title: Coronal curvature and spinal imbalance in degenerative lumbar scoliosis: disc degeneration is associated.
abstract: METHODS
  A retrospective radiographical study.
  
  
  OBJECTIVE
  To determine the association between disc degeneration and spinal malalignment on both coronal and sagittal planes in patients with degenerative lumbar scoliosis (DLS).
  
  
  BACKGROUND
  In recent years, a thorough understanding of spinal coronal balance and sagittal alignment has become more and more important in treating patients with DLS. Although degeneration of discs has been generally accepted as the main cause of DLS, to date no study has documented the relationships between disc degeneration and the curve magnitude as well as spinal imbalance.
  
  
  METHODS
  In this study, 57 patients with DLS were recruited. Degeneration of the apical disc, lower end vertebral (EV) discs and regional lumbar discs (L1-L2 and L5-S1) were quantitatively evaluated by the Pfirrmann score based on T2-weighted magnetic resonance images. Radiographical parameters including Cobb angle, coronal trunk shift, sagittal vertical axis (SVA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence, pelvic tilt, and sacral slope were measured from long-cassette standing upright radiographs. Subjects were assigned to 4 groups: both coronal and sagittal balanced (C+ S+); coronal imbalanced but sagittal balanced (C- S+); coronal balanced but sagittal imbalanced (C+ S-); and both coronal and sagittal imbalanced (C- S-). The Spearman correlation was used to identify the relationship between the Pfirrmann score of disc degeneration and radiographical parameters. Analysis of variance 2×2 factorial design was performed to identify the decisive factors affecting coronal and sagittal balance.
  
  
  RESULTS
  On the basis of the criteria for each group, 19 patients were assigned to group A (C+ S+), 10 patients to group B (C- S+), 11 patients to group C (C+ S-), and 17 patients to group D (C- S-). The Pfirrmann score of regional lumbar disc degeneration strongly correlated with Cobb angle, SVA, TK, and LL (r = -0.364, -0.386, 0.283, and 0.479, respectively, P < 0.01). Specifically, the Pfirrmann score of apical disc degeneration correlated with Cobb angle, whereas degeneration of lower EV discs correlated with SVA, TK, and LL. On the basis of analysis of variance 2 × 2 factorial design, the score of the lower EV disc degeneration significantly correlated with sagittal balance (P < 0.05).
  
  
  CONCLUSIONS
  This study demonstrated that the lower EV disc degeneration strongly correlated with sagittal imbalance in patients with DLS, implying that disc degeneration may be regarded as a potential risk factor for sagittal imbalance. This result strengthened the importance of not selecting the lower EV as the lower instrumented vertebra during the surgical decision making, which may lead to deterioration of sagittal balance. Disc degeneration was also strongly correlated with sagittal malalignment, as demonstrated by a more positive SVA, decreased TK and LL, providing insight into reasons for low quality of life in elderly patients with DLS.
authors.affiliation: Departments of *Spine Surgery, and †General Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.
authors.forename: Hongda
authors.initials: H
authors.lastname: Bao
authors.forename: Feng
authors.initials: F
authors.lastname: Zhu
authors.forename: Zhen
authors.initials: Z
authors.lastname: Liu
authors.forename: Zezhang
authors.initials: Z
authors.lastname: Zhu
authors.forename: Shouyu
authors.initials: S
authors.lastname: He
authors.forename: Yitao
authors.initials: Y
authors.lastname: Ding
authors.forename: Yong
authors.initials: Y
authors.lastname: Qiu
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D055959:Intervertebral Disc Degeneration / Q000150:complications / Q000000981:diagnostic imaging*; D007738:Kyphosis / Q000000981:diagnostic imaging; D008141:Lordosis / Q000000981:diagnostic imaging; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012189:Retrospective Studies; D012600:Scoliosis / Q000000981:diagnostic imaging* / Q000209:etiology; D012720:Severity of Illness Index