‘Lumbar Degenerative Kyphosis’ Is Not Byword for Degenerative Sagittal Imbalance: Time to Replace a Misconception

Lumbar degenerative kyphosis (LDK) is a subgroup of the flat-back syndrome and is most commonly caused by unique life styles, such as a prolonged crouched posture during agricultural work and performing activities of daily living on the floor. Unfortunately, LDK has been used as a byword for degenerative sagittal imbalance, and this sometimes causes confusion. The aim of this review was to evaluate the exact territory of LDK, and to introduce another appropriate term for degenerative sagittal deformity. Unlike what its name suggests, LDK does not only include sagittal balance disorder of the lumbar spine and kyphosis, but also sagittal balance disorder of the whole spine and little lordosis of the lumbar spine. Moreover, this disease is closely related to the occupation of female farmers and an outdated Asian life style. These reasons necessitate a change in the nomenclature of this disorder to prevent misunderstanding. We suggest the name “primary degenerative sagittal imbalance” (PDSI), which encompasses degenerative sagittal misalignments of unknown origin in the whole spine in older-age patients, and is associated with back muscle wasting. LDK may be regarded as a subgroup of PDSI related to an occupation in agriculture. Conservative treatments such as exercise and physiotherapy are recommended as first-line treatments for patients with PDSI, and surgical treatment is considered only if conservative treatments failed. The measurement of spinopelvic parameters for sagittal balance is important prior to deformity corrective surgery. LDK can be considered a subtype of PDSI that is more likely to occur in female farmers, and hence the use of LDK as a global term for all degenerative sagittal imbalance disorders is better avoided. To avoid confusion, we recommend PDSI as a newer, more accurate diagnostic term instead of LDK.

Multiple Spinal Revision Surgery in a Patient with Parkinson's Disease

Parkinson's disease (PD) patients frequently have several spinal deformities leading to postural instabilities including camptocormia, myopathy-induced postural deformity, Pisa syndrome, and progressive degeneration, all of which adversely affect daily life activities. To improve these postural deformities and relieve the related neurologic symptoms, patients often undergo spinal instrumentation surgery. Due to progressive degenerative changes related to PD itself and other complicating factors, patients and surgeons are faced with instrument failure-related complications, which can ultimately result in multiple revision surgeries yielding various postoperative complications and morbidities. Here, we report a representative case of a 70-year-old PD patient with flat back syndrome who had undergone several revision surgeries, including anterior and posterior decompression and fusion for a lumbosacral spinal deformity. The patient ultimately benefitted from a relatively short segment fixation and corrective fusion surgery.

Restoration of Lumbar Lordosis in Flat Back Deformity: Optimal Degree of Correction

STUDY DESIGN: A retrospective comparative study. PURPOSE: To provide an ideal correction angle of lumbar lordosis (LL) in degenerative flat back deformity. OVERVIEW OF LITERATURE: The degree of correction in degenerative flat back in relation to pelvic incidence (PI) remains controversial. METHODS: Forty-nine patients with flat back deformity who underwent corrective surgery were enrolled. Posterior-anterior-posterior sequential operation was performed. Mean age and mean follow-up period was 65.6 years and 24.2 months, respectively. We divided the patients into two groups based on immediate postoperative radiographs-optimal correction (OC) group (PI-9degrees or =55degrees). Radiological and clinical results were analyzed. RESULTS: Patients in OC group had significantly less correction loss and maintained normal sagittal alignment (sagittal vertical axis<5 cm), as compared to patients in UC group (p<0.05). LL of low PI group significantly maintained within 9degrees better than high PI group (p<0.05). Oswestry disability index (ODI) significantly decreased at last follow-up, as compared to preoperative state. However, there was no significant difference in last follow-up ODI between the groups. CONCLUSIONS: In flat back deformity, correction of LL to within 9degrees of PI will result in better sagittal balance. Thus, we recommend sufficient LL to prevent correction loss, especially in patients with high PI.

Postoperative Flat Back: Contribution of Posterior Accessed Lumbar Interbody Fusion and Spinopelvic Parameters

OBJECTIVE: Posterior accessed lumbar interbody fusion (PALIF) has a clear objective to restore disc height and spinal alignment but surgeons may occasionally face the converse situation and lose lumbar lordosis. We analyzed retrospective data for factors contributing to a postoperative flat back. METHODS: A total of 105 patients who underwent PALIF for spondylolisthesis and stenosis were enrolled. The patients were divided according to surgical type [posterior lumbar inter body fusion (PLIF) vs. unilateral transforaminal lumbar interbody fusion (TLIF)], number of levels (single vs. multiple), and diagnosis (spondylolisthesis vs. stenosis). We measured perioperative index level lordosis, lumbar lordosis, pelvic tilt, sacral slope, pelvic incidence, and disc height in standing lateral radiographs. The change and variance in each parameter and comparative group were analyzed with the paired and Student t-test (p<0.05), correlation coefficient, and regression analysis. RESULTS: A significant perioperative reduction was observed in index-level lordosis following TLIF at the single level and in patients with spondylolisthesis (p=0.002, p=0.005). Pelvic tilt and sacral slope were significantly restored following PLIF multilevel surgery (p=0.009, p=0.003). Sacral slope variance was highly sensitive to perioperative variance of index level lordosis in high sacral sloped pelvis. Perioperative variance of index level lordosis was positively correlated with disc height variance (R2=0.286, p=0.0005). CONCLUSION: Unilateral TLIF has the potential to cause postoperative flat back. PLIF is more reliable than unilateral TLIF to restore spinopelvic parameters following multilevel surgery and spondylolisthesis. A high sacral sloped pelvis is more vulnerable to PALIF in terms of a postoperative flat back.

The Result of Minimal Invasive Anterior Lumbar Interbody Fusion with Posterior Lumbar Interbody Fusion on Degenerative Lumbar Flat Back Disease

STUDY DESIGN: Restrospective study. OBJECTIVES: We tried to find out the effects of minimal invasive anterior lumbar interbody fusion (ALIF) combined with posterior lumbar interbody fusion for degenerative lumbar flat back disease. SUMMARY OF LITERATURE REVIEW: ALIF combined with PLIF is effective in correcting lumbar lordosis. However, the complication rate with conventional ALIF is higher on the lower level. MATERIALS AND METHODS: 21 cases (9 men and 12 women, 46-83 years of age) of having undergone minimal invasive ALIF and PLIF due to degenerative flat back disease were reviewed. The follow-up period was an average of 23 months. We compared the pre-postoperative pain, the functional outcome, the correction of sagittal imbalance and lordotic angle. RESULTS: At final follow-up, 21 cases with the solid fusion experienced a great improvement in their lower back pain(VAS: 7.3 --> 2.6) and leg pain (VAS: 7.0 --> 2.7) and ODI(38.5 --> 18.1). And we experienced correction in sagital imbalance. On levels with anterior fusion, lordotic angle is corrected 6.3 degrees while on levels with posterior fusion, lordotic angle is corrected 9.7 degrees. Plumb line is corrected by 5.2cm, and no complication was found in the follow-up period. CONCLUSIONS: Combined surgery with minimal invasive anterior lumbar interbody fusion and posterior fusion is an effective procedure on patients who need long level surgery for correction of lumbar deformity and decompression.

Anterior Lumbar Interbody Fusion for Focal Type of Degenerative Flat Back: Preliminary Report

OBJECTIVE: The purpose of this study is to determine the efficacy of anterior lumbar interbody fusion(ALIF) for the patients with focal type of degenerative flat back. METHODS: The authors reviewed clinical and radiologic data of 16 patients with focal type of degenerative flat back who underwent ALIF during the period between December 1999 and November 2000. The operation procedure was ALIF using titanium or carbon fiber cages of lordotic angle, which were filled with allograft or autograft mixed with allograft through minilaparotomy. RESULTS: The majority of the patients were female(15 female: 1 male) and the mean age was 60.1 years. Six patients were operated on one level, ten on two levels. The mean follow up period was 10.7 months. The mean operation time was 131minutes and the average estimated blood loss was 133ml. Transfusion was not needed in any case. The mean preoperative lumbar lordotic angle was 4.1 degree(-7.4-41.6) and improved to 17.5 degree(-4.5-41.9) postoperatively. Radiological fusion was achieved in 13 patients(81%). The Oswestry disability index score improved from 62.5% to 23.9% and the patient's subjective improvement rate was 80%. Complications were infection in one patient, incisional hernia in one, symptomatic pseudoarthrosis in one and transient sympathetic disturbance in left leg in three. CONCLUSION: In a subset of the patients with degenerative flat back who showed disc degeneration in one or two levels, ALIF using cages improved patient's symptoms effectively. It seems that ALIF through minilaparotomy can be one of the surgical options in the treatment of the focal type of degenerative flat back.

The Results of Pedicle Subtraction Osteotomy in Iatrogenic Flat Back Syndrome / 대한정형외과학회잡지

PURPOSE: To analyze the results of radiologic and clinical outcomes after pedicle subtraction osteotomy in iatrogenic flat back syndrome. MATERIALS AND METHODS: We reviewed 12 surgical cases of iatrogenic flat back syndrome from January 1998 to July 2001 with a follow-up of more than 12 months. All cases were females and an average age was 59.8 years (48-66 years). An average follow-up period was20.4 months (12-37 months). Initial diagnosis were as follows: lumbar degenerative kyphosis, in 5 cases; spinal stenosis, in 5 cases; spondylolisthesis, in 2 cases. For clinical evaluation, 10-point pain scale and 5-point scale for activity level, cosmesis and subjective satisfaction were used. Lumbar lordotic angles and sagittal vertical axis (SVA) were measured. RESULTS: In radiologic results, an average lumbar lordotic angle at preoperative, postoperative and the last follow-up were 5.13+/-21.69 degree, -31.33+/-16.32 degree, -27.50+/-16.73 degree respectively. And average SVA at preoperative, postoperative and the last follow-up were 8.46+/-6.04 cm, 0.62+/-2.24 cm, 2.82+/-2.81 cm respectively. In clinical results, preoperative pain (6), activity (2) and cosmesis (1.8) were improved to 3.2, 3 and 3.2respectively at the last follow-up. Subjective satisfaction was 3.9. CONCLUSION: Pedicle subtraction osteotomy seemed to be very useful surgical option for improvement of clinical results through recovering of lumbar lordotic angle and sagittal balance in cases of iatrogenic flat back syndrome.