Spinal sagittal imbalance in patients with lumbar disc herniation: its spinopelvic characteristics, strength changes of the spinal musculature and natural history after lumbar discectomy

Chen Liang, Jianmin Sun, Xingang Cui, Zhensong Jiang, Wen Zhang, Tao Li, Chen Liang, Jianmin Sun, Xingang Cui, Zhensong Jiang, Wen Zhang, Tao Li

Abstract

Background: Spinal sagittal imbalance is a widely acknowledged problem, but there is insufficient knowledge regarding its occurrence. In some patients with lumbar disc herniation (LDH), their symptom is similar to spinal sagittal imbalance. The aim of this study is to illustrate the spinopelvic sagittal characteristics and identity the role of spinal musculature in the mechanism of sagittal imbalance in patients with LDH.

Methods: Twenty-five adults with spinal sagittal imbalance who initially came to our clinic for treatment of LDH, followed by posterior discectomy were reviewed. The horizontal distance between C7 plumb line-sagittal vertical axis (C7PL-SVA) greater than 5 cm anteriorly with forward bending posture is considered as spinal sagittal imbalance. Radiographic parameters including thoracic kyphotic angle (TK), lumbar lordotic angle (LL), pelvic tilting angle (PT), sacral slope angle (SS) and an electromyography(EMG) index 'the largest recruitment order' were recorded and compared.

Results: All patients restored coronal and sagittal balance immediately after lumbar discectomy. The mean C7PL-SVA and trunk shift value decreased from (11.6 ± 6.6 cm, and 2.9 ± 6.1 cm) preoperatively to (-0.5 ± 2.6 cm and 0.2 ± 0.5 cm) postoperatively, while preoperative LL and SS increased from (25.3° ± 14.0° and 25.6° ± 9.5°) to (42.4° ± 10.2° and 30.4° ± 8.7°) after surgery (P < 0.05). The preoperative mean TK and PT (24.7° ± 11.3° and 20.7° ± 7.8°) decreased to (22.0° ± 9.8° and 15.8 ± 5.5°) postoperatively (P < 0.05). The largest recruitment order on the level of T7-T8, T12-L1 and the herniated level all improved compared with before and after surgery (P < 0.05). All patients have been followed up for more than 2 years. The mean ODI was 77.8 % before surgery to 4.2 % at the final follow-up.

Conclusions: Spinal sagittal imbalance caused by LDH is one type of compensatory sagittal imbalance. Compensatory mechanism of spinal sagittal imbalance mainly includes a loss of lumbar lordosis, an increase of thoracic kyphosis and pelvis tilt. Spinal musculature plays an important role in spinal sagittal imbalance in patients with LDH.

Keywords: Electromyography; Lumbar disc herniation; Spinal musculature; Spinal sagittal imbalance.

Figures

Fig. 1
Fig. 1
Thirty-three year-old man with L4/5 disc herniation (patient No.2). a Preoperative lateral radiograph showed sagittal imbalance. (SVA 18.3 cm). b Immediately after surgery, radiograph showed restored sagittal balance. (SVA −0.5 cm). c, d MRI revealed L4/5 disc herniation with impingement of the left L5 nerve root. e Lateral radiograph taken 2.5 years after surgery showed sagittal balance. (SVA 0.5 cm)
Fig. 2
Fig. 2
Changes of the largest recruitment order of surface EMG (patient No.2). a before surgery. b immediately after surgery

References

    1. Lamartina C, Berjano P, Petruzzi M, Sinigaglia A, Casero G, Cecchinato R, Damilano M, Bassani R. Criteria to restore the sagittal balance in deformity and degenerative spondylolisthesis. Eur Spine J. 2012;21(Suppl 1):S27–31. doi: 10.1007/s00586-012-2236-9.
    1. Vaz G, Roussouly P, Berthonnaud E, Dimnet J. Sagittal morphology and equilibrium of pelvis and spine. Eur Spine J. 2002;11(1):80–7. doi: 10.1007/s005860000224.
    1. Zhu Z, Zhao Q, Wang B, Yu Y, Qian B, Ding Y, Qiu Y. Scoliotic posture as the initial symptom in adolescents with lumbar disc herniation: its curve pattern and natural history after lumbar discectomy. BMC Musculoskelet Disord. 2011;12:216. doi: 10.1186/1471-2474-12-216.
    1. Labelle H, Mac-Thiong JM, Roussouly P. Spino-pelvic sagittal balance of spondylolisthesis: a review and classification. Eur Spine J. 2011;20(Suppl 5):641–6. doi: 10.1007/s00586-011-1932-1.
    1. Endo K, Suzuki H, Tanaka H, Kang Y, Yamamoto K. Sagittal spinal alignment in patients with lumbar disc herniation. Eur Spine J. 2010;19(3):435–8. doi: 10.1007/s00586-009-1240-1.
    1. Suzuki H, Endo K, Kobayashi H, Tanaka H, Yamamoto K. Total sagittal spinal alignment in patients with lumbar canal stenosis accompanied by intermittent claudication. Spine (Phila Pa 1976) 2010;35(9):E344–6. doi: 10.1097/BRS.0b013e3181c91121.
    1. Lee CS, Lee CK, Kim YT, Hong YM, Yoo JH. Dynamic sagittal imbalance of the spine in degenerative flat back: significance of pelvic tilt in surgical treatment. Spine (Phila Pa 1976) 2001;26(18):2029–35. doi: 10.1097/00007632-200109150-00017.
    1. Booth KC, Bridwell KH, Lenke LG, Baldus CR, Blanke KM. Complications and predictive factors for the successful treatment of flatback deformity (fixed sagittal imbalance) Spine (Phila Pa 1976) 1999;24(16):1712–20. doi: 10.1097/00007632-199908150-00013.
    1. Faro FD, Marks MC, Pawelek J, Newton PO. Evaluation of a functional position for lateral radiograph acquisition in adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 2004;29(20):2284–9. doi: 10.1097/01.brs.0000142224.46796.a7.
    1. Horton WC, Brown CW, Bridwell KH, Glassman SD, Suk SI, Cha CW. Is there an optimal patient stance for obtaining a lateral 36” radiograph? A critical comparison of three techniques. Spine (Phila Pa 1976) 2005;30(4):427–33. doi: 10.1097/01.brs.0000153698.94091.f8.
    1. Le Huec JC, Saddiki R, Franke J, Rigal J, Aunoble S. Equilibrium of the human body and the gravity line: the basics. Eur Spine J. 2011;20(Suppl 5):558–63. doi: 10.1007/s00586-011-1939-7.
    1. Bicalho E, Setti JA, Macagnan J, Cano JL, Manffra EF. Immediate effects of a high-velocity spine manipulation in paraspinal muscles activity of nonspecific chronic low-back pain subjects. Man Ther. 2010;15(5):469–75. doi: 10.1016/j.math.2010.03.012.
    1. Abdel-Wanis ME, Kawahara N. The role of neurofibromin and melatonin in pathogenesis of pseudarthrosis after spinal fusion for neurofibromatous scoliosis. Med Hypotheses. 2002;58(5):395–8. doi: 10.1054/mehy.2001.1467.
    1. Chang KW, Leng X, Zhao W, Ching-Wei C, Chen TC, Chang KI, Chen YY. Quality control of reconstructed sagittal balance for sagittal imbalance. Spine (Phila Pa 1976) 2011;36(3):E186–97. doi: 10.1097/BRS.0b013e3181ef6828.
    1. Legaye J, Duval-Beaupere G, Hecquet J, Marty C. Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine J. 1998;7(2):99–103. doi: 10.1007/s005860050038.
    1. Vialle R, Levassor N, Rillardon L, Templier A, Skalli W, Guigui P. Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects. J Bone Joint Surg Am. 2005;87(2):260–7. doi: 10.2106/JBJS.D.02043.
    1. Mac-Thiong JM, Roussouly P, Berthonnaud E, Guigui P. Age- and sex-related variations in sagittal sacropelvic morphology and balance in asymptomatic adults. Eur Spine J. 2011;20(Suppl 5):572–7. doi: 10.1007/s00586-011-1923-2.
    1. Vrtovec T, Janssen MM, Likar B, Castelein RM, Viergever MA, Pernus F. A review of methods for evaluating the quantitative parameters of sagittal pelvic alignment. Spine J. 2012;12(5):433–46. doi: 10.1016/j.spinee.2012.02.013.
    1. Jackson RP, Kanemura T, Kawakami N, Hales C. Lumbopelvic lordosis and pelvic balance on repeated standing lateral radiographs of adult volunteers and untreated patients with constant low back pain. Spine (Phila Pa 1976) 2000;25(5):575–86. doi: 10.1097/00007632-200003010-00008.
    1. Barrey C, Roussouly P, Perrin G, Le Huec JC. Sagittal balance disorders in severe degenerative spine. Can we identify the compensatory mechanisms? Eur Spine J. 2011;20 Suppl 5:626–33. doi: 10.1007/s00586-011-1930-3.
    1. Lamartina C, Berjano P. Classification of sagittal imbalance based on spinal alignment and compensatory mechanisms. Eur Spine J. 2014;23(6):1177–89. doi: 10.1007/s00586-014-3227-9.
    1. Auchincloss CC, McLean L. The reliability of surface EMG recorded from the pelvic floor muscles. J Neurosci Methods. 2009;182(1):85–96. doi: 10.1016/j.jneumeth.2009.05.027.
    1. Lariviere C, Arsenault AB, Gravel D, Gagnon D, Loisel P. Evaluation of measurement strategies to increase the reliability of EMG indices to assess back muscle fatigue and recovery. J Electromyogr Kinesiol. 2002;12(2):91–102. doi: 10.1016/S1050-6411(02)00011-1.
    1. Lariviere C, Arsenault AB, Gravel D, Gagnon D, Loisel P. Surface electromyography assessment of back muscle intrinsic properties. J Electromyogr Kinesiol. 2003;13(4):305–18. doi: 10.1016/S1050-6411(03)00039-7.
    1. Mohseni BM, Rahmani N, Majdoleslam B, Abdollahi I, Ali SS, Ahmad A. Reliability of surface electromyography in the assessment of paraspinal muscle fatigue: an updated systematic review. J Manipulative Physiol Ther. 2014;37(7):510–21. doi: 10.1016/j.jmpt.2014.05.006.
    1. Heydari A, Nargol AV, Jones AP, Humphrey AR, Greenough CG. EMG analysis of lumbar paraspinal muscles as a predictor of the risk of low-back pain. Eur Spine J. 2010;19(7):1145–52. doi: 10.1007/s00586-010-1277-1.
    1. Kuriyama N, Ito H. Electromyographic functional analysis of the lumbar spinal muscles with low back pain. J Nippon Med Sch. 2005;72(3):165–73. doi: 10.1272/jnms.72.165.
    1. Danneels LA, Coorevits PL, Cools AM, Vanderstraeten GG, Cambier DC, Witvrouw EE, De CH. Differences in electromyographic activity in the multifidus muscle and the iliocostalis lumborum between healthy subjects and patients with sub-acute and chronic low back pain. Eur Spine J. 2002;11(1):13–9. doi: 10.1007/s005860100314.
    1. Sarwahi V, Boachie-Adjei O, Backus SI, Taira G. Characterization of gait function in patients with postsurgical sagittal (flatback) deformity: a prospective study of 21 patients. Spine (Phila Pa 1976) 2002;27(21):2328–37. doi: 10.1097/00007632-200211010-00005.
    1. Lee JH, Kim KT, Suk KS, Lee SH, Jeong BO, Kim JS, Eoh JH, Kim YJ. Analysis of spinopelvic parameters in lumbar degenerative kyphosis: correlation with spinal stenosis and spondylolisthesis. Spine (Phila Pa 1976) 2010;35(24):E1386–91. doi: 10.1097/BRS.0b013e3181e88be6.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren