The two Distinct Functional Lordoses of the Lumbar Spine.

STUDY

DESIGN

Retrospective radiographic study of a multicentric prospective database.

OBJECTIVE

This study aimed to analyze lumbar lordosis (LL) proximal and distal arcs relationships with spinopelvic parameters and determine how their distribution varies with pelvic incidence (PI).

SUMMARY OF BACKGROUND DATA: LL is a key component of sagittal spinal alignment, yet its definition and assessment remain debated. Recent evidence suggests LL is not a uniform curvature but a complex structure with proximal and distal arcs exhibiting possibly distinct biomechanical roles.

METHODS

This study included 642 healthy volunteers (mean age: 37.6±16.3) with full-body stereoradiographs, without spinal deformities. Maximum LL was assessed (LLmax), measured between thoracolumbar inflexion vertebra upper endplate and sacral plateau. Correlations between proximal lordosis (LLprox, measured between thoracolumbar inflexion vertebra upper endplate and lumbar apex upper endplate), distal lordosis (LLdist, measured between lumbar apex upper endplate and sacral plateau) and spinopelvic parameters were sought. Subjects were stratified into five PI groups to determine lordosis distribution variation with PI regarding angle and number of vertebrae included in curvature.

RESULTS

LLdist strongly correlated with pelvic parameters, particularly sacral slope (SS, r=-0.83, P<0.001) and PI (r=-0.54, P<0.001), but not with thoracic alignment. LLprox correlated with both pelvic and thoracic parameters, including SS (r=-0.31, P<0.001) and thoracic kyphosis (r=-0.35, P<0.001). As PI increased, the contribution of LLdist to LLmax rose from 55±12% to 66±8% (P<0.001), while the number of vertebrae in the distal arc increased from 1.52±0.50 to 2.32±0.59 (P<0.001). Consequently, LLprox's proportional contribution to LLmax decreased, despite a stable vertebral extent.

CONCLUSION

LL comprises two functionally distinct arcs: a pelvic-driven distal arc and a proximal arc influenced by overlying alignment and pelvic parameters. As PI increases, LL distal arc becomes preponderant. These findings advocate for a segmental approach in clinical assessment and surgical planning, emphasizing the need to consider both arcs independently.

LEVEL OF EVIDENCE: 3.