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Understanding Lordosis

We recently asked Nancy Schommer, our medical correspondent, to interview Dr. Martin Wolpin, an orthopedic surgeon who specializes in spinal deformities. Dr. Wolpin is chief of the scoliosis service of Maimonides Medical Center, Brooklyn, New York.

Q: Dr Wolpin, how would you characterize the spinal condition known as lordosis, which is sometimes referred to as a swayback?
A: Let me begin by giving you some background information. If you look at a side view of a person, you will see that the normal spine has two areas that are lordotic, or curved slightly forward, as in a reverse C. Normally, we all have a certain amount of cervical (neck) lordosis, and lumbar (lower back) lordosis. In the thoracic (chest) we usually have a backward curve or kyphosis. In fact, we want a little lordosis in the neck and lower back because it gives us a good mechanical advantage and a functional position with which to maintain an erect posture.

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Q: Is there a "proper" amount of lordosis in these areas that one should have?
A: The degree of proper lordosis is extremely variable; in the lower back, for example, a lordosis can be as much as 20 to 50 degrees. But I want to stress to your readers that in the majority of cases, lordosis is more of a cosmetic alignment problem and not really a significant functional alignment problem in itself. In fact, rarely do we do anything to treat lordosis, per se, unless there is an underlying condition that is causing an increased lordosis.

Q: What is an example of an underlying condition that can cause an increased lordosis?
A: We're usually dealing with a problem of some significance below the level of the lordosis. For example, a deformity such as spondylolisthesis. In such cases, the lower segment of the spine demonstrates a kyphotic angulation and the lordosis is increased to compensate for that element of kyphosis. Other pathological problems are usually due to underlying neuromuscular conditions.

Q: How would you treat that patient medically?
A: Patients with spondylolisthesis often have tight hamstrings and the body is compensating for that. Thus, we'd probably recommend stretching exercises, such as pelvic tilts, to improve muscle tone and lower the increase of lordosis, or use temporary bracing together with exercise. In many cases, however, we would surgically repair the spondylolisthesis, and that would tend to correct the lordosis. Remember, in these cases, we're not doing surgery to correct the lordosis. We're doing surgery to correct the underlying, more serious problem.

Q: We've heard that loss of lordosis can be a problem. What would cause that?
A: Patients do have problems when they lose their lordosis. As they get older, some patients experience degeneration of the disks and the face joints. These degenerative changes cause them to lose their lordosis of the lower back. We've also found that some scoliosis patients who've had Harrington rods implanted along the lower spine can experience a loss of lordosis. In both these cases, the person has the appearance of a flat back, and as a result can experience pain.

Q: With respect to the flatback that may be caused by Harrington rods, what can done?
A: Although some of these conditions can be repaired surgically, doctors are attempting to avoid the problem in the first place by using one of the new rotational surgical items to treat scoliosis: the CD for example, or the Scottish Rite system. Both of these allow you to build an element of lumbar lordosis while straightening the spine.

Q: From everything you've said, it sounds like lordosis isn't that much of a problem, but that an underlying condition causing the lordosis could be a problem and may need to be treated.
A: That's true. When we see a patient who presents with a lordosis, the first question is: Is the patient clinically symptomatic? In other words, is there a problem of pain or limitation of function? Then we evaluate the person to see whether a structural deformity within the vertebral lies or disk spaces is causing the lordosis. We would also check to see ether there is an underlying neuromuscular problem, such as muscular dystrophy, that is causing a muscle imbalance.

Q: And what do you do if there are no underlying problems?
A: If you rule out all those problems we would not consider the lordosis to be of clinical significance. For most people with an exaggerated lordosis not caused by any underlying dysfunction, posture strengthening exercises would help diminish this cosmetic condition.


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