the early resorption group experienced greater percent reduction of disc herniation between MRI-0-MRI-1 (p=.043), reduction of herniation size for total study duration (p=.007), and percent resorption per day compared to the late resorption group (p<.001). Based on multivariate modeling, greater L4 posterior vertebral height (coeff:14.58), greater sacral slope (coeff:0.12), and greater herniated volume (coeff:0.013) at baseline were found to be most predictive of early resorption (p<.05).

CONCLUSIONS

This is the first comprehensive imaging and clinical phenotypic prospective study, to our knowledge, that has identified distinct determinants for early LDH resorption. Early resorption can occur in 24.7% of LDH patients. We developed a prediction model for early resorption which demonstrated great overall performance according to pretreatment measures of herniation size, L4 posterior body height, and sacral slope. A risk profile is proposed which may aid clinical decision-making and managing patient expectations.

HSA-MIR-183-3P TARGETING ATAXIA-TELANGIECTASIA MUTATED PROTEIN REGULATION OF NF-ΚB SIGNALING PATHWAY AFFECTS CELLULAR SENESCENCE CAUSED BY DNA DAMAGE IN LUMBAR DISC DEGENERATION

Aims

To test the effect of Hsa-miR-183-3p on cell aging and disc degeneration in lumbar intervertebral disc.

Methods

This study combined clinical research with basic cell experiment, analyzing clinical data from patients with lumbar disc degeneration and traumatic lumbar spine fracture, as well as the differences in baseline data. The degree of lumbar disc injury in patients of different ages was also compared. Differentially expressed miRNAs were predicted via GEO database, and qPCR confirmation was determined by collecting cartilage endplates from two groups. ACAN, Col2A1, p16, p21, and p53 were detected by immunofluorescence, Western blot and qPCR in human nucleus pulposus cells. Changes of cell senescence were detected. The binding of Hsa-miR-183-3p to ataxia-telangiectasia mutated protein was confirmed by dual luciferase reporter assay.

Results

Degenerative discs showed elevated expression of hsa-miR-183-3p, which may be upregulated by TNF-α via NF-κB signaling pathway and target ataxia-telangiectasia mutated protein regulation.

Conclusion

Degeneration of the intervertebral disc can be accelerated by TNF-α. Additionally, Hsa-miR-183-3p passed NF-κB signaling pathway is blocked via up-regulation of TNF-α to reduce inflammation via targeting ataxia-telangiectasia mutated protein. As a result, this negative feedback mechanism may assist in maintaining a low degenerative load and preserving chronic disc degeneration.

Elucidation of effect of spinopelvic parameters in degenerative disc disease

INTRODUCTION

This study aims to find out if there is any relationship between disc pathology and spinopelvic morphology, respectively.

METHODS

A total of 152 patients who complained about low back pain were assessed retrospectively. Patients were divided into three groups based on the presence of disc pathology: non-degenerative (ND) (n=34), degenerative disc disease (DDD) (n=80), and lumbar disc herniation (LDH) (n=38). Spinopelvic parameters were measured on the lateral standing radiographs using Surgimap® Software. The degree of degeneration of each disc was evaluated using T2-weighted images according to the Pfirmann classification. Correlation analyses were performed.

RESULTS

No significant difference was observed between the three groups in terms of sagittal spinal and pelvic parameters. Age and BMI were positively correlated with DDD and LDH. PI and proximal lombar lordosis (PLL) were the only effective variables in predicting DDD. PT and distal lumbar lordosis (DLL) were found to be effective variables in predicting LDH. PI and PT values in patients with L1, L2, and L3 DDD were statistically significantly higher than those without degeneration (P<0.05). Although there were no statistical differences between PI and PT values (P>0.05), DLL values in L4 and L5 DDD patients were significantly lower than those without degeneration (P=0.041; P=0.046; P<0.05).

CONCLUSIONS

The sagittal morphology of the spine directly influences the extent of lumbar disc degeneration. As the values of PI and PT increase, disc degeneration tends to occur at higher levels (L1-2-3). Disc degeneration at lower levels (L4-5) was associated with low DLL levels.

LEVEL OF EVIDENCE

Level III, retrospective study.

The role of nerve fibers and their neurotransmitters in regulating intervertebral disc degeneration

Intervertebral disc degeneration (IVDD) has been the major contributor to chronic lower back pain (LBP). Abnormal apoptosis, senescence, and pyroptosis of IVD cells, extracellular matrix (ECM) degradation, and infiltration of immune cells are the major molecular alternations during IVDD. Changes at tissue level frequently occur at advanced IVD tissue. Ectopic ingrowth of nerves within inner annulus fibrosus (AF) and nucleus pulposus (NP) tissue has been considered as the primary cause for LBP. Innervation at IVD tissue mainly included sensory and sympathetic nerves, and many markers for these two types of nerves have been detected since 1940. In fact, in osteoarthritis (OA), beyond pain transmission, the direct regulation of neuropeptides on functions of chondrocytes have attracted researchers' great attention recently. Many physical and pathological similarities between joint and IVD have shed us the light on the neurogenic mechanism involved in IVDD. Here, an overview of the advances in the nervous system within IVD tissue will be performed, with a discussion on in the role of nerve fibers and their neurotransmitters in regulating IVDD. We hope this review can attract more research interest to address neuromodulation and IVDD itself, which will enhance our understanding of the contribution of neuromodulation to the structural changes within IVD tissue and inflammatory responses and will help identify novel therapeutic targets and enable the effective treatment of IVDD disease.

Anemia was associated with multilevel lumbar disc degeneration in patients with low back pain: a single-center retrospective study

PURPOSE

It has not been determined which factors were related to multilevel lumbar disc degeneration (MLDD). The objective of this study was to determine the prevalence of MLDD among symptomatic patients using the magnetic resonance imaging method. The study also aimed to clarify the associations between MLDD and suspected risk factors through a multivariate model.

METHODS

A total of 530 young and middle-aged patients, suffered from low back pain were retrospectively assessed by 2 independent observers, who used sagittal T2-weighted MR imaging. Subjects were divided into two groups, MLDD group and non-MLDD group, according to the number of degenerated discs. Demographic and radiological data included age, gender, weight, height, body mass index, smoking status, alcohol drinking, lumbar lordosis, presence of hypertension (HT), diabetes mellitus and anemia.

RESULTS

There were 309 men and 221 women with an average age of 37.5  ±  8.5 years. In general, 37.7% of patients were diagnosed with disc degeneration (DD) at more than two levels. Triple level DD was the most common pattern and was more prevalent in women (p <0.05). Using multivariate analyses, age (odds ratio [OR]: 1.14; 95% confidence interval [CI] 1.11-1.18; p <0.001), hypertension (OR: 2.67; 95% CI 1.38-5.16; p = 0.03) and anemia (OR: 3.84; 95% CI 2.03-7.28; p <0.001) were significantly associated with MLDD.

CONCLUSION

Despite the young age of this cohort, MLDD is common among patients with low back pain. A significant independent association exists between age, HT, anemia and multilevel disc degeneration in the lumbar region.

Sagittal Balance in Children: Reference Values of the Sacral Slope for the Roussouly Classification and of the Pelvic Incidence for a New, Age-Specific Classification

Background: The Roussouly classification, based on the functional parameter sacral slope (SS), describes the normal sagittal balance in adults and has proved useful for surgery. Reference values in children should be defined, since they are an important treatment target of conservative treatment. Moreover, during growth, there are few correlations between sagittal parameters, and we hypothesize that a new classification based on the anatomical parameter pelvic incidence (PI) could also be useful. We performed a cross-sectional study to identify the reference values for the Roussouly classification during growth and to develop a new classification based on PI in children. Methods: Correlations between sagittal parameters and age were searched in 222 healthy subjects at the first consultation (6–18 years old). A new classification, based on PI, and comprising three types, is defined and compared to the Roussouly classification. Results: With age, correlations among sagittal balance parameters increase, as well as SS and PI, but with different cut-offs. The distribution of Roussouly types do not correspond to that in adulthood; thus, we defined new reference cut-offs. We defined a PI-based classification in three types, not overlapping Roussouly’s. We found a uniform and balanced distribution of cases among the nine possible combinations. Conclusions: In children, we need to use new thresholds for the Roussouly types. The new classification based on PI is correlated with the Roussouly classification, but it is also clearly different. Future studies will determine its validity.

Association between Roussouly classification and characteristics of lumbar degeneration

OBJECTIVE

Different sagittal morphologies are associated with various lumbar degenerative diseases. In this paper, we aim to investigate the association between Roussouly classification and the characteristics of lumbar degeneration.

METHODS

A total of 273 patients with lumbar degeneration diseases were included in this cross-sectional study. The patients were divided into four groups according to the Roussouly classification. The degeneration of intervertebral disc (IVD) and facet joint was evaluated by Pfirrmann and Pathria grading scales, respectively. To elucidate the degenerative characteristics of diverse lumbar sagittal morphologies by comparing the degeneration degree of IVDs and facet joints between four groups.

RESULTS

The differences in sacral slope (SS) and lumbar lordosis (LL) were significant between the four groups (P < 0.05). Type 2 lumbar spine had the highest proportion of high-grade disc degeneration compared with other subtypes (P < 0.05), types 1 and 2 had a higher proportion of high-grade degeneration than types 3 and 4 (P < 0.05). However, type 4 lumbar spine had the highest proportion of high-grade facet joint degeneration compared with other subtypes (P < 0.05), types 3 and 4 had a higher proportion of high-grade degeneration than types 1 and 2 (P < 0.05).

CONCLUSIONS

Risks of advanced disc degeneration are higher for subjects with lumbar spine morphologies of Roussouly type 1 or type 2, especially for subjects with type 2 lumbar spine. Whereas, high-grade degeneration of facet joint tends to occur in type 3 and type 4 lumbar spine, especially for subjects with type 4 lumbar spine.

Imaging Evaluation of Intervertebral Disc Degeneration and Painful Discs-Advances and Challenges in Quantitative MRI

In recent years, various quantitative and functional magnetic resonance imaging (MRI) sequences have been developed and used in clinical practice for the diagnosis of patients with low back pain (LBP). Until now, T2-weighted imaging (T2WI), a visual qualitative evaluation method, has been used to diagnose intervertebral disc (IVD) degeneration. However, this method has limitations in terms of reproducibility and inter-observer agreement. Moreover, T2WI observations do not directly relate with LBP. Therefore, new sequences such as T2 mapping, T1ρ mapping, and MR spectroscopy have been developed as alternative quantitative evaluation methods. These new quantitative MRIs can evaluate the anatomical and physiological changes of IVD degeneration in more detail than conventional T2WI. However, the values obtained from these quantitative MRIs still do not directly correlate with LBP, and there is a need for more widespread use of techniques that are more specific to clinical symptoms such as pain. In this paper, we review the state-of-the-art methodologies and future challenges of quantitative MRI as an imaging diagnostic tool for IVD degeneration and painful discs.

Relationship of back muscle and knee extensors with the compensatory mechanism of sagittal alignment in a community-dwelling elderly population

Compensatory mechanisms, such as a decrease in thoracic spine kyphosis and posterior tilting or rotation of the pelvis, aim to achieve optimal alignment of the spine. However, the effect of muscle strength on these compensatory mechanisms has not been elucidated. This study aimed to investigate the impact of back muscle and lower extremity strength on compensatory mechanisms in elderly people. Overall, 409 community-dwelling elderly participants (164 men, 245 women) were included. Age, disc degeneration, and 2 or more vertebral fractures showed a significant increase of risk for sagittal vertical axis (SVA) deterioration. Conversely, stronger back, hip flexor, and knee extensor muscles reduced the risk for SVA deterioration. To investigate the association of each muscle's strength with compensatory mechanisms, 162 subjects with pelvic incidence-lumbar lordosis > 10° were selected. The linear regression model for thoracic kyphosis demonstrated a negative correlation with back muscle strength and positive correlation with vertebral fracture. The regression analysis for pelvic tilt demonstrated a positive correlation with knee extensor strength. Back, hip flexor, and knee extensor muscle strength were associated with sagittal spinal alignment. Back muscle strength was important for the decrease in thoracic kyphosis, and knee extensor strength was associated with pelvic tilt.

The impact of spino-pelvic parameters on pathogenesis of lumbar disc herniation

PURPOSE

Controversies exist on the relative contribution of sagittal spino-pelvic alignment on pathogenesis of lumbar disc herniation.

METHODS

Spinopelvic alignment parameters, pelvic incidence, pelvic tilt, sacral slope, pelvic radius-S1 end-plate ratio and pelvic radius-S1 angle, in 52 patients with lumbar disc herniation were compared with the same measurements in 43 healthy adult volunteers.

RESULTS

Statistical analysis revealed significant difference in pelvic incidence and sacral slope between patients with lumbar disc herniation and normal population.

CONCLUSION

Patients with lumbar disc herniation have a more vertical sacrum compared to the normal population which may result in higher intradiscal pressure in these patients.

Risk Factors for Recurrent L4-5 Disc Herniation After Percutaneous Endoscopic Transforaminal Discectomy: A Retrospective Analysis of 654 Cases

Background

Percutaneous endoscopic lumbar discectomy (PELD) is an increasingly applied minimally invasive procedure that has several advantages in the treatment of lumbar disc herniation (LDH). However, recurrent LDH (rLDH) has become a concerning postoperative complication. It remains difficult to establish a consensus and draw reliable conclusions regarding the risk factors for rLDH.

Purpose

This retrospective study aimed to investigate the risk factors associated with rLDH at the L4-5 level after percutaneous endoscopic transforaminal discectomy (PETD).

Methods

A total of 654 patients who underwent the PETD procedure at the L4-5 level from October 2013 to January 2020 were divided into a recurrence (R) group (n=46) and a nonrecurrence (N) group (n=608). Demographic and clinical data and imaging parameters were collected and analyzed using univariate and multiple regression analyses.

Results

The current study found a 7% rate of rLDH at the L4/5 level after successful PETD. Univariate analysis showed that older age, high BMI, diabetes mellitus history, smoking, large physical load intensity, moderate disc degeneration, small muscle-disc ratio (M/D), more fat infiltration, large sagittal range of motion (sROM), scoliosis, small disc height index (DHI), small intervertebral space angle (ISA), and small lumbar lordosis (LL) were potential risk factors (P < 0.10) for LDH recurrence after PETD at the L4-5 level. Multivariate analysis suggested that high BMI, large physical load intensity, moderate disc degeneration, small M/D, more fat infiltration, large sROM, small ISA, and small LL were independent significant risk factors for recurrence of LDH after PETD.

Conclusion

Consideration of disc degeneration, M/D, fat infiltration of the paravertebral muscles, sROM, ISA, LL, BMI, and physical load intensity prior to surgical intervention may contribute to the prevention of rLDH following PETD and lead to a more satisfactory operative outcome and the development of a reasonable rehabilitation program after discharge.

Use of the sagittal Cobb* angle to guide the rod bending in the treatment of thoracolumbar fractures: a retrospective clinical study

Background

Pedicle screw fixation is a well-established technique for thoracolumbar fracture. A large number of studies have shown that the bending angle of the connecting rod has a significant correlation with the postoperative spinal stability. However, no studies have confirmed an objective indicator to guide the bending angle of the connecting rod during the operation. Our study aims to define a sagittal Cobb* angle to guide the bending angle of the connecting rod during surgery.

Methods

The frontal and lateral X-ray films in 150 cases of normal thoracolumbar spine were included to measure the normal spinal sagittal Cobb* angle in each segment. The patients who underwent single segment thoracolumbar fractures and pedicle screw internal fixation surgery were included. The radiological parameters included lumbar lordosis (LL), thoracic kyphosis (TK), pelvic tilt (PT), pelvic incidence (PI), sagittal vertical axis (SVA), and sacral slope (SS) were measured. The incidence of adjacent segment degeneration (ASD) 2 years after surgery was measured.

Results

The average values of normal sagittal Cobb* angle in each segment were − 5.196 ± 3.318° (T12), 2.279 ± 3.324° (L1), 7.222 ± 2.798° (L2), and 12.417 ± 11.962° (L3), respectively. The LL in the three groups was 35.20 ± 9.12°, 46.26 ± 9.68°, and 54.24 ± 15.31°, respectively. Compared with the normal group, there were significant differences in group A and group C, respectively (p < 0.05). The results were similar in the parameters of TL, PT, and SS. The incidences of SVA > 50 mm in group A, group B, and group C were 23.33%, 12.50%, and 19.23%, respectively. The parameter of PI in three groups was 41.36 ± 12.69, 44.53 ± 15.27, and 43.38 ± 9.85°, respectively. The incidences of ASD in group A, group B, and group C 2 years after surgery were 21.67%, 13.75%, and 17.95%, respectively.

Conclusions

The study confirmed that the sagittal Cobb* angle can be used as a reference angle for bending rods. When the bending angle of the connecting rod is 4 to 8° greater than the corresponding segment sagittal Cobb* angle, the patient’s spinal sagittal stability is the best 2 years after the operation.

Restoring lumbar lordosis: a systematic review of controlled trials utilizing Chiropractic Bio Physics® (CBP®) non-surgical approach to increasing lumbar lordosis in the treatment of low back disorders

[Purpose] To systematically review controlled trial evidence for the use of lumbar extension traction by Chiropractic BioPhysics^® methods for the purpose of increasing lumbar lordosis in those with hypolordosis and low back disorders. [Methods] Literature searches were performed in Pubmed, PEDro, CINAHL, Cochrane, and ICL databases. Search terms included iterations related to the lumbar spine, low back pain and extension traction rehabilitation. [Results] Four articles detailing 2 randomized and 1 non-randomized trial were located. Trials demonstrated increases in radiographic measured lordosis of 7–11°, over 10–12 weeks, after 30–36 treatment sessions. Randomized trials demonstrated traction treated groups mostly maintained lordosis correction, pain relief, and disability after 6-months follow-up. The non-randomized trial showed lordosis and pain intensity were maintained with periodic maintenance care for 1.5 years. Importantly, control/comparison groups had no increase in lumbar lordosis. Randomized trials showed comparison groups receiving physiotherapy-less the traction, had temporary pain reduction during treatment that regressed towards baseline levels as early as 3-months after treatment. [Conclusion] Limited but good quality evidence substantiates that the use of extension traction methods in rehabilitation programs definitively increases lumbar hypolordosis. Preliminarily, these studies indicate these methods provide longer-term relief to patients with low back disorders versus conventional rehabilitation approaches tested.

Different spinal subtypes with varying characteristics of lumbar disc degeneration at specific level with age: a study based on an asymptomatic population

Background

The relationship between spinal sagittal subtypes and lumbar disc degeneration is unclear. Thus, we aimed to investigate the relationship between lumbar intervertebral disc degeneration and age in asymptomatic healthy individuals with different sagittal alignments.

Methods

In this cross-sectional observational study, we examined 209 asymptomatic young and middle-aged volunteers (123 women and 86 men) who were divided into the following three groups according to age: groups A (20–30 years), B (31–40 years), and C (41–50 years). The volunteers underwent full-spine standing lateral radiography and magnetic resonance imaging (MRI, 3.0 T) of the lumbar spine. Based on panoramic radiography, two observers measured the spinopelvic parameters and classified the spine into Roussouly subtypes. The degree of disc degeneration was assessed based on T2-weighted images according to the Pfirrmann classification.

Results

There was a statistically significant difference in the degree of degeneration of type I spine between groups B and C at L4-L5 (P < 0.03) and L5-S1 (P < 0.01) and between groups A and C at L1-L2 (P < 0.04) and L4-L5 (P < 0.01). The degeneration degree of type II spine at all levels were significantly different between groups A and C. No statistically significant difference was found between groups A and B in all subtypes except for type II spine at L1-L2 (P < 0.04). A significant difference was found at four levels between groups B and C in type III spine (P < 0.05) and between groups A and C. For type IV spine, there was a significant difference in the degree of degeneration at L4-L5 (P < 0.02) between groups A and C. Moreover, almost all single parameters were not strongly correlated with the degree of disc degeneration.

Conclusion

The different spinal subtypes have characteristics of lumbar disc degeneration at specific levels with age. We considered that spinal classification could be used as a predictor of lumbar disc degeneration. Our data may be helpful to increase awareness of the relationship between spinal subtypes and lumbar disc degeneration.

Level of evidence

3

Spinal-pelvic orientation: potential effect on the diagnosis of spondyloarthritis

OBJECTIVE

To assess associations of spinal-pelvic orientation with clinical and imaging-study findings suggesting axial SpA (axSpA) in patients with recent-onset inflammatory back pain.

METHODS

Spinal-pelvic orientation was assessed in DESIR cohort patients with recent-onset inflammatory back pain and suspected axSpA, by using lateral lumbar-spine radiographs to categorize sacral horizontal angle (<40° vs ⩾40°), lumbosacral angle (<15° vs ⩾15°) and lumbar lordosis (LL, <50° vs ⩾50°). Associations between these angle groups and variables collected at baseline and 2 years later were assessed using the χ2 test (or Fisher's exact) and the Mann-Whitney test. With Bonferroni's correction, P < 0.001 indicated significant differences.

RESULTS

Of 362 patients, 358, 356 and 357 had available sacral horizontal angle, lumbosacral angle and LL values, respectively; means were 39.3°, 14.6° and 53.0°, respectively. The prevalence of sacroiliitis on both radiographs and MRI was higher in the LL < 50° group than in the LL ⩾50° group, but the difference was not statistically significant. Clinical presentation and confidence in a diagnosis of axSpA did not differ across angle groups. No significant differences were identified for degenerative changes according to sacral horizontal angle, lumbosacral angle or LL.

CONCLUSION

Spinal-pelvic balance was not statistically associated with the clinical or imaging-study findings suggesting axSpA in patients with recent-onset inflammatory back pain.

[Effect of percutaneous kyphoplasty on lumbar-pelvic correlation in osteoporotic vertebral compressive fractures]

OBJECTIVE

To explore the effect of percutaneous kyphoplasty (PKP) on lumbar-pelvic correlation in osteoporotic vertebral compressive fracture (OVCF).

METHODS

According to the inclusion criteria, 63 patients with primary osteoporosis between January 2012 and June 2017 were selected as the control group and 67 patients with single-segment lumbar OVCF receiving PKP and complete clinical data were included as the observation group. There was no significant difference in gender, age, and lumbar spine bone density between the two groups ( P>0.05). The visual analogue scale (VAS) score and Oswestry Disability Index (ODI) score were used to assess lumbar pain and function before operation and at 3 days after operation in the observation group; lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) were measured in lumbar lateral X-ray films which were taken before PKP and at 1 month after PKP. The same parameters were measured in the lumbar lateral X-ray films which were taken at the time of initial diagnosis in the control group.

RESULTS

All patients were followed up 3-24 months with an average of 5.8 months in the observation group. The VAS score decreased from 5.6±1.8 before PKP to 2.8±1.3 at 3 days after PKP ( t=14.082, P=0.000); ODI decreased from 50.1%±5.0% before PKP to 18.2%±1.8% ( t=47.011, P=0.000). Compared with the control group, the LL, PI, and SS decreased and the PT increased in the observation group, and only the difference in LL between the two groups was significant ( P<0.05). In the observation group, the LL and SS significantly increased ( P<0.05) and PT significantly decreased ( P<0.05) at 1 month after operation when compared with preoperative ones, and PI decreased, but the difference was not significant ( P>0.05). In the control group, LL was positively correlated with PI and SS ( P<0.05); PI was positively correlated with PT and SS ( P<0.05). In the observation group, PI was positively correlated with SS ( P<0.05) before and after PKP.

CONCLUSION

OVCF patients lost the specific lumbar-pelvic correlation. PKP can restore lumbar lordosis, but it still can not restore the normal physiological fitting.

Curve progression in de novo degenerative lumbar scoliosis combined with degenerative segment disease after short-segment fusion

PURPOSE

To validate the reliability of Berjano and Lamartina classification system of surgical planning in cases of de novo degenerative lumbar scoliosis (DNDLS) combined with degenerative segment disease and identify factors contributing to curve progression.

METHODS

Fifty-four cases of type I or II DNDLS were retrospectively reviewed. Health-related quality of life (HRQOL) was assessed using visual analogue scale (VAS) scores for the back and leg, Oswestry Disability Index (ODI), and Japanese Orthopaedic Association (JOA) scores. Radiographic parameters were obtained from X-rays. Improvements in HRQOL were confirmed by a paired t test. Changes in radiographic parameters were confirmed by paired t test and Wilcoxon signed-rank test. Clinical relevance between spinopelvic parameters and Cobb angle progression was analyzed by Spearman correlation coefficient.

RESULTS

The mean follow-up period was 36.8 ± 14.8 months. The scores taken preoperatively versus at the last follow-up were as follows: mean VAS back score, 4.5 ± 2.4 versus 1.8 ± 1.5 (p < 0.01); and mean VAS leg score, 5.2 ± 2.5 versus 1.7 ± 2.1 (p < 0.01). The ODI score improved from 25.3 ± 8.9% to 10.1 ± 5.4% (p < 0.01), whereas the mean JOA score improved from 14.3 ± 4.9 to 21.0 ± 3.7 (p < 0.01). The mean Cobb angle decreased from 17.1° ± 7.4° to 9.4° ± 4.5° postoperatively but worsened to 14.1° ± 6.4° at the last follow-up with a mean progression of 2.1° per year. Cobb angle correction was lost at a mean 2.1° ± 3.3° per year with correlation to T1 pelvic angle and sagittal vertical axis preoperatively.

CONCLUSIONS

Selective decompression and short-segment fusion were effective for treating type I and II cases DNDLS. The Cobb angle increased relative to preoperative sagittal spine alignment. These slides can be retrieved under Electronic Supplementary Material.

The preoperative predictors for subsequent degeneration in L5-S1 disc after long fusion arthrodesis terminating at L5 in patients with adult scoliosis: focus on spinopelvic parameters

BACKGROUND

The subsequent L5-S1 disc degeneration associated with long fusion arthrodesis terminating at L5 in patients with adult scoliosis has been a common concern. However, few studies paid attention to its preoperative predictors, especially in spinopelvic parameters. The purpose of the present study was to clarify the preoperative predictors of subsequent L5-S1 disc degeneration after long fusion arthrodesis terminating at L5 in patients with adult scoliosis on spinopelvic parameters.

METHODS

In this retrospective study, we enrolled 67 patients with adult scoliosis, and the patients were divided into disc degeneration group (DD) and no disc degeneration group (NDD), based on the presence or absence of subsequent L5-S1 disc degeneration. The status of L5-S1 disc was evaluated by a modified version of radiographic classification. Characteristics and spinopelvic parameters of preoperative patients were collected as potential predictors for subsequent lumbosacral disc degeneration after long fusion arthrodesis terminating at L5 in patients with adult scoliosis. Multivariate logistic regression analysis and the receiver operating characteristic curve were used to identify the preoperative predictors, with an adjusted odds ratio (OR) and 95% confidence intervals (CI).

RESULTS

Thirty-six patients (53.73%) with subsequent L5-S1 disc degeneration were divided into group DD (preoperative score 0.81 ± 0.57, last follow-up score 1.83 ± 0.60, P <  0.001), and the other 31 patients were divided into group NDD (preoperative and last follow-up score 0.87 ± 0.49). There was no statistical difference in preoperative score (P = 0.583) of lumbosacral disc between two groups; however, significant statistical difference showed in last follow-up score (P <  0.001). Multivariate logistic regression identified three preoperative predictors: pelvic incidence (PI) (P = 0.018), sagittal vertical axis (SVA) (P = 0.024), and sacrum-femoral distance (SFD) (P = 0.023). PI < 48.5° (OR = 0.911, 95% CI = 0.843-0.984), SVA > 4.43 cm (OR = 1.308, 95% CI = 1.036-1.649), and SFD > 5.65 cm (OR = 1.337, 95% CI = 1.041-1.718) showed satisfied accuracy for predicting subsequent L5-S1 disc degeneration.

CONCLUSION

The prevalence of the subsequent L5-S1 disc degeneration after long fusion arthrodesis terminating at L5 in patients with adult scoliosis was 57.3% (36 of 67 patients). PI < 48.5°, SVA > 4.43 cm, and SFD > 5.65 cm were preoperative predictors for the subsequent L5-S1 disc degeneration. More attention should be paid to prevent the L5-S1 disc from degeneration when these preoperative predictors exist, especially with two or more.