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R NB, Ethiraj P, Ramachandraiah MK, Kumaar A, S NJ. Association Between Spinopelvic Parameters and Clinical Outcomes of Patients Treated With Transforaminal Platelet-Rich Plasma Injections for Lumbar Disc Prolapse. Cureus 2024; 16:e66995. [PMID: 39280506 PMCID: PMC11402276 DOI: 10.7759/cureus.66995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2024] [Indexed: 09/18/2024] Open
Abstract
Introduction Lumbar disc prolapse mainly occurs in the regions involving the L4-L5 and L5-S1 vertebrae. In this context, the significance of spinopelvic parameters becomes notably prominent. Non-invasive management of lumbar disc prolapse encompasses medicinal therapy, physical therapy, exercise, and epidural injections. Because of its autologous blood origin, platelet-rich plasma (PRP) therapy has minimal risks associated with immunogenic reactions and side consequences. We evaluated the extent of pain reduction and improvement of functional outcomes in patients having discogenic low back pain with modified spinopelvic parameters before and after undergoing transforaminal autologous PRP injection interventions. Methodology An observational study was conducted between September 2022 and August 2023 on 100 patients with low back pain for six months. The study population comprised patients who did not respond to conservative treatment; they were recruited from the orthopaedic ward of the emergency medicine department and outpatient department at the RL Jalappa Hospital and Research Centre affiliated with Sri Devaraj Urs Medical College in Kolar, India. Every patient received a thorough evaluation that comprised an extensive medical history, a clinical examination, and imaging of the lumbosacral spine from both the front and side views. After obtaining the patient's consent and confirming their readiness for surgery, a PRP injection was administered. The injection technique followed the standardized protocol and was performed by an experienced spine surgeon in collaboration with orthopaedic residents. Pain evaluations utilizing the Visual Analog Scale (VAS) and assessment of functional outcomes using the Oswestry Disability Index (ODI) scale were conducted before and after PRP injections at the one- and six-month follow-ups. Results The average age of the study participants was 41.82 ± 5.0 years, with 55% of them being male. A total of 39% of study samples exhibited an increased angle in spinopelvic parameters. The independent t-test revealed a statistically significant difference in the mean score of back pain, limb pain, and ODI score between patients with increased and decreased angles of spinopelvic parameters before and after injection (p=0.0001). The severity of back pain, leg pain, and functional disability was significantly reduced in patients with increased angles of spinopelvic parameters following PRP injections at the one-month follow-up (p=0.0001). However, at the six-month follow-up, patients encountered recurring symptoms and worsening back pain, leg pain, and functional disability compared to the one-month follow-up. Conversely, the severity of back pain, leg pain, and functional disability has been markedly reduced in the patients with lower spinopelvic parameter angles following PRP injections at one month (p=0.0001) and six months (p=0.0001) compared to pre-injections. Conclusion During the long-term follow-up, subjects with elevated spinopelvic parameter angles reported a lower level of improvement in functional outcome, leg pain, and back pain. The impact of spinopelvic parameters on back pain severity and functional disability is substantial, significantly affecting the functional outcome of patients with lumbar disc prolapse.
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Affiliation(s)
- Navin Balaji R
- Department of Orthopaedics, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - Prabhu Ethiraj
- Department of Orthopaedics, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - Manoj K Ramachandraiah
- Department of Orthopaedics, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - Arun Kumaar
- Department of Orthopaedics, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - Nagakumar J S
- Department of Orthopaedics, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
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Dharnipragada R, Bostrom N, Bertogliat M, Denduluri LS, Dhawan S, Ladd B, Woodrow S, Parr AM. Sagittal balance in sitting and standing positions: A systematic review of radiographic measures. Heliyon 2024; 10:e28545. [PMID: 38590852 PMCID: PMC10999916 DOI: 10.1016/j.heliyon.2024.e28545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 03/16/2024] [Accepted: 03/20/2024] [Indexed: 04/10/2024] Open
Abstract
Background Sagittal imbalance can be caused by various etiologies and is among the most important indicators of spinal deformity. Sagittal balance can be restored through surgical intervention based on several radiographic measures. The purpose of this study is to review the normal parameters in the sitting position, which are not well understood and could have significant implications for non-ambulatory patients. Methods A systematic review was performed adhering to PRISMA Guidelines. Using R-software, the weighted means and 95% confidence intervals of the radiographic findings were calculated using a random effect model and significance testing using unpaired t-tests. Results 10 articles with a total of 1066 subjects reported radiographic measures of subjects with no spinal deformity in the sitting and standing position. In the healthy individual, standing sagittal vertical axis -16.8°was significantly less than sitting 28.4° (p < 0.0001), while standing lumbar lordosis 43.3°is significantly greater than sitting 21.3° (p < 0.0001). Thoracic kyphosis was not significantly different between the two groups (p = 0.368). Standing sacral slope 34.3° was significantly greater than sitting 19.5° (p < 0.0001) and standing pelvic tilt 14.0° was significantly less than sitting 33.9° (p < 0.0001). Conclusions There are key differences between standing and sitting postures, which could lead to undue stress on surgical implants and poor outcomes, especially for non-ambulatory populations. There is a need for more studies reporting sitting and standing radiographic measures in different postures and spinal conditions.
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Affiliation(s)
- Rajiv Dharnipragada
- University of Minnesota Medical School, University of Minnesota Twin-Cities, Minneapolis, MN 55455, USA
| | - Nick Bostrom
- University of Minnesota Medical School, University of Minnesota Twin-Cities, Minneapolis, MN 55455, USA
| | - Mario Bertogliat
- University of Minnesota Medical School, University of Minnesota Twin-Cities, Minneapolis, MN 55455, USA
| | - Lalitha S. Denduluri
- College of Liberal Arts, University of Minnesota Twin-Cities, Minneapolis, MN 55455, USA
| | - Sanjay Dhawan
- Department of Neurosurgery, University of Minnesota Twin-Cities, Minneapolis, MN 55455, USA
| | - Bryan Ladd
- Department of Neurosurgery, University of Minnesota Twin-Cities, Minneapolis, MN 55455, USA
| | - Sarah Woodrow
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Ann M. Parr
- Department of Neurosurgery, University of Minnesota Twin-Cities, Minneapolis, MN 55455, USA
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Oliveira TL, Silva FD, Filho AGO, Nico MAC, Fernandes ARC, Ramiro S, Pinheiro MM. Relationship between spinal structural damage and sagittal balance in axial spondyloarthritis: Is the thoracic spine the starting point? Semin Arthritis Rheum 2024; 65:152415. [PMID: 38340611 DOI: 10.1016/j.semarthrit.2024.152415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 02/04/2024] [Accepted: 02/06/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVES To assess the relationship between spinal structural damage, sagittal balance parameters and spine curvatures in patients with axial spondyloarthritis (axSpA). MATERIAL AND METHODS In this cross-sectional study, the pelvic and sagittal balance parameters were obtained through EOS® (Biospace, Paris, France). Patients were divided into three groups according to the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) tertiles (G1 ≤6, n = 36; G2: 6.1-31, n = 36; G3 >31, n = 35) and pelvic and sagittal parameters were compared across them. Multivariable regression analysis was performed to analyze the impact of spinal structural damage and of other factors on sagittal vertical axis (SVA), an important sagittal balance parameter. RESULTS A total of 107 patients was included. G2 and 3 exhibited higher mean values of thoracic kyphosis T1-T12 when compared to G1 (10.5°(12.3) vs. 22.3°(17.3) vs. 35.2°(14.6), p < 0.001), and G3 demonstrated lumbar L1-S1 straightening compared to the other groups (55.7°(9) and 50.7°(19.8), G1 and G2, respectively, vs. 35.7°(13.2), p < 0.001). Mean SVA values showed an increasing gradient from G1 to G3 (21.6(25.1) vs. 41(44.3) vs. 84.3(47.2)mm, p < 0.001). In the multivariable regression, a one-unit increase in total mSASSS was associated with an average 0.8 mm higher SVA. CONCLUSIONS Our data showed that more spinal structural damage is associated with a higher SVA, reflecting poorer sagittal balance. Patients with increasing spinal damage have an important increase in thoracic kyphosis suggesting that postural modifications in patients with axSpA might have their origin in the thoracic spine.
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Affiliation(s)
- Thauana L Oliveira
- Rheumatology Division, Federal University of São Paulo/ Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil
| | - Flávio D Silva
- Diagnostic Imaging Department, Federal University of São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil; Diagnostic Imaging Department, Fleury Medicina e Saúde, São Paulo, Brazil
| | - Alípio G O Filho
- Diagnostic Imaging Department, Fleury Medicina e Saúde, São Paulo, Brazil
| | - Marcelo A C Nico
- Diagnostic Imaging Department, Fleury Medicina e Saúde, São Paulo, Brazil
| | - Artur R C Fernandes
- Diagnostic Imaging Department, Federal University of São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil
| | - Sofia Ramiro
- Department of Rheumatology, The Netherlands and Zuyderland Medical Center, Leiden University Medical Center, Heerlen, the Netherlands
| | - Marcelo M Pinheiro
- Rheumatology Division, Head of Spondyloarthritis Section, Federal University of São Paulo/ Escola Paulista de Medicina (UNIFESP/EPM), Rua Borges Lagoa, 913/ 53, Vila Clementino, São Paulo, SP CEP 04038-034, Brazil.
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Jacob AM, Yadav SK, Elhence A, Banerjee S, Gahlot N, Gupta S, Rajnish RK, Kantiwal P, Tiwari S. Evaluation of spinopelvic parameters in patients with lumbosacral transitional vertebra: a cross sectional and comparative study. AMERICAN JOURNAL OF NEURODEGENERATIVE DISEASE 2023; 12:123-132. [PMID: 37736164 PMCID: PMC10509491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/10/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION Lumbosacral transitional vertebra (LSTV) is the most common congenital anomaly of the lumbosacral junction and is a frequent cause of back pain in young patients with a prevalence of 4.6% to 36% in different regions. OBJECTIVE The objective of this study was to evaluate spinopelvic parameters in patients with lumbosacral transitional vertebra and to compare them with the same parameters of low back ache patients without lumbosacral transitional vertebra. METHODS This was a cross-sectional and comparative study conducted among low back ache patients presenting to our tertiary care center. Low back ache patients presenting to the outpatient department of AIIMS Jodhpur were screened for LSTV using radiographs. The spinopelvic parameters of those with LSTV were measured using Surgimap software and compared with the parameters of low back ache patients without LSTV. An Independent sample t-test was done and p-values were calculated. RESULTS The spinopelvic parameters, pelvic incidence, pelvic tilt and lumbar lordosis differed significantly in the patients with LSTV. Pelvic incidence was higher in the group with LSTV (58.5+9.3) when compared to the group without LSTV (50+8.8) with a p-value (<0.001). Pelvic tilt was higher in the group with LSTV (19.4+8.8) when compared to the group without LSTV (13.6+7.8) with a p-value (0.001). Lumbar lordosis was significantly higher in the group with LSTV (57.6+13.2) when compared to the group without LSTV (50.7+12.2) with a p-value (0.007). No significant differences were obtained in sacral slope and Pelvic-incidence and lumbar lordosis mismatch. CONCLUSION LSTV alters the spinopelvic parameters. Altered spinopelvic parameters predispose to spondylolisthesis, degenerative disc disease, and facet joint arthritis and are important in preoperative planning in spine and pelvic surgeries.
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Affiliation(s)
- Akhil Mathew Jacob
- Department of Orthopedics, All India Institute of Medical Sciences, Marudhar Industrial Area2nd Phase, M.I.A. 1st Phase, Basni, Jodhpur 342005, Rajasthan, India
| | - Sandeep Kumar Yadav
- Department of Orthopedics, All India Institute of Medical Sciences, Marudhar Industrial Area2nd Phase, M.I.A. 1st Phase, Basni, Jodhpur 342005, Rajasthan, India
| | - Abhay Elhence
- Department of Orthopedics, All India Institute of Medical Sciences, Marudhar Industrial Area2nd Phase, M.I.A. 1st Phase, Basni, Jodhpur 342005, Rajasthan, India
| | - Sumit Banerjee
- Department of Orthopedics, All India Institute of Medical Sciences, Marudhar Industrial Area2nd Phase, M.I.A. 1st Phase, Basni, Jodhpur 342005, Rajasthan, India
| | - Nitesh Gahlot
- Department of Orthopedics, All India Institute of Medical Sciences, Marudhar Industrial Area2nd Phase, M.I.A. 1st Phase, Basni, Jodhpur 342005, Rajasthan, India
| | - Saurabh Gupta
- Department of Orthopedics, All India Institute of Medical Sciences, Marudhar Industrial Area2nd Phase, M.I.A. 1st Phase, Basni, Jodhpur 342005, Rajasthan, India
| | - Rajesh Kumar Rajnish
- Department of Orthopedics, All India Institute of Medical Sciences, Marudhar Industrial Area2nd Phase, M.I.A. 1st Phase, Basni, Jodhpur 342005, Rajasthan, India
| | - Prabodh Kantiwal
- Department of Orthopedics, All India Institute of Medical Sciences, Marudhar Industrial Area2nd Phase, M.I.A. 1st Phase, Basni, Jodhpur 342005, Rajasthan, India
| | - Sarbesh Tiwari
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical SciencesJodhpur 342005, Rajasthan, India
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Miękisiak G. Failed Back Surgery Syndrome: No Longer a Surgeon's Defeat-A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1255. [PMID: 37512066 PMCID: PMC10384667 DOI: 10.3390/medicina59071255] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/25/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023]
Abstract
The introduction of the term Persistent Spinal Pain Syndrome (PSPS-T1/2), replacing the older term Failed Back Surgery Syndrome (FBSS), has significantly influenced our approach to diagnosing and treating post-surgical spinal pain. This comprehensive review discusses this change and its effects on patient care. Various diagnostic methods are employed to elucidate the underlying causes of back pain, and this information is critical in guiding treatment decisions. The management of PSPS-T1/2 involves both causative treatments, which directly address the root cause of pain, and symptomatic treatments, which focus on managing the symptoms of pain and improving overall function. The importance of a multidisciplinary and holistic approach is emphasized in the treatment of PSPS-T1/2. This approach is patient-centered and treatment plans are customized to individual patient needs and circumstances. The review concludes with a reflection on the impact of the new PSPS nomenclature on the perception and management of post-surgical spinal pain.
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Affiliation(s)
- Grzegorz Miękisiak
- Institute of Medicine, University of Opole, 45-040 Opole, Poland
- Vratislavia Medica Hospital, 51-134 Wrocław, Poland
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A comparison of long-term efficacy of K-rod-assisted non-fusion operation and posterior lumbar interbody fusion for single-segmental lumbar disc herniation. J Clin Neurosci 2021; 95:1-8. [PMID: 34929631 DOI: 10.1016/j.jocn.2021.11.025] [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: 04/20/2021] [Revised: 09/15/2021] [Accepted: 11/21/2021] [Indexed: 11/16/2022]
Abstract
K-rod-assisted non-fusion surgery for the treatment of lumbar disc herniation has been proven to have short-term clinical efficacy. Meanwhile, its long-term effects have not been examined. To observed the long-term clinical efficacy of K-rod-assisted non-fusion operation, this study retrospectively analyzed 22 patients with lumbar disc (L4/5) herniation who underwent K-rod-assisted non-fusion operation (n = 13) or PLIF (n = 9). They were followed-up for more than 5 years. The operation times and blood loss were significantly reduced in the K-rod group compared to the PLIF group. At the last follow-up, the clinical outcomes of the K-rod group were improved compared to those of the PLIF group as observed by the VAS score, JOABPEQ, and ODI. Imaging outcomes at the last follow-up indicated that the loss of height in the L3/4 and L5/S1 intervertebral space, the ROM of L3/4 and L5/S1, and the incidence of adjacent segment degeneration in the PLIF group were significantly higher than those in the K-rod group. According to Pfirrmann grading, Modic changes, and UCLA grading, the incidence of adjacent segment degeneration was 55.6% in the PLIF group and 15.4% in the K-rod group. Changes in spino-pelvic parameters between the two groups were as follows: pelvic index remained unchanged, pelvic tilt angle increased, and lumbar lordosis and sacral slope decreased. Therefore, compared to PLIF, single-segment lumbar disc herniation using K-rod-assisted non-fusion surgery resulted in better long-term clinical efficacy. Our results demonstrate that this procedure can delay adjacent segment degeneration after lumbar surgery.
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Hey HWD, Tan JH, Ong B, Kumar A, Liu G, Wong HK. Pelvic and sacral morphology and their correlation with pelvic incidence, lumbar lordosis, and lumbar alignment changes between standing and sitting postures. Clin Neurol Neurosurg 2021; 211:107019. [PMID: 34775257 DOI: 10.1016/j.clineuro.2021.107019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 10/19/2022]
Abstract
STUDY DESIGN Retrospective Cross-Sectional Radiographic Study. OBJECTIVE This study aims to describe novel radiographic markers of sacropelvic morphology to further define the static and dynamic relationship between the pelvis and the spine, via the analysis of two postures - standing and sitting. SUMMARY OF BACKGROUND DATA There is increasing evidence underlining the importance of spinopelvic radiographic parameters in the holistic management of sagittal spinal deformity given the close relationship between pelvic morphology and spinal profile. METHODS This is a retrospective radiographic study of patients who presented with the first episode of isolated mechanical, low back pain of fewer than 3 months' duration. All patients underwent whole spine radiographs using EOS technology in both standing and relaxed sitting postures. Six novel distance measurements (H1, H2, H3, V1, V2, DD) to determine pelvic dimensions, and 3 novel angles (A, B, C) to determine sacral morphology were described. RESULTS A total of 64 males (58.2%) and 46 females (41.8%) with a mean age of 42.8 ± 18.6 (range:17-81) years old was studied. Between standing and relaxed sitting postures, differences were observed in all sagittal radiographic parameters. Multivariate analysis showed that standing LL< 500 (p = 0.008), standing V1 > 13 cm(p = 0.040), and angle B> 800(p = 0.002) are predictive of PI< 500, standing TK< 300 (p = 0.003) and PI< 500 (p = 0.006) are predictive of LL< 500, and standing PT< 170(p = 0.034), standing H3 ≥ 4 cm (p = 0.030), standing angle C< 420 (p = 0.003), sitting SS≥ 60 (p = 0.002), and sitting PT < 450 (p = 0.013) are predictive of change in LL below mean difference of 420 between standing and relaxed sitting. CONCLUSIONS Apart from the known correlation between TK, LL and PI, low PI was found to be associated with a tall pelvis and a straight sacrum (angle B). Association between a small coccygeal inclination angle (angle C) and smaller change in LL between standing and relaxed sitting may have clinical relevance.
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Affiliation(s)
- Hwee Weng Dennis Hey
- Department of Orthopaedic Surgery, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Jun-Hao Tan
- Department of Orthopaedic Surgery, National University Hospital, Singapore.
| | - Bernard Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Akshay Kumar
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Gabriel Liu
- Department of Orthopaedic Surgery, National University Hospital, Singapore.
| | - Hee-Kit Wong
- Department of Orthopaedic Surgery, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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Baker JF, Chan JC, Moon BG, Robertson PA. Relationship of aortic bifurcation with sacropelvic anatomy: Application to anterior lumbar interbody fusion. Clin Anat 2020; 34:550-555. [PMID: 32249448 DOI: 10.1002/ca.23598] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 03/26/2020] [Accepted: 03/31/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Various sacropelvic parameters such as the pelvic Incidence (PI) are used to predict ideal lumbar lordosis and aid surgical planning. The objective of this study was to establish the relationship between the location of the aortic bifurcation from the sacral promontory and sacropelvic measures including the PI. MATERIALS AND METHODS One hundred sixty five computed tomography (CT) scans obtained for major trauma including the entire spine were identified. Sacropelvic parameters including PI, sacral anatomic orientation, pelvic thickness (PTH), and sacral table angle were measured. Aortic bifurcation was identified on sagittal and coronal imaging and the distance from the sacral promontory (bifurcation-promontory distance [BPD]) measured (mm). RESULTS Mean age of the cohort was 44.3 years (SD 18.5; range 16-88 years); 61.8% male. The mean PI was 49.2° (SD 10.2°; range 30°-80°). The mean BPD was 66.4 mm (SD 13.1 mm; range 38.3-100 mm). In the majority, the bifurcation was at the level of the L4 vertebral body (72.7%). Only age (r = -.389; p < .0001) and PTH (r = .172; p = .027) correlated with the BPD to a significant degree. PI did not correlate with BPD (r = .061; p = .435). Linear regression analysis provided the following predictive equation: BPD = 34.3 mm + 0.30 × PTH. CONCLUSION This study demonstrates a lack of any meaningful correlation between sagittal pelvic parameters and the distance of the aortic bifurcation from the sacral promontory. Surgical planning for fusion surgery in the lumbar spine should include assessment of spinopelvic parameters and if anterior access to the lumbar disc(s) necessary, vascular anatomy should be carefully assessed independent of these measures.
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Affiliation(s)
- Joseph F Baker
- Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand.,Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Jonathan C Chan
- Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Benjamin G Moon
- Department of Radiology, Waikato Hospital, Hamilton, New Zealand
| | - Peter A Robertson
- Department of Orthopaedic Surgery, Auckland City Hospital, Auckland, New Zealand
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