The significance of the lumbosacral curve in idiopathic scoliosis

The purpose of this study is to clarify the role of the lumbosacral curve in idiopathic scoliosis from several points of view. Cases with idiopathic scoliosis were radiologically analysed in the frontal plane, in the horizontal plane with CT-scan and in the sagittal plane, and the relationship of these dimensional deformites in the lumbosacral junction was studied. These findings were also contrasted with the severity, the pattern and the chronological changes of the main curve above. From the results it can be said that the lumbosacral curve is not necessarily a compensatory curve, but may play a more positive role in the formation of the curve pattern of the entire spine. Generally, the lumbosacral junction of thoracic scoliosis was less mobile than that of lumbar and double major cases. It was difficult, however, to predict the potential progress of a mild scoliosis from the attitude of the lumbosacral junction.     

Profiles of the cervical, thoracic, and lumbosacral spine in children and adolescents with lumbosacral spondylolisthesis.

The sagittal and frontal profiles of the entire spine are poorly studied in lumbosacral spondylolisthesis. It was the purpose of this study to further investigate these profiles. Standing posterior-anterior and lateral radiographs in 24 children with lumbosacral spondylolisthesis were reviewed (18 isthmic, 6 congenital). Cervical lordosis, lumbar lordosis, thoracic kyphosis, sagittal vertebral axis, sacral inclination, slip magnitude, slip angle, and sagittal rotation were measured. Cobb magnitude, Risser sign, curve location, and direction were noted for those with scoliosis. Relationships between sagittal variables were explored (Pearson correlation). The average age of patients was 14.7 +/- 2.5 years, slip magnitude was 38 +/- 38%, slip angle was 5 +/- 31 degrees, sagittal rotation was -6 +/- 31 degrees, thoracic kyphosis was 29 +/- 16 degrees, cervical lordosis was -1 +/- 12 degrees, and lumbar lordosis was 62 +/- 22 degrees. Correlations were noted between thoracic kyphosis and sacral inclination, percent slip, slip angle, and sagittal rotation. Sacral inclination decreased as the slip increased. Scoliosis was present in 10 children, with an average curve of 19 +/- 6 degrees. Thoracic kyphosis was less in those with scoliosis (21 +/- 25 degrees versus 33 +/- 25 degrees, p = 0.033). In children with lumbosacral spondylolisthesis, the sacrum becomes more vertical as the slip worsens. As the sacrum becomes more vertical, the thoracic spine becomes more lordotic, which is likely an adaptive mechanism used by the body to maintain forward visual gaze.     

Spontaneous resolution of scoliosis associated with lumbar spondylolisthesis

Background contextScoliosis in association with spondylolisthesis is a common phenomenon. According to the traditional opinion, scoliosis should be managed depending on its classification and flexibility. Recently, Crostelli and Mazza proposed a new opinion toward this topic. They advocate that spondylolisthesis-associated scoliosis, especially severe scoliosis, should be considered as idiopathic scoliosis and must be treated with the same principles used in the treatment of idiopathic scoliosis. According to their viewpoints, more scoliotic curves in association with spondylolisthesis need to be treated, either surgically or conservatively.PurposeTo describe the spontaneous correction of a severe case of scoliosis by internal fixation of the spondylolisthesis.Study designCase report of a patient with scoliosis developing in association with high-grade lumbar spondylolisthesis.MethodsA 12-year-old girl presented with a 2-year history of spinal curvature. She did not have low back or leg pain. The scoliotic deformity corrected readily in the supine position. Radiographs revealed 88% slippage of L5 on S1 in addition to a long section curve of the spine with the main 50° curve at the thoracic level. The spondylolisthesis was repaired with segmental instrumentation and circumferential fusion of L5 and S1.ResultsThe scoliosis showed spontaneous resolution gradually after lumbosacral fusion and reached a complete correction 2 years after surgery.ConclusionsThe relationship between scoliosis and spondylolisthesis is complex. If scoliosis is considered to be caused by spondylolisthesis, surgery for the latter condition might be the only required intervention for the patient. Unnecessary operation for scoliosis should be avoided.     

Scoliosis associated with lumbar spondylolisthesis. A clinical survey of 190 young patients

A series of 190 patients with lumbar spondylolisthesis treated operatively during the years 1948-80 at the mean age of 15.2 years (8-19 years) and reexamined 4-36 years (mean 11.2 years) later are presented. In 92 of them (48%) scoliosis (more than 5 degrees) in association with olisthesis was seen. The slipping affected the fifth segment in 90 and fourth segment in two patients. The female predominance was characteristic in the scoliotic group. Dysplastic changes of the posterior arc were more often seen in the group of patients with scoliosis than in the nonscoliotic group, and they also presented a more severe grade of slipping and lumbosacral kyphosis. The curve was usually mild and was situated in the lumbar area. Patients with a higher degree of lumbosacral kyphosis and more severe slipping also had a statistically higher degree of lumbar scoliosis. Operative treatment of spondylolisthesis consisted of posterior or posterolateral fusion in situ, but two patients were treated using ventral fusion and three severe cases with removal of loose posterior element. Lumbar scoliosis classified as sciatic type disappeared in 25 out of 39 patients after lumbosacral fusion, suggesting the "sciatic muscle spasm" as an etiologic factor. The torsional type of curve resulting from asymmetrical slipping of the vertebra was also corrected in 19 out of 28 cases after fusion. At follow-up patients with remaining lumbar scoliosis represented more low-back pain than those without any curve. In our opinion lumbosacral fusion is indicated before lumbar curve changes to structural scoliosis in symptomatic patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Transverse plane pelvic rotation in adolescent idiopathic scoliosis: primary or compensatory?

Several studies have suggested that the pelvis is involved in the etiology or pathogenesis of adolescent idiopathic scoliosis (AIS). The purpose of this retrospective, cross-sectional radiographic study is to identify any correlation between the transverse plane rotational position of the pelvis in stance and operative-size idiopathic or congenital scoliosis deformities, using Scheuermann’s kyphosis and isthmic spondylolisthesis patients for comparison. The hypothesis tested was that the direction of transverse pelvic rotation is the same as that for a thoracic scoliosis. As a group, AIS patients had a significant transverse plane pelvic rotation in the same direction as the thoracic curve. When subdivided into the six Lenke curve patterns, this was true for the groups with a major thoracic curve: thoracic (1), double thoracic (2) and double curve patterns (3). It was not true for patterns with a major thoracolumbar/lumbar curve: single thoracolumbar/lumbar (5) and double thoracic-thoracolumbar/lumbar (6). Nor was it true for triple (4) curves. The Lenke 1 and 2 major thoracic curves without compensatory thoracolumbar/lumbar curves did not have the predicted pelvic rotation. All congenital scoliosis patients studied had main thoracic curves and significant transverse plane pelvic rotation in the same direction as the thoracic curve. There was no transverse plane pelvic rotation in the Scheuermann’s kyphosis or isthmic spondylolisthesis patients. We interpret these findings as consistent with a compensatory rotation of the pelvis in the same direction as the main thoracic curve in most patients with a compensatory thoracolumbar/lumbar curve as well as in patients with main thoracic congenital scoliosis.     

腰骶角与退变性脊柱滑脱的相关性分析

目的 探讨腰骶角与腰椎稳定性、退变性脊柱滑脱之间的关系。方法 对114例退变性脊柱滑脱患者进行腰椎动力位X线摄片，测量每例患者不同体位的腰骶角度和椎体滑脱程度并进行相关性分析。结果 腰骶角与前向椎间位移不稳及退变性脊柱滑脱之间存在显著正相关；立位、过伸位的腰骶角度及椎体滑脱程度明显大于卧位。结论 腰骶角的大小与退变性脊柱滑脱的发生及椎体滑脱程度有直接的关系，腰椎动力位摄片更有利于脊柱滑脱的显示。     

腰骶内固定的适应证与主要技术

腰骶融合手术为脊柱外科中常用术式,而腰骶内固定有助于腰骶融合。其手术适应证包括腰椎滑脱椎间盘突出与椎管狭窄、畸形以及其他原因缃起的腰骶不稳。腰骶内固定的主要技术有Ｇａｌｖｅｓｔｏｎ技术、髂骨螺钉、骶骨椎弓根螺钉、骶骨构、骶骨棒、骶骨杆、关节突螺钉、腰骶椎体间融合、人工椎间盘等。     

Spondylolisthesis in osteogenesis imperfecta due to pedicle elongation: report of two cases.

STUDY DESIGN: Two cases of spondylolisthesis due to severe elongation of pedicles in osteogenesis imperfecta are reported. OBJECTIVE: To describe an unusual type of spondylolisthesis and its successful management. SUMMARY OF BACKGROUND DATA: Spondylolisthesis is known to occur in osteogenesis imperfecta. Reports in the literature are few. Pedicle elongation resulting in spondylolisthesis has only been reported once. There is no report of a successful treatment of this type of spondylolisthesis resulting from pedicle elongation. METHOD: Two adolescent girls suffering from osteogenesis imperfecta presented with lower back pain and thoracic scoliosis. One of them had high-grade spondylolisthesis of L3-L4, L4-L5, and L5-S1, with a thoracic scoliosis. She was treated with anterior interbody fusion L3 to sacrum without instrumentation. Later, progression of her scoliosis required combined anterior and posterior instrumented fusion T1 to L1. The other girl presented with L5 spondylolisthesis and thoracic scoliosis. She has back pain as well as neurologic symptoms in her legs and is waiting for surgery. RESULTS: At the 3-year follow-up the operated patient is symptom-free from her spine and there has been no progression of either deformity. CONCLUSION: High-grade spondylolisthesis due to elongation of pedicle in osteogenesis imperfecta is uncommon. Anterior interbody fusion of all the involved motion segments has produced good pain relief and arrested deformity progression at the 3-year follow-up.     

An unusual natural history of a L5–S1 spondylolisthesis presenting with a sacral insufficiency fracture

Sacral insufficiency fractures have been described in association with conditions leading to osteoporosis. No association with spondylolisthesis has been described to date. A 60-year-old patient with known lumbosacral isthmic spondylolisthesis presented with exacerbation of symptoms initially thought to be linked to her known spinal pathology. Plain radiography, computer tomography, MRI and bone scan confirmed the presence of a recent sacral insufficiency fracture with anterior angulation. Conservative treatment resulted in improvement of symptoms after 6 months. Care should be taken when considering older patients for more aggressive treatment if they present with exacerbation of back pain and sciatica in the presence of a pre-existing spondylolisthesis. A suspicion of insufficiency fracture should be raised if risk factors exist and further investigations ordered in particular if plain radiography is normal. Lumbosacral fusion might be inappropriate in this setting.     

Lumbosacral joint angles in children

We wished to determine values for the lumbosacral angles in children without spondylolisthesis. Eleven angles were measured on 112 consecutive standing lateral radiographs of children ranging in age from 3 to 18 years. Gender and scoliosis affected only sacral roll and the lumbosacral angle, respectively. Lumbar lordosis, lumbar index, and sacral roll all increased with age. Sagittal rotation and slip angle were negative in children without spondylolisthesis. We recommend that sagittal rotation be used to measure rotation at the lumbosacral joint and that lumbar lordosis be measured using the top of the first and the fifth lumbar vertebra.     

Accuracy and safety of pedicle screw placement in neuromuscular scoliosis with free-hand technique

It is a retrospective analytic study of 1,009 transpedicular screws (689 thoracic and 320 lumbosacral), inserted with free-hand technique in neuromuscular scoliosis using postoperative CT scan. The aim of paper was to determine the accuracy and safety of transpedicular screw placement with free-hand technique in neuromuscular scoliosis and to compare the accuracy at different levels in such population. All studies regarding accuracy and safety of pedicle screw in scoliosis represent idiopathic scoliosis using various techniques such as free-hand, navigation, image intensifier, etc., for screw insertion. Anatomies of vertebrae and pedicle are distorted in scoliosis, hence accurate and safe placement of pedicle screw is prerequisite for surgery. Between 2004 and 2006, 37 consecutive patients, average age 20 years (9–44 years), of neuromuscular scoliosis were operated with posterior pedicle screw fixation using free-hand technique. Accuracy of pedicle screws was studied on postoperative CT scan. Placement up to 2 mm medial side and 4 mm lateral side was considered within-safe zone. Of the 1,009 screws, 273 screws were displaced medially, laterally or on the anterior side showing that 73% screws (68% in thoracic and 82.5% in lumbar spine) were accurately placed within pedicle. Considering the safe zone, 93.3% (942/1009, 92.4% in thoracic and 95.3% in lumbar spine) of the screws were within the safe zone. Comparing accuracy according to severity of curve, accuracy was 75% in group 1 (curve <90°) and 69% in group 2 (curve >90°) with a safety of 94.8 and 91.2%, respectively (P = 0.35). Comparing the accuracy at different thoracic levels, it showed 67, 64 and 72% accuracy in upper, middle and lower thoracic levels with safety of 96.6, 89.2 and 93.1%, respectively, exhibiting no statistical significant difference (P = 0.17). Pedicle screw placement in neuromuscular scoliosis with free-hand technique is accurate and safe as other conditions.     

The natural history of idiopathic scoliosis

A clear understanding of the natural history of idiopathic scoliosis is essential for developing effective treatment. The current information on its natural history indicates that a large number of patients have minor degrees of curvature (approximately 100 per 1000 individuals), although only about two per 1000 individuals warrant treatment because of curve progression. A large number of these curves do not increase even without treatment. Prognostic indicators such as growth, menarch, Risser sign, age at diagnosis, and sex are useful for predicting curve progression but are not always precise. Nonpredictive factors include family history, thoracic kyphosis, lumbar lordosis, lumbosacral transitional anomalies, and trunk balance. Future growth potential and curve severity remain the most reliable considerations in predicting the course of the disorder and in devising suitable approaches to treatment.     

Radiological presentations in relation to curve severity in scoliosis associated with syringomyelia

BACKGROUND: Few radiographic guidelines are available to assist clinicians in deciding when to order magnetic resonance imaging in patients with a normal history and physical examination. Most of the recent reports on the radiographic characteristics of scoliosis are limited by a small number of patients and a shortage of large curves. The association between radiological features and the severity of scoliosis has little been elaborated. The purpose of this study is to further explore the radiological presentations in relation to curve severity in scoliosis associated with Chiari malformation and syringomyelia. METHODS: A total of 87 children and adolescents were divided into 3 groups: group 1 (10 degrees < or = Cobb angle < or = 30 degrees), group 2 (30 degrees < Cobb angle < or = 60 degrees), and group 3 (Cobb angle > 60 degrees). Curves were classified into typical and atypical patterns in the coronal plane, and the sagittal profile was measured. Cerebellar tonsillar descent or syrinx patterns in relation to curve severity and the frequency of atypical curves were also investigated. RESULTS: The frequency of atypical curve patterns from groups 1 to 3 was 46.2%, 45.2%, and 40.7%, respectively. A total of 65.3% of patients with typical curve patterns had atypical features in all of the 3 groups. There was a significant difference of kyphotic angle among the 3 groups showing that the larger curves tended to have greater thoracic kyphosis. Both the degree of cerebellar tonsillar descent and syrinx patterns had no correlation with the curve severity or the frequency of atypical curves. CONCLUSIONS: These results show that radiographic presentations including atypical curve patterns, atypical features in typical curve patterns, and a normal to hyperkyphotic thoracic spine may suggest the need for a preoperative magnetic resonance imaging. Kyphosis may be indicative of progressive scoliosis. There is no evidence to suggest that the degree of cerebellar tonsillar descent and syrinx patterns have an effect on the progress of scoliosis and the frequency of atypical curves.     

Sacral and lumbar-pelvic morphology in high-grade spondylolisthesis

Numerous authors have stressed the importance of posterior arch, vertebral bodies, and intervertebral disk dysplastic changes in lumbosacral spondylolisthesis. An extensive morphologic analysis was conducted of the lumbosacral junction in a series of 100 consecutive patients presenting with severe lumbosacral spondylolisthesis. Statistical correlations were found between the pelvic incidence, sacral slope, and pelvic tilt, as found in healthy volunteers. A statistical relationship exists between the lumbosacral kyphosis and pelvic parameters that explains the global sagittal "balance" of this pathological posture. A well-defined morphological criterion, the "S1 index," strongly correlated with the severity and stiffness of lumbosacral spondylolisthesis.     

Results of preoperative pulmonary function testing of adolescents with idiopathic scoliosis. A study of six hundred and thirty-one patients

BACKGROUND: Previous research has suggested a correlation between pulmonary impairment and thoracic spinal deformity. The curve magnitude, number of involved vertebrae, curve location, and decrease in thoracic kyphosis independently contribute to pulmonary impairment, but the strength of these associations has been variable. The objectives of this study were to test the hypothesis that increased thoracic deformity is associated with decreased pulmonary function and to determine which, if any, radiographic measurements of deformity predict pulmonary impairment. METHODS: Preoperative pulmonary function testing and radiographic examination were performed on 631 patients with adolescent idiopathic scoliosis. Correlation analysis and subsequent stepwise multiple regression analysis were carried out to assess the associations between radiographic measurements of deformity and the results of pulmonary function testing. RESULTS: The magnitude of the thoracic curve, the number of vertebrae involved in the thoracic curve, the thoracic hypokyphosis, and coronal imbalance had a minimal but significant effect on pulmonary function. While these four factors were associated with an increased risk of moderate or severe pulmonary impairment, they explained only 19.7%, 18.0%, and 8.8% of the observed variability in forced vital capacity, forced expiratory volume in one second, and total lung capacity, respectively. The degrees of scoliosis that were associated with clinically relevant decreases in pulmonary function were much smaller than previously described, but the majority of the observed variability in pulmonary function was not explained by the radiographic characteristics of the deformity. CONCLUSIONS: Some patients with adolescent idiopathic scoliosis may have clinically relevant pulmonary impairment that is out of proportion with the severity of the scoliosis, and this may alter the decision-making process regarding which fusion technique will produce an acceptable clinical result with the least additional effect on pulmonary function.     

Scoliosis and spondylolisthesis (author's transl)

The coincidence of a scoliosis with a lumbosacral spondylolysis or spondylolisthesis has remained largely ignored in the German language literature. After a survey of the foreign literature the pathogenesis of various combination forms is discussed. Primarily with the aid of oblique X-rays of lumbar scoliosis a scheme of classification involving 7 categories is worked out. The two main categories comprise unstable spondylolisthetic scolioses with increasing abnormal posture and scoliotic spondylolistheses. In these cases a lumbar scoliosis probably induces an asymmetric spondylolysis. The scheme provides the basis for discussion of conservative and surgical treatment. Taking of a standing X-ray is indispensable as a preliminary measure with every lumbar scoliosis. Oblique X-rays of the lumbosacral section appear to be equally necessary at least once. Unilateral laminar sclerosis can be a valuable sign of contralateral one-sided spondylolyses, as can scoliotic E-forms of the spinal column as well. Spondylolisthetic "scolioses" should be fused in the lumbosacral section at an early stage to prevent secondary structural curvatures. Scoliotic spondylolyses-spondylolistheses at this level should on the other hand, only be fused in serious cases accompanied by pain and progression, supplementing dorsolumbar fusion of scoliosis. In any case, the lowest lumbar vertebra must only be fused in an almost straight position. The correction should also be carried out in the case of difficult spondylolisthetic scolioses prior to the lumbosacral dorsolateral fusion using the v. Lackum transsection cast if certain, above all neurologic, findings permit.     

The evaluation of lumbosacral dysplasia in young patients with lumbosacral spondylolisthesis: comparison with controls and relationship with the severity of slip

Introduction

Comparison of lumbosacral dysplasia between normal individuals and patients with low and high grade spondylolisthesis has not been done previously. The objective of this study is to evaluate the relationship between lumbosacral dysplasia and severity of slip in young patients with lumbosacral spondylolisthesis.

Methods

Postero-anterior and lateral radiographs of 120 normal individuals and 131 patients with developmental spondylolisthesis (91 low and 40 high grades) were reviewed. Quantitative evaluation of lumbosacral dysplasia was done using 6 criteria involving the degree of laminar dysplasia, degree of facet dysplasia, size of L5 transverse processes, L5/S1 disc height, type of sacral doming and L5 lumbar index. Subjects were categorized as having no/low, moderate or severe dysplasia based on the total dysplasia score. Comparisons in total dysplasia score between normal, low grade and high grade groups were performed and the correlation between degree of dysplasia and percentage of slip was assessed.

Results

Most normal individuals (88.3%) had no/low dysplasia; most patients with low grade spondylolisthesis (61.5%) had moderate dysplasia, while most patients with high grade spondylolisthesis (72.5%) had severe dysplasia. There was a significant difference in dysplasia between normal individuals and patients with spondylolisthesis. Dysplasia also varied significantly between low and high grade spondylolisthesis. There was a strong positive correlation (r = 0.63) between severity of dysplasia and percentage of slip.

Conclusion

There is a significant relationship between the severity of spondylolisthesis and lumbosacral dysplasia, with mainly no/low dysplasia observed in controls and increasing total dysplasia scores in higher grades of spondylolisthesis. In addition, a variable degree of dysplasia was found within groups with low or high grade spondylolisthesis, suggesting that different subgroups of patients exist with regard to dysplasia. Thus the degree of dysplasia varies in spondylolisthesis and it is possible that different grades of dysplasia could relate to different prognoses or outcomes with treatment.     

Lumbosacral instrumented fusion: analysis of 124 consecutive cases

One hundred twenty-four cases of lumbosacral fusion receiving transpedicular screw fixation were divided into two groups and reviewed retrospectively. The conditions treated include spondylolisthesis, scoliosis, tumor, trauma, and degenerative disc disease. There were 83 males and 41 females in this consecutive series averaging a 45.2-month follow-up. The primary or first-time arthrodesis rate was 91.9%. A learning curve effect as it relates to operative time but not pedicular screw placement was shown. Instrumentation-related and general medical and surgical complications were low. Infection rates were also low; superficial 2.4%, deep 1.6%. Nonunion or delayed union was salvaged in 10 cases, improving the overall fusion rate to 97.6%. The results of this study support the use of lumbosacral transpedicular screw fixation in select spinal conditions.     

Effect of major axial skeleton trauma on preexisting lumbosacral spondylolisthesis.

The incidental occurrence of lumbar spine fractures in individuals with preexisting first degree lumbosacral isthmic spondylolisthesis may be looked upon as a simulated in vivo biomechanical experiment testing the stability of the lumbosacral subluxation. Among 200 patients with thoracolumbar spine fractures managed at the author's institution during the period of 1980-1989, five such cases were collected. All patients had a grade I isthmic spondylolisthesis at the L5-S1 level, and all sustained a burst fracture of the lumbar spine. In two patients, there was a previous history of low back pain and lumbosacral spondylolisthesis. In the other three patients, the olisthesis was judged to be old by a negative 99mTc-MDP bone scan, whereas the fractured vertebra showed intense uptake and/or by the negative operative findings at L5-S1 level during surgery. It was found that the incidence of lumbosacral spondylolisthesis in patients with thoracolumbar fractures was smaller than in the general population but the difference was not statistically significant (p = 0.213). In addition, it is concluded that mild lumbosacral spondylolisthesis can absorb considerable axial loading without an ascertainable evidence of damage.