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Comparative Study
, 20 (5), 713-9

Sagittal Spinopelvic Alignment and Body Mass Index in Patients With Degenerative Spondylolisthesis

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Comparative Study

Sagittal Spinopelvic Alignment and Body Mass Index in Patients With Degenerative Spondylolisthesis

Sébastien Schuller et al. Eur Spine J.

Abstract

The sagittal orientation and osteoarthritis of facet joints, paravertebral muscular dystrophy and loss of ligament strength represent mechanical factors leading to degenerative spondylolisthesis. The importance of sagittal spinopelvic imbalance has been described for the developmental spondylolisthesis with isthmic lysis. However, it remains unclear if these mechanisms play a role in the pathogenesis of degenerative spondylolisthesis. The purpose of this study was to analyze the sagittal spinopelvic alignment, the body mass index (BMI) and facet joint degeneration in degenerative spondylolisthesis. A group of 49 patients with L4-L5 degenerative spondylolisthesis (12 males, 37 females, average age 65.9 years) was compared to a reference group of 77 patients with low back pain without spondylolisthesis (41 males, 36 females, average age 65.5 years). The patient's height and weight were assessed to calculate the BMI. The following parameters were measured on lateral lumbar radiographs in standing position: L1-S1 lordosis, segmental lordosis from L1-L2 to L5-S1, pelvic tilt, pelvic incidence and sacral slope. The sagittal orientation and the presence of osteoarthritis of the facet joints were determined from transversal plane computed tomography (CT). The average BMI was significantly higher (P=0.030) in the spondylolisthesis group compared to the reference group (28.2 vs. 24.8) and 71.4% of the spondylolisthesis patients had a BMI>25. The radiographic analysis showed a significant increase of the following parameters in spondylolisthesis: pelvic tilt (25.6° vs. 21.0°; P=0.046), sacral slope (42.3° vs. 33.4°; P=0.002), pelvic incidence (66.2° vs. 54.2°; P=0.001), L1-S1 lordosis (57.2° vs. 49.6°; P=0.045). The segmental lumbar lordosis was significantly higher (P<0.05) at L1-L2 and L2-L3 in spondylolisthesis. The CT analysis of L4-L5 facet joints showed a sagittal orientation in the spondylolisthesis group (36.5° vs. 44.4°; P=0.001). The anatomic orientation of the pelvis with a high incidence and sacral slope seems to represent a predisposing factor for degenerative spondylolisthesis. Although the L1-S1 lordosis keeps comparable to the reference group, the increase of pelvic tilt suggests a posterior tilt of the pelvis as a compensation mechanism in patients with high pelvic incidence. The detailed analysis of segmental lordosis revealed that the lordosis increased at the levels above the spondylolisthesis, which might subsequently increase posterior stress on facet joints. The association of overweight and a relatively vertical inclination of the S1 endplate is predisposing for an anterior translation of L4 on L5. Furthermore, the sagittally oriented facet joints do not retain this anterior vertebral displacement.

Figures

Fig. 1
Fig. 1
Physiologic types of sagittal spinopelvic balance according to Roussouly. Type I: low pelvic incidence and low sacral slope with a short caudal lumbar lordosis and a thoracolumbar kyphosis. Type II: low pelvic incidence and low sacral slope with a flat back. Type III: normal pelvic incidence and normal sacral slope with a balanced lumbar lordosis and thoracic kyphosis. Type IV: high pelvic incidence and high sacral slope with an increased lumbar lordosis and a thoracic kyphosis
Fig. 2
Fig. 2
Lumbar lordosis between superior endplates of L1 and S1
Fig. 3
Fig. 3
Segmental lordosis between superior endplate of L4 and inferior endplate of L5
Fig. 4
Fig. 4
Spinopelvic parameters: pelvic tilt, pelvic incidence, sacral slope
Fig. 5
Fig. 5
Sagittal facet joint orientation: angle measurement on axial computed tomography plane
Fig. 6
Fig. 6
Influence of spinopelvic alignment and overweight on degenerative spondylolisthesis. a Normal pelvic incidence and normal lumbar lordosis; b high pelvic incidence and high lumbar lordosis; c high pelvic incidence and high lumbar lordosis + overweight; d high pelvic incidence and high lumbar lordosis + overweight + decrease of pelvic tilt (compensation mechanism); e decompensation of spinopelvic balance resulting in degenerative spondylolisthesis

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