|Year : 2021 | Volume
| Issue : 1 | Page : 105-112
Do spino-pelvic parameters play a role in development of chronic low backache: A prospective analysis
Roop Singh1, Sushil K Yadav1, Rohtas K Yadav2, Jitendra Wadhwani1, Rajesh K Rohilla1, Ravi Rohilla3
1 Department of Orthopaedic Surgery, Paraplegia & Rehabilitation, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences (PGIMS), Rohtak, Haryana, India
2 Department of Radiodiagnosis, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences (PGIMS), Rohtak, Haryana, India
3 Department of Community Medicine, Government Medical College and Hospital (GMCH), Chandigarh, India
|Date of Submission||25-Dec-2019|
|Date of Decision||23-Mar-2020|
|Date of Acceptance||24-Apr-2020|
|Date of Web Publication||01-Oct-2020|
52 / 9-J, Medical Enclave, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences (PGIMS), Medical Rd, Rohtak 124001, Haryana.
Source of Support: None, Conflict of Interest: None
Introduction: The sagittal spino-pelvic alignment patterns are still poorly understood in patients with chronic low back pain (LBP). Clinical observations suggest that aberrations of posture may play a role in the development of LBP. This study was undertaken with the aim to evaluate spino-pelvic parameters in patients with LBP and with a hypothesis that variation in these may predispose to LBP. Materials and Methods: Fifty patients (26 men and 24 women) with mean age 33.54 ± 8.33 years with a history of LBP of minimum 3 consecutive months constituted the study group and were subjected to standing sagittal spino-pelvic radiographs. Data were analyzed and compared with normative data. Results: The mean values of pelvic incidence (PI) and lumbar lordosis angle (LLA) were 48.52 ± 8.99 and 58.78 ± 9.51, respectively. The correlation of PI with lumbosacral angle (LSA), age, body mass index (BMI), and gender was not significant, but a significant correlation was observed with LLA, pelvic angle (PA), pelvic overhang (PO), pelvic tilt (PT), sacrofemoral distance (SFD), sacral horizontal angle (SHA), and sacropelvic translation (SPT). Sacral inclination angle (SIA), SHA, and PI were found to be significantly positively correlated with LLA, whereas pelvisacral angle (PSA), sacropelvic angle (PRS1), and SPT were found to be significantly negatively correlated. Statistically significant difference was observed only regarding pelvic thickness (PTH) and pelvic radius (PR) between patients with chronic LBP and healthy population. Conclusion: Most significant parameters (PI and LLA) used in spino-pelvic balance assessment have a positive significant correlation with majority of the other parameters and the harmony between them help in maintaining normal spinal column stability and alignment. Variation in some of the spino-pelvic parameters (PTH and PR) may predispose to LBP by putting stresses on the spinal column components and stabilizers.
Keywords: Low back pain, lumbar lordosis angle, pelvic incidence, spino-pelvic alignment
|How to cite this article:|
Singh R, Yadav SK, Yadav RK, Wadhwani J, Rohilla RK, Rohilla R. Do spino-pelvic parameters play a role in development of chronic low backache: A prospective analysis. Indian Spine J 2021;4:105-12
|How to cite this URL:|
Singh R, Yadav SK, Yadav RK, Wadhwani J, Rohilla RK, Rohilla R. Do spino-pelvic parameters play a role in development of chronic low backache: A prospective analysis. Indian Spine J [serial online] 2021 [cited 2021 May 12];4:105-12. Available from: https://www.isjonline.com/text.asp?2021/4/1/105/308217
| Introduction|| |
Spinal balance is conceived as the result of an optimal lordotic positioning of the vertebrae above a correctly oriented pelvis, which therefore with its compensatory mechanism acts as an equalizer of spinal balance., The sagittal shape of the spine plays an important role in the development of many spinal disorders., Well known is the close relation between the sagittal shape of the spine and low back pain (LBP) syndrome., Each person has a unique posture and spino-pelvic alignment that is affected by variables such as age, gender, body mass index (BMI), and pelvic morphology. The harmony among spino-pelvic parameters is of utmost significance. Several studies have shown the importance of sagittal spino-pelvic alignment for maintaining a balanced posture in normal population and various spinal pathologies.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, However, it is still not clear about the influence of sagittal spino-pelvic alignment on LBP. Understanding the patterns of variation in spinal alignment may help to discover the association between spinal balance in normal population and low backache patients.
In the past three decades, increasing emphasis is being placed on quantitative evaluation of the parameters of sagittal spino-pelvic alignment, as it is useful for clinical application and treatment of spino-pelvic pathologies. However, no such study has been undertaken in this part of the world previously to address the paucity of data. This study was undertaken with the aim to evaluate spino-pelvic parameters in patients with LBP and with a hypothesis that variation in these from normal may predispose to LBP.
| Materials and Methods|| |
This study was conducted in a tertiary care center from May 2012 to November 2014 and was a part of the larger study in which patients with a history of LBP of mechanical type with minimum 3 consecutive months were evaluated. Cohort included 50 patients (26 men and 24 women) with mean age 33.54 ± 8.33 years. Informed written consent was obtained from all the subjects participating in the study. The study was cleared by the institutional review board and ethical clearance was given. Exclusion criteria, included patients with gross deformity of spine such as scoliosis or spondylolisthesis, fracture of spine, tumors and infections of spine, history of hip or pelvic disorder, contraindication for radiographic exposure (e.g., pregnancy), predominant leg pain, presence of motor deficit, any other associated spine abnormality, and bedridden patients (to exclude disuse atrophy).,
Each patient of study population was thoroughly examined clinically and subjected to standing sagittal spino-pelvic radiographs. Method of taking radiograph and calculation of various spino-pelvic parameters has been defined in [Table 1]. The participants were instructed to stand straight and relaxed, with their knees fully extended. The elbows were flexed, with both hands resting on a horizontal bar at the level of their shoulders. The film to-focus distance was 2 meters.
MS Excel spreadsheet (Microsoft, Redmond, WA, USA) was used to enter the collected data. Data collected were appropriately coded, and cleaned for any possible errors in SPSS (Statistical Package for the Social Sciences) for Windows version 20.0. (IBM Corp., Armonk, NY, USA). Categorical data were presented as percentage (%). Pearson’s chi-square test was used to evaluate differences between groups for categorized variables. In case expected cell count was less than 5 in >20% cells, Fisher’s exact test was used. Normally distributed data were presented as means and standard deviation, or 95% confidence intervals (CI). For comparing two groups containing quantitative variables, independent sample t test was used. In case of violation of normality, Mann–Whitney test was used. Pearson correlation was used for measuring correlation coefficient between two quantitative variables. In case of qualitative variables, Spearman correlation coefficient was applied. All tests were performed at a 5% level significance; thus, a difference was significant if the P value was < 0.05.
| Results|| |
[Table 2] shows the demographic data of study population and comparison with normal population. Of the 50 patients with chronic LBP analyzed, 26 were men and 24 were women with mean BMI of 25.12 ± 2.67 kg/m2. Both the groups were demographically comparable.
|Table 2: Comparison of demographic data of study population and normal Indian population|
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[Table 3] shows values of various radiological parameters of the study group. The mean values of pelvic incidence (PI) and lumbar lordosis angle (LLA) were 49.82 ± 9.19 (range 26–68) and 59.22 ± 11.32 (range 34–87), respectively.
|Table 3: Findings on sagittal spino-pelvic radiographs in the study population|
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[Table 4] shows correlation of PI and LLA with other radiographic parameters and age, gender, and BMI in study group. Correlation of PI with lumbosacral angle (LSA), age, BMI, and gender was not significant. The rest of the parameters were found to be correlated significantly. Pelvic angle (PA), sacral horizontal angle (SHA), sacral inclination angle (SIA), and PI were found to be significantly positively correlated with LLA, whereas pelvisacral angle (PSA), sacropelvic angle (PRS1), and sacropelvic translation (SPT) were found to be significantly negatively correlated.
|Table 4: Correlation of pelvic incidence and lumbar lordosis angle with other radiographic parameters, age, gender, and BMI|
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[Table 5] shows a comparison between various radiological parameters on sagittal spino-pelvic radiographs in study population and reported normative data in healthy Indian population. All the parameters except pelvic radius (PR) and pelvic thickness (PTH) were comparable with each other and there is no significant difference between them (P > 0.05). Only PR and PTH were found to be significant with a mean value of 124.40 ± 9.86 mm and 111.42 ± 10.19 mm in study group and 128.90 ± 8.86 mm and 116.94 ± 9.41 mm in normal healthy population, respectively (P = 0.01 for PR and 0.005 for PTH).
|Table 5: Comparison of findings of spino-pelvic sagittal radiographs between study population and normal healthy Indian population|
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Magnetic resonance imaging (MRI) showed intervertebral disc degeneration in 27 patients (54%) and in 23 cases (46%), MRI was normal and this data has already been published by the authors.,
| Discussion|| |
Sagittal spino-pelvic alignment in normal population and various spinal disorders such as spondylolisthesis, LBP, and lumbar disc disease had been investigated in the past. Existing studies and reported values are summarized in [Table 6].,,,,,,,,,,,,,,,,,,,,, In this study, various radiographic parameters of sagittal spino-pelvic alignment were measured on sagittal spino-pelvic radiographs of 50 patients with chronic LBP and a comparison was done with the normative data reported for healthy Indian population. Our hypothesis was that the variation in spino-pelvic parameters may predispose individuals to LBP.
|Table 6: Various radiographic parameters reported in literature in patients with spinal pathologies|
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PI represents a key parameter in the complex framework of sagittal spinal alignment and related deformity. It is generally accepted that PI becomes stable around the age of 10 years and remains unchanged throughout the adolescence and adulthood for normal subjects but may be altered by the pathological process that modifies the shape of sacrum or the position of acetabulum within the pelvis. It represents the direct sum of SHA and pelvic tilt (PT), PI = SHA + PT.
A number of studies associated PI with clinical indications, where PI was significantly higher for subjects with spondylolisthesis and other spino-pelvic pathologies., Golbakhsh et al. found no significant difference while comparing PI in LBP patients with and without lumbar instability at L5–S1, L4–L5, and L3–L4 levels. However, while evaluating PI separately for each level, they observed significantly lower values of PI in patients with lumbar instability of L5–S1 origin (P = 0.01). Chaléat-Valayer et al. concluded that patients with lower PI are at higher risk for LBP. They ratiocinated as the PI declines, lumbar lordosis decreases and disc pressure and degeneration increases, causing LBP. Sevrain et al. reported a significant relationship between PI and shear stresses in intervertebral discs. In this study, no significant difference and such association was found regarding PI as values were almost comparable to the normative data (P = 0.476). When compared to normal subjects, PI was shown to be significantly higher for subjects with spondylolisthesis,,,,,, spondyloptosis, spondylosis, and other spinopelvic pathologies.,
Contrary to the healthy population, no correlation was found between PI and age (r = 0.037, P = 0.799); PI and BMI (r = 0.267, P = 0.061); and PI and gender (r = –0.275, P = 0.050) in the study group. A relationship between PI and age was reported for the patients with spondylolisthesis. A number of studies evaluated the relationship between PI and LLA, reporting significant correlation of r = 0.40 to 0.74 (P < 0.001).,,, In this study, we found a significant positive correlation in chronic low back patients (r = 0.594, P < 0.001). The strong correlation between PI and SHA, PT, and PRSI and PI and PT had also been reported., This correlation was also observed in this study, r = 0.50 to 0.70 (P < 0.001). Significant correlation was found between PI and other spino-pelvic parameters, that is, PA (r = 0.40, P = 0.004), SFD (r = 0.56, P < 0.001), pelvic overhang (PO) (r = 0.43, P < 0.002), and SPT (r = 0.29, P = 0.038). High correlation was reported between PI and PRS1 with r = 0.95 (P < 0.001) by Legaye. In this study, significant negative correlation was found between PI and PRS1 with r = –0.99 (P < 0.001).
Itio reported a correlation of r = –0.211 (P = 0.035) between PSA and LLA. Similar significant negative correlation was present in our study with r values of –0.61 (P < 0.001). Jackson et al., found significant negative correlation (r = –0.80 to –0.62, P < 0.001) between PRS1 and LLA. In this study, we also found significant negative correlation with r = –0.57 (P < 0.001). Significant correlation was found between LLA and other spino-pelvic parameters, that is, PA (r = –0.29; P = 0.04), SHA (r = 0.83; P < 0.001), and SIA (r = 0.64; P < 0.001). There was no significant correlation regarding SFD, PO and SPT.
Conflicting results have been reported regarding the relationship between lumbar curvatures and LBP. Hansson et al. compared the lumbar lordosis and the ages of asymptomatic, acute, and chronic LBP patients. They found no difference between either of the groups, except for gender. In a study by Jackson and McManus, it was found that in patients with chronic back pain lumbar lordosis was significantly lower and not age or gender related. Nakipoglu et al. also reported no significant differences regarding LLA, SLA L1–L3, SLA L3–S1, SIA, LSA, and SHA. In contrast, Evcik and Yücel found that SIA was larger in patients with chronic LBP. The degree of lumbar lordosis was not different between normal subjects and patients with LBP in the survey by Mousavi and Nourbaksh. Abdominal muscles, back muscles, and pelvic/back ligament function and tone can change lumbar lordosis, and this may affect the diagnosis and treatment in patients with LBP and also affect planning of a proper exercise program for the back or abdominal muscles.
On comparison of data of the normative Indian and chronic LBP patients of this study, no significant differences regarding LLA (P = 0.62), SLA L1–L3 (P = 0.47), SLA L3–S1 (P = 0.35), LSA (P = 0.18), SHA (P = 0.97), and SIA (P = 0.22) were observed except for PR (P = 0.001) and PTH (P = 0.005). The PTH and PR are the only anatomic parameters that represent the distance in the saccropelvic structures. Jackson et al. reported no correlation of PR with subject weight, height, or spinal disorders. Legaye reported significant correlation between PRS1 and PR (r = 0.38–0.73; P < 0.001). In another study, he reported that the close relation between “PI” (and “PR-S1”) and “sagittal pelvic thickness (SPT)” highlighted the ability of a subject to compensate a sagittal disturbance of the spinopelvic unit. In this study, we also found significant correlation between these two spino-pelvic parameters (r = 0.46; P = 0.001). It is now well established that the shape and the spatial orientation of the pelvis determine the organization of the lumbo-thoracic spine. The pelvis, with its static morphology, serves as the base of the spine and articulates with it through the sacrum and sacroiliac joints. The morphology of the pelvis determines the position of the sacrum. The mobile spine adapts to the sacral position, adjusting the degree of curvature to achieve a mechanically efficient posture. Sagittal PTH is strongly connected to the traditional anatomical sagittal angular parameters for the evaluation of the sagittal balance of the spinopelvic unit. Moreover, it allowed a better evaluation of the lever arms of the muscles between pelvis, spine, and hips and the sacroiliac joints. We presume that these two anatomical pelvic parameters (PTH and PR) are reliable for sagittal spinal balance and the variation in these from the normative values may predispose to chronic LBP by altering this harmonious relationship of pelvis and spine; and putting stresses on the spinal column components and stabilizers. It needs to be further validated by robust clinical and biomechanical studies.
This study has few limitations. Numbers of patients included in the study are less. Sagittal vertical axis (SVA) and global sagittal balance were not included due to nonavailability of 36-inch films in our setup at the time of study; we took whole spine radiographs on two films. There were technical problems of stitching two films, and it led to errors in computing these two.
| Conclusion|| |
We conclude from the findings of this study that most significant parameters (PI and LLA) used in spino-pelvic balance assessment have a positive significant correlation with majority of the other parameters and the harmony between them may be helping in maintaining normal spinal column stability and alignment. Variation in some of the spino-pelvic parameters (PTH and PR) may predispose to chronic LBP by altering this harmonious relationship of pelvis and spine, and putting stresses on the spinal column components and stabilizers. These findings can help in identifying subjects prone to develop LBP in the clinical practice. Further extensive clinical and biomechanical studies are needed to validate the role of aberration in these spino-pelvic radiological parameters in causation of low backache.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]