Radiographic measures of thoracic kyphosis in osteoporosis: Cobb and vertebral centroid angles

Estimating thoracic kyphosis without information on upper thoracic kyphosis: an observational study on 455 patients examined by EOS imaging

BACKGROUND

Physiological thoracic kyphosis (TK) allows sagittal balance of human body. Unlike lumbar lordosis (LL), TK has been relatively neglected in the literature. EOS is an imaging technique employing high-sensitivity xenon particles, featured by low-dose exposure combined with high accuracy compared to conventional radiography. The aim of this study was to investigate predictors of TK in patients with phyiological spine morphology using EOS imaging.

METHODS

EOS images of 455 patients without spinal anomalies were retrospectively assessed for TK (T1- T12), upper thoracic kyphosis (UTK, T1-T5), lower thoracic kyphosis (LTK, T5-T12), LL (L1-S1) and pelvic incidence (PI). The latter curves were measured by two researchers separately and the average of the two measurements was used for further analysis. Spearman non-parametric correlation was estimated for age, PI, LL, LTK, UTK and TK. Multiple robust linear regression analysis was employed to estimate TK, controlling for the effect of age, sex, LL and LTK.

RESULTS

The mean age of patients was 28.3 ± 19.2 years and 302 (66.4%) of them were females. The mean TK, UTK and LTK was 45.5° ± 9.3, 16 ± 7.4° and 29.7° ± 8.9, respectively. The mean UTK in people under 40 years of age was 17.0° ± 7.2, whereas for patients 40+ years old it was 13.6° ± 7.4. At univariable analysis TK positively correlated with UTK (p<0.001), LTK (p<0.001) an LL (p<0.001). At multivariable linear regression TK increased with LTK (RC = 0.67; 95%CI: 0.59; 0.75) or LL (RC = 0.12; 95%CI: 0.06; 0.18), whereas it decreased with age (RC = -0.06; 95%CI: -0.09;-0.02).

CONCLUSION

If EOS technology is available, the above linear regression model could be used to estimate TK based upon information on age, sex, LL and LTK. Alternatively, TK could be estimated by adding to LTK 17.0° ± 7.4 for patients < 40 years of age, or 13.6° ± 7.4 in patients 40 + years old. The evidence from the present study may be used as reference for research purposes and clinical practice, including spine examination of particular occupational categories or athletes.

Early skeletal outcomes after hematopoietic stem and progenitor cell gene therapy for Hurler syndrome

Mucopolysaccharidosis type I Hurler (MPSIH) is characterized by severe and progressive skeletal dysplasia that is not fully addressed by allogeneic hematopoietic stem cell transplantation (HSCT). Autologous hematopoietic stem progenitor cell-gene therapy (HSPC-GT) provides superior metabolic correction in patients with MPSIH compared with HSCT; however, its ability to affect skeletal manifestations is unknown. Eight patients with MPSIH (mean age at treatment: 1.9 years) received lentiviral-based HSPC-GT in a phase 1/2 clinical trial (NCT03488394). Clinical (growth, measures of kyphosis and genu velgum), functional (motor function, joint range of motion), and radiological [acetabular index (AI), migration percentage (MP) in hip x-rays and MRIs and spine MRI score] parameters of skeletal dysplasia were evaluated at baseline and multiple time points up to 4 years after treatment. Specific skeletal measures were retrospectively compared with an external cohort of HSCT-treated patients. At a median follow-up of 3.78 years after HSPC-GT, all patients treated with HSPC-GT exhibited longitudinal growth within WHO reference ranges and a median height gain greater than that observed in patients treated with HSCT after 3-year follow-up. Patients receiving HSPC-GT experienced complete and earlier normalization of joint mobility compared with patients treated with HSCT. Mean AI and MP showed progressive decreases after HSPC-GT, suggesting a reduction in acetabular dysplasia. Typical spine alterations measured through a spine MRI score stabilized after HSPC-GT. Clinical, functional, and radiological measures suggested an early beneficial effect of HSPC-GT on MPSIH-typical skeletal features. Longer follow-up is needed to draw definitive conclusions on HSPC-GT's impact on MPSIH skeletal dysplasia.

Patient-reported outcomes 1 and 2 years after transforaminal thoracic interbody fusion (TTIF)

STUDY DESIGN

Retrospective Cohort Study with prospectively collected data.

PURPOSE

Transforaminal interbody fusion was initially designed for the lumbar spine. A similar approach was later introduced for the thoracic spine (TTIF). Here we report the surgical technique and the Core Outcome Measures Index (COMI) at 1-year and 2-year follow-ups, as well as the sagittal radiographic kyphosis correction of TTIF, achieved at 1 year and the latest follow-up.

METHODS

All TTIF procedures from 2012 to 2020 were included. COMI scores were collected preoperatively and at 1- and 2-year follow-ups. The sagittal angle between the upper and lower endplates at the segment where TTIF was performed was measured on preoperative, 1-year postoperative, and last available radiographs.

RESULTS

Seventy-nine TTIF procedures were performed for 64 patients (36% males; mean age 67.5 (SD 15.3) years). COMI score reduced from a mean value of 8.1 (SD 1.4) preoperatively to 4.7 (SD 2.7) at 1-year follow-up and 4.7 (SD 2.7) at 2-year follow-up. The mean correction of segmental kyphosis was 10.8 (SD 7.3, p < 0.0001) degrees at 1-year follow-up and 9.3 (SD 7.0, p < 0.0001) degrees at the final follow-up 3.4 (SD 1.4) years after the operation. Kaplan-Meier analysis for reoperations showed a 5-year survival of 91% (95% CI 0.795-1) for primary TTIF operations and survival of 77% (95% CI 0.651-0.899) for TTIFs performed after earlier fusion operations.

CONCLUSIONS

TTIF is a feasible procedure in the thoracic spine. Kyphosis correction of approximately 10° was maintained at 1-year and final follow-up. Over 69% at 1-year and 61% at 2-year follow-up achieved MCID for COMI.

Reliability of Vertebral Pelvic Angles in Assessment of Spinal Alignment

STUDY DESIGN

Reliability analysis.

OBJECTIVES

Vertebral pelvic angles (VPA) are gaining popularity given their ability to describe the shape of the spine. Understanding the reliability and minimal detectable change (MDC) is necessary to determine how these measurement tools should be used in the manual assessment of spine radiographs. Our aim is to assess intra- and interobserver intraclass correlation coefficients (ICC) and the MDC in the use of VPA for assessing alignment in adult spinal deformity (ASD).

METHODS

Three independent examiners blindly measured T1, T4, T9, L1, and L4PA twice in ASD patients with a 4-week window after the initial measurements. Patients who had undergone hip or shoulder arthroplasty, fused or transitional vertebrae, or whose hip joints were not visible on radiographs were excluded. Power analysis calculated a minimum sample size of 19. Both intra- and interobserver ICC and MDC, which denotes the smallest detectable change in a true value with 95% confidence, were calculated.

RESULTS

Out of the 193 patients, 39 were ultimately included in the study, and 390 measurements were performed by 3 raters. Intraobserver ICC values ranged from .90 to .99. The interobserver ICC was .97, .97, .96, .95, and .92, and the MDC was 5.3°, 5.1°, 4.8°, 4.9°, and 4.1° for T1, T4, T9, L1, and L4PA, respectively.

CONCLUSION

All VPAs showed excellent intra- and interobserver reliability, however, the MDC is relatively high compared to typical ranges for VPA values. Therefore, surgeons must be aware that substantial alignment changes may not be detected by a single VPA.

The intra- and inter-rater reliability of measuring trunk coronal asymmetry by adjusting positioning variability: A prospective study

BACKGROUND

Chronic low back pain (LBP) can lead to muscle spasms, limited range of motion, and abnormal posture, resulting in trunk muscle asymmetry.

OBJECTIVE

This study aimed to assess the intra- and inter-rater reliability of a quantitative measurement of trunk coronal asymmetry in patients with chronic LBP, minimizing unnecessary gravity and friction force using a manual table in the prone position.

METHODS

This prospective study was conducted at a single center, targeting patients with chronic LBP to measure trunk coronal asymmetry on a manual table in the prone position. The intra-class correlation coefficient (ICC) was calculated using one-way random-effects and two-way mixed-effects models.

RESULTS

Fifty-eight patients who had LBP for more than three months were enrolled from May 1, 2021, to December 31, 2021. The intra- and inter-rater reliabilities of the two examiners' measurements were 0.872 and 0.899, and 0.852, respectively. Based on pain severity, the participants were classified into mild and severe groups, with ICCs of 0.823 and 0.889, and 0.936 and 0.918, respectively.

CONCLUSION

Measurement of trunk coronal asymmetry in the prone position using a manual table demonstrates high intra- and inter-rater reliability. In addition, the reliability increases with greater pain severity.

Investigation of the factors influencing spinal manipulative therapy force transmission through the thorax: a cadaveric study

BACKGROUND

Spinal manipulative therapy (SMT) clinical effects are believed to be linked to its force-time profile characteristics. Previous studies have revealed that the force measured at the patient-table interface is most commonly greater than the one applied at the clinician-patient interface. The factors explaining this force amplification remains unclear.

OBJECTIVE

To determine the difference between the force applied to a cadaveric specimen's thoracic spine and the resulting force measured by a force-sensing table, as well as to evaluate the relationship between this difference and both the SMT force-time characteristics and the specimens' characteristics.

METHODS

Twenty-five SMTs with different force-time profiles were delivered by an apparatus at the T7 vertebra of nine human cadaveric specimens lying prone on a treatment table equipped with a force plate. The difference between the force applied by the apparatus and the resulting force measured by the force plate was calculated in absolute force (Fdiff) and as the percentage of the applied force (Fdiff%). Kinematics markers were inserted into T6 to T8 spinous and transverse processes to evaluate vertebral displacements during the SMT thrusts. Mixed-effects linear models were run to evaluate the variance in Fdiff and Fdiff% explained by SMT characteristics (peak force, thrust duration and force application rate), T6 to T8 relative and total displacements, and specimens' characteristics (BMI, height, weight, kyphosis angle, thoracic thickness).

RESULTS

Sixty percent of the trials showed lower force measured at the force plate than the one applied at T7. Fdiff¸ was significantly predicted (R2marginal = 0.54) by peak force, thrust duration, thoracic thickness and T6-T7 relative displacement in the z-axis (postero-anterior). Fdiff% was significantly predicted (R2marginal = 0.56) by force application rate, thoracic thickness and total T6 displacements. For both dependant variables, thoracic thickness showed the highest R2marginal out of all predictors.

CONCLUSION

Difference in force between the clinician-patient and the patient-table interfaces is influenced by SMT force-time characteristics and by thoracic thickness. How these differences in force are associated with vertebral displacements remains unclear. Although further studies are needed, clinicians should consider thorax thickness as a possible modulator of forces being transmitted through it during prone SMT procedures.

Could kyphotic posture disturb body balance in young healthy population?

BACKGROUND

Kyphosis is roughly a slight forward curvature of the spine. A slight kyphosis or posterior curvature is normal throughout the human body and is present in every individual. Hyperkyphotic is a kyphotic angle greater than 40° commonly measured on a lateral X-ray measured by the Cobb method between C7 and T12. Postural instability and loss of balance can result from shifting the center of mass beyond the support base's limits. Studies are showing that kyphotic posture affects the center of gravity and affects falls in the elderly, but there are limited studies on the effect of balance in young individuals.

OBJECTIVES

the correlation between the balance and thoracic kyphosis angle has been investigated.

METHODS

Forty-three healthy individuals over the age of 18 participated in the study. Participants who met the criteria were split into two groups based on their kyphosis angle. For measuring thoracic kyphosis, Flexi Curve is used. Objective evaluation of static balance was made with NeuroCom Balance Manager® static posturography device.

RESULTS

In terms of mean difference, there was no significant difference between the kyphotic and control groups in the balance measures, and there was no correlation between the kyphosis angle and balance measures, according to statistical analysis.

CONCLUSION

According to our study, no significant relationship was found between body balance and thoracic kyphosis in the young population.

Reliability of the Smartphone Application Inclinometer and Flexicurve in Measuring Thoracic Kyphosis

INTRODUCTION

This study examined the inter- and intra-rater reliability of the smartphone inclinometer app (SPI) and flexicurve (FC) for assessing the kyphotic angle in individuals with thoracic kyphosis (TK).

METHODS

This study was conducted with 60 subjects (35 males, 25 females) aged 18 to 25 who presented to Kalyon Medical Center, Gaziantep, Turkey, between December 2021 and March 2022. The subjects were evaluated by two independent assessors using FC and SPI to measure the TK angle. The intraclass correlation coefficient (ICC) was analysed at a 95% confidence interval. The level of agreement between the methods was checked using Bland-Altman analysis.

RESULTS

Inter- and intra-rater measurements were strongly correlated (ICC 0.945 and 0.964, respectively). On the Bland-Altman plots, the FC showed poor agreement with the SPI app (mean difference, 19.81° ± 2.8°). The mean kyphotic angles were 45.15 ± 6.07° and 25.34 ± 4.96°, respectively, as measured by the SPI and FC.

CONCLUSION

This study demonstrated good intra- and inter-rater reliability of the SPI app and FC for the measurement of the spinal curvature (TK) angle in the sagittal plane. A weak agreement was discerned between the SPI and FC methods.

The Effect of a Comprehensive Corrective Exercise Program on Kyphosis Angle and Balance in Kyphotic Adolescents

This study aimed to investigate the effects of a comprehensive corrective exercise program on the kyphosis angle and balance in kyphotic adolescents. A total of 62 male adolescents (between the ages of 10 and 18, mean BMI 21.7 kg/m2) with a thoracic kyphosis (TK) angle of ≥ 50° were divided into three groups using the simple randomization method: CCEP (comprehensive corrective exercise program), TEP (thoracic exercise program) and control group. The CCEP program consisted of corrective exercises plus postural perception training (PPT). Exercise programs were applied for 40−50 min, 3 days a week for 12 weeks. The kyphosis angle was measured using a flexible ruler, and balance was assessed using the Romberg index obtained from pedobarography. After training, a highly significant reduction in the kyphosis angle was observed in the CCEP and TEP groups (p < 0.001). Comparison among the groups showed a greater reduction in the kyphosis angle in the CCEP group (p < 0.020). Postural perception improved in the CCEP group versus other groups (p < 0.001). Improvement of the Romberg index (balance) was found only in the CCEP group upon within-group comparison (p < 0.001), with no difference among the groups (p > 0.05). The use of postural perception in combination with corrective exercise programs for thoracic kyphosis represents a comprehensive approach, and PPT can increase the effectiveness of the intervention.

Validity of sagittal thoracolumbar curvature measurement using a non-radiographic surface topography method

PURPOSE

To estimate the criterion validity of sagittal thoracolumbar spine measurement using a surface topography method in a clinical population against the gold standard and to estimate concurrent validity against two non-radiographic clinical tools.

METHODS

In this cross-sectional validity study, thoracolumbar curvature was measured in adults with spinal conditions recruited from a specialist orthopaedic hospital. A surface topography method using a Kinect sensor was compared to three other measurement methods: spinal radiograph (gold standard), flexicurve and digital inclinometer. Correlation coefficients and agreement between the measurement tools were analysed.

RESULTS

Twenty-nine participants (79% female) were included in criterion validity analyses and 38 (76% female) in concurrent validity analyses. The surface topography method was moderately correlated with the radiograph (r = .70, p < .001) in the thoracic spine, yet there was no significant correlation with the radiograph in the lumbar spine (r = .32, p = .89). The surface topography method was highly correlated with the flexicurve (rs = .91, p < .001) and digital inclinometer (r = .82, p < .001) in the thoracic spine, and highly correlated with the flexicurve (r = .74, p < .001) and digital inclinometer (r = .74, p < .001) in the lumbar spine.

CONCLUSIONS

The surface topography method showed moderate correlation and agreement in thoracic spine with the radiograph (criterion validity) and high correlation with the flexicurve and digital inclinometer (concurrent validity). Compared with other non-radiographic tools, this surface topography method displayed similar criterion validity for kyphosis curvature measurement.

The 7th cervical vertebra wall distance (C7WD) identifies balance control, functional mobility and the risk of multiple falls in elderly community-dwelling women with thoracic hyperkyphosis

BACKGROUND

Thoracic hyperkyphosis is common in the elderly, especially in women, and results in impaired balance control, impaired functional mobility and an increased risk of multiple falls. The 7th cervical vertebra wall distance (C7WD) is a practical method for evaluating thoracic hyperkyphosis.

OBJECTIVE

This study calculated C7WD cut-off scores that may identify impaired balance control, impaired functional mobility and an increased risk of multiple falls in elderly community-dwelling women with thoracic hyperkyphosis. This study also explored the correlation between C7WD, balance control and functional mobility.

METHODS

Sixty participants were assessed for thoracic hyperkyphosis using the C7WD, balance control using the functional reach test (FRT), functional mobility using the timed up-and-go test (TUG) and a history of falls using their personal information.

RESULTS

The data indicated that a C7WD of at least 7.95 cm, 8.1 cm and 8.8 cm had a good to excellent capability of identifying impaired balance control, impaired functional mobility and an increased risk of multiple falls, respectively. The C7WD results were significant and correlated with balance control (rs=-0.68) and functional mobility (rs= 0.41).

CONCLUSIONS

The C7WD may be utilised as a screening tool for these three impairments in this population.

Computer-Aided Diagnosis for Determining Sagittal Spinal Curvatures Using Deep Learning and Radiography

Analyzing spinal curvatures manually is time-consuming and tedious for clinicians, and intra-observer and inter-observer variability can affect manual measurements. In this study, we developed and evaluated the performance of an automated deep learning-based computer-aided diagnosis (CAD) tool for measuring the sagittal alignment of the spine from X-ray images. The CAD system proposed here performs two functions: deep learning-based lateral spine segmentation and automatic analysis of thoracic kyphosis and lumbar lordosis angles. We utilized 322 datasets with data augmentation for learning and fivefold cross-validation. The segmentation model was based on U-Net, which has multiple applications in medical image processing. Here, we utilized parameter equations and trigonometric functions to design spinal angle measurement algorithms. The kyphosis (T4-T12) and lordosis angle (L1-S1, L1-L5) were automatically measured to help diagnose kyphosis and lordosis. The segmentation model had precision, sensitivity, and dice similarity coefficient values of 90.53 ± 4.61%, 89.53 ± 1.8%, and 90.22 ± 0.62%, respectively. The performance of the CAD algorithm was also verified with the Pearson correlation, Bland-Altman, and intra-class correlation coefficient (ICC) analysis. The proposed angle measurement algorithm exhibited high similarity and reliability during verification. Therefore, CAD can help clinicians in reaching a diagnosis by analyzing the sagittal spinal curvatures while reducing observer-based variability and the required time or effort.

Novel insights in Turner syndrome

PURPOSE OF REVIEW

Turner syndrome is the most common sex chromosome abnormality in female individuals, affecting 1/2000-1/2500 female newborns. Despite the high incidence of this condition, the mechanisms underlying the development of multiorgan dysfunction have not been elucidated.

RECENT FINDINGS

Clinical features involve multiple organ systems and include short stature, dysmorphic facial features, delayed puberty and gonadal failure, cardiac and renal abnormalities, audiologic abnormalities, and a high prevalence of endocrine and autoimmune disorders. Paucity of available genotype/phenotype correlation limits the ability of clinicians to provide accurate guidance and management. Given the advent of robust genetic testing and analysis platforms, developments in the genetic basis of disease are materializing at a rapid pace.

SUMMARY

The objective of this review is to highlight the recent advances in knowledge and to provide a framework with which to apply new data to the foundational understanding of the condition.

Intra- and inter-rater reliabilities and differences of kyphotic angle measurements on ultrasound images versus radiographs for children with adolescent idiopathic scoliosis: a preliminary study

PURPOSE

To develop a new method based on 3D ultrasound information to measure the kyphotic angle (KA) on ultrasound (US) images in adolescents with idiopathic scoliosis (AIS) and to evaluate the intra-rater and inter-rater reliabilities and accuracy of the US measurements.

METHODS

Twenty subjects with AIS (17F, 3 M, aged 13.7 ± 2.2 years old) were recruited. One 20 + years experienced rater (R3) measured the KA on radiographs twice using the Cobb method. Two raters (R1, R2), both have at least 1-year experience measured US images twice using the new spinous processes method. The intraclass correlation coefficients (ICC[2,1]) of the intra-rater and inter-rater reliabilities of US KA measurements were calculated. An equation based on US KA measurements to calculate the radiographic KA was generated.

RESULTS

The intra-rater reliability ICC[2,1] (R3) of the X-ray measurement was 0.92 and US KA measurements for R1 and R2 were 0.94 and 0.95, respectively. The inter-rater reliability ICC[2,1] for R1 versus R2 were 0.85 and 0.86, respectively. The mean absolute differences (MAD) of US versus radiography measurements were 4.2 ± 3.0° (R1 vs R3) and 5.0 ± 4.1° (R2 vs R3), respectively. The radiographic equivalent KA = 0.82 × US KA - 5.6°. When using this equation, the overall MAD between US and radiographic KA was 2.9 ± 1.6°.

CONCLUSIONS

The ultrasound spinous process method was reliable to measure the KA. Although there was a systematic bias on the US measurements, after the correction, the MAD of the US and radiographic KA was 2.9 ± 1.6°. Using US allows clinicians to monitor KA without exposing children to ionizing radiation.

Lower thoracic spine extension mobility is associated with higher intensity of thoracic spine pain

Objectives

To evaluate the association of thoracic spine (TS) posture and mobility with TS pain.

Methods

Participants with TS pain reported maximum, average, and night pain in TS area, and pain summary score was calculated. Upright and sitting TS postures were evaluated by inspection. TS posture and mobility (flexion and extension) were recorded using an inclinometer and a tape measure, respectively. Correlations between posture and mobility assessments were calculated using Spearman rank correlation, the association of TS posture and mobility with TS pain by logistic regression analysis.

Results

The participants’ (n = 73, 52 females, age range 22–56) TS pain duration was 12 weeks on average. The correlations for measurements of TS posture and flexion mobility were higher than correlations of other TS measurements being between 0.53 and 0.82. Decreased extension mobility of the upper (from 1^st to 6^th TS segments; Th1–Th6) TS was associated with higher worst pain (OR 1.04, 95% CI 1.00–1.07) and whole TS with pain sum score (OR 1.05, 95% CI 1.01–1.08). Less kyphotic whole TS was associated with lower pain sum score (OR 0.96, 95% CI 0.92–1.00). Greater flexion mobility of upper and lower (Th6–Th12) TS were associated with lower pain sum score (OR 0.96, 95% CI 0.91–1.00, and OR 0.96, 95% CI 0.91–1.00, respectively).

Conclusions

Reduced thoracic extension mobility was associated with higher pain scores and the greater flexion mobility with lower pain scores. Future research is warranted to evaluate if treatments geared toward TS extension mobility improvements would result in lower TS pain.

Sagittal standing spinal alignment and back pain in 8 to 12-year-old children from the Region of Murcia, Spain: The ISQUIOS Program

BACKGROUND

The child's spine shows changes in posture and balance of its curvatures during growth and musculoskeletal spinal conditions are likely to develop, such as back pain (BP).

OBJECTIVE

The purposes of this study were (a) to describe the sagittal spinal alignment in a relaxed standing position and (b) to analyze its association with BP among 8 to 12-year-old children.

METHODS

This was a cross-sectional study. A total of 731 elementary schoolchildren (379 girls and 352 boys), from 16 Spanish schools, participated. An unilevel inclinometer was used to quantify the sagittal spinal curvatures (thoracic and lumbar) in a relaxed standing position. Sagittal spinal morphotype was analyzed by sex, age, weight, height, and BMI. Children's parents or legal guardians filled in a questionnaire according to the children's responses about the BP suffered in the previous week and the preceding year.

RESULTS

The mean angular value of thoracic kyphosis was 36.08 ± 8.99∘ and significantly higher in males than in females (p= 0.036). In contrast, the mean value of lumbar lordosis was 32.11 ± 7.46∘, being higher in females than in men (p< 0.01). The thoracic curve tends to increase by age (p= 0.003). Children who had low back pain (LBP) in the previous week had a significantly greater lumbar curve (35.88 ± 8.20∘) than those who did not have LBP in the preceding week (32.24 ± 7.30∘). The angle for lumbar curvature was a small predictor of LBP occurrence in the assessed children (OR = 1.082 [small]; 95% CI = 1.009-1.160, p= 0.028).

CONCLUSIONS

To conclude, almost 3/4 of the students were classified with normal thoracic kyphosis; however, 27.36% of the students had thoracic hyperkyphosis. Lumbar hyperlordosis was identified in 9.05% of the students, and was 2.5 times more frequent in girls. The lumbar curvature was a small predictor of LBP occurrence in the assessed children and the angle of lumbar curvature that most accurately identified individuals at risk of developing LBP was determined to be 33∘. The results of this study indicate the need to assess sagittal spinal curvatures at school during development ages.

Exploring thoracic kyphosis and incident fracture from vertebral morphology with high-intensity exercise in middle-aged and older men with osteopenia and osteoporosis: a secondary analysis of the LIFTMOR-M trial

Our aim was to explore change in kyphosis and vertebral fracture incidence following 8 months of high-intensity resistance and impact training (HiRIT) or machine-based isometric axial compression (IAC) training in men with osteopenia and osteoporosis. HiRIT and IAC improved posture. HiRIT participants did not experience progression or incident vertebral fracture. IAC participants did experience progression and incident vertebral fracture.

INTRODUCTION

The Lifting Intervention For Training Muscle and Osteoporosis Rehabilitation for Men (LIFTMOR-M) trial examined efficacy and safety of an eight-month, supervised, high-intensity progressive resistance and impact training (HiRIT) program compared with machine-based isometric axial compression (IAC) training in middle-aged and older men with low areal bone mineral density (aBMD). The primary purpose of the current work was to explore change in thoracic kyphosis and incident fracture from vertebral morphology following eight-months of HiRIT or IAC training. The secondary purpose was to explore change in clinical kyphosis measures for HiRIT, IAC and a non-randomized, matched control group.

METHODS

Men (≥ 45 yrs), with low aBMD, were recruited and randomized to HiRIT or IAC, or designated control. Clinical measures of thoracic kyphosis with inclinometry were determined. Cobb angle of kyphosis and vertebral fracture assessment using the Genant semi-quantitative method were determined from lateral thoracolumbar DXA (Medix DR, Medilink, France). Per-protocol (n = 40) and intention-to-treat (n = 93) analyses were conducted.

RESULTS

Forty participants (HiRIT n = 20, IAC n = 20; 66.1 ± 7.8 yrs.; lumbar spine T-score - 0.1 ± 0.8; femoral neck T-score - 1.5 ± 0.5) underwent clinical kyphosis measures and thoracolumbar DXA at baseline and follow-up. No between-group differences were detected in kyphosis change, however, within-group improvements in neutral (HiRIT - 2.3 ± 0.8°; IAC - 2.5 ± 0.8°) and 'standing tall' (HiRIT - 2.4 ± 0.8°; IAC - 2.0 ± 0.8°) postures were observed (p < 0.05). HiRIT improved Cobb angle (- 3.5 ± 1.5°, p = 0.027) from baseline. Over the 8 months, no incident vertebral fractures nor progression of prevalent vertebral fractures occurred for HiRIT participants. Five incident fractures of thoracic vertebrae occurred for IAC and one wedge fracture progressed. Ninety-three participants underwent clinical kyphosis measures at both time-points (HiRIT n = 34, IAC n = 33, control n = 26). HiRIT exhibited a reduction in 'standing tall' kyphosis compared to control (- 2.3 ± 0.6° versus 1.4 ± 0.7°, p < 0.05), but no other between-group differences were detected.

CONCLUSIONS

Although there was no difference in change between intervention groups, thoracic kyphosis appeared to improve in both HiRIT and IAC with exercise exposure. HiRIT improved 'standing tall' posture in comparison to usual activities. HiRIT was not associated with vertebral fracture progression or incident vertebral fracture, but for some IAC participants there was evidence of progression of vertebral fracture severity and incident vertebral fractures, in our small sample. Larger trials are required to confirm the observations of the current work, which was exploratory in nature.

Validity and reliability of smartphone-based Goniometer-Pro app for measuring the thoracic kyphosis

BACKGROUND CONTEXT

It is important to precisely measure thoracic kyphosis while examining the patients and studying effectiveness of therapeutic treatments.

PURPOSE

The present study evaluates validity as well as intra- and inter-rater reliability of health-related Goniometer-Pro android app in measuring thoracic kyphosis.

METHODS

A total number of 31 subjects were examined to validate using markers and measures of the proposed method to mark the spinous process, palpation, and radiologic imaging in the sagittal plane to obtain the thoracic curvature using Cobb method. Moreover, 40 subjects were examined for reliability by applying an evaluator at three occasions with an interval of one week (intra-rater) and three different evaluators at the same place and day (inter-rater).

RESULTS

Findings indicated that there was no significant difference between Cobb angle and the angle from the proposed method in thoracic curvature (p > 0.5). However, significant correlation was observed for the thoracic (r = 0.81, P = 0.000) with an ICC of 0.89. Intra- and inter-rater measurements were significantly correlated.

CONCLUSION

Our proposed method using Goniometer-Pro android app is highly reliable and accurate in determining thoracic curvature values.

The reliability and reproducibility of sagittal spinal curvature measurement using the Microsoft Kinect V2

BACKGROUND

Abnormal sagittal spinal curvature is associated with pain, decreased mobility, respiratory problems and increased mortality. Time-of-flight technology of the Microsoft Kinect sensor can reconstruct a three-dimensional image of the back quickly and inexpensively.

OBJECTIVE

To estimate the extent of the reproducibility of sagittal spine curvature measurement using the Microsoft Kinect sensor.

METHODS

Simultaneous measurement of thoracic and lumbar spine using the Microsoft Kinect sensor in 37 participants. Two investigators gave standardised instructions and each captured 3 images. Thoracic kyphosis and lumbar lordosis angle indexes were calculated using maximum height divided by the length.

RESULTS

Adult participants (mean age in years (SD) = 51.7 (20.6); 57% female; BMI in kg/m2 (SD) = 24.9 (3.3)) kyphosis and lordosis indexes showed high intra-rater and inter-rater ICC values (0.960-0.973). The means of the first images from both raters had significantly larger kyphosis indexes compared to the second and third images, yet no difference between means in lordosis data.

CONCLUSIONS

The results indicate that the Microsoft Kinect sensor has a reproducible method with high intra-rater and inter-rater reliability. The difference between the means over repeated measures suggest the second image capture is more consistent. It is a reproducible and quick method in clinical and research settings.

Determinants of Postoperative Spinal Height Change among Adult Spinal Deformity Patients with Long Construct Circumferential Fusion

Study Design

Retrospective clinical study.

Purpose

To describe postoperative height changes and identify the predictive factors of spinal height (SH) changes among patients with adult spinal deformity (ASD) who underwent circumferential lumbar fusion with instrumentation.

Overview of Literature

Postoperative height changes remain an important issue after spinal fusion surgery that affects the overall satisfaction with surgery. Previous studies of postoperative height change have focused exclusively on young patients with adolescent idiopathic scoliosis (AIS).

Methods

We retrospectively reviewed the clinical and imaging data of ASD patients who underwent lumbar corrective circumferential fusion of ≥3 levels (n=106). SH was defined as the vertical distance between C2 and S1 on a standing lateral image. As potential predictors of postoperative height change, the number of lateral lumbar interbody fusion (LLIF) levels, change in spino-pelvic parameters, total number of levels fused, and pedicle subtraction osteotomies (PSO) were documented. Univariate and multivariate linear regression analyses were performed to identify the predictors of postoperative height change.

Results

The mean SH change was -2.39±50.8 mm (range, -160 to 172 mm). The univariate analyses showed that the number of LLIF levels (coefficient=10.9, p=0.03), the absolute coronal vertical axis change (coefficient=0.6, p=0.01), and the absolute Cobb angle change (coefficient=-0.9, p=0.03) were significant predictors for height change. Patients with PSOs (n=14) tended to have a shorter height postoperatively (coefficient=-26.1); however, this difference was not significant (p=0.07). Multivariate analyses conducted with variables of p<0.20 showed that pelvic tilt (PT) change is an independent contributor to SH change (coefficient=-0.99, p=0.04, R2=0.11).

Conclusions

Utilizing a modified definition of SH used in previous AIS studies, we demonstrated that patients with ASD lose SH postoperatively and that PT change was an independent contributor of SH change.

Validity of flexicurve and motion capture for measurements of thoracic kyphosis vs standing radiographic measurements

Thoracic kyphosis varies among healthy adults and typically increases with age. Excessive kyphosis (hyperkyphosis) is associated with negative health. Spinal alignment also affects spine loading, with implications for conditions such as vertebral fractures and back pain. Valid measurements of kyphosis are necessary for clinical and research assessment of age-related posture changes, and to support improved biomechanical understating of spine conditions. Independent validation of non-radiographic techniques, however, remains limited. The goal of this study was to compare standing radiographic kyphosis measurements with non-radiographic measurements and predictions of thoracic kyphosis using flexicurve and motion analysis markers, in order to determine their validity. Thirteen non-radiographic measures of thoracic kyphosis were obtained in each of 40 adult subjects who also underwent standing radiographs of the thoracic spine. Measures included estimates derived by fitting of polynomials or circles to the non-radiographic data, as well as predictions calculated using previously published methods. Intra-class correlations (ICC) and root-mean square errors (RMSEs) were calculated between radiographic and non-radiographic measures to determine validity. Most non-radiographic estimates of kyphosis show similar, weak to moderate levels of validity when compared to radiographic measurements, and RMSEs ranging from 8.0° to 20.8°. Unbiased estimates of radiographic measurements with moderate to good ICCs were identified, however, based on marker measurements, and new prediction equations were created with similar validity that also account for age and body habitus. Clinical significance: These non-radiographic measurements of thoracic kyphosis can be applied to clinical practice or to clinical studies with recognition of specific limitations.

Classification System of the Sagittal Integral Morphotype in Children from the ISQUIOS Programme (Spain)

The sagittal spinal morphology presents 4 physiological curvatures that increase endurance to axial compression forces and allow adequate postural balance. These curves must remain within normal ranges to achieve a static and dynamic balance, a correct functioning of the muscles and an adequate distribution of the loads, and thus minimize the injury risk. The purpose of this study was to categorize the sagittal spinal alignment according to the different morphotypes obtained for each curve in standing, slump sitting, and trunk forward bending positions in schoolchildren. It was a cross-sectional study. Sagittal spinal curvatures were assessed in 731 students from 16 elementary schools. In the sagittal standing position assessment, 70.45% and 89.06% of schoolchildren presented a “normal” morphotype for both dorsal and lumbar curves, respectively. After the application of the “Sagittal Integral Morphotype” protocol according to the morphotypes obtained in the three positions assessment (standing, slump sitting, and trunk forward bending), it was observed how the frequency of normal morphotypes for the dorsal and lumbar curve decreased considerably (only 32% and 6.6% of children obtained a “normal sagittal integral morphotype” for the thoracic and lumbar curvatures, respectively). These results show how it is necessary to include the slump sitting and trunk forward bending assessment as part of the protocol to define the “integral” sagittal alignment of the spine and establish a correct diagnosis. The use of the diagnostic classification presented in this study will allow early detection of misalignment not identified with the assessment of standing position.

Commercial Postural Devices: A Review

Wearables are devices worn on the human body and are able to measure various health parameters, such as physical activity, energy expenditure and gait. With the advancement of technology, the general population are now spending more hours craning our necks and slouching over smartphones, tablets and computers, et cetera. Bodily posture is representative of physical and mental health. Poor posture can lead to spinal complications and the same can be said vice versa. As the standard of living increases, there is an increase in consumerism and the expectation to maintain such a lifestyle even in the aging population. Therefore, many are able to afford small luxuries in life, such as a piece of technology that could potentially improve their health in the long run. Wearable technology is a promising alternative to laboratory systems for movement and posture analysis. This article reviews commercial wearable devices with a focus on postural analysis. The clinical applicability of posture wearables, particularly in preventing, monitoring and treating spinal and musculoskeletal conditions, along with other purposes in healthcare, will be discussed.

Thoracic Kyphosis Angle in Relation to Low Back Pain among Dentists in Iran

BACKGROUND

Non-specific low back pain (LBP) has a direct impact on the quality of life, active days at work and health care costs.

AIM

This study was conducted to determine the relationship between LBP and thoracic kyphosis angle among dentists.

MATERIAL AND METHODS

This cross-sectional and descriptive-analytical study carried out in the form of census among 84 dentists employed in a specialised clinic in Iran. Dentists LBP prevalence and intensity and thoracic kyphosis angle were evaluated respectively with the self-administered body map questionnaire, visual analogue scale and flexicurve ruler. Statistical data analysis was done using SPSS software, version 22.

RESULTS

The data showed that the prevalence of LBP in dentists was 44.9% and intensity of LBP was reported about 71.9 ± 19.34. Pearson correlation coefficient between thoracic kyphosis angle and dentist's characteristics was not significant except for work experience. The single linear regression model showed that 1.3% of thoracic kyphosis angle changes was positively dependent on LBP. Also, the present study proved that thoracic kyphosis angle changes were positively dependent to 2.6%, 10.8% and 5.7 percent of age, work experience and Body Mass Index (BMI), respectively.

CONCLUSION

Despite the lack of significant statistical relation between LBP and thoracic kyphosis angle, there is a high prevalence and intensity of LBP among Dentists. To reduce the risk of work-related LBP among dentists, managing factors such as BMI, work postures and exercises during work should be taken into consideration.

Thoracic kyphosis assessment in postmenopausal women: an examination of the Flexicurve method in comparison to radiological methods

The Flexicurve ruler is an alternative method to radiographs for measuring thoracic kyphosis (curvature), but it is not certain that it is comparable. This study shows that Flexicurve can estimate radiographic vertebral centroid angles with less error than Cobb angles but that its accuracy would be inadequate for most clinical purposes.

INTRODUCTION

The Flexicurve ruler provides a non-radiological method of measuring thoracic kyphosis (TK) that has moderately strong correlations with the gold-standard radiographic Cobb angle method, while consistently underestimating the TK angle. Cobb angles can include measurement errors that may contribute to poor agreement, particularly in older populations. The vertebral centroid angle could be a better radiographic reference method for the validation of Flexicurve. Using two separate radiographic measurements of TK, we examined the validity of Flexicurve. We aimed to ascertain the level of agreement between measures and to empirically explore reasons for between-method differences.

METHODS

TK angles determined using Flexicurve and radiographic Cobb and vertebral centroid methods were compared using data from 117 healthy postmenopausal women (mean (SD) age 61.4 (7.0) years). Bland and Altman plots were used to assess differences between methods. Age, bone mineral density and body mass index were examined as characteristics that might explain any differences.

RESULTS

Flexicurve angles were scaled prior to analysis. There was no statistically significant difference between angles produced by Flexicurve and vertebral centroid methods (MD - 2.16°, 95%CI - 4.35° to 0.03°) although differences increased proportionally with TK angles. Flexicurve angles were significantly smaller than radiographic Cobb angles and depending on the scaling method used, systematic error ranged between - 2.48° and - 5.19°. Age accounts for some of the differences observed (R² < 0.08, p < 0.005).

CONCLUSIONS

TK measured using the Flexicurve shows better agreement with the radiographic vertebral centroid method, but inaccuracy of the Flexicurve increases with increasing angle of kyphosis.

Compensatory Mechanisms for Kyphotic Change in the Cervical Spine According to Alignment Analysis of the Cases after Anterior Cervical Corpectomy and Fusion

BACKGROUND

Compensatory mechanisms for cervical kyphosis are unclear. Few alignment analyses have targeted ongoing cervical kyphosis and detailed the effects of compensatory alignment changes.

METHODS

We analyzed the radiographic alignment parameters of 31 patients (21 men and 10 women) with postoperative kyphotic changes after anterior cervical corpectomy and fusion (ACCF) between 2006 and 2015. This analysis included lordotic angle of the fusion area, fusion area length, cervical lordosis angle (CL), O-C7 angle (O-C7a), and cervical sagittal vertical axis (cSVA) as basic parameters and occipito-C2 angle (O-C2a), adjacent cranial angle, adjacent caudal angle, and T1 slope as compensatory parameters at 2 time points after surgery.

RESULTS

Alignment analysis revealed that CL was significantly decreased by 5.0 ± 7.7° (P < 0.01) and O-C7a was changed by only -0.2 ± 6.8° (P = 0.75). An inverse correlation was found between ΔCL and ΔO-C2a (ρ = -0.40), with a nearly 1:1 relationship in the scatter diagram. ΔT1 slope had no direct compensatory correlation with ΔCL (P = 0.28) but was strongly correlated with ΔcSVA (ρ = 0.78). The scatter diagram of ΔcSVA and ΔT1 slope showed compensatory relevance and a shifted point to its collapse as the T1 slope lost control of cSVA; thereafter, both parameters incessantly increased, and ΔT1 and ΔcSVA became positive.

CONCLUSIONS

When CL decreased after ACCF, ΔO-C2 immediately compensated for the CL loss that could lead to failure to obtain horizontal gaze. If cSVA increased, Δcaudal adjacent angle and ΔT1 slope (extension below the kyphosis) compensated for the horizontal offset translation. The noncompensatory status (ΔcSVA and ΔT1 positive) may necessitate further correction surgery in which the caudal fused level is beyond T1.

Back Muscle Function in Older Women With Age-Related Hyperkyphosis: A Comparative Study

OBJECTIVE

The purpose of this study was to compare static maximal back extensor muscle force, endurance, and characteristics of flexion relaxation phenomenon (FRP) in older women with and without age-related hyperkyphosis.

METHODS

Maximum back extensor force and endurance measured in a sitting position with a designed load cell setup; appearance, onset, and offset angles of FRP; and extension relaxation ratio (ERR) during a dynamic flexion-extension task were compared between 24 older women with hyperkyphosis (thoracic kyphosis angle ≥50°), mean age 65 ± 4.4 years, and 24 older women without hyperkyphosis (thoracic kyphosis angle ≪50°), mean age 63 ± 4.3 years. Variables of force, endurance, angles of FRP, and ERR were analyzed using an independent sample t test. A χ² test was used to identify differences between groups in FRP appearance.

RESULTS

Static back extensor force and endurance were significantly lower among those with versus those without hyperkyphosis (P ≪ .001). Although the 2 groups did not differ in FRP appearance and ERR in the superficial erector spinal muscles (P ≫ .05), FRP in the hyperkyphosis group started sooner and ended later than in the group without hyperkyphosis (P ≪ .05).

CONCLUSION

Our study indicates that women with age-related hyperkyphosis had decreased static maximal force and endurance of the back extensor muscles and prolonged myoelectrical silence of the superficial erector spinal muscles. Reduced endurance of the superficial erector spinal muscles may trigger early onset of FRP and prolonged relaxation of these muscles.

High-intensity exercise did not cause vertebral fractures and improves thoracic kyphosis in postmenopausal women with low to very low bone mass: the LIFTMOR trial

Our aim was to assess risk of vertebral fracture during high-intensity resistance and impact training (HiRIT) for postmenopausal women with low bone mass. HiRIT did not induce vertebral fracture, as evidenced by a reduction in kyphosis following 8 months of training and a lack of change in vertebral morphology.

INTRODUCTION

The LIFTMOR trial demonstrated a novel, HiRIT program notably improved bone mass in postmenopausal women with osteopenia and osteoporosis. While no clinical signs or symptoms of vertebral crush fracture were evident during the trial, anecdotal feedback suggests that concerns about safety of HiRIT in the osteoporosis demographic remain. The aim of the current work was to assess vertebral body morphology, Cobb angle, and clinical measures of thoracic kyphosis in participants in the LIFTMOR trial for evidence of vertebral fracture following 8 months of supervised HiRIT.

METHODS

Participants were randomized to either 8 months of 30-min, twice-weekly, supervised HiRIT or unsupervised, low-intensity, home-based exercise (CON). Lateral thoracolumbar DXA scans (Medix DR, Medilink, France) were performed at baseline and follow-up. Cobb angle was determined, and vertebral fracture identification was performed using the semiquantitative Genant method. Clinical kyphosis measurements were performed in relaxed standing (neutral posture) and standing tall using an inclinometer and a flexicurve.

RESULTS

The HiRIT group exhibited a reduction in inclinometer-determined standing tall thoracic kyphosis compared to CON (- 6.7 ± 8.2° vs - 1.6 ± 8.1°, p = 0.031). Both the HiRIT and CON groups exhibited within-group improvement in kyphosis in relaxed standing as measured by both inclinometer and flexicurve (p < 0.05). There were no changes in vertebral fracture classification in the HiRIT group post-intervention. A single, new, wedge deformity was observed for CON.

CONCLUSIONS

Supervised HiRIT was not associated with an increased risk of vertebral fracture in postmenopausal women with low bone mass. Indeed, a clinically relevant improvement in thoracic kyphosis was observed following 8 months of supervised HiRIT, further supporting its efficacy as an osteoporosis intervention for postmenopausal women with low to very low bone mass.

Effects of exercise programs on kyphosis and lordosis angle: A systematic review and meta-analysis

Many authors are interested in the effects that a specific exercise program could have on sagittal spinal curvatures. The purpose of this study was to determine the effects of different exercise programs on thoracic kyphosis and lumbar lordotic angle. This meta-analysis adhered to the PRISMA guideline and it was registered at PROSPERO. Five electronic databases (Pub Med, Cochrane, WOS, PEDro and EBSCO) were searched up to 31 July 2018. Eligible studies were randomized controlled trials that applied an exercise intervention and measured a kyphosis and/or lordotic angle. Study quality was performance by PEDro score. Risk of bias was assessed using the SIGN 50 checklist for randomized controlled trials. External validity was assessed using the EVAT. Ten randomized controlled trials were included for systematic review and meta-analysis. Meta-analysis with a random effect model was performed to infer the pooled estimated standardized mean difference. All studies were RCTs and they involved a total of 284 cases and 255 controls. Seven studies measured kyphosis angle. A large significant effect of the exercise on kyphosis was identified (SMD = -1.400 (95% CI-2.150 a -0.660), p = 0.000). Four studies assessed lordotic angle and moderate but not significant improvement was shown (SMD = -0.530 (95% CI-1.760 a -0.700), p = 0.401). The results suggest that exercise programs may have a positive effect on thoracic kyphosis angle, but no clear effect on lordotic angle. This systematic review suggests that strengthening rather than stretching could be more relevant for kyphosis and both qualities are important for lordosis. It is necessary to conduct more randomized controlled trials to assess the effects of strengthening and/or stretching program on kyphosis and lordotic angle and to establish the type of the exercise that is better for maintaining the sagittal disposition within normal ranges.

Reliability and validity of non-radiological measures of thoracic kyphosis in chronic obstructive pulmonary disease

Background/Aims:

Thoracic kyphosis in people with chronic obstructive pulmonary disease can be measured from digital photogrammetry or three-dimensional motion capture. This study aimed to determine the reliability, validity and agreement for non-radiological measures of thoracic kyphosis in chronic obstructive pulmonary disease.

Methods:

A total of 19 participants with chronic obstructive pulmonary disease were included. Cobb angles from chest radiographs and spinous process landmarks using photogrammetry and three-dimensional motion capture were evaluated.

Findings:

The mean kyphosis (± standard deviation) was 48.8 ± 10.9 degrees by radiograph; 49.6 ± 12.9 degrees by three-dimensional motion capture and 52.2 ± 11.1 degrees by photogrammetry. Radiographic Cobb angle and photogrammetry measurements demonstrated excellent intra- and inter-rater reliability. Correlation between non-radiological kyphosis measurements and chest radiographs was strong (Pearson's r2 >0.75 for both). Limits of agreement between radiographs and 3D motion capture were –9 degrees to 7 degrees, and –12 to 8 degrees between radiographs and photogrammetry.

Conclusions:

Non-radiological measures of thoracic kyphosis are reliable and valid in chronic obstructive pulmonary disease.

Increased lumbar spinal column laxity due to low-angle, low-load cyclic flexion may predispose to acute injury

Lumbar spinal column laxity contributes to instability, increasing the risk of low back injury and pain. Until the laxity increase due to the cyclic loads of daily living can be quantified, the associated injury risk cannot be predicted clinically. This work cyclically loaded 5-vertebra lumbar motion segments (7 skeletally-mature cervine specimens, 5 osteoporotic human cadaver specimens) for 20 000 cycles of low-load low-angle (15°) flexion. The normalized neutral zone lengths and slopes of the load-displacement hysteresis loops showed a similar increase in spinal column laxity across species. The intervertebral kinematics also changes with cyclic loading. Differences in the location and magnitude of surface strain on the vertebral bodies (0.34% ± 0.11% in the cervine specimens, and 3.13% ± 1.69% in the human cadaver specimens) are consistent with expected fracture modes in these populations. Together, these results provide biomechanical evidence of spinal column damage during high-cycle low-load low-angle loading.

Reliability of sagittal vertical axis measurement and association with measures of age-related hyperkyphosis

[Purpose] Persons with age-related hyperkyphosis often have concomitant sagittal plane imbalance of the spine. This study investigated the reliability of sagittal vertical axis (SVA) measurement of sagittal balance, association between thoracic Cobb angle of kyphosis and SVA measure of sagittal balance, and compared the degree of SVA in males and females with age-related hyperkyphosis. [Participants and Methods] Measurements of SVA and Cobb angle of kyphosis were obtained from baseline radiographs of 112 community-dwelling males and females, mean age 70.0 (SD=5.7) years with kyphosis ≥40 degrees, recruited for a randomized controlled trial. Spearman correlation coefficients were used to determine associations between SVA and kyphosis, and Wilcoxon nonparametric tests to compare SVA between genders. [Results] SVA was acquired with excellent intra-rater [0.95 (95% CI: 0.88, 0.98)] and inter-rater reliability [0.93 (95% CI: 0.83,0.97)]. There was no significant correlation between Cobb angle of thoracic kyphosis and SVA, (r=−0.05). More males than females had sagittal imbalance (SVA≥5 cm). [Conclusion] In older adults with hyperkyphosis, SVA was a reliable measure of sagittal balance, and more extreme in males. SVA was not associated with Cobb angle of thoracic kyphosis, and could be considered an independent phenotype of age-related hyperkyphosis to be targeted in future intervention trials.

Proficiencies of Zingiber officinale against spine curve and vertebral damage induced by corticosteroid therapy associated with gonadal hormone deficiency in a rat model of osteoporosis

This study was assessed to examine whether Zingiber officinale (ZO) can prevent spine disorder and trabecular microarchitecture disruption in osteoporotic murin model. Three groups of male rats were selected: Controls (CTRL), combined model of osteoporosis (CMO), in which rats were orchidectomized and treated with cortisol, and CMO treated with ZO (CMO + ZO). One month after the surgical procedures, the rats were sacrificed. Lumbar curve of the spine has been evaluated using the kyphotic method. The spines were submitted to histological and histomorphometric analysis and mineral (calcium and phosphorus) metabolism assessment. Compared to CTRL, the mean kyphotic angle (KA) was significantly higher in CMO rats. The spinal deconditioning associated decreased bone trabecular volume and a disrupted microarchitecture. A disorder was observed in the serum and bone levels of calcium and phosphorus in the combined severe osteopenia model. An increase in the level of TRAcP associated with an increase in osteoclast number and activity has been reported. These disturbances were reduced following the use of ZO in the CMO + ZO group. Finally, ginger might be an alternative therapeutic candidate for the treatment of severe osteopenia induced vertebral damage and spine curve disruption.

A computerized method for evaluating scoliotic deformities using elliptical pattern recognition in X-ray spine images

BACKGROUND AND OBJECTIVE

Several studies have evaluated the reproducibility of the Cobb angle for measuring the degree of scoliotic deformities from X-ray spine images, and proposed different geometric models for describing the spinal curvature. The ellipse was shown to be an adequate geometric form, but was not yet applied for the identification and quantification of scoliotic curvatures. The purpose of this study is therefore to propose and validate a novel computerized methodology for the detection of elliptical patterns from X-ray images to evaluate the extent of the underlying scoliotic deformity.

METHODS

For anteroposterior each X-ray spine image, the spine curve is first reconstructed from vertebral centroids. The ellipse that best fits to the obtained spine curve is the found within a least square and genetic algorithm optimization framework. The geometric parameters of the resulting best fit ellipse are finally used to define an index that quantifies the spinal curvature.

RESULTS

The proposed methodology was validated on three synthetic images and then successfully applied to 20 clinical anteroposterior X-ray spine images of patients with a different degree of scoliotic deformity, with the resulting maximal relative error of 3% for the synthetic images and an overall error of 0.5 ± 0.4 mm (mean ± standard deviation) for the clinical cases.

CONCLUSIONS

The results indicate that the proposed computerized methodology is able to reliably reproduce scoliotic curvatures using the geometric parameters of the underlying ellipses. In comparison to conventional approaches, the proposed methodology potentially produces less errors, requires a relatively low observer interaction, takes into account all vertebrae within the observed scoliotic deformity, and allows for both qualitative and quantitative evaluations that may complement the diagnosis, study and treatment of scoliosis.

Hyperkyphotic measures using distance from the wall: validity, reliability, and distance from the wall to indicate the risk for thoracic hyperkyphosis and vertebral fracture

C7WD is a practical, valid, and reliable measure that could clearly indicate a risk of hyperkyphosis and vertebral fracture in the elderly. The findings might be particularly of use in regions difficult to access radiology or for the determination of those who need further invasive radiologic examination and therapy.

PURPOSE

To investigate psychometric properties of the 7th cervical vertebra wall distance (C7WD) to determine the risk of thoracic hyperkyphosis and spinal fracture, as compared to a standard radiologic Cobb's method.

METHODS

Community-dwelling elderly (n = 104), aged at least 60 years with occiput-wall distance > 0 cm, were assessed for their C7WD using rulers and a specially developed tool for an accurate perpendicular distance from C7 to the wall: infrared-gun kyphosis wall distance tool (IG-KypDisT). The first 15 participants were also involved in the reliability tests by a healthcare professional, village health volunteer, and caregiver. Within 7 days, all participants were at a hospital to complete a lateral plain radiograph (Cobb's method).

RESULTS

Outcomes of C7WD had excellent correlation to the Cobb angles (r = 0.87 for rulers and r = 0.92 for IG-KypDisT), with excellent reliability when used by all three raters (ICC_3,3 = 0.85-0.99). The C7WD of at least 7.5 and 9.5 cm had the best diagnostic properties to determine the risk of thoracic hyperkyphosis and vertebral fracture, respectively.

CONCLUSION

C7WD is valid and reliable with good diagnostic properties for thoracic hyperkyphosis and vertebral fracture. The findings confirm the use of C7WD using traditional ruler-based method as a practical tool to screen and monitor severity of thoracic hyperkyphosis in clinics and communities. In addition, the measurement using the IG-KypDisT provided accurate data that can be saved for further analysis; it is therefore suggested for research settings. The findings would promote the standardization of hyperkyphosis measurements in various settings.

Relationship between spinal morphology and function and adolescent non-specific back pain: A cross-sectional study

CONTEXT

Non-specific back pain has become a public health problem affecting adolescent health.

OBJECTIVE

To examine the relationships between abnormalities in spinal morphology and non-specific back pain among adolescents.

DESIGN

Cross-sectional study.

SETTING

Junior and senior high schools.

PATIENTS

Participants were screened using a questionnaire regarding back pain. Students in the pain group (n= 273, 121 boys and 152 girls) reported experiencing upper and/or lower back pain within the previous month, and those who did not report pain were assigned to the group without pain (n= 127, 63 boys and 64 girls). Participants who had experienced acute upper and/or lower back injuries within the previous month or received a definitive diagnose of disease were excluded.

METHODS

The SpinalMouse® was used to measure the thoracic kyphosis angle (TKA), lumbar lordosis angle (LLA), sacrum/hip angle (SA), and incline angle (INA) in both the standing position and sitting position. The SpinalMouse® also was used to measure the sacral, thoracic, and lumbar range of motion (ROM) in the fully flexed position and fully extended position in the sagittal plane. The thoracic and lumbar ROM in left/right lateral flexion was recorded. The Matthiass test was used to assess changes in the measured angles upon loading.

RESULTS

Among junior high school students, 47.0% of boys and 53% of girls had an abnormal TKA. Among senior high school students, 52.6% of boys and 46.99% of girls had an abnormal TKA. The incidence of LLA abnormality was significantly higher among junior high boys than girls (p< 0.05), as was the incidence of hypolordosis (p< 0.05). Significantly fewer senior high boys than girls had a normal LLA value (p< 0.05). An excessive TKA (p< 0.05, odds ratio = 1.236) and limited lumbar ROM (p< 0.01, odds ratio = 0.975) were correlated with back pain in adolescents.

CONCLUSIONS

The incidences of TKA and LLA abnormality are high among Chinese adolescents, and an excessive TKA and insufficient total lumbar ROM may be risk factors for non-specific back pain in adolescents.

Systematic Review of Postural Assessment in Individuals With Obstructive Respiratory Conditions: MEASUREMENT AND CLINICAL ASSOCIATIONS

PURPOSE

Changes in posture in individuals with an obstructive respiratory disease have been reported, but the extent of these deviations and their clinical significance is not well understood. This study aimed to systematically review the literature of the skeletal structural alignment in children and adults with an obstructive respiratory disease, describe the measurement techniques used, and determine the clinical relevance of any alternations.

METHODS

Observational cohort or cross-sectional studies of postural assessment were identified, with 2 reviewers independently assessing study quality.

RESULTS

A total of 18 studies were included, 12 in cystic fibrosis (CF), 5 in asthma, and 1 in chronic obstructive pulmonary disease (COPD). The overall quality assessment rating was 12.6 out of 16. Increased thoracic kyphosis or scoliosis was found in both children and adults with CF. Increased shoulder protraction and elevation were evident in asthma and COPD, although changes in spinal curvature were variable. The clinical impact of postural changes was diverse, with an inconsistent influence on lung function. A mix of methods was applied for postural assessment.

CONCLUSIONS

Skeletal structural malalignment appears to be present in some individuals with an obstructive respiratory disease, although the extent of alterations and its clinical impact is variable. Photogrammetry is used to provide a comprehensive assessment of posture in these populations.

The Reliability of Standing Sagittal Measurements of Spinal Curvature and Range of Motion in Older Women With and Without Hyperkyphosis Using a Skin-Surface Device

OBJECTIVE

The purpose of this study was to investigate the intrarater reliability of a skin-surface instrument (Spinal Mouse, Idiag, Voletswil, Switzerland) in measuring standing sagittal curvature and global mobility of the spine in older women with and without hyperkyphosis.

METHODS

Measurements were made in 19 women with hyperkyphosis (thoracic kyphosis angle ≥50°), mean age 67 ± 5 years, and 14 women without hyperkyphosis (thoracic kyphosis angle <50°), mean age 63 ± 6 years. Sagittal thoracic and lumbar curvature and mobility of the spine were assessed with the Spinal Mouse during neutral standing, full spinal flexion, and full spinal extension. Tests were performed by the same examiner on 2 days with a 72-hour interval. The intrarater reliability of the measurements was analyzed using the intraclass correlation coefficient, standard error of measurement and minimal detectable change.

RESULTS

Intraclass correlation coefficients ranged from 0.89 to 0.99 in both groups. The standard errors of measurement ranged from 1.02° to 2.06° in the hyperkyphosis group and from 1.15° to 2.22° in the normal group. The minimal detectable change ranged from 2.85° to 5.73° in the hyperkyphosis group and from 3.20° to 6.17° in the normal group.

CONCLUSIONS

Our results indicated that the Spinal Mouse has excellent intrarater reliability for the measurement of sagittal thoracic and lumbar curvature and mobility of the spine in older women.

Accuracy of a Radiological Evaluation Method for Thoracic and Lumbar Spinal Curvatures Using Spinous Processes

OBJECTIVE

The purpose of this study was to assess a radiographic method for spinal curvature evaluation in children, based on spinous processes, and identify its normality limits.

METHODS

The sample consisted of 90 radiographic examinations of the spines of children in the sagittal plane. Thoracic and lumbar curvatures were evaluated using angular (apex angle [AA]) and linear (sagittal arrow [SA]) measurements based on the spinous processes. The same curvatures were also evaluated using the Cobb angle (CA) method, which is considered the gold standard. For concurrent validity (AA vs CA), Pearson's product-moment correlation coefficient, root-mean-square error, Pitman- Morgan test, and Bland-Altman analysis were used. For reproducibility (AA, SA, and CA), the intraclass correlation coefficient, standard error of measurement, and minimal detectable change measurements were used.

RESULTS

A significant correlation was found between CA and AA measurements, as was a low root-mean-square error. The mean difference between the measurements was 0° for thoracic and lumbar curvatures, and the mean standard deviations of the differences were ±5.9° and 6.9°, respectively. The intraclass correlation coefficients of AA and SA were similar to or higher than the gold standard (CA). The standard error of measurement and minimal detectable change of the AA were always lower than the CA.

CONCLUSION

This study determined the concurrent validity, as well as intra- and interrater reproducibility, of the radiographic measurements of kyphosis and lordosis in children.

Reliability of novice physiotherapists for measuring Cobb angle using a digital method

BACKGROUND

The Cobb's method is the most accurate and reliable method for kyphosis measurement. Conventionally, a sagittal Cobb angle was commonly derived from a lateral plain film. With computer technology, a digital method is widely used in common clinical settings, but the existing reliability data involved only experienced raters.

OBJECTIVES

To assess the interrater and intrarater reliability of a digital Cobb's method using novice physiotherapists.

METHODS

Fifteen participants, with an occiput wall distance of more than 0 cm, were interviewed and assessed for their demographics. Then they were filmed for lateral spinal radiography over the area of thoracic spine in a standing position, and the Cobb angle was analyzed by four raters, including an expert physician and three novice physiotherapists, using a SurgimapSpine programme.

RESULTS

The average Cobb angles among the four raters showed no significant difference (p = 0.984). Outcomes of their measurements had excellent intrarater and interrater reliability [intraclass correlation coefficient (ICC3,3) = 0.995-0.997] with a small range of standard errors of the measurement (<1°).

CONCLUSION

A digital Cobb's method had excellent reliability when used by a novice health professional rater. The findings confirm the ease of using this method to detect and monitor kyphosis in general hospitals, clinics, or research facilities.

Pelvic Floor Symptoms and Spinal Curvature in Women

OBJECTIVES

To characterize the association between thoracic (T) and lumbar (L) spinal curvature and pelvic floor (PF) symptoms (pelvic organ prolapse, urinary incontinence [UI], fecal incontinence [FI]).

METHODS

Of women undergoing a bone mineral density scan from January 2007 to October 2010, patients who completed PF symptom questionnaires and had T and/or L spine radiographs or computed tomography examinations within 3 years of questionnaire completion were included in this study. The spine angles were measured using the Cobb angle method. The T and L curvatures were categorized as hypokyphosis (<20°), normal T kyphosis (20-40°), hyperkyphosis (>40°), hypolordosis (<40°), normal L lordosis (40-70°), and hyperlordosis (>70°). The presence and type of UI were identified with the 3 Incontinence Questionnaire and FI with the Modified Manchester Questionnaire. Pelvic organ prolapse was defined as a positive response to the presence of a bulge question from the PF Distress Inventory-20.

RESULTS

Of 1665 eligible women, 824 and 302 (mean age 64 ± 10 for both) had T and L spine images, respectively. No differences in PF symptoms were observed in the T or L spine groups categorized by hypo-, normal, and hyperkyphosis/lordosis except for urgency UI being more prevalent in the hypolordosis group (P = 0.01). However, upon further characterization using logistic regression, no association was noted between PF symptoms and T or L spine angles; no differences in the mean angles were found between women with versus without PF symptoms (P ≥ 0.05).

CONCLUSIONS

The current study shows that the T and L spinal curvatures are not associated with the presence of PF symptoms.

Scheuermann's disease in a juvenile male from the late Roman necropolis of Torrenueva (3rd-4th century CE, Granada, Spain)

This study details a severe case of Scheuermann's disease (SD) in a well-preserved skeleton of a juvenile male (designated TOR302), dated to 3rd-4th century CE, from the late Roman necropolis of Torrenueva (Granada, Spain). Individual TOR302 shows an evident kyphotic curve in the thoraco-lumbar spine, which is characterised by: (i) vertebral bodies of thoracic vertebra T2, thoracic segment T4-T9, and thoraco-lumbar segment T12-L2 wedged at >5°; (ii) slight anterior extensions of the epiphyseal ring; (iii) Schmorl's nodes on the superior and/or inferior plates; and (iv) a Cobb angle of 75°, derived from thoracic segments T4-T9. In addition, TOR302 shows other skeletal malformations as the secondary results of abnormal growth, due to altered biomechanical forces imposed by the spinal deformity, including: (i) lateral distortion of the spine that causes a slight secondary scoliotic curve; (ii) pelvic obliquity; and (iii) discrepancy in the length of the limbs. We argue that the secondary skeletal abnormalities allowed the individual to adapt to his spinal deformity meaning he was able to walk without the aid of a stick. Despite SD being a common modern clinical finding, few cases have been reported in ancient skeletal remains. This case therefore represents an important contribution to the palaeopathological literature.

Age-related hyperkyphosis: update of its potential causes and clinical impacts-narrative review

The present study aims to qualitatively review the contributing factors and health implications of age-related hyperkyphosis. We conducted a narrative review of observational and cohort studies describing the risk factors and epidemiology of hyperkyphosis from 1955 to 2016 using the following key words: kyphosis, hyperkyphosis, posture, age-related hyperkyphosis, kyphotic posture, aetiology and causes. This review included 77 studies. Approximately 60-70 % of the most severe hyperkyphosis cases have no evidence of underlying vertebral compression fractures. Other proposed factors contributing to hyperkyphosis are degenerative disc disease, weakness of back extensor muscles and genetic predisposition. Strength and endurance of back extensor muscles are very important for maintaining normal postural alignment. Recent evidence suggests that age-related hyperkyphosis is not equivalent to spinal osteoporosis. Due to the negative impact of hyperkyphosis on physical function, quality of life and mortality rates, physicians should focus not only on osteoporosis, but also on age-related postural changes. More research about the relationship between spinal morphology and modifiable factors, especially the structural and functional parameters of trunk muscles, could further illuminate our understanding and treatment options for hyperkyphosis.

The effect of a corrective functional exercise program on postural thoracic kyphosis in teenagers: a randomized controlled trial

OBJECTIVE

To investigate the effects of a corrective functional exercise program on postural thoracic kyphosis in teenagers in China.

DESIGN

A single-blind randomized controlled trial including students with a thoracic kyphosis angle (TKA) >40° measured using the SpinalMouse.

SETTING

China Institute of Sport Science and three middle schools in Beijing, China.

SUBJECTS

A total of 181 subjects were included in this trial; of these, 164 subjects were included in the analyses (intervention group, n = 81; control group, n = 83).

INTERVENTION

The intervention group received a functional exercise program designed to correct postural thoracic kyphosis, and the control group received an exercise program designed in accordance with the state-regulated curriculum.

MAIN MEASURES

The primary outcome variable was TKA. Secondary outcome variables were lumbar lordosis angle (LLA), sacral angle (SA), and incline angle (INA) measured in the upright position; thoracic, lumbar, and sacral spine range of motion (ROM) and INA ROM (change in center of gravity) measured in the forward bending and extended positions; and changes in TKA, LLA, SA, and INA measured during the Matthiass test.

RESULTS

There were significant differences in pretest and posttest TKA in both groups (intervention group: pretest 47.09 ± 5.45, posttest 38.31 ± 9.18, P < 0.0001; control group: pretest 47.47 ± 6.06, posttest 43.59 ± 7.49, P < 0.0001). After adjustment for gender and pretest values, there were significant differences in posttest TKA, change in SA, and thoracic ROM in the intervention group compared to the control group ( P < 0.05).

CONCLUSION

The corrective functional exercise program designed for this study improved exaggerated thoracic kyphosis in teenagers.

The LIFTMOR-M (Lifting Intervention For Training Muscle and Osteoporosis Rehabilitation for Men) trial: protocol for a semirandomised controlled trial of supervised targeted exercise to reduce risk of osteoporotic fracture in older men with low bone mass

INTRODUCTION

The primary aim of the proposed study is to examine the efficacy of an 8-month supervised, high-intensity progressive resistance training and impact loading programme in comparison with a supervised machine-based isometric exercise training programme using the bioDensity system in older men with low bone mass. We will also determine the safety and acceptability of each exercise training mode. Intervention group responses will be compared with those of a self-selected, non-randomised control sample of sex-matched and age-matched men who will follow their usual lifestyle activities for 8 months.

METHODS AND ANALYSIS

Apparently healthy men over 50 years with low bone mass, screened for medical conditions and medications known to adversely affect bone health, will be recruited. Eligible participants will be randomly allocated to 8 months of either exercise programme with block randomisation based on presence or absence of osteoporosis medications. A twice-weekly, 30-minute, supervised exercise programme will be conducted for both groups. The primary outcome will be change in femoral neck areal bone mineral density determined by dual-energy X-ray absorptiometry (DXA). Secondary outcomes, assessed at baseline and 8 months, will include: DXA-derived whole-body, bilateral proximal femur and lumbar spine areal bone mineral density; proximal femur bone geometry and volumetric density extracted using three-dimensional hip analysis software; anthropometry; body composition; kyphosis; vertebral fracture assessment; physical function; safety (adverse events and injuries); and compliance. Intention-to-treat and per-protocol analyses will be conducted.

DISCUSSION

Whether a high-intensity, low-repetition progressive resistance training and impact loading programme or a machine-based isometric exercise programme can improve determinants of fracture risk, without causing injury, has not been examined in men. Determination of the efficacy, safety and acceptability of such programmes will facilitate formulation of future exercise guidelines for older men with low bone mass at risk of fragility fracture, a group who have previously been under-represented.

ETHICS AND DISSEMINATION

Participant confidentiality will be maintained with publication of results. The study has been granted ethical approval from the Griffith University Human Research Ethics Committee (Protocol number AHS/07/14/HREC).

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (www.anzctr.org.au)ANZCTR12616000344493; Pre-results.

Dynamic corset versus three-point brace in the treatment of osteoporotic compression fractures of the thoracic and lumbar spine: a prospective, comparative study

BACKGROUND

The three-point orthosis is the most commonly used brace in the conservative treatment of osteoporotic vertebral fractures. The Spinomed^® dynamic orthosis represents an alternative.

AIMS

We compared efficacy and safety of these two types of brace in treating osteoporotic vertebral fractures.

METHODS

One hundred forty patients, aged 65-93 years, sustaining osteoporotic vertebral fracture were consecutively recruited and divided into two groups, and treated with either three-point orthosis or dynamic corset. Patients were evaluated with Visual Analogue Scale, Oswestry Low Back Pain Disability Questionnaire, and measurement of forced expiratory volume in the first second. Regional kyphosis angle, Delmas Index, and height of the fractured vertebral body were also measured on full-spine X-rays. Follow-up intervals were 1, 3, and 6 months after trauma. The complications encountered during the 6-month follow-up were recorded.

RESULTS

At the 3- and 6-month follow-ups, there was a significant difference (p < 0.05) in pain, disability, and respiration in favor of the dynamic orthosis group. At 6-month follow-up, there was no significant difference (p > 0.05) in all the radiological parameters between groups. Complications were reported for 28 patients in the three-point orthosis group, and for eight patients in the dynamic corset group (p < 0.05).

DISCUSSION

Biofeedback activation of back muscles is probably a key factor in improving functional outcome with dynamic orthosis.

CONCLUSIONS

Compared to three-point orthosis, patients treated with dynamic orthosis had a greater reduction in pain and a greater improvement in quality of life and respiratory function, with equal effectiveness in stabilizing the fracture, and fewer complications.

Study of Hyperkyphosis, Exercise and Function (SHEAF) Protocol of a Randomized Controlled Trial of Multimodal Spine-Strengthening Exercise in Older Adults With Hyperkyphosis

BACKGROUND

Hyperkyphosis negatively affects health status, physical mobility, and quality of life, but there is no standard protocol for treating people with hyperkyphosis. Treatment options include targeted exercise.

OBJECTIVES

This single-site randomized controlled trial (RCT) will determine the efficacy of a targeted multimodal spine-strengthening exercise program, compared with no exercise intervention, among community-dwelling men and women aged ≥60 years.

DESIGN

The RCT is a parallel-group design, with 1:1 randomization to exercise and attentional control groups.

SETTING

The study will be conducted at one primary site (one academic medical center partnered with one local community medical center).

PARTICIPANTS

One hundred men and women, aged ≥60 years, with thoracic kyphosis ≥40 degrees will be randomized.

INTERVENTION

The targeted multimodal spine-strengthening exercise intervention includes exercise and postural training delivered by a physical therapist in a group of 10 participants, 3 times a week for 6 months. Controls receive monthly health education meetings in a group of 10 participants and monthly calls from the study coordinator to monitor physical activity and any adverse events.

MEASUREMENTS

The primary outcome is change in Cobb angle of kyphosis measured from lateral spine radiographs at baseline and 6 months. Secondary outcomes include change in physical function (assessed with the modified Physical Performance Test, Timed "Up & Go" Test, timed loaded standing, 4-m walk, and Six-Minute Walk Test) and health-related quality of life (assessed with the modified Scoliosis Research Society instrument [SRS-30] self-image domain and Patient Reported Outcomes Measurement Information System [PROMIS] global health and physical function indexes). Additional secondary outcomes include pain, physical activity level, spinal flexion and extension muscle strength, paraspinal extensor muscle density, and adverse events.

LIMITATIONS

Blinding of the participants and instructors providing the intervention is not possible.

CONCLUSIONS

The efficacy of a high-quality, adequately powered exercise intervention in men and women with kyphosis ≥40 degrees will be evaluated to determine whether targeted multimodal spine-strengthening exercise reduces hyperkyphosis in older adults and improves important secondary outcomes of physical function and health-related quality of life.

The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery

BACKGROUND

Positive spinal regional and global sagittal malalignment has been repeatedly shown to correlate with pain and disability in thoracolumbar fusion.

OBJECTIVE

To evaluate the relationship between regional cervical sagittal alignment and postoperative outcomes for patients receiving multilevel cervical posterior fusion.

METHODS

From 2006 to 2010, 113 patients received multilevel posterior cervical fusion for cervical stenosis, myelopathy, and kyphosis. Radiographic measurements made at intermediate follow-up included the following: (1) C1-C2 lordosis, (2) C2-C7 lordosis, (3) C2-C7 sagittal vertical axis (C2-C7 SVA; distance between C2 plumb line and C7), (4) center of gravity of head SVA (CGH-C7 SVA), and (5) C1-C7 SVA. Health-related quality-of-life measures included neck disability index (NDI), visual analog pain scale, and SF-36 physical component scores. Pearson product-moment correlation coefficients were calculated between pairs of radiographic measures and health-related quality-of-life scores.

RESULTS

Both C2-C7 SVA and CGH-C7 SVA negatively correlated with SF-36 physical component scores (r =-0.43, P< .001 and r =-0.36, P = .005, respectively). C2-C7 SVA positively correlated with NDI scores (r = 0.20, P = .036). C2-C7 SVA positively correlated with C1-C2 lordosis (r = 0.33, P = .001). For significant correlations between C2-C7 SVA and NDI scores, regression models predicted a threshold C2-C7 SVA value of approximately 40 mm, beyond which correlations were most significant.

CONCLUSION

Our findings demonstrate that, similar to the thoracolumbar spine, the severity of disability increases with positive sagittal malalignment following surgical reconstruction.