Lumbar degenerative disease after oblique lateral interbody fusion: sagittal spinopelvic alignment and its impact on low back pain

DOI: https://doi.org/10.21203/rs.3.rs-18785/v1

Abstract

Background: The objective of the retrospective study was to investigated the incidence and risk factors of low back pain (LBP) in patients with lumbar degenerative disease after single-level oblique lateral interbody fusion(OLIF).

Methods: In this retrospective study, 120 patients who undergoing single-level OLIF to treat lumbar degenerative disease were recruited. Preoperative and postoperative radiographic parameters, including segmental lordosis(SL), lumbar lordosis(LL), disk height(DH), pelvic incidence(PI), pelvic tilt (PT), sacral slope(SS), thoracic kyphosis(TK), C7-sagittal vertical axis (SVA). Visual analog scale(VAS) for back and leg pain, and Oswestry Disability Index(ODI), were used to evaluate symptoms and quantify disability. All patients achieved at least two-year follow-up.

Results: A total of 120 Patients who complained low back pain were apportioned to LBP group (n=38; VAS scores for back pain≥3) or Non-LBP group (n=82;VAS scores for back pain<3). There was no difference in age(P=0.082), gender(P=0.425), body mass index(P=0.138), degenerative spondylolisthesis or lumbar spinal stenosis(P=0.529) surgical level(P=0.651), blood Loss (P=0.889) and operative time(P=0.731) between the groups. In both groups, the ODI and VAS scores for back pain and leg pain were significantly improved at the final follow-up compared to the preoperative scores (P=0.003). Furthermore, except for the LBP (P=0.000), there were no significant differences in these scores between the two groups at the final follow-up (P > 0.05). According to the radiographic parameters, in Non-LBP group, the LL, SL, DH, TK and SS had all significantly improved; PT and C7-SVA significantly decreased at the final follow-up compared to the preoperative values. The DH in both groups had significantly improved, no significant difference was found(P=0.325). In the final follow-up, LL, PI-LL, PT and C7-SVA in Non-LBP group had more improvements compared to the LBP group (P<0.05) . Multivariate analysis showed that PT, PI-LL and C7-SVA were identified as significant risk factors for LBP after OLIF.

Conclusion: The clinical outcomes of OLIF for single-level lumbar degenerative disease were satisfactory. Our findings showed that PT, PI-LL mismatch and C7-SVA had the greatest impact on the incidence of LBP. Therefore, patients with appropriate decreased PT, improved C7-SVA and PI-LL match experienced less low back pain. 

Background

Lumbar degenerative disease represents the symptoms of back pain, radiculopathy and neurogenic claudication. The degenerative spondylolisthesis and lumbar spinal stenosis are the most frequent types. The sagittal spinopelvic alignment has become increasingly important for investigating preoperative planning and surgical outcomes.[1-3] Failure to account for sagittal spinopelvic alignment might increase the risk for spinal misalignment and lead to the poor clinical outcomes. Therefore, achieving an ideal sagittal spinopelvic alignment has been recommended for optimal postoperative clinical outcomes.[4-6] The evaluation of sagittal balance is now taken into account more frequently for surgical decisions. [7-9]

Various lumbar interbody fusion techniques has been developed for the management of degenerative lumbar disease, which were thought to be superior compared to conservative treatment. There are several theoretical advantages of fusion techniques, such as restoration of disc height(DH), correction of sagittal spinal balance, and decompression of the neural foramina.[10-12] Recently, oblique lumbar interbody fusion (OLIF) is one of the emerging minimally invasive techniques which has progressively been used. The advantages of this minimally invasive technique is avoiding injury to the paraspinal muscles, psoas muscle, and lumbar plexus, owing to it reach the intervertebral space by the retroperitoneal channel directly.[13-15]

During the procedures, DH could be restored with larger cages; sagittal and coronal alignment could be corrected; spinal canal could be decompression indirectly. However, despite this advantages, there is still parts of patients complain the residual low back pain(LBP). Previous studies have reported sagittal spinal misalignment has been shown to be a risk factor for LBP after fusion.[16-18 ] However, to our knowledge, there is no study regarding on the impact factors of LBP after OLIF. It was our hypothesis that the restored the sagittal spinopelvic alignment is beneficial to relieve the LBP. To determine this, the present retrospective study investigated the incidence and risk factors of LBP of patients with lumbar degenerative disease after OLIF.

Methods

This study retrospectively identified patients who were admitted to our hospital and underwent single-level OLIF surgery from January 2015 and December 2017. The surgery was performed by the same team of surgeons. Inclusion criteria: patients who were diagnosed with symptomatic degenerative spondylolisthesis and/or lumbar spinal stenosis that could not be effectively treated conservatively for 3 months. Patients with isthmic spondylolisthesis, scoliosis, inflammatory spine disease, history of lumbar and abdominal surgery, multi-level degenerative disease of the lumbar spine, trauma, malignancy and infection were excluded from this retrospective study. The Ethics Committee of Third Hospital of Hebei Medical University approved this study. Patient consent for review of medical records was not required, as all data was de-identified. All protocols were conducted in accordance with the research principles in the Declaration of Helsinki. 

The OLIF procedure

All procedures were completed by the same surgeon. The patient was positioned right lateral decubituson on the operating table. The intervertebral disc was approached with a blunt probe. In order to protect posterior muscle and lumbar plexus, blunt dissection was performed through the plane between the retroperitoneal fat and psoas muscle in the retroperitoneal space to access the lumbar spine. Discectomy was performed through this access portal. After opening the annulus fibrosus, then intervertebral disc and cartilage end plate were removed.The cage loaded with allogeneic demineralized bone matrix mixed with cancellous bone was inserted into the intervertebral space under the intraoperative C-arm fluoroscopic guidance.

Clinical Measurements

Clinical and radiographic data were examined preoperative and the final follow-up data. For each patient, the following data were collected: age, gender, body mass index (BMI), diagnosis(degenerative spondylolisthesis or lumbar spinal stenosis), surgical level, operating times and blood loss. Clinical measurements included: Oswestry disability index (ODI) questionnaires were administered for functional evaluation; the Visual Analog Scale (VAS) was used to assess for back pain and leg pain.

Radiographic measurements included: lumbar lordosis (LL) was measured the angle between the upper end plate of L1 and S1; segmental lordosis(SL)was measured the angle between the lower endplate of the vertebra above the surgical level and the upper endplate of the vertebra below the surgical level; thoracic kyphosis (TK)was measured the angle between the upper endplate of T5 and the lower endplate of T12; C7-sagittal vertical axis (SVA) was measured the distance between the C7 plumb line and posterosuperior border of S1; pelvic incidence(PI) was measured the angle between thevertical line of the sacral endplate and the line connecting the middle of the sacral endplate and the midpoint of the bilateral femoral head center; pelvic tilt (PT ) was measured the angle between the line connecting the middle of the sacral endplate and the midpoint of the bilateral femoral head center and the plumb line. sacral slope(SS) was measured the angle between the horizontal plane and the sacral plate; DH was measured an average value of the anterior disc height and the posterior disc height.(Figure 1)

Statistical Analysis

Statistical analyses were performed using SPSS software (Version 22.0, Chicago, IL, USA).In all the analyses, P value <0.05 was considered to be a statistically significant difference. The differences between preoperative and the final follow-up measurements were analyzed using paired sample t-test; independent t-test or chi-squared test was used to identify significant differences between groups; multivariate logistic regression analysis was used to determine the risk factors related to LBP. Results were presented as mean ± standard deviation.

Results

Demographic data are summarized in table 1. A total of 120 patients were included in this study and their mean follow-up period was 28.3months (range, 26-32 months). Patients who complained low back pain were apportioned to LBP group (n=38; VAS scores for back pain≥3) or Non-LBP group (n=82;VAS scores for back pain<3); Table 1). There was no difference in age(P=0.082), gender(P=0.425), body mass index(P=0.138), degenerative spondylolisthesis or lumbar spinal stenosis(P=0.529) surgical level(P=0.651), blood Loss (P=0.889) and operative time(P=0.731) between the groups. None of them required additional surgery on either the surgical level or adjacent levels for recurrent symptoms. Two patients were found thigh numbness and two patients were found transient thigh flexion weakness, all of them have resolved spontaneously within 3 month after operation. Six patients was found cage subsidence after surgery, and one patients have received second-stage posterior fixation.

Clinical outcomes: In both groups, the ODI and VAS scores for back pain and leg pain were significantly improved at the final follow-up compared to the preoperative scores (P=0.003). Furthermore, except for the low back pain (P=0.000), there were no significant differences in these scores between the two groups at the final follow-up (P > 0.05).

Radiographic outcomes:The statistical data in this study showed that in the Non-LBP group, the LL, SL, DH and SS all significantly improved; PT and C7-SVA significantly decreased at the final follow-up. The final follow-up DH was12.8±1.9mm in the LBP group and 13.1±0.9 mm in the Non-LBP group, and this difference was not significant (P=0.325). The final follow-up SL, PI and TK was 7.5°±3.5°, 48.6°±12.2° and 26.3°±11.5° in the LBP group, respectively. no significant difference was found compared to the values in Non-LBP group(P > 0.05). In contrast, the final follow-up PT in the Non-LBP and LBP groups were 15.1°±7.3° and 22.3°±10.8°, respectively, and this difference was significant (P=0.000). The LL for the Non-LBP and LBP groups were 42.2°±11.2 °and 35.8°±8.7°, respectively, at the final follow-up, and these differences were also significant.(P=0.027) In the final follow-up, PI-LL in Non-LBP group had more improvements compared to the LBP group. (P=0.006) The C7-SVA decreased significantly from 51.8±38.9mm to 46.1±37.9mm in the LBP group. Meanwhile, in the Non-LBP group, the C7-SVA decreased significantly from 45.1±37.9mm to 18.0±28.5mm and which was a significant difference in the final follow-up compared between the 2 groups. (P=0.000)(Table 2).

To compare the relative impact of these variables on the incidence of LBP, multiple logistic regression analysis was performed. With a P value < 0.2 applied in a univariate analysis, age,SS, PT, LL, PI-LL, and C7-SVA were analyzed as dependent variables with a forward stepwise method. Based on this analysis, PT, PI-LL and C7-SVA were identified as significant risk factors for LBP after OLIF (Table 3).

Discussion

The most important finding of this present study demonstrated that unadjusted pelvic retroversion (insufficient decreased PT), C7-SVA (body lean forward) and PI-LL mismatch were the risk factors for the LBP after OLIF. Therefore, the insufficient decreased PT implied that pelvic still keep retroversion, could not correct the body lean forward and PI-LL mismatch, which might be the reason for the LBP.

Recently, OLIF has become a popular method of treating lumbar degenerative disease with the advantage of minimizing iatrogenic injury on the posterior vertebral structures compared to the posterior lumbar surgery. Theoretically, the indirect neural decompression could be performed by the restore the intervertebral height.[19.21] Abbasi et al performed 303 OLIF procedures on 568 levels and reported OLIF was a safe and efficacious procedure for the degenerative disease.[22] Lin et al found OLIF could achieve equivalent clinical and radiologic outcomes by indirect decompression compared to other posterior lumbar surgery. And it also have better restoration of DH and less blood loss.[23] Chang et al showed favorable clinical outcomes after OLIF for the lumbar spinal stenosis.[24] Similar to their studies, we analyzed 2 groups ( Non-LBP and LBP groups) comparably matched in terms of demographic data and clinical outcomes who were treated with OLIF after a minimum 2 year follow-up. Both groups have significant improved.

Previous studies have suggested that restoring sagittal spinopelvic parameters may play a significant role in improving the quality of life after surgery. Therefore, it is particularly important to identify and restore adequate sagittal spinopelvic alignment when performing fusion. The authors’ hypothesis was that sagittal malalignment was a risk factor strongly correlated with LBP in patients after surgery. It is well known that pathogenesis and development of degenerative lumbar disease was biomechanical changes caused by sagittal unbalance.[25, 26] The PI was an anatomic parameter which played a fundamental role in the sagittal balance and spinal degeneration. As a result, a higher PI implied a higher SS and LL, which might lead to higher shear forces at the lumbosacral junction. That is one of the reason for developing spondylolisthesis.[2729] According to the posterior lumbar surgery, many studies had suggested that increased SS and LL may lead to better clinical outcomes and less LBP. Failure to reach proper sagittal balance can result in compensatory mechanisms such as decreased SL and LL, increased PT, which have adverse effects on back muscle and eventually lead to LBP[4, 29, 30]. Recently, Liow et al reviewed 63 patients who underwent short-segment lumbar fusion surgery and found patients with higher SS (SS ≥ 30°) experienced less LBP. In their opinion, increased LL and SS indicating better clinical outcomes and sagittal balance.[31]

During the surgery, the larger cage placed at both side of the endplate and located anteriorly vertebral body. In spite of OLIF has effective procedure to indirectly spinal canal decompression and increased SS, there were still parts of patients experienced residual LBP after surgery. From the current study, The statistical data showed that SS in the Non-LBP group at the last follow-up (31.7°±6.9°) significantly improved compared to preoperative values. Nevertheless, SS in the LBP group (26.9°±6.9°)was significantly lower than the other group. After the multiple logistic regression analysis, SS was not the risk factor for LBP after OLIF. As is known to everyone, increased PT means represents pelvic retroversion, which compensates for sagittal spinal imbalance. PT༜20°is recommend to correct the sagittal imbalance and relieve symptoms.[29] In this study, PT in the Non-LBP and LBP groups were 22.3°±10.8° and 15.1°±7.3°at the final follow up, it found significant difference compared to the preoperative value. (P = 0.000) The results suggested degree of the decreased PT in LBP group was not enough to compensated the sagittal imbalance and associated with residual back pain.

In addition, many researches has reported the increased LL and SL correlate with improved clinical outcomes.[3234] Our results showed that there is a significantly improved SL achieved by single-level OLIF in both groups. although the SL in Non-LBP group were slightly higher than that in LBP group, our results do not show a statistically significant difference between the two groups. However, the LL in Non-LBP group was significant higher than that in LBP group.This suggested that the impact of the interbody fusion is not enough to altering overall alignment.The C7-SVA has been reported to be an important index to assess sagittal imbalance. In our study, C7-SVA significantly decreased in both groups at the final follow-up. The changes of C7-SVA in Non-LBP group was more than that in the LBP groups. Additionally, PI-LL of less than 10° was used to indicate whether sagittal reconstruction has been achieved in the Non-LBP group. we found that OLIF could improve the LL and correct the PI-LL mismatch. Furthermore, the decreased C7-SVA was as evidenced by adjustment of LL. Saadeh et al reported single-level lateral lumbar interbody fusion achieved greater improvements in regional lordosis. In their study, global lordosis was not impacted by the single-level intervention. [35] Schwab et al showed the postoperative PI-LL mismatch causes greater residual LBP and proposed SVA, PT, and PI-LL were most closely related to poor clinical outcomes and LBP. [36]

In the perspective of the parameters, although surgery improved the DH, LL,SL,PI-LL match and C7-SVA, ideal sagittal balance could not be achieved in LBP group. OLIF could only limitedly restore sagittal balance with the help of increased the intervertebral height by placing the larger interbody cage anteriorly within the wider distraction of intervertebral space. On the one hand, deficient vertebral distraction is not sufficient for spinal decompression, but also affects the correction of sagittal imbalance. On the other hand, excessive vertebral distraction cause overlarge interbody cage which may increase the risk of subsidence into the endplate and reduce fusion rates. It significantly increased mechanical stress on the adjacent discs. Furthermore, the position of the interbody cage also affected the recovery of the intervertebral height, which indirectly affected the restoration of LL and SL. Therefore, a larger intervertebral cage at the anterior middle third column would be improvement the balance of sagittal spinopelvic alignment. However,with regard to the SL, each level contributes a different and limited magnitude to LL.Therefore, we considered that restoration the intervertebral space height by cage insertion which might not enough alter the mechanical dynamics of the spine.

Limitation

This study has several limitations. First, this is a mall sample size in a single institution retrospective study with relatively short follow-up period. Future study will need a larger cohort followed for a longer period. Second, in the current study, one patients have received second-stage posterior fixation, most patients did not received posterior fixation, whether necessary of posterior fixation for all patients is still need longer follow-up. Third, although the patients with minor sagittal unbalance in this study had better restored the DH, and corrected the LL after surgery, whether OLIF could correct patients with degenerative scoliosis or major unbalance is still unknown. Furthermore, it is still a challenge to determine that how to correct sagittal spinopelvic alignment and in order to maintain optimal postoperative sagittal balance.

Conclusion

This present study demonstrated the clinical outcomes of single-level OLIF for the surgical treatment of lumbar degenerative disease was satisfactory after a minimum 2 year follow-up. According to our results, among the risk factors reported, PT, PI-LL mismatch and C7-SVA had the greatest impact on the incidence of LBP. Therefore, it is particularly important to identify and restore sagittal spinopelvic alignments when performing this procedures.

Abbreviations

Disc height: DH; Oblique lumbar interbody fusion:OLIF; Low back pain:LBP; Oswestry disability index: ODI; Visual Analog Scale :VAS; Lumbar lordosis:LL; Segmental lordosis:SL; thoracic kyphosis: TK; Sagittal vertical axis :SVA; Pelvic incidence:PI; Pelvic tilt: PT; Sacral slope:SS)

Declarations

Acknowledgements

Not applicable.

Authors’ contributions

JL and DZ carried out the manuscript preparation and experimental design, YS conducted patient visits and statistical analysis of the data. JL and DZ carried out the statistical analysis of the data. BQ revised the manuscript critically for important intellectual content and gave final approval of the version to be published. All authors read and approved the final version of this manuscript.

Authors’ information

1Department of Orthopedic Surgery, Third Hospital of Hebei Medical University;2The Key Laboratory of Orthopedic Biomechanics of Hebei Province, 139 Ziqiang Road, Shijiazhuang 050051, China. 

Funding

There was no direct funding source aligned to this study.

Availability of data and materials

Not applicable.

Ethics approval and consent to participate

The Ethics Committee of Third Hospital of Hebei Medical University approved this study. Patient consent for review of medical records was not required, as all data was de-identified. All protocols were conducted in accordance with the research principles in the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

This material has not been published and is not under consideration elsewhere. The authors declare that they have no competing interests.

Acknowledgements

We thank Dr. Yingze Zhang for his support in obtaining the approval of the ethics committee for this study.

References

  1. Zárate-Kalfópulos B, Reyes-Tarrago F, Navarro-Aceves LA, et al.Characteristics of Spinopelvic Sagittal Alignment in Lumbar Degenerative Disease.World Neurosurg. 2019 ;126:e417-e421.
  2. Madkouri R, Brauge D, Vidon-Buthion A, et al. Improvement in sagittal balance after decompression surgery without fusion in patients with degenerative lumbar stenosis: clinical and radiographic results at 1 year. World Neurosurg. 2018;114:e417-e424.
  3. Lai Q, Gao T, Lv X, et al. Correlation between the sagittal spinopelvic alignment and degenerative lumbar spondylolisthesis: a retrospective study.BMC Musculoskelet Disord. 2018;19(1):151.
  4. Aoki Y, Nakajima A, Takahashi H, et al. Influence of pelvic incidence-lumbar lordosis mismatch on surgical outcomes of short-segment transforaminal lumbar interbody fusion.BMC Musculoskelet Disord. 2015;16:213.
  5. Tempel ZJ, Gandhoke GS, Bolinger BD, et al. The Influence of Pelvic Incidence and Lumbar Lordosis Mismatch on Development of Symptomatic Adjacent Level Disease Following Single-Level Transforaminal Lumbar Interbody Fusion.Neurosurgery. 2017;80(6):880-886.
  6. Sebaaly A, Grobost P, Mallam L, et al. Description of the sagittal alignment of the degenerative human spine.Eur Spine J. 2018;27(2):489-496.
  7. Mardare MOprea MPopa I, et al. Sagittal balance parameters correlate with spinal conformational type and MRI changes in lumbar degenerative disc disease: results of a retrospective study.Eur J Orthop Surg Traumatol. 2016;26(7):735-43.
  8. Johnson RD, Valore A, Villaminar A, et al.Pelvic parameters of sagittal balance in extreme lateral interbody fusion for degenerative lumbar disc disease.J Clin Neurosci. 2013 ;20(4):576-581.
  9. Phan K, Nazareth A, Hussain AK, et al. Relationship between sagittal balance and adjacent segment disease in surgical treatment of degenerative lumbar spine disease: meta-analysis and implications for choice of fusion technique.Eur Spine J. 2018 Aug;27(8):1981-1991.
  10. Cho JH, Joo YS, Lim C, et al.Effect of one- or two-level posterior lumbar interbody fusion on global sagittal balance.Spine J. 2017;17(12):1794-1802.
  11. Tessitore E, Melloni I, Gautschi OP, et al. Effect of mono-or bisegmental lordosizing fusion on short-term global and index sagittal balance: a radiographic study.J Neurosurg Sci. 2019;63(2):187-193.
  12. Yamasaki K, Hoshino M, Omori K, et al. Risk Factors of Adjacent Segment Disease After Transforaminal Inter-Body Fusion for Degenerative Lumbar Disease.Spine (Phila Pa 1976). 2017 ;42(2):E86-E92.
  13. Li JX, Phan K, Mobbs R.Oblique Lumbar Interbody Fusion: Technical Aspects, Operative Outcomes, and Complications.World Neurosurg.2017 ;98:113-123.
  14. Xu DS, Walker CT, Godzik J, et al.Minimally invasive anterior, lateral, and oblique lumbar interbody fusion: a literature review.Ann Transl Med. 2018;6(6):104.
  15. Xiao L, Zhao Q, Sun X, et al. Relationship Between Alterations of Spinal/Pelvic Sagittal Parameters and Clinical Outcomes After Oblique Lumbar Interbody Fusion.World Neurosurg. 2020 Jan;133:e156-e164.
  16. Ogura Y, Shinozaki Y, Kobayashi Y, et al. Impact of sagittal spinopelvic alignment on clinical outcomes and health-related quality of life after decompression surgery without fusion for lumbar spinal stenosis.J Neurosurg Spine. 2019 Jan 25:1-6.
  17. Tatsumi M, Mkoba EM, Suzuki Y, et al.Risk factors of low back pain and the relationship with sagittal vertebral alignment in Tanzania.BMC Musculoskelet Disord. 2019 ;20(1):584.
  18. Hori Y, Matsumura A, Namikawa T, et al.Does sagittal imbalance impact the surgical outcomes of short-segment fusion for lumbar spinal stenosis associated with degenerative lumbar scoliosis?J Orthop Sci. 2019 Mar;24(2):224-229.
  19. Fujibayashi S, Hynes RA, Otsuki B, et al. Effect of indirect neural decompression through oblique lateral interbody fusion for degenerative lumbar disease. Spine (Phila Pa 1976). 2015;40:E175-E182.
  20. Sato J, Ohtori S, Orita S, et al. Radiographic evaluation of indirect decompression of mini-open anterior retroperitoneal lumbar interbody fusion: oblique lateral interbody fusion for degenerated lumbar spondylolisthesis. Eur Spine J. 2017;26:671-678.
  21. Jin J, Ryu KS, Hur JW, et al. Comparative study of the difference of perioperative complication and radiologic results: MIS-DLIF (minimally invasive direct lateral lumbar interbody fusion) versus MIS-OLIF (minimally invasive oblique lateral lumbar interbody fusion). Clin Spine Surg. 2018;31:31-36.
  22. Abbasi A, Khaghany K, Orandi V, et al.Clinical and Radiological Outcomes of Oblique Lateral Lumbar Interbody Fusion.Cureus. 2019;11(2):e4029.
  23. Lin GX, Akbary K, Kotheeranurak V, et al.Clinical and Radiologic Outcomes of Direct Versus Indirect Decompression with Lumbar Interbody Fusion: A Matched-Pair Comparison Analysis.World Neurosurg. 2018;119:e898-e909.
  24. Chang SY, Nam Y, Lee J, et al.Impact of Preoperative Diagnosis on Clinical Outcomes of Oblique Lateral Interbody Fusion for Lumbar Degenerative Disease in a Single-institution Prospective Cohort.Orthop Surg. 2019;11(1):66-74.
  25. Farrokhi MR, Haghnegahdar A, Rezaee H, et al. Spinal sagittal balance and spinopelvic parameters in patients with degenerative lumbar spinal stenosis; a comparative study. Clin Neurol Neurosurg. 2016;151:136-141.
  26. Buckland A, Ramchandran S, Day L, et al. Radiological lumbar stenosis severity predictsworsening sagittal malalignment on full-body standing stereoradiographs. Spine J. 2017;17:1601-1610.
  27. Gille O, Bouloussa H, Mazas S, et al. A new classification system for degenerative spondylolisthesis of the lumbar spine.Eur Spine J. 2017 ;26(12):3096-3105.
  28. Zhao J, Xiao Y, Zhai X, et al. Difference of Sagittal Alignment between Adolescents with Symptomatic Lumbar Isthmic Spondylolisthesis and the General Population. Sci Rep. 2018;8(1):10956.
  29. Kim MK, Lee SH, Kim ES, et al. The impact of sagittal balance on clinical results after posterior interbody fusion for patients with degenerative spondylolisthesis: a pilot study. BMC Musculoskelet Disord. 2011;12:69.
  30. Chun SW, Lim CY, Kim K, et al. The relationships between low back pain and lumbar lordosis: a systematic review and metaanalysis. Spine J. 2017;17:1180–1191.
  31. Liow MHL, Goh GS, Chua JL, et al.Sagittally Balanced Degenerative Spondylolisthesis Patients With Increased Sacral Slope and Greater Lumbar Lordosis Experience Less Back Pain After Short-Segment Lumbar Fusion Surgery.Clin Spine Surg. 2020 Jan 6. doi: 10.1097/BSD.0000000000000923. [Epub ahead of print]
  32. Sun J, Wang JJ, Zhang LW, et al.Sagittal Alignment as Predictor of Adjacent Segment Disease After Lumbar Transforaminal Interbody Fusion.World Neurosurg. 2018;110:e567-e571.
  33. Buell TJ, Chen CJ, Nguyen JH, et al. Surgical correction of severe adult lumbar scoliosis (major curves ≥ 75°): retrospective analysis with minimum 2-year follow-up.J Neurosurg Spine. 2019 Jun 21:1-14.
  34. Carlson BB, Saville P, Dowdell J, et al. Restoration of lumbar lordosis after minimally invasive transforaminal lumbar interbody fusion: a systematic review. Spine J. 2019 ;19(5):951-958.
  35. Saadeh YS, Joseph JR, Smith BW, et al.Comparison of Segmental Lordosis and Global Spinopelvic Alignment After Single-Level Lateral Lumbar Interbody Fusion or Transforaminal Lumbar Interbody Fusion.World Neurosurg. 2019 ;126:e1374-e1378.
  36. Schwab F, Patel A, Ungar B, et al.Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery.Spine (Phila Pa 1976). 2010;35(25):2224-31.

Tables

Table1. Demographic data of patients between LBP group and Non-LBP group

 

LBP group

Non-LBP group

P value

Age  (years)

60.5±9.3

57.8±10.2

0.082

Gender (M/F)

13/25

36/46

0.425

BMI (kg/m2)

29.1 ±3.8 

27.12 ±5.1 

0.138

Diagnosis

 

 

0.529

degenerative spondylolisthesis 

28

55

 

lumbar spinal stenosis

10

27

 

Surgical level

 

 

0.651

L3-4

8

22

 

L4-5

30

60

 

Blood Loss (mL)

106.6±11.1

105.8±9.9

0.889

Operative time(min)

95.9±15.2

97.96±11.8 

0.731

 

 

 

Table2. Comparison of preoperative and the final follow-up radiographic parameters between LBP group and Non-LBP group

 

LBP group

Non-LBP group

 

preoperative

final follow-up

preoperative

final follow-up

LL

32.6±13.9

35.8±8.7* 

36.8±10.9

42.2±11.2* **

SL

4.1±2.5

7.5±3.5* 

4.9±3.2

8.8±2.9* 

TK

25.6±12.2

26.3±11.5

20.5±11.7

24.5±10.3* 

C7-SVA

51.8±38.9

46.1±37.9* 

45.1±37.9

18.0±28.5* **

PI

48.6±12.2

48.6±12.2

46.1±8.2

46.1±8.2

PT

23.9±11.3

22.3±10.8

19.8±7.5

15.1±7.3* **

SS

25.1±9.7

26.9±6.9

27.2±8.9

31.7±6.9* **

DH

8.5±3.2

12.8±1.9* 

8.3±2.1

13.1±0.9* 

PI-LL

19.8±8.9

16.5±6.8

9.8±5.9

4.5±3.6* **

* Significant difference was between the preoperative and the final follow-up;

** Significant difference was between LBP group and Non-LBP group. 

 


Table 3. Comparison of preoperative and the final follow-up the visual analogue scale (VAS), Oswestry disability index (ODI) between LBP group and Non-LBP group 

 

LBP group

Non-LBP group

 

preoperative

final follow-up

preoperative

final follow-up

VAS for back pain 

5.9±2.4

3.5±1.2*

5.2±2.2

1.7±1.1*** 

VAS for leg pain 

5.1±1.4

2.1±1.5*

5.3±1.6

1.5±1.1*

ODI

25.5±7.4

12.0±4.7*

25.1±6.7

11.5±3.3*

*Significant difference was between the preoperative and the final follow-up;

** Significant difference was between LBP group and Non-LBP group.