What is the treatment for loss of normal lumbar lordosis?

Treatment for Loss of Normal Lumbar Lordosis

For patients with loss of normal lumbar lordosis, an intensive course of physical therapy focusing on individual strengthening exercises for posterior pelvic tilt muscles (rectus abdominis, gluteus maximus, hamstring) is recommended as the first-line treatment. 1, 2

Understanding Loss of Lumbar Lordosis

Loss of lumbar lordosis refers to the flattening of the normal inward curve of the lower back. This condition can lead to:

• Back pain
• Difficulty standing erect
• Altered sagittal balance
• Reduced spinal mobility

Diagnostic Evaluation

Before initiating treatment, proper evaluation is essential:

• Imaging: Standing lateral X-rays are the most useful for evaluating sagittal plane balance 3, 4

  • The C7-S1 measurement should fall within 2 cm of the anterior aspect of the sacrum 4
  • Ensure proper positioning: supine with legs straight for AP views, hips and knees flexed to 90° for lateral views 3

• Clinical Assessment:

  • Evaluate for associated conditions like degenerative disc disease
  • Assess for neurological deficits
  • Check for hip flexion contractures that may contribute to lordosis issues 4

Treatment Algorithm

First-Line Treatment:

1. Physical Therapy:

   • Individual strengthening exercises targeting posterior pelvic tilt muscles 2
   • Focus on rectus abdominis, gluteus maximus, and hamstring strengthening 2
   • This approach has been shown to improve pelvic tilt angles, increase lumbar ROM, and decrease pain 2

2. Lumbar Orthotic Devices:

   • Lordotic lumbar braces can serve as rehabilitation tools 5
   • These devices provide compression in the lumbar region and help correct sagittal plane balance 5
   • Studies show they can improve postural control and balance strategies 5

Second-Line Treatment:

If conservative measures fail after 6 weeks, consider:

1. Advanced Imaging:

   • MRI for soft tissue and neural pathology assessment 3
   • CT for detailed bony anatomy evaluation 3

2. Surgical Options (for carefully selected patients with disabling pain):

   • Lumbar fusion for one- or two-level degenerative disease without stenosis or spondylolisthesis 1
   • When fusion is necessary, avoid distraction instrumentation extending into the lower lumbar spine or sacrum, as this is the most frequent cause of iatrogenic loss of lordosis 4

Important Considerations

• Avoid Common Pitfalls:

  • Simple supportive cushions under the knees produce no practical reduction in lumbar lordosis 6
  • Many degenerative findings on imaging may be incidental and not correlate with symptoms 3

• Normal Lordosis Values:

  • There is no absolute "normal" value for lumbar lordosis 4, 7
  • Normal lordosis varies based on age, gender, BMI, ethnicity, and activity level 7
  • Overall sagittal plane balance is more important than specific angle measurements 4

• Surgical Complications:

  • The "flat-back syndrome" is a disabling complication of spinal fusion, particularly when instrumentation extends to lower lumbar spine or sacrum 4
  • Surgical correction of established loss of lordosis is difficult with high complication rates 4

By following this treatment approach, most patients with loss of normal lumbar lordosis can achieve significant improvement in symptoms and function, with surgery reserved only for those who fail conservative management.