Shinshu Med J, 69⑶：111～120, 2021

綜説

Spinal Deformity and the Musculoskeletal Cohort Studyof the General Older Population
Masashi Uehara1）＊, Jun Takahashi1）, Shota Ikegami1）2）, Ryosuke Tokida2）
Hikaru Nishimura2）, Noriko Sakai3） and Hiroyuki Kato1）2）
1） Department of Orthopaedic Surgery, Shinshu University School of Medicine
2） Rehabilitation Center, Shinshu University Hospital3） Department of Orthopaedic Surgery, New Life Hospital

Key words : spinal deformity, global alignment, pelvic parameter, general elderly population,
epidemiological study
Ⅰ Introduction
The proportion of adults aged 65 years or more in

Hospital, and the Obuse town office.
Ⅱ History of Spinal Postural Abnormality Studies

Japan has reached 28 ％ according to the 2019 Minis­

In 2001, Simmons described two types of adulttry of Internal Affairs and Communications Statistics

spinal deformities : degenerative lumbar scoliosis with

Bureau Population Census. It is socially important to

no or minimal rotational deformity (Type I), andunveil the impact of aging and extend healthy life

degenerative lumbar scoliosis, which is often second­

expectancy. One of the most important factors di­ary to pre-existing scoliosis and exhibits a large

minishing healthy life expectancy is the aging ofrotational deformity with substantial loss in lumbar

motor organs, such as the bones, joints, nerves, andlordosis (LL) (Type II). These deformities requiremuscle tendons. In recent years, corrective surgeries

different bracing and correction methods, with Typefor spinal postural abnormalities in the sagittal plane

I usually necessitating a short brace and Type IIof the spine have been performed in older adults

requiring correction with a longer brace using sagittal

across Japan since it was reported that such disorders

plane reconstruction3）.

are associated with impaired walking and mobility,

In 2005, Aebi et al. defined adult scoliosis as a spinal

respiratory and digestive symptoms, and low backdeformity with a Cobb angle of 10 degrees or more

. However, little research exists on the epide­in the coronal plane at the end of growth4）. They also

miology, pathogenesis, evaluation methods, and treat­classified postural abnormalities of the spine after

ment effects on gait and mobility for spinal posturalbone maturation into three types based on etiology4）.

abnormality in order to establish treatment guidelines.

Type I scoliosis is the most common type of deformity

In this paper, we review the history of spinal pos­and is defined as primary degenerative scoliosis ortural abnormalities and discuss the Obuse Study, ade novo scoliosis. The curve in Type I scoliosis ismusculoskeletal cohort study of agricultural commu­

essentially a continuous progression of anterior ver­nity residents conducted by our department in con­tebral body deviation with asymmetrical degenera­

junction with the Rehabilitation Center, New Lifetion of the intervertebral discs accompanied by rota­

pain

1）
2）

tion with the fulcrum at the facet joint on one side.
＊

Corresponding author : Masashi Uehara	Department of Orthopaedic Surgery, Shinshu University
School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano
390-8621, Japan
E-mail : umasa@shinshu-u.ac.jp

No. 3, 2021

Type I scoliosis is more common in primary degen­erative scoliosis than in secondary degenerative idio­
pathic curves5）. Type II scoliosis is considered a rem­nant of congenital or idiopathic scoliosis. Idiopathic
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Uehara・Takahashi・Ikegami et al.

curves from other etiologies of secondary degenera­

based on clinically significant associations of radio­tion exist in several forms depending on the type ofgraphic parameters through prospective studies10）.

treatment previously given. Type III scoliosis is con­

Their sixth group was modified to include deformi­

sidered a deformity caused by lumbosacral lesions,ties in the sagittal plane only10）. The classification

lower extremity disease, and osteoporosis6）. Degen­also took into account an index of global balance.

erative idiopathic scoliosis, which is more prevalentAround the same time, the Scoliosis Research Soci­in the surgically treated lumbar or thoracolumbarety (SRS) introduced a classification system withspine, is associated with lower functional scores after

the goals of accurately classifying adult spinal

Harrington surgery, worse Oswestry disability index

postural abnormalities and providing a framework

7）

scores, and increased Modic change .

Also, in 2005, Schwab et al. proposed a radiographic

to help develop evidence-based approaches for the
management of those conditions11）.

classification method based on the degree of L1-S1

In 2008, Kuntz IV et al. proposed a neutral uprightlordotic angle and the coronal plane obliquity of L3 inspinal alignment in asymptomatic volunteers12）. The

standing radiographs8）. Ninety-eight adult patients

authors emphasized that global spinal alignment waswith scoliosis were included in the study and followed

maintained within a narrow range for horizontal gazefor a minimum of 2 years. Although the Cobb angle

and balance of the spine over the pelvis and femoral

did not correlate with visual analogue scale (VAS)

head in asymptomatic volunteers despite large varia­

scores or general health status (36-Item Short-Formtions in the regional curve from the occiput to the9）

Health Survey) , significant associations were iden­tified between L3 coronal plane obliquity, L1-S1
lordotic angle, and VAS results (p＜0.05). Mean VAS
pain scores were 27.7 for Type I scoliosis, 43.3 forType II scoliosis, and 47.1 for Type III scoliosis(Type I vs. Type III : p＜0.05). The operative rate (i.e.,

pelvis12）.
Fig.1 shows the history of spinal postural abnor­
mality studies.
Ⅲ Pelvic Parameters in Spinal Postural
Abnormalities

failure of conservative treatment, including orthotics,

Dubousset et al. presented the concept of the cone

physical therapy, and pharmacological treatment, forof economy in 1994, which considered that standingat least 3 months) was 0 ％ for Type I, 9 ％ for Typeposture was maintained in a cone with the foot as

8）

II, and 22.7 ％ for Type III (p＝0.002) .

the fulcrum. The dimensions of the cone became

One year later, Schwab et al. presented a new clas­

smaller in a stable posture and larger in an unstablesification system for spinal postural abnormalities

posture (Fig. 2)13）. In patients with spinal posturalFig. 1
112

History of spinal postural abnormality studies

Fig. 2

Cone of economy
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Spinal deformity and the musculoskeletal cohort study of the general older population

Fig. 3 Radiographic parameters of sagittal spinal alignment (adapted from Uehara 2019 [33])Abbreviations : SVA, sagittal vertical axis ; GT, global tilt ; CL, cervical lordosis ; CSVA, cervical sagittal vertical axis ;T1S, T1 slope ; TK, thoracic kyphosis ; LL, lumbar lordosis ; SS, sacral slope ; PT, pelvic tilt ; PI, pelvic incidence.

abnormalities, increasing pelvic tilt (PT) and lower

These three pelvic parameters are interrelated byextremity compensatory functions are used to main­

the equation PI＝PT＋SS. Several studies have since

tain the standing position in the cone13）. In 1992,

shown that pelvic parameters and health-related

Duval-Beaupère et al. described three major pelvic

quality of life are potentially related1）21）22）.

sagittal parameters : pelvic incidence (PI), PT, andⅣsacral slope (SS). They stated that LL should have a

Indicators in Corrective Surgery

necessary angle according to PI and considered thatIn 2012, the SRS revised its classification of spinal

the key to standing alignment was the pelvis (Fig.

postural abnormalities by adding pelvic parame­

14）
15）

. In addition, they pointed out that a small PI

ters (SRS-Schwab classification). In this revision, a

was disadvantageous for an economical standing

deformity was described by its main coronal curve

posture since it shortened the lever arm for the hippattern and its degree using the Cobb angle, with

3)

14）

extensors to operate . PI is a relatively constant

three modifiers applied : the relationship between

morphological parameter of the pelvis, with only

PI and LL (PI-LL), PT, and the anterior shift ofslight changes throughout adulthood. However, PI

the vertical axis of the sagittal plane of the seventh

16）
-19）

, and

cervical vertebra (SVA). This provided an index ofrecent studies have described PI changes with age,spinal pelvis parameters to surgeons to better define

values vary widely even in healthy subjects
20）

especially in women .

malalignment and correction goals. The theory of

According to the above findings, childbearing maycorrection is that LL according to PI, thoracic kypho­

be one of the reasons for high PI in women over 40

sis according to LL, and coordination of the lower

years of age ; as PI increases, LL must also increase

extremities are required to maintain standing pos­

proportionally to maintain vertical balance in theture23）.

sagittal plane. PT and SS are posture-dependent

Since the publication of the SRS-Schwab classifica­

values that vary with pelvic rotation on the hip axis.

tion as an index for corrective surgery, advances in

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113

Uehara・Takahashi・Ikegami et al.

spinal implants have led to a worldwide increase in

Physical function measurements included the follow­

fusion procedures for spinal postural abnormalities.

ing : knee flexion/extension muscle strength, grip

However, there are few reports on optimal spinal

strength, one-leg standing time, the stand-up test,alignment parameters in healthy individuals, and age-and the two-step test.

specific spinal deformity correction goals remain contro­
versial24）25）. Furthermore, sagittal plane alignment inhealthy individuals differs depending on ethnicity ;Ⅵ Obuse Study : Analysis of Sagittal Spinal
Alignment Parameters33）

in a study comparing pelvic parameters in a popula­

The mean and standard deviation (SD) of eachtion from Mexico, Caucasians, and Asians, both LL

parameter for each age group and gender are shown

26）

and SS were smaller in Asians . Arima et al. alsoin Table 1. In the sagittal plane global alignment ofreported that PI was largest in African-Americans

the spine, SVA became larger and spinal alignmentand smallest in Asians, while LL was smallest in

shifted anteriorly with age in both men and women.

27）

Asians . Several formulas for corrective indices in theStatistical examination showed that SVA was signifi­

Japanese have also been reported28）-30）, and epidemi­

cantly shifted forward in men in their 80s and in

ological studies on spinal posture in healthy volun­

women in their 70s as compared with the values of

31）
32）

teers currently exist
Ⅴsubjects in their 50s. This was especially pronounced.

Overview of the Obuse Studyin women, with SVA in the 80s age group shifting
anteriorly by an average of 66 mm versus the 50s

Led by then-Professor Kato, the Department ofage group (Fig. 4). The changes in cervicothoracic

Orthopaedic Surgery of Shinshu University Schoolalignment parameters by age were clearly differ­of Medicine established the Obuse Study, a cohort

ent between genders. In men, anterior shift of the

population study of Japanese residents in agricultural

cervical spine was evident from the age of 60 years

areas, in 2014. The investigation aimed to study the(Fig. 5). In women, decreased lumbar kyphosis anddegree and frequency of age-related changes toposterior PT occurred at a younger age than in men.

bones, joints, and muscle tendons as a collaborative

The decrease in PT appeared roughly 10 years before

effort among Shinshu University (Department of Or­

that in male subjects (Fig. 6). An increase in thoracic

thopaedic Surgery and Rehabilitation Center), thekyphosis angle was significant only in men over 70

33）
-43）

local government, and town hospitals.

To create the Obuse cohort, we randomly selected

years of age, although the increase was 4 to 6 degrees
in both sexes (Fig. 5).

1,297 of 5,352 townspeople aged 50-89 years in the

The Obuse Study revealed several key findings :resident registry of Obuse town, Nagano Prefecture,① a decrease in LL in both men and women, with a sig­

and sent them information on the proposed musculo­

nificant decrease in women ; ② a decrease in sacral tilt

skeletal examinations. A total of 412 people, approxi­

in both men and women, with a significant decrease

mately 50 men and 50 women across four age groups

in women ; ③ a significant change in SS in women,(50s, 60s, 70s, and 80s), who agreed to the testingwith changes occurring approximately 10 years earlier

were included in the study. Standing lateral radio­

than in men ; and ④ clear evidence of age-related

graphs and physical function measurements of thealignment changes in the cervical spine. There was awhole spine were taken. Reference values for eachclear difference between genders in cervical spine sag­parameter of sagittal spinal column alignment for

ittal alignment changes due to aging, with a marked

each age group and gender were calculated from theanterior shift in men.

standing lateral radiographs. The Dunnett test wasused to determine the extent to which changes inalignment occurred, and from which age in reference
to values obtained for the 50-year-old participants.
114

Ⅶ Obuse Study : Relationship between Spinal
Postural Abnormalities and Motor Function34）
The relationships between sagittal plane parame­
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Spinal deformity and the musculoskeletal cohort study of the general older population
Table 1

Spinal sagittal alignment parameters of the Obuse Study cohort (adapted from Uehara 2019 [33])SexAge(years)

N

SVA
(mm)

GT
(deg.)

CL(deg.)

CSVA
(mm)

T1S
(deg.)

TK(deg.)

LL(deg.)

SS(deg.)

PT(deg.)

PI(deg.)

Male

50s

50

6
(26)

13
(7)

10
(10)

23
(14)

25
(6)

25
(8)

44
(11)

33
(8)

12
(6)

45
(9)

60s

53

9
(38)

17
(11)

9
(11)

28
(15)

27
(8)

29
(8)

45
(13)

31
(9)

14
(8)

45
(10)

70s

55

22
(30)

19
(8)

13
(12)

29
(12)

29
(9)

31
(10)

45
(13)

33
(9)

16
(6)

49
(10)

80s

45

57
(49)

29
(12)

14
(15)

31
(17)

31
(10)

31
(13)

38
(12)

28
(6)

21
(7)

49
(9)

All

203

22
(41)

19
(11)

12
(12)

28
(15)

28
(8)

29
(10)

43
(12)

31
(8)

16
(7)

47
(10)

17
(38)

18
(11)

11
(12)

27
(15)

28
(8)

29
(9)

44
(12)

32
(8)

15
(7)

46
(10)

Weighted＊
Female

50s

47

－5
(26)

14
(8)

9
(10)

18
(11)

23
(7)

27
(9)

51
(11)

36
(8)

14
(6)

49
(9)

60s

61

5
(30)

19
(11)

9
(9)

16
(8)

22
(7)

31
(10)

47
(14)

31
(10)

17
(8)

48
(11)

70s

54

30
(36)

26
(11)

13
(11)

17
(11)

25
(10)

30
(11)

42
(14)

29
(9)

23
(10)

53
(11)

80s

48

61
(60)

36
(16)

19
(12)

19
(16)

30
(14)

33
(19)

38
(20)

25
(11)

27
(11)

51
(11)

All

210

22
(46)

23
(14)

12
(11)

17
(11)

25
(10)

30
(12)

45
(16)

30
(10)

20
(10)

50
(11)

19
(45)

22
(14)

12
(11)

17
(11)

24
(10)

30
(12)

45
(16)

31
(10)

20
(10)

50
(11)

Weighted＊

Values represent the mean standard deviation.
based on the Japanese population composition of July 2017.
Abbreviations : SVA, sagittal vertical axis ; GT, global tilt ; CL, cervical lordosis ; CSVA,
cervical sagittal vertical axis ;T1S, T1 slope ; TK, thoracic kyphosis ; LL, lumbar lordosis ; SS, sacral slope ; PT, pelvic tilt ; PI, pelvic incidence.

＊

Fig. 4 Deviation in the whole spine from 50 years of age (adapted from Uehara 2019 [33])Note : Error bars represent 95 ％ confidence intervals.
Abbreviations : SVA, sagittal vertical axis ; GT, global tilt.

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Uehara・Takahashi・Ikegami et al.

Fig. 5 Deviation in the cervical and thoracic spine from 50 years of age (adapted from Uehara 2019 [33])Note : Error bars represent 95 ％ confidence intervals.
Abbreviations : CL, cervical lordosis ; CSVA, cervical sagittal vertical axis ; T1S, T1 slope ; TK, thoracic kyphosis.

Fig. 6 Deviation in the lumbopelvic region from 50 years of age (adapted from Uehara 2019 [33])Note : Error bars represent 95 ％ confidence intervals.
Abbreviations : LL, lumbar lordosis ; SS, sacral slope ; PT, pelvic tilt ; PI, pelvic incidence.
116

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Spinal deformity and the musculoskeletal cohort study of the general older population

Fig. 7 Effect on physical performance tests of a ＋1 standard deviation shift of sagittal spinal alignment parameters(adapted from Tokida 2019 [34])Note : Bands represent 95 ％ confidence intervals. All values were adjusted for age and sex.
Abbreviations : SVA, sagittal vertical axis ; GT, global tilt ; CSVA, cervical sagittal vertical axis ; CL, cervical lordosis ;TK, thoracic kyphosis ; LL, lumbar lordosis ; PT, pelvic tilt ; SD, standard deviation.

ters and physical function test values are shown incolumn alignment parameters. Larger SVA, GT, CSVA,

Fig. 5. Knee extension and flexion muscle strengthand PT all correlated with significantly lower scores

were not remarkably associated with any sagittal(p＜0.01 for all), while larger LL was associated withplane parameter. Grip strength was significantly (p＜higher scores (p＜0.01) (Fig. 7).

0.01) associated with global tilt (GT) (p＜0.01), an index

The Obuse Study clearly showed that poor spinalof cervical sub-total alignment, with a mean of 0.8 kg

sagittal alignment was associated with diminished(95 ％ confidence interval 0.2-1.4 kg) lower when GT

motor function performance in the general older popu­

was ＋1 SD (11 degrees for men and 14 degrees forlation. Since poor alignment can be easily visualized

women) greater than the mean. Similarly, larger PT

as a change in the appearance of standing posture,

was associated with lower grip strength (p＝0.02).

it may be applicable for use in population health screen­

One-leg standing time was significantly related to SVA

ing. If a simple index for confirming spinal sagittal(p＜0.01), GT (p＜0.01), and LL (p＝0.03), and wasalignment in a standing posture and an evaluation

shorter when SVA or GT was larger or LL was smaller

method can be developed, it may be easier to detect; when SVA was deviated anteriorly by ＋1 SD (41older individuals in need of nursing care at an earlier

mm for men and 47 mm for women) from the mean,

stage to extend healthy life expectancy in Nagano

one-leg standing time was shorter by an average ofPrefecture.

3.8 seconds (95 ％ confidence interval 2.1-5.5 seconds).
The stand-up test was significantly associated with

Ⅷ

Conclusions

SVA (p＜0.01), GT (p＜0.01), and CSVA (p＜0.01). Lastly,

The Department of Orthopaedic Surgery of Shinshu

the two-step score was associated with several spinal

University School of Medicine has been conducting

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Uehara・Takahashi・Ikegami et al.

a randomly selected exercise screening and epide­age. The worsening of spinal postural abnormalities

miological study (Obuse Study) of older people in

may also be related to declines in motor function. In

cooperation with the Rehabilitation Center in Shin­the second phase of the Obuse Study, longitudinal

shu University Hospital, New Life Hospital, and theevaluations will analyze the changes in spinal posture

town office in Obuse, Nagano Prefecture, since 2014. The

over time to formulate prevention and intervention

results indicate the presence of gender differences instrategies for spinal postural abnormalities.

the progression of spinal postural abnormalities with
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