When is compensation for lumbar spinal stenosis a clinical sagittal plane deformity?

Aaron J. Buckland, Shaleen Vira, Jonathan H. Oren, Renaud Lafage, Bradley Y. Harris, Matthew A. Spiegel, Bassel G. Diebo, Barthelemy Liabaud, Themistocles S. Protopsaltis, Frank J. Schwab, Virginie Lafage, Thomas J. Errico, John A. Bendo

Research output: Contribution to journalArticle

16 Citations (Scopus)

Abstract

Background Context Degenerative lumbar stenosis (DLS) patients have been reported to lean forward in an attempt to provide neural decompression. Spinal alignment in patients with DLS may resemble that of adult spinal deformity (ASD). No previous studies have compared and contrasted the compensatory mechanisms of DLS and ASD patients. Purpose This study aimed to determine the differences in compensatory mechanisms between DLS and ASD patients with increasing severity of sagittal spinopelvic malalignment. Contrasting these compensatory mechanisms may help determine at what severity sagittal malalignment represents a clinical sagittal deformity rather than a compensation for neural compression. Study Design/Setting This is a retrospective clinical and radiological review. Patient Sample Baseline x-rays in patients without spinal instrumentation, with the clinical radiological and diagnoses of DLS or ASD, were assessed for patterns of spinopelvic compensatory mechanisms. Patients were stratified by sagittal vertical axis (SVA) according to the Scoliosis Research Society-Schwab [SRS-Schwab] classification. Outcome Measures Radiographic spinopelvic parameters were measured in the DLS and ASD groups, including SVA, pelvic incidence−lumbar lordosis mismatch (PI−LL), T1 spinopelvic inclination (T1SPi), T1 pelvic angle (TPA), and pelvic tilt (PT). Methods The two diagnosis cohorts were propensity-matched for PI and age. Each group contained 125 patients and was stratified according to the SRS-Schwab classification. Regional spinopelvic,lower limb, and global alignment parameters were assessed to identify differences in compensatory mechanisms between the two groups with differing degrees of deformity. No funding was provided by any third party in relation to carrying out this study or preparing the manuscript. Results With mild to moderate malalignment (SRS-Schwab groups “0,” or “+” for PT, PI−LL, or SVA), DLS patients permit anterior truncal inclination and recruit posterior pelvic shift instead of pelvic tilt to maintain balance, while providing relief of neurologic symptoms. Adult spinal deformity patients with mild to moderate deformity recruit pelvic tilt earlier than DLS patients. With moderate to severe malalignment, no significant difference was found in compensatory mechanisms between DLS and ASD patients. Conclusions Patients with DLS permit mild to moderate deformity without recruiting compensatory mechanisms of PT, reducing truncal inclination and thoracic hypokyphosis to achieve neural decompression. However, with moderate to severe deformity, their desire for upright posture overrides the desire for neural decompression, evident by the adaptation of compensatory mechanisms similar to that of ASD patients.

Original languageEnglish (US)
Pages (from-to)971-981
Number of pages11
JournalSpine Journal
Volume16
Issue number8
DOIs
StatePublished - Aug 1 2016
Externally publishedYes

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Spinal Stenosis
Pathologic Constriction
Scoliosis
Decompression
Lordosis
Research
Manuscripts
Neurologic Manifestations
Posture

Keywords

  • Adult spinal deformity
  • Compensatory mechanisms
  • Lumbar stenosis
  • Neural decompression
  • Sagittal malalignment
  • Spinopelvic alignment
  • SRS classification

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine
  • Clinical Neurology

Cite this

Buckland, A. J., Vira, S., Oren, J. H., Lafage, R., Harris, B. Y., Spiegel, M. A., ... Bendo, J. A. (2016). When is compensation for lumbar spinal stenosis a clinical sagittal plane deformity? Spine Journal, 16(8), 971-981. https://doi.org/10.1016/j.spinee.2016.03.047

When is compensation for lumbar spinal stenosis a clinical sagittal plane deformity? / Buckland, Aaron J.; Vira, Shaleen; Oren, Jonathan H.; Lafage, Renaud; Harris, Bradley Y.; Spiegel, Matthew A.; Diebo, Bassel G.; Liabaud, Barthelemy; Protopsaltis, Themistocles S.; Schwab, Frank J.; Lafage, Virginie; Errico, Thomas J.; Bendo, John A.

In: Spine Journal, Vol. 16, No. 8, 01.08.2016, p. 971-981.

Research output: Contribution to journalArticle

Buckland, AJ, Vira, S, Oren, JH, Lafage, R, Harris, BY, Spiegel, MA, Diebo, BG, Liabaud, B, Protopsaltis, TS, Schwab, FJ, Lafage, V, Errico, TJ & Bendo, JA 2016, 'When is compensation for lumbar spinal stenosis a clinical sagittal plane deformity?', Spine Journal, vol. 16, no. 8, pp. 971-981. https://doi.org/10.1016/j.spinee.2016.03.047
Buckland, Aaron J. ; Vira, Shaleen ; Oren, Jonathan H. ; Lafage, Renaud ; Harris, Bradley Y. ; Spiegel, Matthew A. ; Diebo, Bassel G. ; Liabaud, Barthelemy ; Protopsaltis, Themistocles S. ; Schwab, Frank J. ; Lafage, Virginie ; Errico, Thomas J. ; Bendo, John A. / When is compensation for lumbar spinal stenosis a clinical sagittal plane deformity?. In: Spine Journal. 2016 ; Vol. 16, No. 8. pp. 971-981.
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abstract = "Background Context Degenerative lumbar stenosis (DLS) patients have been reported to lean forward in an attempt to provide neural decompression. Spinal alignment in patients with DLS may resemble that of adult spinal deformity (ASD). No previous studies have compared and contrasted the compensatory mechanisms of DLS and ASD patients. Purpose This study aimed to determine the differences in compensatory mechanisms between DLS and ASD patients with increasing severity of sagittal spinopelvic malalignment. Contrasting these compensatory mechanisms may help determine at what severity sagittal malalignment represents a clinical sagittal deformity rather than a compensation for neural compression. Study Design/Setting This is a retrospective clinical and radiological review. Patient Sample Baseline x-rays in patients without spinal instrumentation, with the clinical radiological and diagnoses of DLS or ASD, were assessed for patterns of spinopelvic compensatory mechanisms. Patients were stratified by sagittal vertical axis (SVA) according to the Scoliosis Research Society-Schwab [SRS-Schwab] classification. Outcome Measures Radiographic spinopelvic parameters were measured in the DLS and ASD groups, including SVA, pelvic incidence−lumbar lordosis mismatch (PI−LL), T1 spinopelvic inclination (T1SPi), T1 pelvic angle (TPA), and pelvic tilt (PT). Methods The two diagnosis cohorts were propensity-matched for PI and age. Each group contained 125 patients and was stratified according to the SRS-Schwab classification. Regional spinopelvic,lower limb, and global alignment parameters were assessed to identify differences in compensatory mechanisms between the two groups with differing degrees of deformity. No funding was provided by any third party in relation to carrying out this study or preparing the manuscript. Results With mild to moderate malalignment (SRS-Schwab groups “0,” or “+” for PT, PI−LL, or SVA), DLS patients permit anterior truncal inclination and recruit posterior pelvic shift instead of pelvic tilt to maintain balance, while providing relief of neurologic symptoms. Adult spinal deformity patients with mild to moderate deformity recruit pelvic tilt earlier than DLS patients. With moderate to severe malalignment, no significant difference was found in compensatory mechanisms between DLS and ASD patients. Conclusions Patients with DLS permit mild to moderate deformity without recruiting compensatory mechanisms of PT, reducing truncal inclination and thoracic hypokyphosis to achieve neural decompression. However, with moderate to severe deformity, their desire for upright posture overrides the desire for neural decompression, evident by the adaptation of compensatory mechanisms similar to that of ASD patients.",
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T1 - When is compensation for lumbar spinal stenosis a clinical sagittal plane deformity?

AU - Buckland, Aaron J.

AU - Vira, Shaleen

AU - Oren, Jonathan H.

AU - Lafage, Renaud

AU - Harris, Bradley Y.

AU - Spiegel, Matthew A.

AU - Diebo, Bassel G.

AU - Liabaud, Barthelemy

AU - Protopsaltis, Themistocles S.

AU - Schwab, Frank J.

AU - Lafage, Virginie

AU - Errico, Thomas J.

AU - Bendo, John A.

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N2 - Background Context Degenerative lumbar stenosis (DLS) patients have been reported to lean forward in an attempt to provide neural decompression. Spinal alignment in patients with DLS may resemble that of adult spinal deformity (ASD). No previous studies have compared and contrasted the compensatory mechanisms of DLS and ASD patients. Purpose This study aimed to determine the differences in compensatory mechanisms between DLS and ASD patients with increasing severity of sagittal spinopelvic malalignment. Contrasting these compensatory mechanisms may help determine at what severity sagittal malalignment represents a clinical sagittal deformity rather than a compensation for neural compression. Study Design/Setting This is a retrospective clinical and radiological review. Patient Sample Baseline x-rays in patients without spinal instrumentation, with the clinical radiological and diagnoses of DLS or ASD, were assessed for patterns of spinopelvic compensatory mechanisms. Patients were stratified by sagittal vertical axis (SVA) according to the Scoliosis Research Society-Schwab [SRS-Schwab] classification. Outcome Measures Radiographic spinopelvic parameters were measured in the DLS and ASD groups, including SVA, pelvic incidence−lumbar lordosis mismatch (PI−LL), T1 spinopelvic inclination (T1SPi), T1 pelvic angle (TPA), and pelvic tilt (PT). Methods The two diagnosis cohorts were propensity-matched for PI and age. Each group contained 125 patients and was stratified according to the SRS-Schwab classification. Regional spinopelvic,lower limb, and global alignment parameters were assessed to identify differences in compensatory mechanisms between the two groups with differing degrees of deformity. No funding was provided by any third party in relation to carrying out this study or preparing the manuscript. Results With mild to moderate malalignment (SRS-Schwab groups “0,” or “+” for PT, PI−LL, or SVA), DLS patients permit anterior truncal inclination and recruit posterior pelvic shift instead of pelvic tilt to maintain balance, while providing relief of neurologic symptoms. Adult spinal deformity patients with mild to moderate deformity recruit pelvic tilt earlier than DLS patients. With moderate to severe malalignment, no significant difference was found in compensatory mechanisms between DLS and ASD patients. Conclusions Patients with DLS permit mild to moderate deformity without recruiting compensatory mechanisms of PT, reducing truncal inclination and thoracic hypokyphosis to achieve neural decompression. However, with moderate to severe deformity, their desire for upright posture overrides the desire for neural decompression, evident by the adaptation of compensatory mechanisms similar to that of ASD patients.

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KW - Adult spinal deformity

KW - Compensatory mechanisms

KW - Lumbar stenosis

KW - Neural decompression

KW - Sagittal malalignment

KW - Spinopelvic alignment

KW - SRS classification

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