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Journal of Clinical Orthopaedics and Trauma logoLink to Journal of Clinical Orthopaedics and Trauma
. 2022 Feb 2;26:101788. doi: 10.1016/j.jcot.2022.101788

Correlation of spinopelvic parameters with functional outcomes in surgically managed cases of lumbar spinal tuberculosis- A retrospective study

Syed Ifthekar 1, Gagandeep Yadav 1, Kaustubh Ahuja 1, Samarth Mittal 1, Sudhakar P Venkata 1, Pankaj Kandwal 1,∗
PMCID: PMC8844813  PMID: 35211375

Abstract

Background

The advanced stage of vertebral involvement in spinal tuberculosis (STB) can cause vertebral body collapse, which leads to kyphotic deformity and paraplegia in severe cases. Surgery is indicated in patients having disabling back pain, progressive neurological deficit, and instability in spine despite conservative management. The derangement of lumbar parameters, especially the loss of lumbar lordosis has been found to cause functional deterioration in patients. With the current evidences in place, this study was done to evaluate the correlation between the restoration of lumbar lordosis, pelvic parameters, and functional outcome when posterior only approach was used to manage the lumbar STB.

Methods

Active Tuberculosis of lumbar vertebra (L1-S1) confirmed by radiology (X-ray, MRI) and histopathological examination were included. All the cases scheduled for surgery underwent radiographs, CT scan, and MRI scans. Lumbar lordosis and other pelvic parameters were calculated on X-rays. VAS scores and ODI scores were documented during the follow-up to assess functional well-being.

Results

A total of 33 (22 M:11 F) patients were included in the study. The mean lumbar lordosis pre-operatively was −22.84 ± 11.19° which was corrected to −37.03 ± 9.02° (p < 0.05) post-operatively. The pelvic tilt pre-operatively was 25.33 ± 6.75° which was corrected to 19.63 ± 5.84° (p < 0.05) post-operatively. The mean ODI improved from 84.33 ± 11.84 to 26.93 ± 8.74 (p < 0.05) at the final follow-up. The mean VAS score pre-operatively was 8.06 ± 1.27 which improved to 2.45 ± 0.93 (p < 0.05) in the post-operative period.

Conclusion

The study found a strong negative correlation between ODI scores and lumbar lordosis and a strong positive correlation between pelvic tilt and ODI scores. But the correlation needs to be further studied and evaluated by a well-constructed study especially with a control group treated conservatively.

Keywords: Lumbar tuberculosis, Lumbar lordosis, Pelvic parameters

1. Introduction

The harmonious relationship between the spinal curves and pelvic anatomy is the cornerstone in treating spinal deformities and degenerative conditions.1 The bipedal stance by humans is an ergonomic posture and the pelvis is a key structure in maintaining stability and influencing the spinal alignment.2 It is of utmost importance to study spinopelvic relations when describing conditions affecting the sagittal balance of the individual.1,2 The lumbar lordosis plays an important role in maintaining the sagittal balance and any reduction in this parameter results in anterior displacement of centre of gravity which in-turn increases the energy expenditure during gait.3 The derangement of spinopelvic alignment, especially the loss of lumbar lordosis is a major cause for functional deterioration in degenerative lumbar disorders.3,4 Though extensive research has been done regarding the spinopelvic balance concerning degenerative conditions and deformities of the spine, very minimal literature is available in infective conditions of the spine like STB.5, 6, 7, 8 Instability, neurological deficits are known indications of surgery in STB, but there is no evidence in the literature which emphasises on surgery to restore the altered sagittal spinal curves in STB. With the current shreds of evidence in place, this study was done to evaluate the correlation between the restoration of spinopelvic parameters and functional outcome when the posterior only approach was used to manage lumbar spinal tuberculosis.

2. Patients and methods

This was a retrospective cohort study conducted in a tertiary health care center. After obtaining ethical clearance (Reg No: ECR/736/IEC/89), the medical records of the patients from the tuberculosis register who were surgically treated from Jan 2018 to December 2019 were retrieved manually and a total of 76 patients of STB were identified. Out of 76, 33 patients satisfied the inclusion criteria and were included in the study (Table 1). Analysis of the patient's data with special consideration on pre- and post-surgical parameters was done.

Table 1.

Showing selection of patients.

2.

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Inclusion criteria- All surgically operated cases in the age group of 18–60 years with tuberculosis of lumbar vertebrae (L1-S1) confirmed by radiology (X-ray, MRI) and histopathological examination were included in the study. Patients with involvement of other spinal segments along with lumbar and sacral spine and labelled as contiguous and non-contiguous lesions were also included in the study.

Exclusion criteria- Disseminated systemic tuberculosis, pyogenic spondylodiscitis, patients previously operated on the lumbar spine, pre-existing congenital/acquired deformities due to other causes, patients with end-stage disorders, patients unable to withstand surgery and patients with incomplete records (all pre-operative and post-operative images, complete history, and course of chemotherapy) were excluded from the study.

Treatment protocol- The patients were labelled as tubercular cases only after thorough clinico-radiologic examination and histopathological confirmation. The diagnostic workup included blood investigations (ESR, CRP, and screening for HIV status), radiographs, CT, and MRI scans. Antitubercular therapy was started HRZE (Isoniazid(H) 5 mg/kg, Rifampicin (R) 10 mg/kg, Pyrazinamide(Z) 25 mg/kg, Ethambutol (E) 15 mg/kg) for 2 months and HRE for 10 months. The patients who failed conservative management for STB, the patients with intractable pain, neurological deficits not improving with anti-tubercular chemotherapy (ATT) or worsening neurology when patient was on ATT were planned for surgery.

The radiographs were obtained in a standing position when there was no neurological deficit. The lumbar lordosis was measured by measuring the angle between the superior endplate of the L1 vertebra and the superior endplate of S1 vertebra. The pelvic tilt (PT) was measured by the angle subtended by two lines, one from the centre of femoral heads to the centre of the S1 end plate and another from centre of the femoral head and the vertical reference line. The sacral slope was measured by a tangent line to the superior endplate of the S1 vertebra and a horizontal reference line. The pelvic incidence (PI) was measured by the angle subtended by two lines, one line perpendicular to the S1 endplate from its midpoint and a second line extending from the mid-point of the S1 endplate to the midpoint of femoral heads (Fig. 1, Fig. 2). The patients were followed up regularly to document functional, neurological, and radiological outcomes post-operatively. Functional outcomes were documented in terms of VAS and ODI scores, neurological in terms of Frankel grade. Surgical parameters like duration of surgery and blood loss were also documented. Patients were followed up at regular intervals with images and clinical assessment, CT scan was done at final follow-up to assess fusion.

Fig. 1.

Fig. 1

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(A)- Pre-operative standing anteroposterior and lateral x-ray of lumbosacral spine of a 35yr old male diagnosed with Potts spine L3L4.The image shows lumbar lordosis = 28, sacral slope = 34 and pelvic tilt = 20. (B)- Pre-operative sagittal T1 weighted MR image of LS spine showing hypointense lesion of L3–L4 vertebrae with indentation of the thecal sac. (C)- Pre-operative sagittal T2 weighted MR image of LS spine showing hyperintense lesion of L3–L4 vertebrae with indentation of the thecal sac. (D)- Immediate post-operative x ray showing correction of lumbar lordosis to −44°. (E)-Post-operative x-ray at 12 months of follow up when ATT was stopped with maintained lumbar lordosis. (F) -A full length standing x-ray at final follow up of 20 months.

Fig. 2.

Fig. 2

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(A)- Pre-operative standing anteroposterior and lateral X-ray of LS Spine showing reduced lumbar lordosis of −10 and a lesion at L4–L5.(B)- Immediate post-operative standing anteroposterior and lateral X-ray of LS spine showing the improved lumbar lordosis.(C)- Final post-operative standing anteroposterior and lateral X-ray of LS Spine showing maintained lumbar lordosis of −40.

Statistical analysis- Once the data was collected and tabulated, descriptive statistics were used for continuous variables. All the measurements were made on radiographs by two independent experts who were blinded to the results and the mean of their readings was taken as the final value. In case of disagreement, the dispute was solved by discussion and by the senior surgeon's opinion. Paired t-test was used to find the significance in changes of VAS, ODI scores, and lumbar lordosis before and after surgery. A p-value of <0.05 was considered significant. Pearson's correlation coefficient (r-value) was used to find out the correlation between functional outcome (ODI score) and correction of lumbar lordosis, spinopelvic parameters at the final follow up.

3. Results

A total of 33 patients were included in the study. 22 out of 33 were males and 11 were female patients. The mean age of patients was 39.7 ± 15.06 years (18–60yrs) (Table 2). Five patients had multifocal contiguous lesions and three patients had non-contiguous lesions away from the lumbar spine i.e., mid-dorsal spine. The presence of disabling back pain interfering with activities of daily living (ADL) despite conservative treatment for three months was seen in twenty-four patients, neurological deficits developing during chemotherapy or worsening of neuro deficits during chemotherapy was seen in 9 patients. Two patients (6.06%) had Frankel A, two (6.06%) presented with Frankel B neurology, five (15.1% of total patients) had Frankel C and twenty-four (72.7%) had Frankel E neurology (Table 2). Surgery performed was posterior instrumentation with anterior column reconstruction using Cage; Open (n = 19), Minimally invasive spine surgery (n = 7). Posterior column shortening using Pedicle subtraction Osteotomy (PSO) was done in 7 patients. 3 patients required complex lumbosacral fixation extending to iliac bone. Autogenous bone graft was used in all our patients for fusion.

Table 2.

Demographic factors of patients in the study and VAS, ODI score.

Pt.No Vertebra Involved Neurology (Frankel grade) Age Sex Pre op VAS Post op VAS Pre op ODI Post op ODI
1 L4L5 E 19 M 8 3 90 38
2 L3L4 C 35 M 10 4 84 30
3 L2L3 & D6D7 A 60 M 7 2 80 20
4 L2L3 C 60 F 9 2 86 26
5 L4L5 E 24 M 7 2 74 24
6 L2L3 E 29 F 7 1 93 26
7 L2-L4 E 30 M 9 1 96 24
8 L2L3 E 18 M 8 2 88 26
9 L1L2 E 30 F 8 3 90 28
10 L3L4 E 31 M 9 2 92 30
11 L1-L3 A 40 M 8 3 93 36
12 L1L2 E 54 M 6 2 76 12
13 L2-L4 E 39 M 8 2 94 21
14 L1L2 E 55 F 8 3 78 17
15 D11-L4 E 30 M 7 2 60 12
16 L5S1 E 60 M 6 1 42 20
17 L1L2 E 18 F 8 2 88 34
18 L2L3& C5C6 C 52 M 8 2 70 32
19 L1L2 E 20 F 5 1 82 14
20 L4L5 E 26 M 9 3 86 37
21 L4L5 &C6C7 C 45 M 9 4 74 22
22 L3L4 B 35 M 10 2 93 40
23 L2L3 E 60 F 10 2 96 36
24 L2L3 B 55 M 8 2 100 44
25 L4-S1 C 48 M 10 4 100 46
26 L1L2 E 19 F 9 2 86 32
27 L3L4 E 31 M 9 3 92 26
28 L2L3 E 56 F 7 4 82 28
29 L2L3 E 58 M 6 2 76 16
30 L4-S1 E 48 M 8 4 84 26
31 L4L5 E 52 F 9 3 94 26
32 L1L2 E 30 M 9 4 88 22
33 L3L4 E 44 F 7 2 76 18
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VAS-Visual Analogue score, ODI- Oswestry disability index.

The mean duration of surgery was 203.3 ± 64.4 min. The average blood loss in the study group was 701.8 ± 755.11 ml (50–3000 ml). The mean pre-operative lumbar lordosis of −22.84 ± 11.19° corrected to −37.03 ± 9.02° (p < 0.05) in final follow-up. The mean sacral slope pre-operatively was 24.63 ± 7.14° which was corrected to 31.54 ± 5.72° (p < 0.05) postoperatively. The pelvic tilt pre-operatively was 25.33 ± 6.75° which was corrected to 19.63 ± 5.84° (p < 0.05) post-operatively. The mean pelvic incidence was 51.12 ± 4.76° (details in Table 3). The mean VAS score pre-operatively was 8.06 ± 1.27 which improved to 2.45 ± 0.93 post-operatively (p < 0.05). The mean ODI pre-operatively was 84.33 ± 11.84 and was 26.93 ± 8.74 (p < 0.05) at final follow-up. The mean postoperative follow-up was 18.03 ± 3.3 months (14–26 months).

Table 3.

Measurement comparisons in pre-and post-op period.

Pt. no DURATION BLOOD LOSS Pre op lumbar lordosis (−) Post Op lumbar lordosis (−) Lordosis at final follow up Pre-op PT Post op PT Pre& Post op PI Pre-op SS Post op SS follow up in months
1 240 600 22 32 30 20 20 48 22 25 24
2 210 50 32 40 38 18 18 45 30 34 26
3 150 2000 38 52 48 20 14 54 30 36 26
4 180 1200 26 40 36 14 16 48 34 36 22
5 240 100 36 44 42 20 14 48 22 32 24
6 180 500 18 34 33 18 16 45 22 30 20
7 360 200 2 36 35 14 12 50 22 26 20
8 180 300 28 42 40 20 16 54 34 38 20
9 180 450 26 38 36 34 16 48 14 30 20
10 150 3000 18 32 31 32 24 52 20 28 19
11 180 3000 18 30 29 32 28 58 26 26 19
12 180 500 46 54 52 30 14 52 22 30 18
13 330 450 18 40 39 32 18 50 18 34 18
14 360 400 32 46 45 26 16 56 30 38 17
15 210 500 38 50 48 28 14 50 24 28 17
16 180 160 40 46 42 22 26 55 34 38 17
17 180 700 16 22 21 26 26 56 30 32 17
18 120 1800 24 32 30 28 24 52 26 28 16
19 240 600 24 46 45 16 14 48 22 34 16
20 300 800 24 30 29 36 28 50 12 24 16
21 180 1400 34 44 43 22 16 54 35 40 16
22 200 500 14 20 19 14 26 52 36 28 20
23 180 450 6 26 25 28 24 54 24 28 15
24 150 400 12 26 24 32 28 58 22 26 16
25 330 1200 8 22 20 30 32 52 20 20 16
26 150 300 6 26 25 32 26 44 10 20 16
27 180 250 8 30 29 34 22 48 14 28 15
28 120 200 22 34 33 32 22 56 22 36 14
29 180 200 32 46 45 30 18 62 34 42 16
30 150 300 24 36 34 28 24 56 28 34 15
31 180 300 10 40 37 28 14 46 18 34 15
32 150 150 18 42 40 26 14 50 22 38 14
33 210 200 32 46 45 16 10 46 30 38 15
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PT- Pelvic tilt, SS-Sacral slope.

Correlation findings of spinopelvic parameters: There was a strong negative correlation between postoperative ODI scores and improvement in the lumbar lordosis; Pearson correlation r = −0.9 and p < 0.05 (Fig. 3). There was a moderate negative correlation between postoperative ODI scores and an increase in sacral slope (r = −0.6, p-value < 0.01) (Fig. 4). There was a strong positive correlation between pelvic tilt and postoperative ODI scores (r = 0.7, p value < 0.01) (Fig. 5).

Fig. 3.

Fig. 3

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Pearson’s correlation scatter plot showing a strong negative correlation between postoperative ODI scores and improvement in the lumbar lordosis (r = −0.9 and p < 0.05).

Fig. 4.

Fig. 4

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Pearson’s correlation scatter plot showing a moderate negative correlation between postoperative ODI scores and the sacral slope. (r = −0.6, p-value < 0.01).

Fig. 5.

Fig. 5

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Pearson’s correlation scatter plot showing a strong positive correlation between postoperative ODI scores and pelvic tilt (r = 0.7, p value < 0.01).

All the patients had clinical and radiological improvement during treatment. Fusion was achieved in all the patients as assessed by CT scan images. There was an improvement in neurology in all the patients with deficits. All the Frankel C and Frankel B patients improved to Frankel E at final follow-up. Frankel A patients improved to Frankel D at final follow-up. None of the patients showed recurrence of the disease till the last follow-up. Two patients with Frankel E had neurological deterioration by two grades after correction of deformity in the immediate post-operative period which was treated by extension of decompression. One patient had a superficial infection which healed with regular dressings.

4. Discussion

The lumbar spine in normal individuals has a lordotic curvature. The majority of lordosis is imparted by the lower two vertebra and intervening discs of the lumbar spine.9 This normal curvature of the lumbar spine is necessary for an ergonomic weight transfer from the upper half of the body to the lower limbs. Any decrease in the lordosis of the lumbar spine leads to altered sagittal alignment which in turn leads to increased energy expenditure and low back pain. The role of sagittal balance and alignment in the outcomes have been extensively studied in the treatment of various spinal disorders like adult spinal deformities, idiopathic scoliosis and spondylolisthesis.10 There is very little evidence in the literature regarding the effect of decreased lumbar lordosis in infective disorders of the spine like spinal tuberculosis (STB). Tuberculosis of the lumbar spine commonly affects the vertebral bodies, which can result in significant loss of lordosis which can further affect the sagittal alignment.11

Neurological deficits in STB occur mainly due to compression of the thecal sac, kyphotic deformity, and instability. The usual aim of surgical treatment of STB is to address the compression or instability. The STB may heal with medical treatment alone when there is no significant compression and instability.12 The resultant kyphotic deformity or the loss of lumbar lordosis in a medically treated STB may have detrimental effects on an individual due to altered spinopelvic parameters. The altered spinopelvic parameters leading to poor functional outcomes have been well described in the literature. In a comparative study of lumbar lordosis angle of patients suffering from low back pain with the lordosis angle of healthy volunteers by McManus et al., the study group found that the lordosis angle was significantly decreased in the patients with low back pain.13 Any change in the local sagittal parameters of the lumbar and lumbosacral spine can influence the parameters of the neighbouring vertebrae and subsequently the entire alignment by compensation.

Following the landmark article of examining the relationship between sagittal alignment and clinical status by Glassman et al., a large number of studies reporting the relationship between sagittal parameters and clinical outcomes have been published.4,10,14, 15, 16, 17, 18 The spine, pelvis, and lower limb areas are involved in compensation to balance the axis of gravity.19,20 Any failure to compensate and maintain the normal sagittal balance of the body leads to poor clinical outcomes. The positive sagittal balance has a strong correlation with poor health-related quality of life scores and the proper restoration of sagittal plane alignment is critical for improving the clinical outcomes in patients with deformities.21,22 An acceptable clinical outcome would be expected when the correction is in a certain range of spinopelvic parameters.23,24

Most of the lordosis of the lumbar spine is due to the last two vertebrae and disc spaces. When there is involvement of these vertebrae by the disease process, the lordosis decreases drastically and the sagittal balance is also compromised. The mean pre-operative lumbar lordosis in our study was −22.84° which improved to −37.03° post-operatively. On correlating there was a strong negative correlation between the functional outcome measured by ODI and restoration of lumbar lordosis. In a study done by Shetty AP et al., there was a significant correlation between maintaining the lumbar lordosis and good functional outcome.11 Restoration of this lordosis has definite biomechanical advantages and improves the functional outcome of patients. This was further proven in similar studies done by Yu b et al., Xu Z et al. where the kyphosis was corrected from 26.4° to 22.1° preoperatively to −11.3° and −5.3° of lordosis postoperatively.25,26 The lordosis increases as the sacral slope increases and pelvic tilt decreases. The mean sacral slope in our study increased from 24.63 ± 7.14° to 31.54 ± 5.72°. The pelvic tilt decreased from 25.33 ± 6.75° to 19.63 ± 5.84°. There was a moderate negative relation between sacral slope and improvement in ODI scores and a strong positive correlation between pelvic tilt and improvement in ODI scores at final follow-up. Pelvic incidence did not show any significant change in the pre-and post-operative period and the values were very similar. We could not find any study in the literature comparing the sacral slope and pelvic tilt with the functional outcomes in infective conditions of the spine. KT Yeh et al. studied the effect of sacropelvic parameters in 120 patients of the degenerative spine and concluded that a value of pelvic tilt more than 23.4° correlated poorly with functional outcomes.27 Liow et al. studied 63 patients of degenerative spondylolisthesis and the effect of sacral slope and lumbar lordosis on functional outcomes. The study group found out that increased sacral slope patients in the post-operative period experienced less pain and good functional outcomes.28 The sacral slope in our study patients also increased post-operatively which correlated with the above studies. The average Pre-operative VAS score was 8.06 which improved post-operatively to 2.45. The mean ODI Score preoperatively in the study was 84.33 which improved postoperatively to 26.9. In similar study done by Zhang HQ et al. the ODI score improved to 7.29 with a very good functional outcome.29 In a study done by Yu B et al., the ODI score improved from 28.6 to 10.4 25.

Most of the literature explaining the surgical treatment of STB stresses on decompression of neurological elements with regaining neurological function as the main aim. The literature hypothesizes that improvement in neurological status translates into better functional outcomes. However, this may be true to an extent in the thoracic and cervical spine but this hypothesis may not apply to the lumbar and lumbosacral spine where neurological deficits are not pronounced. Jain et al. studied 27 patients of lumbar STB treated surgically, in which all had neurological recovery.30 Zhang HQ et al. studied 28 patients who were treated surgically by posterior decompression and reported neurological improvement in all patients. The neurology improved by at least 2 grades.29 The neurological recovery depends on how well the decompression and instability are addressed. While improvement of neurology is one of the aims of surgery in STB, good functional outcomes at the end of the treatment with a minimal disability remains the other aim. The anatomical understanding and the importance of maintaining the lumbar lordosis for the efficient upright activity is well described by Farfan HF in his study.31 Various methods can be chosen to restore the lumbar lordosis like open and minimally invasive methods. Minimally invasive methods can be chosen when decompression required is not extensive and instability is the major concern of surgery.6,32 Our study consisted of seven such patients where decompression was done and lordosis restored by minimally invasive techniques.

The lumbosacral region of the spine is special as it serves as a connecting link between the spine and pelvis. The inherent sacropelvic harmony is essential for the general well-being of the patient. Tuberculosis of the lumbar spine does not present with neurological deficits as frequently as the dorsal spine due to the anatomical spacious canal and lack of cord below L1. However, the disability is due to loss of sacropelvic harmony, like loss of lumbar lordosis and corresponding changes in pelvic parameters. The lower lumbar vertebrae provide the maximum lordosis and affection of these vertebrae with loss of vertebral body height leads to a significant change in the pelvic parameters.9 Our study has shown the strong negative correlation between loss of lumbar lordosis and decreased functional scores as well as the betterment of these functional scores with improvement in lumbar lordosis. Therefore, these patients should be identified early in the disease process before the destruction of the vertebral bodies to avoid surgery. If these patients present late with significant vertebral body destruction, surgery should be done to restore the pelvic parameters. The present study attempts to correlate functional outcome with pelvic parameters and stresses restoring the lumbar lordosis and sacropelvic parameters to improve outcomes when treating lumbar STB.

Limitations: The study could not detail the effects of pelvic parameters on the overall sagittal alignment due to lack of full-length spine x-rays in standing. A conservatively treated control group would have helped in better understanding whether the improvement of ODI score is due to restoration of spinopelvic parameters or due to healing of the disease. The radiographs taken in patients with complete deficits were not in a standing position. A further study with a larger sample size, with a conservatively treated control group and patients with intact neurology with whole spine x-rays, can be studied to see the effects of sagittal spinal alignment and its effect on the functional outcomes.

5. Conclusion

There was a strong negative correlation between ODI score and lumbar lordosis. There was a strong positive correlation between pelvic tilt and ODI scores and a moderate correlation between sacral slope and ODI scores. These findings suggest that the main treatment strategies of lumbar STB should aim at restoring lumbar lordosis and spinopelvic harmony. A prospective study with conservatively managed control group is required to further the clinical benefits of restoring the lumbar lordosis by performing surgery.

Source of funding

None.

CRediT authorship contribution statement

Syed Ifthekar: Methodology, Software. Gagandeep Yadav: Software, Validation. Kaustubh Ahuja: Data curation, Writing – original draft. Samarth Mittal: Visualization, Investigation. Sudhakar P Venkata: Supervision. Pankaj Kandwal: Conceptualization, Writing – review & editing.

Declaration of competing interest

None.

Contributor Information

Syed Ifthekar, Email: dr.syedifthekar@gmail.com.

Gagandeep Yadav, Email: gagandeepyadav@gmail.com.

Kaustubh Ahuja, Email: kaustubh1@live.in.

Samarth Mittal, Email: shankymtl11@gmail.com.

Sudhakar P Venkata, Email: torpedo89@gmail.com.

Pankaj Kandwal, Email: pankaj.orth@aiimsrishikesh.edu.in, pankajkandwal27@gmail.com.

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