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Hey HWD, Low TL, Soh HL, Tan KA, Tan JH, Tan TH, Thomas AC, Ka-Po Liu G, Wong HK, Tan JHJ. Prevalence and Risk Factors of Degenerative Spondylolisthesis and Retrolisthesis in the Thoracolumbar and Lumbar Spine - An EOS Study Using Updated Radiographic Parameters. Global Spine J 2024; 14:1137-1147. [PMID: 36749604 PMCID: PMC11289555 DOI: 10.1177/21925682221134044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
STUDY DESIGN Single centre, cross-sectional study. OBJECTIVES The objective is to report the prevalence of spondylolisthesis and retrolisthesis, analyse both conditions in terms of the affected levels and severity, as well as identify their risk factors. METHODS A review of clinical data and radiographic images of consecutive spine patients seen in outpatient clinics over a 1-month period is performed. Images are obtained using the EOS® technology under standardised protocol, and radiographic measurements were performed by 2 independent, blinded spine surgeons. The prevalence of both conditions were shown and categorised based on the spinal level involvement and severity. Associated risk factors were identified. RESULTS A total of 256 subjects (46.1% males) with 2304 discs from T9/10 to L5/S1 were studied. Their mean age was 52.2(± 18.7) years. The overall prevalence of spondylolisthesis and retrolisthesis was 25.9% and 17.1% respectively. Spondylolisthesis occurs frequently at L4/5(16.3%), and retrolisthesis at L3/4(6.8%). Majority of the patients with spondylolisthesis had a Grade I slip (84.3%), while those with retrolisthesis had a Grade I slip. The presence of spondylolisthesis was found associated with increased age (P < .001), female gender (OR: 2.310; P = .005), predominantly sitting occupations (OR:2.421; P = .008), higher American Society of Anaesthesiology grades (P = .001), and lower limb radiculopathy (OR: 2.175; P = .007). Patients with spondylolisthesis had larger Pelvic Incidence (P < .001), Pelvic Tilt (P < .001) and Knee alignment angle (P = .011), but smaller Thoracolumbar junctional angle (P = .008), Spinocoxa angle (P = .007). Retrolisthesis was associated with a larger Thoracolumbar junctional angle (P =.039). CONCLUSION This is the first study that details the prevalence of spondylolisthesis and retrolisthesis simultaneously, using the EOS technology and updated sagittal radiographic parameters. It allows better understanding of both conditions, their mutual relationship, and associated clinical and radiographic risk factors.
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Affiliation(s)
- Hwee Weng Dennis Hey
- Department of Orthopaedic Surgery, National University Hospital (NUH), Singapore
| | - Tian Ling Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hui Ling Soh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kimberly-Anne Tan
- Department of Orthopaedic Surgery, National University Hospital (NUH), Singapore
| | - Jun-Hao Tan
- Department of Orthopaedic Surgery, National University Hospital (NUH), Singapore
| | - Tuan Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Gabriel Ka-Po Liu
- Department of Orthopaedic Surgery, National University Hospital (NUH), Singapore
| | - Hee-Kit Wong
- Department of Orthopaedic Surgery, National University Hospital (NUH), Singapore
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Zhou Q, Sun X, Wang B, Zhu Z, Qiu Y. How Does the Slump Sitting Radiograph Increase Proportion of Segmental Instability and Kyphotic Alignment of Lumbar Degenerative Spondylolisthesis? Orthop Surg 2024; 16:551-558. [PMID: 38214017 PMCID: PMC10925499 DOI: 10.1111/os.13962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 11/07/2023] [Accepted: 11/14/2023] [Indexed: 01/13/2024] Open
Abstract
OBJECTIVE Clinical and radiographic degenerative spondylolisthesis (CARDS) classification was proposed to differentiate homogenous lumbar degenerative spondylolisthesis (LDS) subgroups. The sitting radiograph exhibited lumbar malalignment with maximum lumbar kyphosis, intervertebral kyphosis, and spondylolisthesis.This study aimed to assess the sitting radiograph for distribution of clinical and radiographic degenerative spondylolisthesis classification, and to elucidate its significance for exhibiting kyphotic alignment (CARDS type D) and segmental instability. METHODS A cohort of 101 patients with symptomatic lumbar degenerative spondylolisthesis (LDS) between September 2018 and December 2020 were recruited. The distribution and relibility of CARDS classification with or without sitting radiograph was assessed. The translational and angular range of motion and segmental instability was also evaluated. Univariate analysis of variance was used for multiple groups, and the least significant difference for two groups. Kappa consistency test of intrarater and interrater was evaluated for CARDS classification with or without sitting radiograph. Chi-square test was used to compare paried categorical data. RESULTS Utility of sitting radiographs for CARDS classification revealed higher percentage of type D than that without the sitting radiograph (p < 0.001). The sitting radiograph revealed a larger slip distance than the flexion radiograph (p = 0.003), as well as a lower slip angle than flexion radiograph (p < 0.001). The sitting-supine modality demonstrated the largest translational range of motion compared to the sitting-extension (p < 0.001) and flexion-extension modalities (p < 0.001). The sitting-supine modality showed larger angular range of motion than the flexion-extension modality (p < 0.001). The percentage of flexion, extension, upright, supine, and sitting radiograph to identify translational instability was higher than that without sitting radiograph (p < 0.001), as well as taking angular motion ≥10° as an additional criterion for segmental instability (p < 0.001). CONCLUSION The CARDS classification was reliable for LDS. The sitting radiograph showed maximal slip distance and kyphotic slip angle. Application of the sitting radiograph was necessary for evaluating segmental instability and kyphotic alignment of LDS.
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Affiliation(s)
- Qingshuang Zhou
- Division of Spine Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital Clinical College of Jiangsu UniversityNanjingChina
| | - Xu Sun
- Division of Spine Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital Clinical College of Jiangsu UniversityNanjingChina
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower HospitalAffiliated Hospital of Medical School, Nanjing UniversityNanjingChina
| | - Bin Wang
- Division of Spine Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital Clinical College of Jiangsu UniversityNanjingChina
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower HospitalAffiliated Hospital of Medical School, Nanjing UniversityNanjingChina
| | - Zezhang Zhu
- Division of Spine Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital Clinical College of Jiangsu UniversityNanjingChina
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower HospitalAffiliated Hospital of Medical School, Nanjing UniversityNanjingChina
| | - Yong Qiu
- Division of Spine Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital Clinical College of Jiangsu UniversityNanjingChina
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower HospitalAffiliated Hospital of Medical School, Nanjing UniversityNanjingChina
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Lin F, Zhou Z, Li Z, Shan B, Zhou Z, Sun Y, Zhou X. Utility of a fulcrum for positioning support during flexion-extension radiographs for assessment of lumbar instability in patients with degenerative lumbar spondylolisthesis. J Neurosurg Spine 2022; 37:535-540. [PMID: 35523252 DOI: 10.3171/2022.3.spine22192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors investigated a new standardized technique for evaluating lumbar stability in lumbar lateral flexion-extension (LFE) radiographs. For patients with lumbar spondylolisthesis, a three-part fulcrum with a support platform that included a semiarc leaning tool with armrests, a lifting platform for height adjustment, and a base for stability were used. Standard functional radiographs were used for comparison to determine whether adequate flexion-extension was acquired through use of the fulcrum method. METHODS A total of 67 consecutive patients diagnosed with L4-5 degenerative lumbar spondylolisthesis were enrolled in the study. The authors analyzed LFE radiographs taken with the patient supported by a fulcrum (LFEF) and without a fulcrum. Sagittal translation (ST), segmental angulation (SA), posterior opening (PO), change in lumbar lordosis (CLL), and lumbar instability (LI) were measured for comparison using functional radiographs. RESULTS The average value of SA was 5.76° ± 3.72° in LFE and 9.96° ± 4.00° in LFEF radiographs, with a significant difference between them (p < 0.05). ST and PO were also significantly greater in LFEF than in LFE. The detection rate of instability was 10.4% in LFE and 31.3% in LFEF, and the difference was significant. The CLL was 27.31° ± 11.96° in LFE and 37.07° ± 12.963.16° in LFEF, with a significant difference between these values (p < 0.05). CONCLUSIONS Compared with traditional LFE radiographs, the LFEF radiographs significantly improved the detection rate of LI. In addition, this method may reduce patient discomfort during the process of obtaining radiographs.
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Affiliation(s)
| | | | - Zhiwei Li
- 2Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, China
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Jiang J, Hu J, Cai HP, Niu L, Zheng ML, Chen X, Zhang WZ. Radiographic analysis of dynamic lumbar motion during the five-repetition sit-to-stand test in degenerative lumbar spondylolisthesis. BMC Musculoskelet Disord 2022; 23:800. [PMID: 35996131 PMCID: PMC9394038 DOI: 10.1186/s12891-022-05761-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/16/2022] [Indexed: 11/30/2022] Open
Abstract
Background To investigate the mechanisms of low back pain triggered by the five-repetition sit-to-stand test (5R-STS test) in degenerative lumbar spondylolisthesis (DLS) from radiographic perspective, as well as to determine the most useful diagnostic modalities in the evaluation of segmental instability. Methods We retrospectively performed a study of 78 patients (23 men and 55 women) with symptomatic DLS at L4/5 in our institution between April 2020 and December 2021. Each patient was assessed by using the 5R-STS test and received a series of radiographs including the upright standing, normal sitting, standing flexion–extension radiographs, and supine sagittal MR images. Enrolled patients were divided into two groups based on the 5R-STS test score: severe group and mild group. Translational and angular motion was determined by comparing normal sitting radiograph (N) with upright standing radiograph (U) (Combined, NU), flexion/extension radiographs (FE) as well as normal sitting radiograph (N) with a supine sagittal MR image (sMR) (Combined, N-sMR). Results Overall, 78 patients were enrolled, and there were 31(39.7%) patients in group S and 47(60.3%) patients in group M, with an average age of 60.7 ± 8.4 years. The normal sitting radiograph demonstrated the maximum slip percentage (SP) and the highest kyphotic angle both in group S and group M. Compared with group M, group S revealed significantly higher SP in the normal sitting position (24.1 vs 19.6; p = 0.002). The lumbar slip angular in group S with a sitting position was significantly higher than that in group M (-5.2 vs -1.3; p < 0.001). All patients in group S had objective functional impairment (OFI) and 28 patients of them were diagnosed with lumbar instability by using the combination of normal sitting radiograph (N) and supine sagittal MR image (sMR) (Combined, N-sMR). Conclusion DLS patients with positive sign of the 5R-STS test is a distinct subgroup associated with lumbar instability. The modality of the combination of normal sitting radiograph (N) and supine sagittal MR image (sMR) had a significant advantage in terms of the ability to identify segmental instability.
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Affiliation(s)
- Jiang Jiang
- Department of Orthopedics, The Affiliated Provincial Hospital of Anhui Medical University, Hefei, China
| | - Jun Hu
- Department of Orthopedics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Hai-Ping Cai
- Department of Orthopedics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Lei Niu
- Department of Orthopedics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Meng-Long Zheng
- Department of Radiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Xi Chen
- Department of Orthopedics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China. .,, Hefei, China.
| | - Wen-Zhi Zhang
- Department of Orthopedics, The Affiliated Provincial Hospital of Anhui Medical University, Hefei, China. .,, Hefei, China.
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Zhou Q, Sun X, Qiu Y, Zhu Z, Xu L, Pu X, Yang B, Wang S. Utility of the decubitus or the supine rather than the extension lateral radiograph in evaluating lumbar segmental instability. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:851-857. [PMID: 35133496 DOI: 10.1007/s00586-021-07098-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/20/2021] [Accepted: 12/18/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To determine the superiority of decubitus and supine radiographs for the reduction of olisthesis instead of the extension radiograph, and the inconsistency of the CT scout view, 3D-reconstruction and MR image in evaluating segmental instability. METHODS A cohort of 154 low-grade lumbar degenerative spondylolisthesis patients with the average age of (60.9 ± 8.6) years were enrolled. Slip percentage was measured on the flexion, upright and extension radiographs, the decubitus lateral radiograph, CT scout view, the supine median sagittal 3D-reconstruction and MR image. The translational range of motion was calculated, and segmental instability was defined as translational motion ≥ 8%. RESULTS The flexion radiograph showed higher slip percentage than upright radiograph (p < 0.001). The slip percentage of the MR image was lower than CT scout view (p = 0.003) and CT sagittal radiograph (p = 0.001) on the basis of statistical differences among three groups (p = 0.002). The slip percentage of the CT scout view, decubitus radiograph, and extension radiograph was statistically different (p = 0.01). The CT scout view and sagittal reconstruction had lower slip percentage than the extension radiograph (p = 0.042; p = 0.003, respectively). Both the flexion-supine and flexion-decubitus modality had larger translational motion than the flexion-extension modality (p = 0.007; p < 0.001, respectively). CONCLUSION Many modalities and techniques are used to show the vertebral displacement and its possible change and any cane used in the daily practice. In this study, supine and decubitus lateral radiography have larger reduction of olisthesis than the extension radiograph. The flexion radiograph coupled with a supine or decubitus radiograph reveals greater mobility than the flexion-extension modality.
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Affiliation(s)
- Qingshuang Zhou
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital Clinical College of Jiangsu University, Nanjing, China
| | - Xu Sun
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital Clinical College of Jiangsu University, Nanjing, China.,Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yong Qiu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital Clinical College of Jiangsu University, Nanjing, China. .,Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.
| | - Zezhang Zhu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital Clinical College of Jiangsu University, Nanjing, China.,Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Liang Xu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xiaojiang Pu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Bo Yang
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Sinian Wang
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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Shlobin NA, Le N, Scheer JK, Tan LA. State of the Evidence for Proximal Junctional Kyphosis Prevention in Adult Spinal Deformity Surgery: A Systematic Review of Current Literature. World Neurosurg 2022; 161:179-189.e1. [DOI: 10.1016/j.wneu.2022.02.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/12/2022] [Accepted: 02/14/2022] [Indexed: 12/01/2022]
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Wang XW, Chen X, Fu Y, Chen X, Zhang F, Cai HP, Ge C, Zhang WZ. Analysis of lumbar lateral instability on upright left and right bending radiographs in symptomatic patients with degenerative lumbar spondylolisthesis. BMC Musculoskelet Disord 2022; 23:59. [PMID: 35039039 PMCID: PMC8764856 DOI: 10.1186/s12891-022-05017-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 01/11/2022] [Indexed: 12/03/2022] Open
Abstract
Background To evaluate lumbar mobility in various positions using upright left and right bending radiographs in patients with degenerative lumbar spondylolisthesis (DLS), as well as to assess the impact of lateral instability on patient-reported outcomes. Methods This study retrospectively reviewed a consecutive series of patients with DLS between January 2019 and October 2020. The enrolled patients were divided into two groups: the lateral instability group (group L) and non-lateral instability group (group NL). Translational and angular motion in both sagittal and coronal planes and patient-reported outcomes were compared between the two groups. Results There were 104 (59.8%) patients in group L and 70 (40.2%) patients in group NL, with an average age of 60.6 ± 7.8 years. Patients with a right bending posture in group L had a higher slip percentage (14.2 ± 7.4% vs 9.2 ± 3.2%, p = 0.01) and slip angle (6.3 ± 1.5° vs 2.2 ± 0.8°, p = 0.021). Compared with group NL, group L demonstrated significantly larger angular motion in the coronal plane (2.4 ± 1.3° vs 1.0 ± 0.7°, p = 0.008). Patients with lateral instability had worse preoperative back pain (6.1 ± 1.6 vs 2.7 ± 1.9, p = 0.01) and Oswestry Disability Index (ODI) scores (37.7 ± 5.5 vs 25.6 ± 2.6, p = 0.002). In terms of pain characteristics, group L was characterized by pain when getting out of a car, when rising from a chair, and when climbing stairs (all p values < 0.05). Conclusion Lumbar lateral instability, that is, increased mobility in the coronal plane on lateral bending radiographs, translational and/or angular, correlates to more pronounced patient related symptoms in degenerative L4–5 spondylolisthesis. The existence of lumbar lateral instability leads to worse impacts on patient-reported outcomes when patients change their positions including getting out of a car, rising from a chair, and climbing stairs.
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Affiliation(s)
- Xin-Wen Wang
- Department of Orthopedics, Spine Center, The First Affiliated Hospital of USTC: Anhui Provincial Hospital, No. 17, Lujiang Road, Hefei, 230001, China
| | - Xi Chen
- Department of Orthopedics, Spine Center, The First Affiliated Hospital of USTC: Anhui Provincial Hospital, No. 17, Lujiang Road, Hefei, 230001, China
| | - Yang Fu
- Department of Orthopedics, Spine Center, The First Affiliated Hospital of USTC: Anhui Provincial Hospital, No. 17, Lujiang Road, Hefei, 230001, China
| | - Xiao Chen
- Department of Orthopedics, Spine Center, The First Affiliated Hospital of USTC: Anhui Provincial Hospital, No. 17, Lujiang Road, Hefei, 230001, China
| | - Feng Zhang
- Department of Orthopedics, Spine Center, The First Affiliated Hospital of USTC: Anhui Provincial Hospital, No. 17, Lujiang Road, Hefei, 230001, China
| | - Hai-Ping Cai
- Department of Orthopedics, Spine Center, The First Affiliated Hospital of USTC: Anhui Provincial Hospital, No. 17, Lujiang Road, Hefei, 230001, China
| | - Chang Ge
- Department of Orthopedics, Spine Center, The First Affiliated Hospital of USTC: Anhui Provincial Hospital, No. 17, Lujiang Road, Hefei, 230001, China
| | - Wen-Zhi Zhang
- Department of Orthopedics, Spine Center, The First Affiliated Hospital of USTC: Anhui Provincial Hospital, No. 17, Lujiang Road, Hefei, 230001, China.
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Hey HWD, Lim JCL, Law GW, Liu GKP, Wong HK. Understanding the Pathophysiology of L5-S1 Loss of Lordosis and Retrolisthesis: An EOS Study of Lumbopelvic Movement Between Standing and Slump Sitting Postures. World Neurosurg 2021; 158:e654-e661. [PMID: 34785359 DOI: 10.1016/j.wneu.2021.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 11/08/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To understand the pathophysiology of L5-S1 loss of lordosis and retrolisthesis by comparing 2 commonly assumed physiological weight-bearing postures. METHODS This was a prospective comparative study of whole-body standing and slump sitting EOS radiographs in clinic patients presenting with back pain or lower limb radicular pain. Patients with prior spinal intervention, malignancy, trauma, inflammatory diseases, transitional lumbosacral vertebra, pregnancy, and L5-S1 retrolisthesis or spondylolisthesis from nondegenerative causes were excluded. C7 sagittal vertical axis, global cervical angle, global thoracic angle, global lumbar angle, thoracolumbar angle, T1-slope, pelvic incidence, pelvic tilt, sacral slope, L5-S1 angle, L5-S1 vertebral translation, L5-S1 disc height, and presence of L4-5 vertebral translation were measured. Univariate and multivariate analyses were performed to identify predictors of L5-S1 lordosis loss and retrolisthesis. RESULTS L5-S1 loss of lumbar lordosis (7.02 ± 9.90°, P < 0.001), retrolisthesis (0.07 ± 0.411 cm, P < 0.001), and loss of disc height (0.10 ± 0.23 cm, P < 0.001) occurred when changing from standing to slump sitting along with other sagittal profile changes (P < 0.001). Taller L5-S1 disc height (odds ratio [OR] 2.57, P = 0.04), larger lumbar range-of-motion change (OR 3.82, P = 0.012), lower sacral slope on sitting (OR 2.50, P = 0.043), and presence of L4-5 spondylolisthesis (OR 2.75, P = 0.032) were predictive of larger L5-S1 lordosis loss (>7°) on multivariate analysis, while larger lumbar range-of-motion change (OR 2.21, P = 0.050) and presence of L4-5 spondylolisthesis (OR 3.08, P = 0.023) were predictive of greater L5-S1 retrolisthesis (>0.07 cm). CONCLUSIONS Degenerative L5-S1 loss of lordosis and retrolisthesis likely result from long-standing lower lumbar spine bending forces against the posterior ligamentous complex with slump sitting, predisposed by a negatively sloped sacrum and increased lumbar flexibility.
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Affiliation(s)
| | | | - Gin Way Law
- Department of Orthopaedic Surgery, National University Hospital, Singapore
| | - Gabriel Ka-Po Liu
- Department of Orthopaedic Surgery, National University Hospital, Singapore
| | - Hee-Kit Wong
- Department of Orthopaedic Surgery, National University Hospital, Singapore
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Sielatycki JA, Metcalf T, Koscielski M, Devin CJ, Hodges S. Seated Lateral X-ray Is a Better Stress Radiograph of the Lumbar Spine Compared to Standing Flexion. Global Spine J 2021; 11:1099-1103. [PMID: 32748641 PMCID: PMC8351069 DOI: 10.1177/2192568220939527] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
STUDY DESIGN Prospective lumbar radiograph analysis. OBJECTIVE To compare changes in lumbar lordosis in standing flexion versus seated lateral radiographs. METHODS Standing lateral, standing flexion, and seated lateral X-rays of the lumbar spine were obtained in patients presenting with low back pain. Trauma, tumor, and revision cases were excluded. Changes in global lumbar as well as segmental lordosis were measured in each position. RESULTS Seventy adult patients were reviewed. Overall, the greatest changes in lordosis were seen at L4-S1 in both the seated and flexion X-rays (12.5° and 6.3°, respectively). Greater kyphosis was seen in seated versus flexion X-rays (21.6° vs 15.8°); changes in lordosis from L1-L3 were similar in both positions, with little change seen at these levels (approximately 5° to 7°). On subgroup analysis, these differences were magnified in analyzing only patients that moved at least 20° globally, and there were no significant differences between sitting and flexion in "stiff" patients that moved less than 20° globally. CONCLUSION Greater lumbar kyphosis was seen in the seated position compared to standing flexion, especially from L4-S1. Given these results we suggest the use of seated lateral X-rays to dynamically assess the lumbar spine. These findings may also guide future research into the mechanism and clinical relevance of a stiff versus mobile lumbar spine, as well as into the sensitivity of seated X-rays in detecting instability.
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Affiliation(s)
- J. Alex Sielatycki
- Center for Sports Medicine and Orthopedics, Chattanooga Orthopedic Group, Chattanooga, TN, USA,J. Alex Sielatycki, Center for Sports Medicine and Orthopedics, Chattanooga Orthopedic Group, Chattanooga, TN 37404-3322, USA.
| | | | | | - Clinton J. Devin
- Vanderbilt University Medical Center, Nashville, TN, USA,Steamboat Orthopedic and Spine Institute, Steamboat Springs, CO, USA
| | - Scott Hodges
- Center for Sports Medicine and Orthopedics, Chattanooga Orthopedic Group, Chattanooga, TN, USA
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Innmann MM, Merle C, Phan P, Beaulé PE, Grammatopoulos G. Differences in Spinopelvic Characteristics Between Hip Osteoarthritis Patients and Controls. J Arthroplasty 2021; 36:2808-2816. [PMID: 33846047 DOI: 10.1016/j.arth.2021.03.031] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/26/2021] [Accepted: 03/10/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study of patients with hip primary osteoarthritis and a matched, asymptomatic, volunteers (controls) group aimed to determine spinopelvic differences between the two groups and their consequences for total hip arthroplasty. METHODS 104 patients (52 in each group) had their sagittal spinopelvic parameters (lumbar lordosis angle, sacral slope, pelvic tilt, pelvic incidence, and the pelvic-femoral angle) measured in the standing, relaxed-seated, and deep-flexed seated positions. Spinopelvic movement was calculated as the change between the different positions, and individual spinopelvic mobility was classified in accordance with the change in pelvic tilt as previously described (ΔPT: stiff (<10°), normal (10-30°), and hypermobile (>30°)). RESULTS Transitioning from the standing to relaxed-seated position, patients demonstrated 13˚ less hip flexion (P < .001), 12˚ more posterior pelvic tilt (P = .006), and 6˚ more lumbar flexion (P = .038) compared with controls. Transitioning from the standing to deep-flexed seated position, patients demonstrated 18˚ less hip flexion (P < .001), accompanied by a posterior and not an anterior pelvic tilt as in the controls (7˚ ± 14 vs -6˚ ± 17; P < .001). Patients showed a higher percentage of spinopelvic hypermobility (19% vs 2%; P = .008). CONCLUSION The reduced ability of flexion in the arthritic hip, leads to posterior pelvic tilt in the relaxed-seated position. This is associated with a likely compensatory increased lumbar flexion to keep an upright position. Therefore, spinopelvic hypermobility has to be defined as pathologic. When moving to the deep-flexed seated position, decreased flexion of the arthritic hip prevents the pelvis from tilting anteriorly while the lumbar spine performs a compensatory flexion by approximately the same amount compared with controls. LEVEL OF EVIDENCE Level II, diagnostic study.
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Affiliation(s)
- Moritz M Innmann
- Division of Orthopaedic Surgery, The Ottawa Hospital, Critical Care Wing, Ottawa, Ontario, Canada; Department of Orthopaedics and Trauma Surgery, Heidelberg, Heidelberg, Germany, Heidelberg, Germany
| | - Christian Merle
- Department of Orthopaedics and Trauma Surgery, Heidelberg, Heidelberg, Germany, Heidelberg, Germany
| | - Philippe Phan
- Division of Orthopaedic Surgery, The Ottawa Hospital, Critical Care Wing, Ottawa, Ontario, Canada
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, The Ottawa Hospital, Critical Care Wing, Ottawa, Ontario, Canada
| | - George Grammatopoulos
- Division of Orthopaedic Surgery, The Ottawa Hospital, Critical Care Wing, Ottawa, Ontario, Canada
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Hey HWD, Tay HW, Wong GC, Tan KA, Lau ETC, Wong SJ, Liu KPG, Wong HK. Fulcrum to Generate Maximum Extension of the Spine and Hip-Proposing A New Strategy using EOS Imaging for Patient-specific Assessment of Degenerated Lumbar Spines. Spine (Phila Pa 1976) 2021; 46:E832-E839. [PMID: 33660680 DOI: 10.1097/brs.0000000000004025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective, radiographic comparative study conducted in a single academic institution. OBJECTIVE This study aims to compare fulcrum extension with conventional extension imaging to determine maximum "hip lordosis" (HL), an important novel patient-specific parameter in spinal realignment surgery, as well as understand the extension capabilities of the lower lumbar spine, which together, are key contributors to whole-body balancing. SUMMARY OF BACKGROUND DATA Recent literature recognizes the hip as an important contributor to whole-body lordosis beyond a compensator for spinal imbalance. METHODS Patients >45 years' old with mechanical low back pain due to degenerative spinal conditions were included and grouped based on the imaging performed-fulcrum or conventional extension. All imaging was performed using EOS under standardized instructions and visual aids. Radiographic parameters include global lumbar angle (GLA), inflexion-S1 (Inf-S1) angle, segmental lumbar angles, pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), femoral alignment angle (FAA), HL and spinocoxa angle (SCA). Unpaired t test was used to compare between radiographic parameters. RESULTS One hundred patients (40 males and 60 females, mean age 63.0 years) underwent either fulcrum or conventional extension EOS® imaging. Both groups had comparable baseline radiographic parameters. Fulcrum extension gave a larger mean GLA (-60.7° vs. -48.5°, P = 0.001), Inf-S1 angle (-58.8° vs. -48.8°, P = 0.003), SCA (-36.5° vs. -24.8°, P < 0.001), L4/5 and L5/S1 lordosis (-20.7° vs. -17.7°, P = 0.041, and -22.3° vs. -17.1°, P = 0.018, respectively), compared to conventional extension. PI, SS, PT, FAA, and HL were similar between both extension postures. CONCLUSION Fulcrum extension, compared to conventional extension, is better at generating lordosis in the lower lumbar spine, thus improving preoperative assessment of stiffness or instability of the lumbar spine. Both extension methods were equally effective at determining the patient-specific maximum HL to assess the flexibility and compensation occurring at the hip, potentially guiding surgical management of patients with degenerative spines.Level of Evidence: 3.
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Affiliation(s)
- Hwee Weng Dennis Hey
- University Orthopedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hui Wen Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gordon Chengyuan Wong
- University Orthopedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore
| | - Kimberly-Anne Tan
- University Orthopedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore
| | - Eugene Tze-Chun Lau
- University Orthopedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore
| | - Seng Juong Wong
- University Orthopedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore
| | - Ka-Po Gabriel Liu
- University Orthopedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore
| | - Hee-Kit Wong
- University Orthopedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Nishida N, Izumiyama T, Asahi R, Jiang F, Ohgi J, Yamagata H, Imajo Y, Suzuki H, Funaba M, Sugimoto S, Fukushima M, Chen X, Sakai T. Analysis of individual differences in pelvic and spine alignment in seated posture and impact on the seatbelt kinematics using human body model. PLoS One 2021; 16:e0254120. [PMID: 34242288 PMCID: PMC8270461 DOI: 10.1371/journal.pone.0254120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 06/20/2021] [Indexed: 11/18/2022] Open
Abstract
Analysis using human body models has been performed to reduce the impact of accidents; however, no analysis has shown a relationship between lumbar and pelvic/spine angle and seat belts in reducing human damage from accidents. Lumbar and pelvic/spine angles were measured in 75 individuals and the measurements were used to create three different angles for the Total Human Model for Safety model. In the present study, we focused on lumber lordosis (LL) and pelvic angle (PA). A normal distribution and histogram were used for analysis of PA (01, 10, and 50). The Total Human Model for Safety, including LL and PA, was corrected using finite element software. Simulations were conducted under the conditions of the Japan New Car Assessment Programme (JNCAP) 56 kph full lap frontal impact. Using the results of the FEM, the amount of lap-belt cranial sliding-up, anterior movement of the pelvis, posterior tilt of the pelvis, head injury criterion (HIC), second cervical vertebrae (C2) compressive load, C2 moment, chest deflectiou (upper, middle, and lower), left and right femur load, and shoulder belt force were measured. The lap-belt cranial sliding-up was 1.91 and 2.37 for PA10 and PA01, respectively, compared to PA50; the anterior movement of the pelvis was 1.08 and 1.12 for PA10 and PA01, respectively; and the posterior tilt of the pelvis was 1.1 and 1.18 for PA10 and PA01, respectively. HIC was 1.13 for PA10 and 1.58 for PA01; there was no difference in C2 compressive load by PA, but C2 moment increased to 1.59 for PA10 and 2.72 for PA01. It was found that as LL increases and the PA decreases, the seat belt becomes likely to catch the iliac bone, making it harder to cause injury. This study could help to reconsider the safe seat and seatbelt position in the future.
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Affiliation(s)
- Norihiro Nishida
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube City, Yamaguchi Prefecture, Japan
| | - Tomohiro Izumiyama
- Crash Safety Development Department, Vehicle Development Division, Mazda Motor Corporation, Aki-gun, Hiroshima Prefecture, Japan
| | - Ryusuke Asahi
- Crash Safety Development Department, Vehicle Development Division, Mazda Motor Corporation, Aki-gun, Hiroshima Prefecture, Japan
| | - Fei Jiang
- Faculty of Engineering, Yamaguchi University, Ube City, Yamaguchi Prefecture, Japan
| | - Junji Ohgi
- Faculty of Engineering, Yamaguchi University, Ube City, Yamaguchi Prefecture, Japan
| | - Hiroki Yamagata
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube City, Yamaguchi Prefecture, Japan
| | - Yasuaki Imajo
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube City, Yamaguchi Prefecture, Japan
| | - Hidenori Suzuki
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube City, Yamaguchi Prefecture, Japan
| | - Masahiro Funaba
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube City, Yamaguchi Prefecture, Japan
| | - Shigeru Sugimoto
- Crash Safety Development Department, Vehicle Development Division, Mazda Motor Corporation, Aki-gun, Hiroshima Prefecture, Japan
| | - Masanobu Fukushima
- Crash Safety Development Department, Vehicle Development Division, Mazda Motor Corporation, Aki-gun, Hiroshima Prefecture, Japan
| | - Xian Chen
- Faculty of Engineering, Yamaguchi University, Ube City, Yamaguchi Prefecture, Japan
| | - Takashi Sakai
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube City, Yamaguchi Prefecture, Japan
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Alex Sielatycki J, Devin CJ, Pennings J, Koscielski M, Metcalf T, Archer KR, Dunn R, Craig Humphreys S, Hodges S. A novel lumbar total joint replacement may be an improvement over fusion for degenerative lumbar conditions: a comparative analysis of patient-reported outcomes at one year. Spine J 2021; 21:829-840. [PMID: 33346156 DOI: 10.1016/j.spinee.2020.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Effective alternatives to lumbar fusion for degenerative conditions have remained elusive. Anterior total disc replacement does not address facet pathology or central/recess stenosis, resulting in limited indications. A posterior-based motion-preserving option that allows for neural decompression, facetectomy, and reconstruction of the disc and facets may have a role. PURPOSE The purpose was to compare one-year patient-reported outcomes for a novel, all-posterior, lumbar total joint replacement (LTJR - replacing both the disc and facet joints) against transforaminal lumbar interbody fusion (TLIF) for degenerative lumbar conditions warranting fusion (degenerative spondylolisthesis, recurrent disc herniation, severe foraminal stenosis requiring facet removal, and adjacent segment degeneration). STUDY DESIGN/SETTING A retrospective analysis of prospectively collected data comparing outcomes for LTJR patients to TLIF patients at an academic teaching hospital. PATIENT SAMPLE Analysis was conducted on 156 adult TLIF patients who were propensity matched to the 52 LTJR patients for a total sample of 208. OUTCOME MEASURES Self-reported Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) for back and leg pain were compared preoperatively, 3 months and 1 year after surgery. METHODS The implant is a motion-preserving lumbar reconstruction that replaces the function of both the disc and facets and is implanted using a bilateral transforaminal approach with complete facetectomies. Adult patients with degenerative lumbar pathology undergoing either LTJR or open TLIF were analyzed. These degenerative conditions included: grade 1 degenerative spondylolisthesis, recurrent disc herniation, adjacent segment disease, disc degeneration with severe foraminal stenosis). Trauma, tumor, grade 2 or higher spondylolisthesis, spinal deformity, and infection cases were excluded. Propensity score matching was performed to ensure parity between the cohorts. Multivariable regression analyses were done to compare the 1-year results as measured by 3 different standards to assess procedure success. RESULTS At 3 months, both the LTJR and TLIF cohorts showed significant and similar improvements in ODI and NRS back and leg pain. At 1 year, the LTJR cohort showed continued improvement in ODI and NRS back pain, while the TLIF group showed a plateau for ODI, back and leg pain. In a series of three multivariable logistic regressions, LTJR was shown to provide 3.3 times greater odds of achieving the minimal clinical symptom state in disability and pain (ODI <20%, NRS back and leg pain <2) and 2.4 and 4.1 times greater odds of achieving substantial clinical benefit (18% reduction in ODI) and minimal clinically important difference (30% reduction in ODI) as compared to TLIF. CONCLUSIONS Here we present a comparative analysis for the first 52 patients undergoing a novel, posterior-based LTJR for the lumbar spine versus TLIF for degenerative pathology. The approach for the LTJR allows for wide neural decompression, facetectomy, and complete discectomy, with the implant working to replace the function of the disc and facets to preserve motion. At 1 year, the LTJR cohort showed significant improvement in ODI and NRS back and leg pain as compared to TLIF. These results suggest that wide neural decompression combined with motion preservation using this novel LTJR may represent a viable alternative to TLIF for treating certain degenerative conditions. A prospective controlled trial is under development to further evaluate the efficacy, safety, and durability of this procedure.
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Affiliation(s)
| | - Clinton J Devin
- Steamboat Orthopaedic and Spine Institute, Steamboat Springs, CO, USA; Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - Tyler Metcalf
- The Ohio State University College of Medicine, Columbus, OH, USA
| | | | - Robert Dunn
- University of Cape Town, Cape Town, South Africa
| | | | - Scott Hodges
- Center for Sports Medicine and Orthopaedics, Chattanooga, TN, USA; 3Spine, Boston, MA, USA
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14
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Patwardhan AG, Sielatycki JA, Havey RM, Humphreys SC, Hodges SD, Blank KR, Muriuki MG. Loading of the lumbar spine during transition from standing to sitting: effect of fusion versus motion preservation at L4-L5 and L5-S1. Spine J 2021; 21:708-719. [PMID: 33160033 DOI: 10.1016/j.spinee.2020.10.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/30/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Transition from standing to sitting significantly decreases lumbar lordosis with the greatest lordosis-loss occurring at L4-S1. Fusing L4-S1 eliminates motion and thus the proximal mobile segments maybe recruited during transition from standing to sitting to compensate for the loss of L4-S1 mobility. This may subject proximal segments to supra-physiologic flexion loading. PURPOSE Assess effects of instrumented fusion versus motion preservation at L4-L5 and L5-S1 on lumbar spine loads and proximal segment motions during transition from standing to sitting. STUDY DESIGN Biomechanical study using human thoracolumbar spine specimens. METHODS A novel laboratory model was used to simulate lumbosacral alignment changes caused by a person's transition from standing to sitting in eight T10-sacrum spine specimens. The sacrum was tilted in the sagittal plane while constraining anterior-posterior translation of T10. Continuous loading-data and segmental motion-data were collected over a range of sacral slope values, which represented transition from standing to different sitting postures. We compared different constructs involving fusions and motion preserving prostheses across L4-S1. RESULTS After L4-S1 fusion, the sacrum could not be tilted as far posteriorly compared to the intact spine for the same applied moment (p<.001). For the same reduction in sacral slope, L4-S1 fusion induced 2.9 times the flexion moment in the lumbar spine and required 2.4 times the flexion motion of the proximal segments as the intact condition (p<.001). Conversely, motion preservation at L4-S1 restored lumbar spine loads and proximal segment motions to intact specimen levels during transition from standing to sitting. CONCLUSIONS In general, sitting requires lower lumbar segments to undergo flexion, thereby increasing load on the lumbar disks. L4-S1 fusion induced greater moments and increased flexion of proximal segments to attain a comparable seated posture. Motion preservation using a total joint replacement prosthesis at L4-S1 restored the lumbar spine loads and proximal segment motion to intact specimen levels during transition from standing to sitting. CLINICAL SIGNIFICANCE After L4-S1 fusion, increased proximal segment loading during sitting may cause discomfort in some patients and may lead to junctional breakdown over time. Preserving motion at L4-S1 may improve patient comfort and function during activities of daily living, and potentially decrease the need for adjacent level surgery.
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Affiliation(s)
- Avinash G Patwardhan
- Musculoskeletal Biomechanics Laboratory, Edward Hines, Jr, VA Hospital, Hines, IL, USA; Department of Orthopaedic Surgery and Rehabilitation, Loyola University Stritch School of Medicine, Maywood, IL, USA.
| | - J Alex Sielatycki
- Center for Sports Medicine and Orthopaedic Surgery, Chattanooga, TN, USA
| | - Robert M Havey
- Musculoskeletal Biomechanics Laboratory, Edward Hines, Jr, VA Hospital, Hines, IL, USA
| | | | - Scott D Hodges
- Center for Sports Medicine and Orthopaedic Surgery, Chattanooga, TN, USA
| | - Kenneth R Blank
- Musculoskeletal Biomechanics Laboratory, Edward Hines, Jr, VA Hospital, Hines, IL, USA
| | - Muturi G Muriuki
- Musculoskeletal Biomechanics Laboratory, Edward Hines, Jr, VA Hospital, Hines, IL, USA
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15
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Zhou QS, Sun X, Chen X, Xu L, Qian BP, Zhu Z, Qiu Y. Utility of Natural Sitting Lateral Radiograph in the Diagnosis of Segmental Instability for Patients with Degenerative Lumbar Spondylolisthesis. Clin Orthop Relat Res 2021; 479:817-825. [PMID: 33165051 PMCID: PMC8083840 DOI: 10.1097/corr.0000000000001542] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 09/28/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Segmental instability in patients with degenerative lumbar spondylolisthesis is an indication for surgical intervention. The most common method to evaluate segmental mobility is lumbar standing flexion-extension radiographs. Meanwhile, other simple radiographs, such as standing upright radiograph, a supine sagittal magnetic resonance imaging (MRI) or supine lateral radiograph, or a slump or natural sitting lateral radiograph, have been reported to diagnose segmental instability. However, those common posture radiographs have not been well characterized in one group of patients. Therefore, we measured slip percentage in a group of patients with degenerative lumbar spondylolisthesis using radiographs of patients in standing upright, natural sitting, standing flexion, and standing extension positions as well as supine MRI. QUESTIONS/PURPOSES We asked: (1) Does the natural sitting radiograph have a larger slip percentage than the standing upright or standing flexion radiograph? (2) Does the supine sagittal MRI reveal a lower slip percentage than the standing extension radiograph? (3) Does the combination of the natural sitting radiograph and the supine sagittal MRI have a higher translational range of motion (ROM) and positive detection rate of translational instability than traditional flexion-extension mobility using translational instability criteria of greater than or equal to 8%? METHODS We retrospectively performed a study of 62 patients (18 men and 44 women) with symptomatic degenerative lumbar spondylolisthesis at L4 who planned to undergo a surgical intervention at our institution between September 2018 and June 2019. Each patient underwent radiography in the standing upright, standing flexion, standing extension, and natural sitting positions, as well as MRI in the supine position. The slip percentage was measured three times by single observer on these five radiographs using Meyerding's technique (intraclass correlation coefficient 0.88 [95% CI 0.86 to 0.90]). Translational ROM was calculated by absolute values of difference between two radiograph positions. Based on the results of comparison of slip percentage and translational ROM, we developed the diagnostic algorithm to evaluate segmental instability. Also, the positive rate of translational instability using our diagnostic algorithms was compared with traditional flexion-extension radiographs. RESULTS The natural sitting radiograph revealed a larger mean slip percentage than the standing upright radiograph (21% ± 7.4% versus 17.7% ± 8.2%; p < 0.001) and the standing flexion radiograph (21% ±7.4% versus 18% ± 8.4%; p = 0.002). The supine sagittal MRI revealed a lower slip percentage than the standing extension radiograph (95% CI 0.49% to 2.8%; p = 0.006). The combination of natural sitting radiograph and the supine sagittal MRI had higher translational ROM than the standing flexion and extension radiographs (10% ± 4.8% versus 5.4% ± 3.7%; p < 0.001). More patients were diagnosed with translational instability using the combination of natural sitting radiograph and supine sagittal MRI than the standing flexion and extension radiographs (61% [38 of 62] versus 19% [12 of 62]; odds ratio 3.9; p < 0.001). CONCLUSION Our results indicate that a sitting radiograph reveals high slip percentage, and supine sagittal MRI demonstrated a reduction in anterolisthesis. The combination of natural sitting and supine sagittal MRI was suitable to the traditional flexion-extension modality for assessing translational instability in patients with degenerative lumbar spondylolisthesis. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Qing-Shuang Zhou
- Q.-S. Zhou, X. Sun, X. Chen, B.-P. Qian, Z. Zhu, Y. Qiu, Department of Spine Surgery, Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
- X. Sun, L. Xu, B-P. Qian, Z. Zhu, Y. Qiu, Department of Spine Surgery, Drum Tower Hospital, Nanjing, Clinical College of Jiangsu University China
| | - Xu Sun
- Q.-S. Zhou, X. Sun, X. Chen, B.-P. Qian, Z. Zhu, Y. Qiu, Department of Spine Surgery, Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
- X. Sun, L. Xu, B-P. Qian, Z. Zhu, Y. Qiu, Department of Spine Surgery, Drum Tower Hospital, Nanjing, Clinical College of Jiangsu University China
| | - Xi Chen
- Q.-S. Zhou, X. Sun, X. Chen, B.-P. Qian, Z. Zhu, Y. Qiu, Department of Spine Surgery, Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
- X. Sun, L. Xu, B-P. Qian, Z. Zhu, Y. Qiu, Department of Spine Surgery, Drum Tower Hospital, Nanjing, Clinical College of Jiangsu University China
| | - Liang Xu
- Q.-S. Zhou, X. Sun, X. Chen, B.-P. Qian, Z. Zhu, Y. Qiu, Department of Spine Surgery, Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
- X. Sun, L. Xu, B-P. Qian, Z. Zhu, Y. Qiu, Department of Spine Surgery, Drum Tower Hospital, Nanjing, Clinical College of Jiangsu University China
| | - Bang-Ping Qian
- Q.-S. Zhou, X. Sun, X. Chen, B.-P. Qian, Z. Zhu, Y. Qiu, Department of Spine Surgery, Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
- X. Sun, L. Xu, B-P. Qian, Z. Zhu, Y. Qiu, Department of Spine Surgery, Drum Tower Hospital, Nanjing, Clinical College of Jiangsu University China
| | - Zezhang Zhu
- Q.-S. Zhou, X. Sun, X. Chen, B.-P. Qian, Z. Zhu, Y. Qiu, Department of Spine Surgery, Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
- X. Sun, L. Xu, B-P. Qian, Z. Zhu, Y. Qiu, Department of Spine Surgery, Drum Tower Hospital, Nanjing, Clinical College of Jiangsu University China
| | - Yong Qiu
- Q.-S. Zhou, X. Sun, X. Chen, B.-P. Qian, Z. Zhu, Y. Qiu, Department of Spine Surgery, Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
- X. Sun, L. Xu, B-P. Qian, Z. Zhu, Y. Qiu, Department of Spine Surgery, Drum Tower Hospital, Nanjing, Clinical College of Jiangsu University China
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16
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Lee NJ, Mathew J, Kim JS, Lombardi JM, Vivas AC, Reidler J, Zuckerman SL, Park PJ, Leung E, Cerpa M, Weidenbaum M, Lenke LG, Lehman RA, Sardar ZM. Flexion-extension standing radiographs underestimate instability in patients with single-level lumbar spondylolisthesis: comparing flexion-supine imaging may be more appropriate. JOURNAL OF SPINE SURGERY (HONG KONG) 2021; 7:48-54. [PMID: 33834127 PMCID: PMC8024755 DOI: 10.21037/jss-20-631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 12/01/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Generally, most spine surgeons agree that increased segmental motion viewed on flexion-extension radiographs is a reliable predictor of instability; however, these views can be limited in several ways and may underestimate the instability at a given lumbar segment. METHODS Consecutively collected adult (≥18 years old) patients with symptomatic single-level lumbar spondylolisthesis were reviewed from a two-surgeon database from 2015 to 2019. Routine standing lumbar X-rays (neutral, flexion, extension) and supine lumbar MRI (sagittal T2-weighted imaging sequence) were performed. Patients were excluded if they had prior lumbar surgery, missing radiographic data, or if the time between X-rays and MRI was >6 months. RESULTS All 39 patients with symptomatic, single-level lumbar spondylolisthesis were identified. The mean age was 57.3±16.7 years and 66% were female. There was good intra- and inter-rater reliability agreement between measured values on the presence of instability. The slip percentage (SP) difference was significantly highest in the flexion-supine (FS) (5.7 mm, 12.3%) and neutral standing-supine (NS) (4.3 mm, 8.7%) groups, both of which were significantly higher compared with the flexion-extension (FE) group (1.8 mm, 4.5%, P<0.001). Ventral instability based on SP >8% was observed more frequently in FS (79.5%) and NS (52.6%) groups compared with FE group (16.7%, P<0.001). No statistically significant correlation was found between SP and disc angle for all radiographic views. CONCLUSIONS Comparing standing lateral and flexion X-rays with supine MRIs provides higher sensitivity to assess instability than standard flexion-extension radiographs. The FS and NS comparisons also show greater slip percentage differences at higher slip grades, but not at different lumbar levels. These changes are not dependent on age or gender.
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Affiliation(s)
- Nathan J Lee
- Department of Orthopaedics, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Justin Mathew
- Department of Orthopaedics, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Jun S Kim
- Department of Orthopaedics, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Joseph M Lombardi
- Department of Orthopaedics, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Andrew C Vivas
- Department of Orthopaedics, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Jay Reidler
- Department of Orthopaedics, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Scott L Zuckerman
- Department of Orthopaedics, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Paul J Park
- Department of Orthopaedics, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Eric Leung
- Department of Orthopaedics, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Meghan Cerpa
- Department of Orthopaedics, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Mark Weidenbaum
- Department of Orthopaedics, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Lawrence G Lenke
- Department of Orthopaedics, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Ronald A Lehman
- Department of Orthopaedics, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Zeeshan M Sardar
- Department of Orthopaedics, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
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Kao Y, Liu Z, Leng J, Qu Z, Song Q, Liu Y, Wang Z. A Preoperative Predictive Model of Lower Lumbar Spine Instability Based on Three-Dimensional Computed Tomography: A Retrospective Case-Control Pilot Study. Orthop Surg 2021; 13:484-492. [PMID: 33554427 PMCID: PMC7957420 DOI: 10.1111/os.12861] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/07/2020] [Accepted: 10/18/2020] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This study aimed to build a predictive model of lower lumbar instability. METHODS This retrospective study included 199 patients. Patients were divided into the lower lumbar instability group (LLIG) (n = 98) and lower lumbar stability group (LLSG) (n = 101). All participants of LLIG were recruited over a 2-year period (2015-2017) from the patients who accept lumbar surgery at the First Hospital of Jilin University. The LLSG was selected from outpatients who had underwent lumbar spine computed tomography (CT) and Flexion and extension radiographs (FER) at the First Hospital of Jilin University from 2015 to 2017. Several lower lumbar parameters were measured, including Lordosis angle (LA), intervertebral height (IH), ratio of anterior height to posterior height (APR), angle between endplate and anterior edge of vertebral body (AEPVa), sagittal slip ratio (SSR), and angle between the upper endplate and z-axis on sagittal plane (AUEZS). These parameters were keyed into the SPSS software to create a predictive model for classification. Sensitivity, specificity, predictive accuracy, and Kappa value were used to evaluate the predictive model. RESULTS Compared with LLSG, the LA of LLIG decreased by 3.49° (126.54° vs 130.3°). Similarly, the IH of LLIG decreased by 1.23°mm, 1.66°mm, and 0.71°mm at L3-4, L4-5, and L5-S1. Compared with LLSG, the SSR of LLIG is higher at L3-4, L4-5, and L5-S1 (0.54 vs 0.51, 0.57 vs 0.46, and 0.59 vs 0. 47). Moreover, the APR of LLIG is higher than those of LLSG at L3-4, L4-5, and L5-S1 (1.97 vs 1.81, 2.40 vs 1.97, and 2.69 vs 2.26). The LLIG has bigger AEPVa than LLIG at L3-4, L4-5, and L5-S1. Compared with LLSG, the AUEZS of LLIG is bigger at L3-4 (91.75° vs 90.81°) and smaller at L4-5 and L5-S1(84.63° vs 85.85° and 73.27° vs 75.01°). The SSR (L4) show highest predictive accuracy (83%) when every parameter was fed to LDA classifier to generate a univariate model. All parameters represent a statistically significant difference (P < 0.05) between LLSG and LLIG. The model including LA, APR (L5-S1), IH (L4-5), SSR (L5), AUEZS (L5) has highest predictive accuracy of 88.2%. The sensitivity, specificity, and Kappa value are 88.7%, 93.1%, and 0.77. CONCLUSION The predictive model has good classification performance and can be an auxiliary tool for clinicians to evaluate lumbar instability in preoperative patients with severe pain aggravated by lumbar movement.
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Affiliation(s)
- Yanbing Kao
- Departments of Spine Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Zijing Liu
- Nursing Platform of Spinal Surgery Department, The First Hospital of Jilin University, Changchun, Jilin, People's Republic of China
| | - Jiali Leng
- Department of Hospice, The First Hospital of Jilin University, Changchun, Jilin, People's Republic of China
| | - Zhigang Qu
- Departments of Spine Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - QingXu Song
- Departments of Spine Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yi Liu
- Departments of Spine Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Zhenyu Wang
- Departments of Spine Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
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Son S, Lee SG, Kim WK, Ahn Y, Jung JM. Disc height discrepancy between supine and standing positions as a screening metric for discogenic back pain in patients with disc degeneration. Spine J 2021; 21:71-79. [PMID: 32687982 DOI: 10.1016/j.spinee.2020.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/14/2020] [Accepted: 07/14/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The diagnosis of discogenic low back pain (LBP) from disc degeneration of the lumbar spine is often evaluated with discography. Noninvasive, simple screening methods other than invasive discography are useful, as evidence supporting clinical findings and magnetic resonance imaging (MRI) have come to the forefront. PURPOSE To investigate disc height (DH) discrepancy between supine and standing positions on simple radiography to clarify its clinical screening value in individuals with discogenic LBP. STUDY DESIGN/SETTINGS Retrospective matched cohort design. PATIENT SAMPLE Ninety-two patients with early to middle stage disc degeneration (Pfirrmann grade II, III, or IV). OUTCOME MEASURES Each subject underwent simple radiographs and MRI. Baseline characteristics, including demographic data and MRI findings, and radiological findings, including DH discrepancy, segmental angle, and sagittal balance, were analyzed. DH discrepancy ratio was calculated as (1 - [calibrated DH on standing radiography/calibrated DH on supine radiography]) × 100%. METHODS We matched LBP group of 46 patients with intractable discogenic pain (≥7 of visual analog scale scores) confirmed by discography with control group of 46 patients with similar stage disc degeneration with mild LBP (≤4 of visual analog scale scores). Binary regression analysis, receiver operating characteristic curve analysis, and cut-off value for diagnosis were used to evaluate and clarify diagnostic value of various factors. RESULTS There was no significant difference between the two groups in terms of baseline characteristics, including age, sex, body mass index, pathological level, and magnetic resonance findings such as disc degeneration, high intensity zone, and para-spinal muscle volume. Among the various radiological findings, the calibrated mean DH in the standing position (20.87±5.65 [LBP group] vs. 26.95±3.02 [control group], p<.001) and the DH discrepancy ratio (14.55±6.13% [LBP group] vs. 1.47±0.75% [control group], p=.007) were significantly different between the two groups. The cut-off value for DH discrepancy ratio to screen discogenic LBP was ≥6.04%. Additionally, as a compensation for pain, sagittal vertical axis (3.43±2.03 cm [LBP group] vs. -0.54±3.05 cm [control group], p=.002) and pelvic incidence (54.74±6.76° [LBP group] vs. 43.98±8.67° [control group]; p=.006) were different between the two groups. CONCLUSIONS The results suggest that DH discrepancy between the supine and standing positions could be a screening metric for discogenic LBP in early to middle stage disc degeneration of the lumbar spine.
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Affiliation(s)
- Seong Son
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Nadong-Gu, Incheon, 21565, South Korea.
| | - Sang Gu Lee
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Nadong-Gu, Incheon, 21565, South Korea
| | - Woo Kyung Kim
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Nadong-Gu, Incheon, 21565, South Korea
| | - Yong Ahn
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Nadong-Gu, Incheon, 21565, South Korea
| | - Jong Myung Jung
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Nadong-Gu, Incheon, 21565, South Korea
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Risk Factors Predicting C- Versus S-shaped Sagittal Spine Profiles in Natural, Relaxed Sitting: An Important Aspect in Spinal Realignment Surgery. Spine (Phila Pa 1976) 2020; 45:1704-1712. [PMID: 32890306 DOI: 10.1097/brs.0000000000003670] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A cross-sectional study on a randomly selected prospective cohort of patients presenting to a single tertiary spine center. OBJECTIVE The aim of this study was to describe the clinical and radiographic parameters of patients with S- and C-shaped thoracolumbar sagittal spinal profiles, and to identify predictors of these profiles in a natural, relaxed sitting posture. SUMMARY OF BACKGROUND DATA Sagittal realignment in adult spinal deformity surgery has to consider the sitting profile to minimize the risks of junctional failure. Persistence of an S-shaped sagittal profile in the natural, relaxed sitting posture may reflect a lesser need to accommodate for this posture during surgical realignment. METHODS Consecutive patients with low back pain underwent whole body anteroposterior and lateral radiographs in both standing and sitting. Baseline clinical data of patients and radiographic parameters of both standing and sitting sagittal profiles were compared using χ, unpaired t tests, and Wilcoxon rank-sum test. Subsequently, using stepwise multivariate logistic regression analysis, predictors of S-shaped curves were identified while adjusting for confounders. RESULTS Of the 120 patients included, 54.2% had S-shaped curves when sitting. The most common diagnoses were lumbar spondylosis (26.7%) and degenerative spondylolisthesis (26.7%). When comparing between patients with S- and C-shaped spines in the sitting posture, only diagnoses of degenerative spondylolisthesis (odds ratio [OR], 5.44; P = 0.01) and degenerative scoliosis (OR, 2.00; P = 0.039), and pelvic incidence (PI) >52.5° (OR, 5.48; P = 0.008), were predictive of an S-shaped sitting sagittal spinal alignment on multivariate analysis. CONCLUSION Stiffer lumbar curves (eg, patients with degenerative spondylolisthesis and degenerative scoliosis) or those who have a predilection for an S-shaped standing sagittal profile when sitting (eg, high PI) may be more amenable to fusion in accordance with previously studied sagittal realignment targets. In contrast, more flexible curves may benefit from less aggressive lordotic realignment to prevent potential junctional failures. LEVEL OF EVIDENCE 3.
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Nishida N, Izumiyama T, Asahi R, Iwanaga H, Yamagata H, Mihara A, Nakashima D, Imajo Y, Suzuki H, Funaba M, Sugimoto S, Fukushima M, Sakai T. Changes in the global spine alignment in the sitting position in an automobile. Spine J 2020; 20:614-620. [PMID: 31821889 DOI: 10.1016/j.spinee.2019.11.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 11/26/2019] [Accepted: 11/26/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Studies of the changes in spine alignment in the sitting position have been limited to specific spine segments. Because there have been few studies of global spinopelvic alignment in the sitting position, it is important to assess the changes associated with this position for such settings as developing future design of seats and achieving appropriate restoration of spine alignment. PURPOSE This study aimed to measure changes in global spine alignment when people are sitting in car seats and to analyze the characteristics of those changes. STUDY DESIGN This was a prospective, collaborative study of the radiological evaluation of changes in global spine alignment. PATIENT SAMPLE The study included 113 asymptomatic adult participants (56 men and 57 women) without a history of spine disease or lower limb surgery, and with no current lower back or leg pain. OUTCOME MEASURES Radiographic findings were assessed by measurement of various angles: cervical lordosis (CL), thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), C7 sagittal vertical axis (C7-SVA), T1 spinopelvic inclination (T1SPI), and T1 pelvic angle (TPA). METHODS Radiographs were obtained in the standing and sitting positions. The objective variables analyzed statistically were spine alignments (CL, TK, TLK, LL, C7-SVA, T1SPI, TPA, SS, PT, and PI) measured in the standing position, body alignments (CL, TK, TLK, LL, C7-SVA, T1SPI, TPA, SS, and PT) measured in the sitting position, and stand-to-sit changes (∆CL, ∆TK, ∆TLK, ∆LL, ∆C7-SVA, ∆T1SPI, ∆TPA, ∆SS, and ∆PT). Explanatory variables were sex, age, body height, and body mass index. RESULTS Changing posture from standing to sitting decreased CL by an average of 5.3°, slightly decreased TK by an average of 1.3°, increased TLK by an average of 6.8°, decreased LL by an average of 35°, decreased SS by an average of 49.2°, increased PT by an average of 49.2°, shifted C7-SVA backward by an average of 106.7 mm, decreased T1SPI by an average of 18.8°, and increased TPA by an average of 21.1°. Statistical analysis revealed that ΔLL was significantly decreased in elderly participants. After the stand-to-sit change, ΔTLK and ∆TPA were significantly increased in taller participants and ΔT1SPI was significantly decreased in taller participants. CONCLUSIONS Among other changes, most notably LL is decreased and the pelvic tilt is increased when a person is sitting in a car seat. However, these changes in spine alignment differ with age and height. These findings may be useful for the development of future design of seats and for achieving appropriate surgical restoration of spine alignment.
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Affiliation(s)
- Norihiro Nishida
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan.
| | - Tomohiro Izumiyama
- Vehicle Development Division, Crash Safety Development Department, Mazda Motor Corporation, 3-1, Shinchi, Fuchu-cho, Aki-gun, Hiroshima Prefecture 730-8670, Japan
| | - Ryusuke Asahi
- Vehicle Development Division, Crash Safety Development Department, Mazda Motor Corporation, 3-1, Shinchi, Fuchu-cho, Aki-gun, Hiroshima Prefecture 730-8670, Japan
| | - Hideyuki Iwanaga
- Department of Radiological Technology, Yamaguchi University Hospital, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan
| | - Hiroki Yamagata
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan
| | - Atsushi Mihara
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan
| | - Daisuke Nakashima
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan
| | - Yasuaki Imajo
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan
| | - Hidenori Suzuki
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan
| | - Masahiro Funaba
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan
| | - Shigeru Sugimoto
- Vehicle Development Division, Crash Safety Development Department, Mazda Motor Corporation, 3-1, Shinchi, Fuchu-cho, Aki-gun, Hiroshima Prefecture 730-8670, Japan
| | - Masanobu Fukushima
- Vehicle Development Division, Crash Safety Development Department, Mazda Motor Corporation, 3-1, Shinchi, Fuchu-cho, Aki-gun, Hiroshima Prefecture 730-8670, Japan
| | - Takashi Sakai
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan
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Hey HWD, Ng NLW, Loh KYS, Tan YH, Tan KA, Moorthy V, Lau ETC, Liu G, Wong HK. Sagittal Radiographic Parameters of the Spine in Three Physiological Postures Characterized Using a Slot Scanner and Their Potential Implications on Spinal Weight-Bearing Properties. Asian Spine J 2020; 15:23-31. [PMID: 32160727 PMCID: PMC7904478 DOI: 10.31616/asj.2019.0198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 10/13/2019] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Prospective radiographic comparative study. PURPOSE To compare and understand the load-bearing properties of each functional spinal unit (FSU) using three commonly assumed, physiological, spinal postures, namely, the flexed (slump sitting), erect (standing) and extended (backward bending) postures. OVERVIEW OF LITERATURE Sagittal spinal alignment is posture-dependent and influences the load-bearing properties of the spine. The routine placement of intervertebral cages "as anterior as possible" to correct deformity may compromise the load-bearing capabilities of the spine, leading to complications. METHODS We recruited young patients with nonspecific low back pain for <3 months, who were otherwise healthy. Each patient had EOS images taken in the flexed, erect and extended positions, in random order, as well as magnetic resonance imaging to assess for disk degeneration. Angular and disk height measurements were performed and compared in all three postures using paired t-tests. Changes in disk height relative to the erect posture were caclulated to determine the alignment-specific load-bearing area of each FSU. RESULTS Eighty-three patients (415 lumbar intervertebral disks) were studied. Significant alignment changes were found between all three postures at L1/2, and only between erect and flexion at the other FSUs. Disk height measurements showed that the neutral axis of the spine, marked by zones where disk heights did not change, varied between postures and was level specific. The load-bearing areas were also found to be more anterior in flexion and more posterior in extension, with the erect spine resembling the extended spine to a greater extent. CONCLUSIONS Load-bearing areas of the lumbar spine are sagittal alignment-specific and level-specific. This may imply that, depending on the surgical realignment strategy, attention should be paid not just to placing an intervertebral cage "as anterior as possible" for generating lordosis, but also on optimizing load-bearing in the lumbar spine.
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Affiliation(s)
- Hwee Weng Dennis Hey
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster, National University Health System, Singapore
| | - Nathaniel Li-Wen Ng
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster, National University Health System, Singapore
| | - Khin Yee Sammy Loh
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Yong Hong Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Kimberly-Anne Tan
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster, National University Health System, Singapore
| | - Vikaesh Moorthy
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Eugene Tze Chun Lau
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster, National University Health System, Singapore
| | - Gabriel Liu
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster, National University Health System, Singapore
| | - Hee-Kit Wong
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster, National University Health System, Singapore
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Dennis Hey HW, Choong DAW, Lin AZ, Lau ETC, Teo AQA, Liu G, Wong HK. Patient and radiographer assessment of slump sitting flexion compared to conventional standing forward bending flexion. JOURNAL OF SPINE SURGERY 2018; 4:750-756. [PMID: 30714007 DOI: 10.21037/jss.2018.09.07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background A comparative survey from patients and radiographers of the new slump sitting flexion posture and the conventional standing forward bending posture. This study was performed to compare the technical and logistical aspects of the slump sitting versus the forward bending posture. Slump sitting flexes the lumbar spine more than the forward bending and increases the diagnosis rate of sagittal spinal instability up to 40% depending on the diagnostic criteria used. This should not come at the expense of patient safety and comfort nor burden the radiographers. Methods Sixty patients were recruited from a single tertiary spine centre. Patients were block randomised into two groups with either the forward bending or the slump sitting being performed first. Feedback was obtained through self-administered questionnaires from patients regarding perceived safety, convenience and comfort, plus from radiographers regarding the imaging process, proxy measures of radiographer ability and scan difficulty. Results There was no significant difference between the baseline characteristics in both groups. Majority (63%) of patients preferred slump sitting and felt that forward bending caused pain (P=0.025). Overall, slump sitting was equivalent in comfort, perceived safety and ease to forward bending. Despite requiring more logistics (P=0.031), more effort to set up (P=0.002) and explain (P=0.012), the majority of radiographers (83%) preferred slump sitting. This method was felt to be less dangerous (P=0.015) and easier to maintain (P<0.001). Conclusions This study showed that the superiority of slump sitting in allowing more lumbar flexion compared to the forward bending comes with patient safety or comfort. The technical demands of the learning curve can be offset with training. As such, slump sitting flexion views should be adopted as the standardized method for assessing spinal instability.
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Affiliation(s)
- Hwee Weng Dennis Hey
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Denise Ai Wen Choong
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Adrian Zhigao Lin
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Eugene Tze-Chun Lau
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Alex Quok An Teo
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Gabriel Liu
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Hee-Kit Wong
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
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Chen X, Zhou QS, Xu L, Chen ZH, Zhu ZZ, Li S, Qiu Y, Sun X. Does kyphotic configuration on upright lateral radiograph correlate with instability in patients with degenerative lumbar spondylolisthesis? Clin Neurol Neurosurg 2018; 173:96-100. [DOI: 10.1016/j.clineuro.2018.07.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 07/21/2018] [Accepted: 07/28/2018] [Indexed: 10/28/2022]
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Lumbar Spine Alignment in Six Common Postures: An ROM Analysis With Implications for Deformity Correction. Spine (Phila Pa 1976) 2017; 42:1447-1455. [PMID: 28240654 DOI: 10.1097/brs.0000000000002131] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A cross-sectional study of prospectively collected data. OBJECTIVE To compare lumbar spine alignment in six common postures, and estimate loss in range of motion (ROM) relative to standing. SUMMARY OF BACKGROUND DATA Ideal position for fusion of lumbar spine remains unknown. Although surgical fusion is necessary for deformity correction and symptom relief, the final position in which the vertebrae are immobilized should provide maximum residual function. METHODS Data were collected prospectively from 70 patients with low back pain recruited over a year. All subjects had x-rays performed in slump sitting, forward bending, supine, half squatting, standing, and backward bending postures. ROM quantified in terms of sagittal global and segmental Cobb angles was measured from L1 to S1. Loss of ROM relative to standing was calculated for each posture. Analysis of variance and unpaired t tests were used to identify differences in alignment between postures. RESULTS Slump sitting gives the greatest lumbar flexion followed by forward bending, and supine postures (P < 0.001). Backward bending produces greater lumbar extension than standing (P = 0.035). Half-squatting and standing postures were not significantly different (P = 0.938). For all postures, L4-5 and L5-S1 segments remained in lordosis, with L4-5 having greater ROM than L5-S1. L1-2 turns kyphotic in lying supine, L2-3 at forward bending, and L3-4 at slump sitting in the form of a "kyphosing cascade." Should the entire lumbar spine be fused in standing position from L1-S1, there would likely be a mean loss of 47.6° of lumbar flexion and 5.9° of lumbar extension. CONCLUSION The present study demonstrates the extent of flexibility required of the lumbar spine in assuming various postures. It also enables comparison of the differences in degree of motion occurring in the lumbar spine, both across postures and across segments. Significant loss in ROM, particularly flexion, is anticipated with fusion modeled after the lordotic standing lumbar spine. LEVEL OF EVIDENCE 2.
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