|Year : 2018 | Volume
| Issue : 1 | Page : 14-19
Effect of aging and lumbar spondylosis on lumbar lordosis
Francis Osita Okpala
Department of Radiology, Federal Teaching Hospital Abakaliki, Abakaliki, Ebonyi State, Nigeria
|Date of Web Publication||30-May-2018|
Dr. Francis Osita Okpala
Department of Radiology, Federal Teaching Hospital Abakaliki, P.M.B 102 Abakaliki, Abakaliki, Ebonyi State
Source of Support: None, Conflict of Interest: None
Background: Lumbar lordosis (LL), the anterior convexity of the lumbar spine in the mid-sagittal plane, gives the spine some resilience and helps in protecting it from compressive forces because some of the force is taken by the anterior longitudinal ligaments. In aging and lumbar spondylosis, the intervertebral discs undergo the same degenerative changes though at different rates, and in both, while some authors reported a straightening of LL, others reported no significant change. This morphologic information would hopefully influence therapeutic decision-making, particularly in lumbar spondylosis, which though usually asymptomatic, is a common cause of low back pain. Aim: The aim of the study was to investigate the effect of aging and lumbar spondylosis on LL. Subjects and Methods: Lumbosacral joint angle (LSJA), an angular measure of LL, was retrospectively measured in 252 normal and 329 spondylotic adolescent and adult supine lateral lumbosacral spine archival radiographs, and data were analyzed with IBM SPSS Statistics 23.0 (New York, USA). Results: Normal LSJA range was 5°–39°; the mean was 18.7° and showed insignificant variation with gender and aging. Spondylotic range was 5°–40° and the mean (20.8°) differed from the normal mean by about 2°, which probably have inconsequential effect on the lumbar curvature, suggesting that the normal and spondylotic mean values are essentially equal. The spondylotic mean also showed insignificant variation with aging and inconsequential 1° gender difference in favor of females. Conclusion: LL is substantially maintained in aging and lumbar spondylosis.
Keywords: Aging, change, lumbar lordosis, lumbar spondylosis
|How to cite this article:|
Okpala FO. Effect of aging and lumbar spondylosis on lumbar lordosis. Acta Med Int 2018;5:14-9
| Introduction|| |
Lumbar lordosis (LL), the anterior convexity of the lumbar spine in the midsagittal plane, gives the spine some resilience and helps in protecting it from compressive forces because some of the force is taken by the anterior longitudinal ligaments. Although it can be measured by radiographic and nonradiographic (e.g., goniometry, flexible rulers, software, spinal mouse, spinal pantograph, and inclinometer ) methods, a supine lateral lumbosacral spine radiograph accurately measures LL, and this radiographic method is still the gold standard.,,
The reported factors that may influence the degree of LL include sex, age, position (recumbent, sitting, and standing), footwear (i.e., high-heeled shoes), and pathological disorders (e.g., muscle spasm or pain and mechanical joint lesions such as lumbar spondylosis)., Aging and lumbar spondylosis are two very similar processes involving the degeneration of intervertebral disc (IVD) though at different rates; aging discs, and degenerative discs have the same low water and proteoglycan content. Due to the similarity in the pathological changes in the lumbar IVD in aging and degenerative disc disease, this study was designed to assess the possible effect of aging and lumbar spondylosis on the degree of LL.
Some authors have reported that, in old age, the LL often becomes flattened (i.e., straightened),, while some reported no significant variation. In lumbar spondylosis, a flattening of the LL has also been reported by some authors, while some reported no significant variation. Therefore, whether the LL flattens with aging, and with lumbar spondylosis, is debatable.
The aim of this study was to investigate the effect of aging and lumbar spondylosis on LL; this morphologic information would hopefully influence therapeutic decision-making, particularly in lumbar spondylosis, which though usually asymptomatic, is a common cause of low back pain.,
| Subjects and Methods|| |
The archival lateral lumbosacral spine radiographs of 252 normal and 329 spondylotic adolescent and adult patients of two tertiary health institutions in the Southeastern part of Nigeria were retrospectively reviewed over a period of 5 years: 1996–2000. Ethical approval was obtained from one of them. The two institutions routinely take their lateral lumbar radiographs in supine position, using the standard radiographic imaging technique. Thus, in positioning for imaging, (i) patient would normally be laid in true lateral position in the center of the X-ray couch; (ii) head supported with a pillow; (iii) nonopaque sponge roll placed under the thoracolumbar spine (to make the long axis of the spine parallel to the film); (iv) arms raised to the head; (v) hips and knees flexed, and the legs placed comfortably using padding; and then, (vi) entire body immobilized. After positioning the patient, (a) anatomical marker would be inserted; (b) over-couch X-ray beam collimated and centered to the midline at the level of lower costal margin (corresponding to L3 spinous process), and the central X-ray vertical at 90° to the film; and then, (c) X-ray exposure done in arrested respiration using appropriate exposure factors.
Inclusion criteria were (a) patients aged 15 years and above (the choice of this age was to ensure that almost all have attained spinal maturity); (b) normal appearances [Figure 1]; and (c) signs of lumbar spondylosis. The signs were vertebral body osteophytosis (bony overgrowths especially at the anterior, lateral, and less commonly, posterior aspects of the superior and inferior margins of vertebral bodies) as the only finding, or in addition  with decreased IVD height, and subarticular sclerosis [Figure 2].,, Radiographs showing additional pathologies (other than the lumbar spondylotic signs mentioned above) or belonging to patients <15 years of age were excluded from the study.
|Figure 1: Normal supine lateral lumbosacral spine plain radiograph showing normal vertebral bodies, intervertebral disc height, and posterior elements|
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|Figure 2: Spondylotic supine lateral lumbosacral spine plain radiograph showing vertebral body osteophytes (anterior and posterior in L4 and L5), decreased L4/L5 intervertebral disc height, and subarticular sclerosis of adjacent L4/L5 vertebral bodies|
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Patient's age, sex, and citizenship of Southeast region of Nigeria were recorded from the request form, usually enclosed in the film jacket. The radiographs were mounted on a well-illuminated viewing screen, measurement lines were drawn (using a pencil and a 30 cm long transparent ruler), and the lumbosacral joint angle (LSJA), one of the angular measures of LL, measured in degrees with a protractor. The LSJA is the angle formed by two lines; the first is across the plane of the inferior endplate of L5 and the second line is across the superior endplate of S1[Figure 3]., All measurements were made by the author to avoid interobserver error and great effort was made to avoid repeating the measurement of any radiograph by documenting the patients' name, age, and sex with the recorded angles and also making a mark in the film jacket of all reviewed radiographs. Patients' names were, however, not revealed in the analyses.
|Figure 3: Lumbosacral joint angle measurement lines in normal (a) and spondylotic (b) supine lateral lumbosacral spine plain radiographs. The lumbosacral joint angle is the angle between a line across the plane of the inferior endplate of L5 and a second line across the superior endplate of S1|
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The radiographs were grouped into age groups with a class interval size of 10. The age groups, in years, were (1) 11–20, (2) 21–30, (3) 31–40, (4) 41–50, (5) 51–60, (6) 61–70, (7) 71–80, and (8) 81–90. As determined by the data, in the normal group, the male age group stopped at Group 5, and the female at Group 6; in the spondylotic group, the male age group stopped at Group 8 and the female at Group 7.
Data were analyzed with SPSS (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp.), and P < 0.05 was considered statistically significant. The statistical methods employed included mean, standard deviation, test of significance, and graphical display.
| Results|| |
The mean age (standard deviation) of 252 patients with normal radiographs was 35.0 (11.3) years (range = 15–69 years), while that of the 329 spondylotic patients was 52.1 (13.7) years (range = 17–90 years) [Table 1].
|Table 1: Mean age (male, female, and total) of the normal and spondylotic patients|
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In the normal patients, the mean (standard deviation) of the LSJA was 18.7 (5.7)° (range = 5°–39°) and showed insignificant variation with gender (t = 1.354; P = 0.18) [Table 2] and age groups (i.e., aging) [Table 3] and [Figure 4]a, [Figure 4]b.
|Table 2: Mean lumbosacral joint angle of the normal and spondylotic patients by gender|
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|Table 3: Summary of t-tests (using Bonferroni correction) of mean lumbosacral joint angles (male, female, and total) by age groups (i.e., aging)|
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|Figure 4: Variation of normal (a, b) and spondylotic (c, d) mean lumbosacral joint angles with age groups (i.e., aging).|
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In the spondylotic patients, the LSJA range was 5°–40°. The mean (standard deviation) was 20.8 (5.5)°, and this mean differed from the normal mean by only 2.1° (t = 6.767, P = 0.001) [Table 2] and [Figure 5]c. Although this slight difference was statistically significant, the effect it will have in the degree of lumbar curvature is most probably inconsequential, suggesting that the normal and spondylotic mean values are essentially equal. The spondylotic mean also showed insignificant variation with age groups (i.e., aging) [Table 3] and [Figure 4]c, [Figure 4]d and inconsequential 1.1° gender difference in favor of females (t = 2.065; P = 0.04); the female was 21.4 (5.8)° and the male was 20.3 (5.2)° [Table 2].
|Figure 5: Normal versus spondylotic patients: t-test of mean lumbosacral joint angles according to gender (a=Males; b=Females; c=Total)|
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| Discussion|| |
In this study, the mean LL showed an insignificant variation with aging [Table 3] and [Figure 4]a, [Figure 4]b. This finding is similar to those of Murrie et al. (who measured the LL in supine lumbar spine Magnetic Resonance Images of Caucasians, in Cambridge, the United Kingdom) and Okpala (who quantified the LL in supine lateral lumbar radiographs, using the lumbosacral angle (LSA), in a retrospective study in Nigeria). This finding, however, contradicts the report by Schmorl and Junghanns (who reported flattening of LL in old age in Michigan, USA) and Amonoo-Kuofi (who, in Saudi Arabia, used the LSA to measure the LL and reported that the LL varied steadily with age and showed a tendency to decrease after the sixth decade). This contradiction might partly be due to the fact that, in the angular measurement of LL, investigators have used different parameters.
Furthermore, in spondylotic patients in the current study, the mean LL showed no significant variation with age groups (i.e., aging), just like what was observed in the normal patients [Table 3] and [Figure 4]c, [Figure 4]d. This is probably due to the fact that lumbar spondylosis and aging are very similar processes involving the degeneration of the IVD though occurring at different rates.
Furthermore, in this study, the mean LL of spondylotic patients differed from that of normal patients by about 2° [Table 2] and [Figure 5]a,[Figure 5]b,[Figure 5]c. This very slight difference is, however, probably of little clinical importance because the effect it will have on the lumbar curvature is most probably inconsequential, suggesting that the normal and spondylotic values are essentially equivalent, and that, in lumbar spondylosis, the spine still significantly maintains its natural morphology of within-normal LL. This finding contradicts some literature reports, but it is in agreement with some others. It contradicts the report by Schafer, Jackson and McManus, and Harrison et al., all in the USA, who reported reduced LL in lumbar spondylosis. Jackson and McManus did a prospective study in erect position, using a variant of the Cobb method (L1–S1) in Missouri, while Harrison et al. did their study in erect position, using software to measure the LL by another variant of the Cobb method (T12–S1) and LSA method in Alabama. Perhaps the use of different parameters by these investigators might partly account for this contradiction.
On the other hand, the finding in this study that, in lumbar spondylosis, the spine still significantly maintains its natural morphology of within-normal LL is in agreement with the reports by Schmorl and Junghanns, Papadakis et al., Lin et al., Łebkowski et al., Tüzün et al., and Esmailiejah et al. The studies by these investigators involve different racial groups, different angular measures of LL, with some in erect posture, and some of the studies' prospective. Papadakis et al. did a cross-sectional study and used software to study the LL with the Cobb method in erect lateral lumbar radiographs of Greek females. Lin et al. measured the lumbar lordotic angle, LSA, and sacral inclination angle in their study in Taiwanese adults. Łebkowski et al. studied Polish adults with radiography. Tüzün et al. used a variant of the Cobb (L1–S1) and LSA methods, in erect radiographs, in their prospective study in Turkey. Esmailiejah et al. did a prospective study in Tehran, Iran, in erect posture, and the LSJA was one of the methods they used to evaluate the LL. According to Schmorl and Junghanns, the curve of the lumbar spine gives it certain resilience and helps to protect the spine from compressive forces; a flattened or straightened LL would, therefore, seem unnatural.
In this study, normal and spondylotic patients were not matched for age. Attainment of spinal maturity was the primary consideration in patients' selection. This is because the development of LL stops at spinal maturity, usually between 13 and 18 years.,, Supine lateral lumbosacral spine radiographs were used in this study because it accurately measures LL and is still the gold standard;,, furthermore, it has a standard radiographic imaging technique which guarantees the reproducibility of the spine curvature measurements. Therefore, the findings in this study that aging and lumbar spondylosis do not result in significant change in LL is most likely reliable. Although erect radiographs would have been preferable due to some concerns about posture and its possible effect on spine curvature, some authors have shown that the LL is not significantly different in the erect and recumbent positions.,
The limitations in this study include: (a) possible noninclusion of few normal patients (aged 13–14 years) that could have attained spinal maturity because the studied minimum age was 15 years and (b) few of the radiographs could have been taken in the erect position, though the two study centers routinely take their lateral lumbosacral spine radiographs in the supine position. In (a) and (b), however, the very small number of radiographs involved makes them statistically irrelevant. Furthermore, some authors have shown that the LL is not significantly different in the erect and recumbent positions.
A prospective longitudinal study (with either the radiographic or magnetic resonance techniques) of two individual groups (normal aging and lumbar spondylosis) aged 15 years and above, with follow-up every 5–10 years until 90 years of age or death, whichever comes first, is recommended as further study.
| Conclusion|| |
The normal mean LL showed no significant change with aging, but in lumbar spondylosis, there was a very slight change of about 2°, which is probably of little clinical significance, suggesting that the normal and spondylotic mean values are essentially equal. Therefore, LL is significantly maintained in aging and lumbar spondylosis.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]