CAN PATIENTS WITH SAGITTALLY WELL‐COMPENSATED LUMBAR DEGENERATIVE KYPHOSIS BENEFIT FROM SURGICAL TREATMENT FOR INTRACTABLE BACK PAIN?

OBJECTIVETo analyze pre- and postoperative x-rays of sagittal spines and to review the surgical results of 21 patients with lumbar degenerative kyphosis whose spines were sagittally well compensated by compensatory mechanisms but who continued to suffer from intractable back pain METHODSWe performed a retrospective review of 21 patients treated with combined anterior and posterior spinal arthrodesis. Inclusion criteria were: lumbar degenerative kyphosis patients with intractable back pain and whose spines were sagittally well compensated by a compensatory mechanism, defined as a C7 plumb line to the posterior aspect of the L5–S1 disc of less than 5 cm. Outcome variables included: radiographic measures of preoperative, postoperative, and follow-up films; clinical assessment using the mean Numeric Rating Scale, Oswestry Disability Index, and Patient Satisfaction Index; and a review of postoperative complications. RESULTSAll patients were female (mean age, 64.5 years; age range, 50–74 years). The mean preoperative sagittal imbalance was 19.5 (± 17.6) mm, which improved to −15.8 (± 22.2) mm after surgery. Mean lumbar lordosis was 13.2 degrees (± 15.3) before surgery and increased to 38.1 degrees (± 14.4) at follow-up (P < 0.0001). Mean thoracic kyphosis was 5.5 degrees (± 10.2) before surgery and increased to 18.9 degrees (± 12.4) at follow-up (P < 0.0001). Mean sacral slopes were 12.9 degrees (± 11.1) before surgery and increased to 26.3 degrees (± 9.6) at follow-up (P < 0.0001). The mean Numeric Rating Scale score improved from 7.8 (back pain) and 8.1 (leg pain) before surgery to 3.0 (back pain) and 2.6 (leg pain) after surgery (P < 0.0001). The mean Oswestry Disability Index scores improved from 56.2% before surgery to 36.7% after surgery (P < 0.0001). In 18 (85.5%) of 21 patients, satisfactory outcomes were demonstrated by the time of the last follow-up assessment. CONCLUSIONThis study shows that even lumbar degenerative kyphosis patients with spines that are sagittally well compensated by compensatory mechanisms may suffer from intractable back pain and that these patients can be treated effectively by the restoration of lumbar lordosis.

[1]  J. Jang,et al.  Changes in sagittal alignment after restoration of lower lumbar lordosis in patients with degenerative flat back syndrome. , 2007, Journal of neurosurgery. Spine.

[2]  L. Lenke,et al.  An Analysis of Sagittal Spinal Alignment Following Long Adult Lumbar Instrumentation and Fusion to L5 or S1: Can We Predict Ideal Lumbar Lordosis? , 2006, Spine.

[3]  R. Poolman,et al.  Clinical outcome and radiographic results after operative treatment of Scheuermann's disease , 2002, European Spine Journal.

[4]  P. Anderson,et al.  Analysis of the Sagittal Plane After Surgical Management for Scheuermann’s Disease: A View on Overcorrection and the Use of an Anterior Release , 2002, Spine.

[5]  E. Berthonnaud,et al.  Sagittal morphology and equilibrium of pelvis and spine , 2002, European Spine Journal.

[6]  B. Boisaubert,et al.  The sagittal anatomy of the sacrum among young adults, infants, and spondylolisthesis patients , 2002, European Spine Journal.

[7]  J. Yoo,et al.  Dynamic Sagittal Imbalance of the Spine in Degenerative Flat Back: Significance of Pelvic Tilt in Surgical Treatment , 2001, Spine.

[8]  V. Deviren,et al.  Management of Fixed Sagittal Plane Deformity: Results of the Transpedicular Wedge Resection Osteotomy , 2001, Spine.

[9]  L. Lenke,et al.  Complications and predictive factors for the successful treatment of flatback deformity (fixed sagittal imbalance). , 1999, Spine.

[10]  J. Hecquet,et al.  Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves , 1998, European Spine Journal.

[11]  H. Shufflebarger,et al.  Effect of wide posterior release on correction in adolescent idiopathic scoliosis. , 1998, Journal of pediatric orthopedics. Part B.

[12]  M. Liang,et al.  The North American Spine Society Lumbar Spine Outcome Assessment Instrument: Reliability and Validity Tests , 1996, Spine.

[13]  Kevin W. McEnery,et al.  An Analysis of Sagittal Spinal Alignment in 100 Asymptomatic Middle and Older Aged Volunteers , 1995, Spine.

[14]  T. Lowe,et al.  An Analysis of Sagittal Curves and Balance After Cotrel-Dubousset Instrumentation for Kyphosis Secondary to Scheuermann's Disease: A Review of 32 Patients , 1994, Spine.

[15]  R. Jackson,et al.  Radiographic Analysis of Sagittal Plane Alignment and Balance in Standing Volunteers and Patients with Low Back Pain Matched for Age, Sex, and Size: A Prospective Controlled Clinical Study , 1994, Spine.

[16]  H. Shufflebarger,et al.  Anterior and Posterior Spinal Fusion Staged Versus Same‐Day Surgery , 1991, Spine.

[17]  M Bernhardt,et al.  Segmental Analysis of the Sagittal Plane Alignment of the Normal Thoracic and Lumbar Spines and Thoracolumbar Junction , 1989, Spine.

[18]  M. Jensen,et al.  The Subjective Experience of Acute Pain An Assessment of the Utility of 10 Indices , 1989, The Clinical journal of pain.

[19]  T. Iwahara,et al.  Lumbar Degenerative Kyphosis: Clinical, Radiological and Epidemiological Studies , 1988, Spine.

[20]  R. Winter,et al.  Treatment of symptomatic flatback after spinal fusion. , 1988, The Journal of bone and joint surgery. American volume.

[21]  W. Richardson,et al.  Combined Single Stage Anterior and Posterior Osteotomy for Correction of latrogenic Lumbar Kyphosis , 1988, Spine.

[22]  J McWilliam,et al.  Cervical and lumbar lordosis and thoracic kyphosis in 8, 11 and 15-year-old children. , 1987, European journal of orthodontics.

[23]  S. Voutsinas,et al.  Sagittal profiles of the spine. , 1986, Clinical orthopaedics and related research.

[24]  E. Thomasen.  Vertebral osteotomy for correction of kyphosis in ankylosing spondylitis. , 1985, Clinical orthopaedics and related research.

[25]  T. Beeker,et al.  Toward Standards for Posture: Postural Characteristics of the Lower Back System in Normal and Pathologic Conditions , 1985, Spine.

[26]  E. Bleck,et al.  Radiographic Determination of Lordosis and Kyphosis in Normal and Scoliotic Children , 1983, Journal of pediatric orthopedics.

[27]  J C Fairbank,et al.  The Oswestry low back pain disability questionnaire. , 1980, Physiotherapy.

[28]  C. Larson,et al.  Osteotomy of the spine for correction of flexion deformity in rheumatoid arthritis. , 1969, Clinical orthopaedics and related research.

[29]  Cobb,et al.  Outlines for the study of scoliosis , 1948 .