Lumbar lordosis

Lumbar lordosis is a key postural component that has interested both clinicians and researchers for many years. Despite its wide use in assessing postural abnormalities, there remain many unanswered questions regarding lumbar lordosis measurements. Therefore, in this article we reviewed different factors associated with the lordosis angle based on existing literature and determined normal values of lordosis. We reviewed more than 120 articles that measure and describe the different factors associated with the lumbar lordosis angle. Because of a variety of factors influencing the evaluation of lumbar lordosis such as how to position the patient and the number of vertebrae included in the calculation, we recommend establishing a uniform method of evaluating the lordosis angle. Based on our review, it seems that the optimal position for radiologic measurement of lordosis is standing with arms supported while shoulders are flexed at a 30° angle. There is evidence that many factors, such as age, gender, body mass index, ethnicity, and sport, may affect the lordosis angle, making it difficult to determine uniform normal values. Normal lordosis should be determined based on the specific characteristics of each individual; we therefore presented normal lordosis values for different groups/populations. There is also evidence that the lumbar lordosis angle is positively and significantly associated with spondylolysis and isthmic spondylolisthesis. However, no association has been found with other spinal degenerative features. Inconclusive evidence exists for association between lordosis and low back pain. Additional studies are needed to evaluate these associations. The optimal lordotic range remains unknown and may be related to a variety of individual factors such as weight, activity, muscular strength, and flexibility of the spine and lower extremities.     

The relationship between lumbar lordosis and radiologic variables and lumbar lordosis and clinical variables in elderly,African-American women

Several authors have hypothesized that there is a link between lumbar lordosis and low back pain. These relationships have not been previously described in a sample consisting exclusively of elderly, African-American women. The purpose of this study was to describe the relationship between lumbar lordosis and radiologic variables and lumbar lordosis and clinical variables in elderly, African-American women. A total of 475 African-American women enrolled in the multicenter Study of Osteoporotic Fractures participated in this ancillary, cross-sectional, study of lumbar lordosis. These women received lumbar spine radiographs and completed a questionnaire on low back pain and its impact on their daily lives. Lumbar lordosis tertiles were created based on radiographic measurements. Comparisons were made between the tertiles for differences in radiologic and clinical variables. Significant differences (p < 0.0025) were observed between the lordosis tertiles and the presence of spondylolisthesis, intervertebral disc space, and vertebral wedging. No significant differences were observed between the lordosis tertiles for the occurrence of low back pain, symptoms associated with low back pain, and disability experienced from low back pain. The degree of lumbar lordosis was associated with radiologic variables but was not associated with symptoms or decreased function from low back pain. These findings question the clinical utility of the lumbar lordosis measurement in elderly, African-American women.     

Spinal anesthesia and lumbar lordosis

Hyperbaric bupivacaine 0.5% (3.0 ml) was injected intrathecally in two groups of 20 patients. Both groups of patients lay in the lateral position with their hips flexed at 90 degrees. In group F, the hip flexion was maintained for 5 minutes after turning supine. In group S, the hips were straightened before the patients were turned to the supine position. The technique of hip flexion to reduce the lumbar lordosis did not significantly limit the height of anesthetic blockade. The distribution of height of anesthetic blockade showed marked bimodality (P less than 0.05) in both groups, in group F at T4 and T9 and in group S at T3 and T9. Cardiovascular side effects were minimal and equal in both groups.     

Thoracic lordosis in idiopathic scoliosis

Lordosis, a significant aspect of thoracic scoliosis, is difficult to assess with routine clinical radiographs. Computerized analysis of 138 sets of standardized anteroposterior and lateral radiographs served to elicit the three-dimensional structure of scoliosis. Spinal curvatures in the usual anatomic planes and in the sagittal and frontal planes of the apical vertebrae were measured. Lordosis was present in 35% of curves greater than or equal to 40 degrees and in 50% of curves greater than 49 degrees. Lordosis may be a contraindication for brace treatment.     

Surgical correction of congenital thoracic lordosis

A 13-year-old girl with rigid congenital thoracic lordosis and congenital scoliosis was treated by a three-stage procedure of anterior transthoracic closing wedge osteotomies, posterior osteotomies of the laminar synostosis, correction of the deformity by sublaminar wires pulled back to a kyphotic bent Luque rod, and a later "pulling-out" procedure on the lateral chest wall.     

The development of the lumbar lordosis

Summary A postmortem material of lumbar spines from individuals aged 0–25 years was studied. Spines from newborn mature or premature infants were generally straight or kyphotic above a well marked lumbo-sacral angle. The development of the lordosis takes place during the first 3 years after birth and commences before the children start to sit, stand or walk. Children who never assume the erect position develop a lumbar lordosis to the same degree and at the same time as other children. Growth retardation gives a delay in the emergence of the lumbar lordosis.

---

Zusammenfassung Ein Postmortalmaterial von lumbalen Wirbelsäulen von Individuen im Alter von 0–25 Jahren wurde studiert. Die Wirbelsäulen von Neugeborenen, maturen oder prämaturen Kindern, waren gewöhnlich gerade oder kyphotisch über einem gut markierten lumbosacralen Winkel. Die Entwicklung der Lordose findet während der ersten 3 Jahre nach der Geburt statt und beginnt, bevor die Kinder zu sitzen, gehen oder stehen anfangen. Kinder, die niemals die aufrechte Stellung erreichen, entwickeln eine lumbale Lordose von demselben Grad und zu derselben Zeit wie andere Kinder. Wachstumshemmung gibt einen Aufschub des Auftretens der lumbalen Lordose.

---

Résumé Nous avons examiné des colonnes vertébrales, excisées d'individus morts entre l'âge de 0 à 25 ans. Les colonnes vertébrales de prématurés ou de nouveau-nés étaient pour la plupart droites ou cyphotiques au-dessus d'un angle sacro-vertébral nettement marqué. La lordose débute avant que l'enfant commence à s'asseoir, à se mettre debout ou à marcher, et se développe au cours des trois premières années postnatales. Les enfants qui n'adoptent jamais la position verticale développent une lordose lombaire au même degré et en même temps que les autres enfants. La croissance retardée fait que la lordose lombaire apparaît plus tard que normalement.

     

Lumbar lordosis in osteoporosis and in osteoarthritis

The curvature of the lumbar spine and the risk of developing either osteoporosis (OP) or osteoarthritis (OA) are influenced by many common factors. The aim of this study is to determine whether lumbar lordosis is different between patients with either disease and healthy persons. A cross-sectional, blinded, controlled design was implemented. One hundred and twelve postmenopausal women were evaluated for bone mineral density as well as undergoing spinal radiography. Lordosis measurement was performed with Cobb’s method. The sample was divided in four groups: patients with OP (n = 34, L1–L5 = 40.7°, L1–S1 = 54.1°), patients with OA (n = 29, L1–L5 = 38°, L1–S1 = 52.3°), patients with both diseases (n = 20, L1–L5 = 41.8°, L1–S1 = 52.3°) and controls (n = 29, L1–L5 = 38.6°, L1–S1 = 51.8°). For all participants age, height, weight, body mass index, physical activity level and basal metabolic rate were measured and recorded. The results revealed that although the four groups have significant constitutional differences, lumbar lordosis was comparable between them. The reasons for the lack of association are discussed.     

颈椎曲度的测量方法及其临床意义

颈椎曲度的测量是临床上评价颈椎功能的基本方法和确定治疗方案的重要参考指标,然而针对不同情况下如何选择合适的测量方法,以及各测量方法间的相关性研究尚不充分.越来越多的研究表明,使用不同的测量方法可直接影响颈椎异常曲度的判断.因此,通过颈椎曲度测量方法的比较研究,对不同颈椎曲度条件下颈椎病变的临床治疗有着重要的意义.     

Radiographic analysis of lumbar lordosis: centroid, Cobb, TRALL, and Harrison posterior tangent methods

STUDY DESIGN: Delayed, repeated measures, with three examiners each twice digitizing thirty lateral lumbar radiographs. OBJECTIVES: To determine the reliability and clinical utility of the centroid, Cobb, tangential radiologic assessment of lumbar lordosis (TRALL), and Harrison posterior tangent line-drawing methods for analysis of lumbar lordosis. BACKGROUND DATA: Cobb's method is commonly used for curvature analysis on lateral lumbar radiographs, whereas the centroid, TRALL, and Harrison posterior tangent methods are not widely used. METHODS: Thirty lateral lumbar radiographs were digitized twice by each of three examiners. To evaluate reliability of determining global and segmental alignment, all four vertebral body corners of T12-S1 and the superior margin of the femur head were digitized. Angles created were segmental and global centroid, (two-line) Cobb angles, and intersections of posterior tangents. A global TRALL angle was determined. Means, standard deviations, mean absolute differences, interclass and intraclass correlation coefficients (ICC), and confidence intervals were calculated. RESULTS: The interobserver and intraobserver reliabilities of measuring all segmental and global angles were in the high range (ICCs > 0.83). The mean absolute differences of observers' measurements were small (0.6 degrees -2.0 degrees ). Distal segmental (L4-S1) and global angles of lumbar curvature were dependent on the method of measurement. CONCLUSIONS: All four radiographic methods had high reliability and low mean absolute differences of observers' measurements. Because it lacks a segmental analysis, the TRALL method is not recommended. The centroid, Cobb, and Harrison posterior tangent methods provide global and segmental angles. However, the centroid segmental method requires three segments and is less useful for a stability analysis.     

Bilateral implantation of low-profile interbody fusion cages: subsidence, lordosis, and fusion analysis.

BACKGROUND CONTEXT: The use of interbody fusion cages as a treatment for degenerative disc disease has become widespread. Low-profile cages have been developed to allow a closer fit when implanting bilateral cages in patients with smaller vertebral bodies. Some surgeons feel the open design also allows better bone contact and visualization. This is particularly true when two low-profile cages are used adjacent to one another. Because of the open design of low-profile interbody fusion cages, there has been concern regarding such issues as subsidence, lordosis and fusion rates. PURPOSE: This retrospective review of paired bilateral reduced profile interbody fusion cages was completed to assess changes in subsidence, lordosis and fusion. As a secondary goal, patient outcomes were measured to determine overall health since surgery and the patient's satisfaction with the spine surgery, in an attempt to assess the effect of the outcome variables cited supra. STUDY DESIGN: This was a retrospective evaluation of patients who underwent anterior lumbar interbody fusion with low-profile interbody fusion cages. PATIENT SAMPLE: Seventy-one consecutive patients who underwent bilateral implantation of low-profile interbody fusion cages were evaluated. OUTCOME MEASURES: A patient self-evaluation, which included a Short Form (SF)-36 and questions regarding patient satisfaction were administered to patients who were at least 1 year postoperative. Subsidence and lordosis measurements were completed. Fusion was assessed by the operating surgeon. METHODS: Low-profile interbody fusion cages (BAK/Proximity, Centerpulse Spine-Tech, Inc., Minneapolis, MN) were implanted bilaterally in at least one level from L3-L4 to L5-S1. Most patients had degenerative disc disease with leg and back pain that was not responsive to conservative treatment and demonstrated segmental instability or collapse. A small percentage of patients had either a degenerative spondylolisthesis (7.0%) or an isthmic spondylolisthesis (4.2%). Autograft harvested from the iliac crest was used in all cases. Demographic, surgical and follow-up data were retrospectively collected from patient charts. A clinical outcome questionnaire that included an SF-36 as well as questions regarding patient satisfaction was either mailed to each patient who was at least 1 year postsurgery or given to patients to complete at their 1-year visit. Patients were routinely followed radiographically before surgery, immediately after surgery and at 3, 6, 12 and 24 months after surgery. Fusion was assessed by the operating surgeon using lateral radiographs often in conjunction with a thin-slice computed tomography (CT) scan. Criteria for a successful fusion were lack of motion, anterior bridging bone and lack of lucencies on flexion/extension X-rays and/or contiguous bone through the cage using a thin-cut sagittal CT scan. Lateral X-rays on each patient were also measured for subsidence and lordosis changes. RESULTS: A total of 71 patients (45 men, 26 women) with a mean age of 43.4 years (range, 25 to 74) were evaluated. Thirty-six percent of the patients were smokers, and 96% were worker's compensation patients. Thirty-two percent of the patients had previous lumbar surgery. A total of 100 operative levels were evaluated. There were 45 one-level, 23 two-level and three three-level cases. Forty-nine percent were level L5-S1, 43% were L4-L5 and 8% were L3-L4. The mean duration of symptoms was 31.5 months. Mean surgical time, mean blood loss and mean hospital stay were 139 minutes, 186 cc and 3.34 days, respectively. There were no intraoperative or postoperative complications attributable to the construct and no cases of cage migration or collapse. Patients who were at least 1-year postsurgery and had follow-up X-rays or had undergone a CT scan at this time point were evaluated for fusion status. Sixty-three patients were assessed for fusion. Fifty-four (86%) of these patients were determined to have a solid fusion. Mean time to fusion was 10 months. Fusion was assessed as solid only if all operative levels were fully fused. Mean subsidence of the anterior region was 1.97 mm, whereas the mean subsidence of the posterior region was 0.82 mm. Lordosis was unchanged at all surgical levels with mean lordosis in L3-L4 decreasing only slightly from 13 degrees before surgery to 12 degrees after surgery. L4-L5 and L5-S1 showed only slight increases in lordosis changing from 17 to 18 degrees at L4-L5 and from 17 to 19 degrees at L5-S1. These changes were not statistically significant. The clinical outcome questionnaires had a return rate of 68%. Of the 48 patients who completed the questionnaire, 75% responded that they were happy with the surgical results and would definitely recommend the surgery to a friend. Sixty-seven percent agreed that surgery met their expectations or that surgery improved their condition enough that they would go through it again for the same outcome. The results of the SF-36 portion of the survey revealed that the physical and mental composite scores were within normal range of the US population that has experienced back pain or sciatica. CONCLUSION: Bilateral implantation of low-profile cages in this patient population led to satisfactory outcomes. Subsidence and changes in lordosis were minimal. Fusion rates were good, especially for one-level cases. Patient satisfaction was relatively high, considering the population consisted of 96% worker's compensation cases. With proper surgical technique, bilateral low-profile cages can be used effectively to treat patients with degenerative disc disease.     

The lumbar lordosis below Harrington instrumentation for scoliosis

This retrospective study evaluates lumbar lordosis in 43 patients before and after Harrington instrumentation into the lumbar spine. The authors measured overall lumbar lordosis, lordosis of unfused lumbar levels, and sagittal vertical axis. Lordosis decreased progressively in lower levels of fusion. The increase in lordosis below the fusion did not compensate for the overall loss of lordosis. The sagittal vertical axis moved forward, producing a subtle, asymptomatic form of flat back syndrome.     

Measurement of lumbar lordosis: inter-rater reliability, minimum detectable change and longitudinal variation

STUDY DESIGN: Repeated measures design to examine reliability and longitudinal variation of lumbar lordosis measurement. OBJECTIVES: To determine the interrater reliability, minimum detectable change (MDC) and longitudinal variation of the Cobb method for measuring lumbar lordosis using standardized rules. SUMMARY OF BACKGROUND DATA: The reliability of the 4-line Cobb method for measuring lumbar lordosis was not examined when standardized rules were instituted for drawing the lines. METHODS: A random sample of participants was selected from the Pittsburgh clinic of the multicenter Study of Osteoporotic Fractures for radiographic measurement of lumbar lordosis reliability (n=48) and stability (n=109). A standardized version of the 4-line Cobb method was used for all measurements of lordosis. The Intraclass Correlation Coefficient (ICC) was used to calculate interrater reliability for lordosis and to measure the stability of this measure over an approximate 2-year-time period. The standard error of measurement and MDC were calculated for lordosis measurement based on the ICC value. RESULTS: The interrater reliability coefficient for lumbar lordosis was in the excellent range (ICC=0.98; 95% CI: 0.95, 0.99). The MDC based on measurements between raters was 3.90 degrees. The ICC value for the stability, or reliability from time 1 to time 2, of lordosis measurement over time was 0.81 (95% CI: 0.74, 0.87). CONCLUSION: This study demonstrates that the 4-line Cobb method can be a highly reliable and precise method for measuring lumbar lordosis if standardized procedures are used. The Cobb method has an MDC that is appropriate for clinical use. Also, there is minimal longitudinal variation in lordosis measurements over a 2-year period.     

The association of spinal osteoarthritis with lumbar lordosis

Background  

Careful review of published evidence has led to the postulate that the degree of lumbar lordosis may possibly influence the development and progression of spinal osteoarthritis, just as misalignment does in other joints. Spinal degeneration can ensue from the asymmetrical distribution of loads. The resultant lesions lead to a domino- like breakdown of the normal morphology, degenerative instability and deviation from the correct configuration. The aim of this study is to investigate whether a relationship exists between the sagittal alignment of the lumbar spine, as it is expressed by lordosis, and the presence of radiographic osteoarthritis.     

A method for dynamic measurement of lumbar lordosis

Trunk flexion-extension is accomplished with pelvic and thoracic rotation in the sagittal plane and a smooth coordination of lumbar vertebral translation and rotation. Several systems exist that measure gross trunk movements, but they typically do not track changes in lumbar arc length or curvature. A method for dynamic measurement of changes in lumbar arc length that uses a lordosimeter is presented. A static validation study of postures showed that the measurements are repeatable and compare favorably with a standard measure of lumbar curvature. In a dynamic validation study of a lifting task with a 23-kg load, the measurement method was highly correlated with thoracic and pelvic angular displacement. A discussion of the utility of this measure in biomechanical modeling is presented. A clinical or field version of the lordosimeter is also described.     

Posterior lumbar interbody fusion and segmental lumbar lordosis

Introduction

The sagittal plane of body produces a convex curve anteriorly referred to as the lordotic curve. Malalignment of lordotic curve leads to low back disorders and lumbar spinal surgery has been known to cause this. This study was a retrospective analysis of the effects of posterior lumbar interbody fusion using cages on segmental lumbar lordosis.

Materials and methods

We conducted a retrospective study involving 27 patients of which 16 were females and 11 were males. All patients underwent single level posterior lumbar interbody fusion with insertion of non-wedged intervertebral cage and pedicle screw fixation. Intraoperatively, all patients had a change from knee chest position to prone to augment their lumbar lordosis. The minimum follow up was 2 years and fusion was achieved in 21 patients.

Results

Segmental lordotic angles increased from 15.2° to 20.6° at L4/5 level and from 17.8° to 24.5° at L5/S1 level, preoperative to postoperative, respectively (P < 0.01 at both levels).

Conclusion

Thus apparently, posterior lumbar interbody fusion with insertion of non-wedged intervertebral cage and pedicle screw fixation results in creation and maintenance of lumbar lordosis.     

The role of lumbar lordosis, vertebral end-plate inclination, disc height, and facet orientation in degenerative spondylolisthesis

Degenerative spondylolisthesis (DS) is a common condition of the aging spine, but the underlying pathomechanisms remain controversial. Most previous studies focused on the role of facet-joint alignment and reported a pronounced sagittal orientation. This, however, may also be a secondary feature to the slippage. This study analyzed several radiologic findings in the lower lumbar spine in 23 patients with DS (group A) and 40 age- and sex-matched controls (group B). Facet-joint angulation, intervertebral disc height, lordosis of the lumbar spine (L1-S1), and inclination of the L4, L5, and S1 end plates were assessed from neutral standing lateral radiographs and computed tomography (CT) or magnetic resonance imaging (MRI) investigations. Two findings were found to be significantly different between the groups. Facet joints were aligned more sagittal in group A, and the inclination of the vertebral end plates was more horizontal in group B. There was no statistical difference in lumbar lordosis or L4-5 disc height between the two groups, with disc height being decreased in both groups. In group A, more gliding was associated with a further decrease in disc space, pronounced sagittal alignment of the L4-5 facet joints, and a decrease in lumbar lordosis. We concluded that further studies should focus on the analysis of spinal alignment and lower lumbar end-plate orientation to identify patients at risk for development of DS.     

Relationship between thoracic hypokyphosis, lumbar lordosis and sagittal pelvic parameters in adolescent idiopathic scoliosis

Purpose

Sagittal spine and pelvic alignment of adolescent idiopathic scoliosis (AIS) is poorly described in the literature. It generally reports the sagittal alignment with regard to the type of curve and never correlated to the thoracic kyphosis. The objective of this study is to investigate the relationship between thoracic kyphosis, lumbar lordosis and sagittal pelvic parameters in thoracic AIS.

Methods

Spinal and pelvic sagittal parameters were evaluated on lateral radiographs of 86 patients with thoracic AIS; patients were separated into hypokyphosis group (n = 42) and normokyphosis group (n = 44). Results were statistically analyzed. The lumbar lordosis was lower in the hypokyphosis group, due to the low proximal lordosis. The thoracic kyphosis was not correlated with any pelvic parameters but with the proximal lordosis. The pelvic incidence was correlated with sacral slope, pelvic tilt, lumbar lordosis and highly correlated with distal lumbar lordosis in the two groups. There was a significant linear regression between thoracic kyphosis and proximal lordosis and between pelvic incidence and distal lordosis.

Conclusions

We can consider that the proximal part of the lordosis depends on the thoracic kyphosis and the distal part depends on the pelvic incidence. The hypokyphosis in AIS is independent of the pelvic parameters and could be described as a structural parameter, characteristic of the scoliotic deformity.