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Abstract
Objectives
To evaluate the natural history of conservatively treated lumbar degenerative kyphosis (LDK).
Summary of Literature Review
The correlations between the clinical and radiologic parameters of general adult spinal deformity (ASD) are widely known. However, in LDK, dynamic sagittal imbalance is present during ambulation, meaning that its pathogenesis and natural history are different and not widely recognized compared to those of other forms of ASD, resulting in many controversies regarding treatment. To elucidate the natural history of LDK, we analyzed the clinical and radiologic outcomes of patients, comparing their first and final follow-up visits, and evaluated correlations among clinical and radiologic parameters.
Materials and Methods
From June 2006 to January 2014, 31 patients diagnosed with LDK who underwent conservative treatment were studied. The mean age of the patients was 72.5 years, and the mean follow-up period was 59.2 months. Clinical and radiologic evaluations were conducted on the first and final follow-up visits. Clinical evaluations were done using a visual analog scale and the Oswestry disability index, and radiologic evaluations were performed using spinal and pelvic parameters over a follow-up period of at least 24 months.
Results
Patients who were diagnosed with LDK and underwent conservative treatment showed no significant differences in their clinical outcomes between the first and final follow-up. Some radiologic parameters significantly progressed. There were no significant differences between clinical and radiologic parameters at the initial and final follow-up visits.
Conclusions
During the follow-up period of patients diagnosed with LDK, some radiologic parameters progressed. However, the progress of LDK and the clinical symptoms reported by the patients did not significantly change. Decisions regarding the treatment of LDK should not be made according to radiologic parameters showing the degree of deformity, but by carefully determining the patients’ clinical symptoms and disability level.
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Fig.1.
The fists-on-clavicle (A) or cross-arm position (B) is recommended with an extended hip and knee while taking radiographs.
Fig. 2.
Schema displaying Cobb's method for thoracic kyphosis, thoracolumbar kyphosis, lumbar lordosis, and the sagittal vertical axis. The pelvic parameters (pelvic tilt, sacral slope, and pelvic incidence) are also indicated for the lateral whole spine. LL, lumbar lordosis; TK, thoracic kyphosis; TLK, thoracolumbar kyphosis; SVA, sagittal vertical axis; PI, pelvic incidence; SS, sacral slope; PT, pelvic tilt.
Fig. 3.
Schematic diagram relating the clinical and radiological param-eters at the initial and final follow-up visits.
Fig. 4.
Differential diagnosis of sagittal imbalance. (A) Initial radiograph of a 65-year-old man shows L3-on-L4 spondylolisthesis with severe pain and disability. (B) Magnetic resonance imaging shows L3-L4 spinal stenosis. (C) The patient underwent L4 nerve root block. (D) Two months later, the pain subsided and follow-up radiography revealed no sagittal imbalance.
Fig. 5.
A 64-year-old woman with lumbar degenerative kyphosis with sagittal imbalance. (A) Initial radiograph showing sagittal imbalance and an Oswestry disability index (ODI) score of 42%. (B) Sagittal imbalance developed 97 months after conservative treatment was initiated, and her ODI score (40%) slightly decreased.
Fig. 6.
An 84-year-old woman with lumbar degenerative kyphosis with sagittal imbalance. (A) Initial radiograph showing sagittal imbalance and an Oswestry disability score (ODI) of 30%. (B) Sagittal imbalance had not developed 60 months after conservative treatment, but the ODI score (32%) slightly increased.
Table 1.
Average results of clinical index in initial and last follow-up
| Initial | Last follow-up | p-value | |
|---|---|---|---|
| VAS∗ | 3.3 (2∼6) | 3.4 (2∼5) | 0.763 |
| ODI† | 31.9 (19∼58) | 34.7 (20∼52) | 0.102 |
Table 2.
Average values of radiologic parameters in initial and last follow-up
| Initial | Last follow-up | p-value | |
|---|---|---|---|
| LL (°)∗ | 6.2(−15.6∼24.9) | −5.4(−20.3∼8.4) | 0.001†† |
| TK (°)† | 8.1(1.3∼13.4) | 8.4(1.2∼22) | 0.841 |
| TLK (°)‡ | 15.9(1.4∼31.6) | 19.5(2.3∼37.8) | <0.001†† |
| SVA (cm)§ | 8.5(5.5∼24.3) | 17.0(5.8∼45.8) | 0.003†† |
| PI (°)|| | 57.5(36.3∼85) | 59.8(38.3∼80.9) | 0.188 |
| SS (°)¶ | 18.4(1.1∼28.4) | 19.4(2.1∼32.7) | 0.482 |
| PT (°)∗∗ | 39.2(22.5∼65.2) | 40.4(29.6∼60.8) | 0.403 |
| PI-LL (°) | 51.1(35.4∼76.1) | 67.4(39.7∼101) | <0.001†† |
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