Relationship between lumbar lordosis, pelvic parameters, PI-LL mismatch and outcome after short fusion surgery for lumbar degenerative disease. Literature review, rational and presentation of public study protocol: RELApSE study (registry for evaluation of lumbar artrodesis sagittal alignEment)

Abstract

Background: Vertebral arthrodesis for degenerative pathology of the lumbar spine still remains burdened by clinical problems with significant negative results. The introduction of the sagittal balance assessment with the evaluation of the meaning of pelvic parameters and spinopelvic (PI-LL) mismatch offered new evaluation criteria for this widespread pathology, but there is a lack of consistent evidence on long-term outcome.

Methods: The authors performed an extensive systematic review of literature, with the aim to identify all potentially relevant studies about the role and usefulness of the restoration or the assessment of Sagittal balance in lumbar degenerative disease. They present the study protocol RELApSE (NCT05448092 ID) and discuss the rationale through a comprehensive literature review.

Results: From the 237 papers on this topic, a total of 176 articles were selected in this review. The analysis of these literature data shows sparse and variable evidence. There are no observations or guidelines about the value of lordosis restoration or PI-LL mismatch. Most of the works in the literature are retrospective, monocentric, based on small populations, and often address the topic evaluation partially.

Conclusions: The RELApSE study is based on the possibility of comparing a heterogeneous population by pathology and different surgical technical options on some homogeneous clinical and anatomic-radiological measures aiming to understanding the value that global lumbar and segmental lordosis, distribution of lordosis, pelvic tilt, and PI-LL mismatch may have on clinical outcome in lumbar degenerative pathology and on the occurrence of adjacent segment disease.

Keywords: Fusion surgery; Lumbar degenerative disease; Lumbar lordosis; Neurosurgery; Pelvic Index (PI), Lumbar Lordosis (LL); Short Form-12 (ODI-12), body mass index (BMI); Spine; antero-lateral interbody fusion (ALIF), latero-lateral interbody fusion (LLIF); segmental lumbar lordosis (LS), Oswestry disability index; transforaminal interbody fusion (TLIF), posterior interbody fusion (PLIF).

Fig. 1

The flow-chart showing the selection according to PRISMA criteria of the articles used for the review.

Fig. 2

The figure shows the main Sagittal balance parameters used for the study (part A) namely Lumbar lordosis (red A), Sacral slope (red B), Pelvic Tilt (red C), Pelvic incidence (red D) and as can be seen in the X-ray images in maximum extension (part B) and maximum flexion (part C) of the patients, they can vary even significantly.

Fig. 3

We report the clinical case of a 57-year-old woman with chronic low back pain and degenerative discopathy with L4-L5 listhesis (standing Rx A, and preoperative MRI, B) who benefited from a significant improvement in sagittal balance parameters after stabilization surgery with double MS-TLIF L3-L4-l5 with lordotic cages (CT scan after 1 month, C and MRI control after 6 months).