A distinct wedge-shaped deformity of the thoracolumbar vertebrae in Lumbar Disc Degeneraion Patients

doi:10.21203/rs.3.rs-2857989/v1

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A distinct wedge-shaped deformity of the thoracolumbar vertebrae in Lumbar Disc Degeneraion Patients

https://doi.org/10.21203/rs.3.rs-2857989/v1

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Purpose. To determine how the shape of vertebral in thoracolumbar zoon may be associated with spine saggital balance and upper lumbar disc degeneration(ULDD).

Methods. Assessed the imaging of 58 patients who underwent operation at The Tenth People’s Hospital of Shanghai. MRI, CT and plain radiographs of the lumbar spine were evaluated. Vertebral deformities on plain radiographs were identified by wedge-shaped vertebral (WSV, wedge-shaped angle>5). These deformities were assessed for association with saggital balance alignment and ULDD.

Results. Cervical lordosis (CL), thoracic kyphosis (TK), and thoracolumbar kyphosis (TLK) in thoracolumbar wedge-shaped vertebral (TLWSV) group were significantly greater than none wedged-shaped vertebral (NWSV) group (p<0.05). Besides, the upper lumbar disc Pfirrmann grades is also significantly greater in TLWSV group. However, sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI), C7 plumb line and T10 plumb line was similar between TLWSV group and NWSV group (P >0.05), which might is related with the compensation mechanism of spine.

Conclusion. This is the first study to examine WSV on plain radiographs of the lumbar spine for saggital balance alignment and ULDD. Patients with WSV in thoracolumbar regeion reported worsening spine saggital alignment and ULDD. This highlights the relationship between WSV and spine saggital alignment and suggests WSV may accelerate ULDD.

Level of Evidence: 3

wedge-shaped vertebral

lumbar

degeneration

disc

deformity

Thoracolumbar spine is a transition from thoracic to lumbar region, which transforms from flat, coronally oriented articular facets (thoracic like) to curved facets that are oriented more sagittally (lumbar like). Two key functional features in this region are the orientation and transverse curvature of the zygapophyseal facets. The thoracic facets permit flexion, extension, lateral flexion, and axial rotation of the vertebral. The lumbar facets serve to limit rotation while permitting flexion-extension movements[1]. This stress condition leads to prevalence of morphology changes due to the saggital loading. Among all abnormalities, wedging is the most common type. WSV often results from vertebral fractures[2]. According to previous study, WSV can change the mechanics of adjacent levels by increasing the angle of superior endplate tilt. The load of vertebrae adjacent to the WSV will change from perpendicular to the endplate to a more shearing, off-axis load. Another cause of WSV is Scheuermann's disease. The Sorenson[3] criteria for the diagnosis of Scheuermann's disease is having at least three consecutive wedge-shaped vertebrae showing more than 5° of wedging. But in thoracolumbar region, Scheuermann’s disease may be characterized by one or more of endplate irregularities, Schmorl's nodes, and interspace narrowing[4], which is "atypical" Scheuermann’s disease. In clinical practice, we noted a unique deformity in thoracolumbar region. This deformity is distinguished by only one or more WSV(> 5°) in patients without spine trauma, end-plate irregularities or "atypical" Scheuermann’s disease. And MRIs show intervertebral disc degeneration (IVDD) in majority of patients with this deformity, even in young patients. This study was designed to characterize the distinct deformity along the thoracolumbar spine and to identify the relationship between the deformity and IVDD in lumbar disc degeneration patients.

The study design was approved by Ethics Committee of The Tenth People’s Hospital of Shanghai, and informed consent was obtained from each patient.

Patients

The sample of this study is 58 patients with lumbar disc degeneration visiting The Tenth People’s Hospital of Shanghai for operation from January 2018 to July 2020. The including criteria is: (1) age between 20 and 60 years; (2) no history of any spinal surgery (including simple lumbar discectomy); (3) no spinal deformities (including scoliosis, isthmic spondylolisthesis, sacralization or lumbarization); (4) no spinal trauma or tumors.

Radiologic Evaluation

We had whole-spine plain roentgenograms by the multi-purpose Digital R/F System (Sonialvision Safire 17, Shimadzu Corporation) for every patient. The patients were asked to stand in a relaxed erect position with the knees held in extension and hands placed on supports. The distance between the subject and the radiographic source was constant. The X-ray was taken from the skull to the proximal femora.⁶ A 17 9 14-inch film was then prepared for each subject. For each enrolled participant, sagittal alignment parameters and pelvic parameters were measured on a standing whole spine x-ray. All radiological parameters were measured by two attending spinal surgeons and their average value was adopted. Patients whose measurements had significant difference were excluded.

The sagittal alignment parameters included the cervical lordosis (CL, C2-C7), thoracic kyphosis (TK; T5–T12), thoracolumbar kyphosis (TLK, T10-L2), lumbar lordosis (LL; L1–S1), upper lumbar lordosis (ULL, L1-L3) and lower lumbar lordosis (LLL, L4-S1). The pelvic parameters included sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). Coronal imbalance was defined to the difference between C7 plumb line and T10 plumb line. The above parameters were measured following previously established methods[5]. An example of the measurement is shown in Fig. 1.

Patients were divided into thoracolumbar wedged-vertebral (TLWSV) group and none wedged-vetebral(NWSV) group based on the presence of WSV in thoracolumbar spine. Patients in TLWSV group had at least one TLWSVs and patients without TLWSV was divided into NWSV group.

Lumbar spine magnetic resonance imaging (MRI) was performed on a 1.5-T scanner (Siemens Impact Expert; Siemens Medical Systems, Erlangen, Germany) with a consistent protocol, which was used to determine the degree of the thoracolumbar disc degeneration (TLDD). The slice thickness was 5 or 10 mm and the imaging matrix was 256 x 128. Both spin echo (SE) 1000/100ms (T2-weighted) and gradient echo120/30ms (T1-weighted) multislice, sagittal sequences were obtained to cover the whole thoracolumbar spine. The degeneration of thoracolumbar discs were graded respectively using modified Pfirrmann grading system[6], which was based on MRI signal intensity, disc structure, distinction between nucleus and anulus, and disc height. Modified Pfirrmann disc grades were determined by an experienced consultant radiologist, blinded to the demographics and clinical data of participants. TLDD sum scores were calculated through the summation of Pfirrmann scores from each thoracolumbar disc. TLDD was identified as TLDD sum scores ≥ 6.

Statistical analysis

Statistical analyses were performed using standardized SPSS software (version 22.0,SPSS Inc., Chicago, IL).Two-sample t tests were used to compare age and the data from whole spine standing radiograph. Sexual ratio and the proportion of TLDD were compared between the two groups by chi-square test. The statistical significance level was set at a P value less than 0.05.

Demographics

There are 30 patients in TLWSV group and 28 patients in NWSV group. The incidence of TLWSV is 51.7%. The baseline characteristics of two groups were compared in Table 1. The mean age of the participants with TLWSV was 42.63 ± 10.87 years, and that of participants in NWSV group was 38.64 ± 10.70 years; this difference was not statistically significant (P = 0.130). And The chi-square analysis showed that there was no difference in age between the two groups. (p > 0.05). However, the TLWSV group showed an degeneration predominance (degeneration proportion = 63.33%), whereas the mild-to moderate deformity group did not (degeneration proportion = 35.71%) (P = 0.036). However, there were significant difference in the proportion of disc degeneration (p < 0.05) (Table 1). The degeneration proportion of TLWSV group is higher than NWSV group. Especially the wedge-shaped incidence of T12(60%) is highest in thoracolumbar (Table 2). Moreover, TLDD summation of Pfirrmann scores are significant different between two group.(P < 0.05)

Table 1

Demographic Characteristics of the TLWSV Group and NWSV Group
variable	WSV	UWSW	p value
Age,y	42.63 ± 10.87	38.64 ± 10.70	0.13
M:F	26:10:00	11:10	0.13
Degeneration proportion	19:11	10:18	0.036

Table 2

wedge-shape incidence of thoracolumbar vertebrae
vertebrea	number	incidence
T11	12	40%
T12	18	60%
L1	15	50%
L2	3	10%

Sagittal Alignment Parameters and Pelvic Alignment

As mentioned above, the TLWSV group and the NWSV group were defined based on the presentation of WSV. The marked deformity group demonstrated significantly increased CL,TK and TLK. (Table 3) The marked deformity group also showed increased LLL but not to a statistically significant extent. The two groups showed no significantly different pelvic compensation (Table 4).

Table 3

Comparison of Sagittal Alignment Between WSV group and NWSV group
variable	WSV	UWSW	p value
CL(°)	-11.46 ± 13.09	-3.07 ± 11.58	0.012
TK(°)	20.55 ± 10.71	12.07 ± 10.54	0.004
TLK(°)	7.68 ± 6.91	2.41 ± 6.67	0.005
LL(°)	-34.93 ± 20.77	-31.14 ± 17.03	0.449
ULL(°)	-3.62 ± 7.75	-5.02 ± 7.27	0.479
LLL(°)	-26.37 ± 12.17	-20.11 ± 12.49	0.058

Table 4

Comparison of Pelvic Parameters Between WSV group and NWSV group
variable	WSV	UWSW	p value
PI	47.62 ± 10.84	44.48 ± 8.94	0.232
PT	19.98 ± 7.81	18.34 ± 9.41	0.476
SS	28.82 ± 10.36	27.01 ± 9.1	0.48
C7PL	2.69 ± 4.86	4.12 ± 4.11	0.232
T12PL	0.89 ± 2.9	1.42 ± 3.63	0.547

Radiologic Findings on Lumbar Spine MRI

Thoracolumbar disc degeneration were evaluated on T2-weighted sagittal images of lumbar spine MRI. The results are presented in Table 5. Generally, the degenerative were observed more frequently in participants with TLWSV. Especially, T11/T12 intervetebral disc showed a signicant higher degeneration incidence(p = 0.022). The sum of TLWSV group showed significantly higher Pfirrmann disc degeneration grades in thoracolunmbar disc than NWSV group(P = 0.024).

Table 5

Comparison of thoracolumbar intervetebral disc Pfirrmann grades Between the TLWSV and the NWSV Group
disc	WSV	UWSW	p value
T11/T12	2.53 ± 0.97	2 ± 0.72	0.022
T12/L1	2.13 ± 0.73	1.86 ± 0.36	0.076
L1/L2	1.67 ± 0.61	1.61 ± 0.63	0.715
SUM(T11/12)	6.33 ± 1.73	5.46 ± 1	0.024

Each individual has an intrinsic spine shape that is partly maintained during postural changes[7]. Interestingly, we noted a distinct deformity, which is WSV. Most vertebral deformities or fractures involve the mid-thoracic and thoracolumbar junction, which was consistent with the results of previous studies[8–10]. Up to now, vertebral anterior wedge deformities is explained as a two-stage process, with initial endplate damage followed by subsequent collapse of the anterior cortex[11].

In this study, WSV presented in 51.7% patients, which is a relatively high incidence. The problems caused by vertebral wedging include pain, disability and poor quality of life such as exercise intolerance.[12] There are some discussions in the literature regarding the possible etiologies of mild radiographic vertebral changes, including fracture, normal variants, degenerative changes, mild osteoporotic fracture and osteoarthritis.[13–15] In some other studies, a preexisting compression fracture, the L5/S1 disc degeneration grade, and the cross-sectional area of the multifidus and psoas muscle are all the risk factors of WSV.[16] In this study, we excluded the patients with history of trauma. Our study demonstrates that TLWSV are seen in all ages, suggesting that they are likely to be congenital deformities, which is similar to Scheuermann's disease.

The results of this study showed marked radiographic similarities between WSV and SD, such as changes in spine sagittal alignment and intervertebral disc degeneration. This deformity is also similar to compression fracture. We could learn from compression fracture to get a better understanding of biomechanism of WSV. In compression fracture, stress peaks were often presented in the annulus, and became more marked posteriorly when specimens were compressed in extension to simulate erect standing[17]. Fracture reduced intradiscal pressure by 39% and 46% in flexion, and by 57 and 65% in extension, whereas posterior stress peaks increased by 65% and 196% in flexion. Vertebral fracture reduced height, stiffness and pressure in the nucleus of adjacent intervertebral discs, and transferred compressive load-bearing to the neural arch[18]. Wedge fractures decompress the disc, increasing load-bearing by the neural arches, and reducing loading of the anterior vertebral bodies. This compensation may reduce fracture risk in a short time. However, in a long time, stress-shielding of the anterior vertebral body will accelerate bone loss in this region and ultimately increase the risk of further fracture [19]. This mechanism could affect the shape of adjacent vertebral, leading to change in spine saggital alignment.

Based on our observations, ULDD was found to occur frequently in patients with thoracolumbar vertebral wedge-shaped deformities. In WSV patients, sagittal imbalance is a common and disabling condition. There is significant difference in CL, TK and TLK between the two groups. In LLL, WSV group is relatively higher (p = 0.058). To maintain a balanced posture and a forward visualized gaze, hyperkyphosis is commonly compensated with a nonstructural hyperlordosis of other sections of spine in younger people with flexible spines[20], consistent with the result of our study. We supposed that kyphosis in thoracic and thoracolumbar region would account for the compensation in LL. Besides, vertebral could adapted in shape to the new intervertebral disc space with retained signal intensities, may still be functional for weight bearing and stability of the spinal unit[21]. In addition, other compensation is also important, such as splaying of intervertebral space, hip retroversion and knee flexion[20, 22, 23].

WSV easily can be missed in young people. The findings in the lateral radiograph can be slight and obscure, and probably not all children with back traumas are examined radiographically[24]. Therefore, these deformties often are overlooked. They also have been considered unimportant because they are assumed to heal completely without backache later. Based on our observations, WSV is related to ULDD. We should pay attention to the thoracolumbar discs in patients where radiological signs of WSV are present on their spine images and in necessity we maybe need to take some more radical measures.

This study had several limitations. In this study, whole-spine plain roentgenograms and MRIs of every patient are essential. It is difficult to obtain whole-spine plain roentgenograms and MRIs from healthy people. We could get whole-spine plain roentgenograms and MRIs from hospitalized patients easily. So the sample of this study is patients with lumbar disc degeneration visiting our institution for operation.

WSV as a consequence of compression fracture has been published[24–26]. Our study provided novel insights to mechanism of WSV. In this study, we excluded the patients with history of trauma, Scheuermann's disease and its atypical type, other spinal deformities and spinal trauma or tumors. So WSV could be a congenital deformity, which is similar to Scheuermann's disease. Just like Scheuermann's disease[27, 28], the incidence of disc degeneration is significantly higher in WSV patients. In initial stage of WSV, there are many compensation mechanisms. The symptom is not serious. So WSV is often overlooked in younger people. The symptoms get worse and worse with age. because of the change of stress state, lumbar vertebral will experience creep deformation. Creep deformation impacts spine neuromuscular control and stability, and ultimately the development of low back disorders[29].

To our knowledge, our study is the first to demonstrate how WSV are clinically significant phenomena that would have influence on spine saggital balance and accelerate ULDD. It is noteworthy that there is no difference between the two groups in pelvic parameters, LL, ULL and LLL. This phenomenon might be a result of compensation of spine. Based on our observation, incidence of TLWSV is relative high in general population. however WSV is usually neglected. A more radical and aggressive treatment modality is required in cases with WSV.

Ethical Approval

The study was approved by the Bioethics Committee of Shanghai Tenth People’s Hospital.

Consent to Participate

All patients included in this study provided written informed consent.

Consent to Publish

Informed consent was obtained from all participants included in the study. Authors agree to publication.

Acknowledgments

No grants and technical support need to be acknowledged for.

Author Contribution

All the authors participated in the study design, data collection and the writing of the manuscript.

Haoyu Gong and Jiajun Yan Contributed equally to this paper.

Funding

No grant & financial support for this study.

Competing Interests

The authors declare no competing interests.

Data availability

All data analyzed during this study are available from the corresponding author upon request.

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No competing interests reported.

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A distinct wedge-shaped deformity of the thoracolumbar vertebrae in Lumbar Disc Degeneraion Patients

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