What are the treatment options for straightening of the lumbar lordosis?

Treatment of Straightening of Lumbar Lordosis

Start with supervised exercise programs focusing on paraspinal and abdominal muscle strengthening for 3-6 months before considering any surgical intervention. 1, 2

Initial Conservative Management (First-Line Treatment)

Straightening of lumbar lordosis on imaging is typically a nonspecific finding that most commonly represents muscle spasm from pain or positioning artifact rather than true structural pathology. 2 This means treatment should focus on identifying and addressing the underlying pain generator rather than treating the radiographic finding itself.

Conservative Treatment Protocol

• Initiate supervised exercise programs targeting paraspinal and abdominal muscles to provide better spinal support 1, 2
• Physical therapy should be the cornerstone of initial management 2
• Proper positioning with flexed hips and knees at 90° can reduce physiological lordosis and provide symptomatic relief 1, 2
• Continue conservative management for 3-6 months minimum before considering surgical options 1, 2

Important Diagnostic Considerations

Ensure proper patient positioning during imaging to avoid misinterpreting positioning artifacts as pathology. 2 Positioning artifacts are extremely common, and flexed hips/knees at 90° are required to accurately assess lumbar lordosis. 1, 2

Muscle spasm from any painful condition can cause protective straightening of the lumbar spine, making this a nonspecific finding that reflects pain rather than structural pathology. 2 Therefore, clinical correlation is essential to identify the actual underlying cause of symptoms.

Advanced Imaging When Needed

• MRI of the lumbar spine is the initial imaging modality of choice for patients with subacute or chronic low back pain who have failed conservative therapy 2
• Plain radiographs should only be obtained in patients who have failed 6 weeks of conservative therapy and are candidates for surgery or intervention 2
• CT may be useful for preoperative planning to delineate osseous margins and aid in hardware trajectory planning 2

Surgical Intervention (Only After Conservative Failure)

Surgical intervention should only be considered after failure of 3-6 months of conservative management AND when significant neurological symptoms or progressive instability are present. 1, 2

Surgical Indications

• Progressive neurological deficits should prompt more urgent surgical evaluation 1, 2
• Chronic low back pain due to degenerative disc disease refractory to conservative treatment 1, 2
• Lumbar stenosis with associated degenerative spondylolisthesis requiring decompression 1, 2

Surgical Options

• Lumbar fusion is recommended for chronic low back pain due to degenerative disc disease that is refractory to conservative treatment 1, 2
• Posterolateral fusion (PLF) is recommended for patients with lumbar stenosis and associated degenerative spondylolisthesis who require decompression 1, 2
• Pedicle screw fixation should be considered as an adjunct to lumbar PLF in cases with spinal instability or kyphosis 1

Correlation Between Lordosis and Clinical Outcomes

There is a significant positive correlation between lumbar lordosis and postoperative outcome (ODI score, r = 0.31, p < 0.01). 3 This suggests that maintaining or restoring appropriate lordosis during surgical intervention may improve clinical outcomes, though sagittal alignment is not solely dependent on anterior column support. 3

Common Pitfalls to Avoid

• Do not treat the radiographic finding of straightened lordosis as a primary diagnosis - it requires clinical correlation to identify the underlying cause 2
• Avoid premature surgical intervention - ensure 3-6 months of conservative management has been attempted first 1, 2
• Recognize positioning artifacts during imaging to avoid unnecessary treatment 1, 2
• Do not ignore progressive neurological deficits - these require more urgent evaluation despite the general recommendation for conservative management 1, 2