Obesity

Back pain and sagittal spine alignment in obese patients

eligible for bariatric surgery

Journal: Obesity

Manuscript ID Draft

Manuscript Type: Original Article

Date Submitted by the Author: n/a

Complete List of Authors: Mello, Alexandre; Universidade Federal do Estado do Rio de Janeiro, Escola
de Medicina e Cirurgia; Instituto Nacional de Traumatologia e Ortopedia,
Cirurgia da Coluna Vertebral
Martins, Glaucus; Hospital Federal de Ipanema, Orthopaedics;
Universidade Federal do Rio de Janeiro, Orthopaedics
Heringer, André; Hospital Federal de Ipanema, Orthopaedics
Gamallo, Raphael; Hospital Federal de Ipanema, Orthopaedics
Martins Filho, Luiz Felippe; Hospital Federal de Ipanema, Orthopaedics
Abreu, Antônio; Universidade Federal do Rio de Janeiro, Orthopaedics
Carvalho, Antônio Carlos; Universidade Federal do Rio de Janeiro,
Radiology

Keywords: Obesity, Low Back Pain, Radiology, Quality of Life

ScholarOne, 375 Greenbrier Drive, Charlottesville, VA, 22901

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Back pain and sagittal spine alignment in
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obese patients eligible for bariatric surgery
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10 Alexandre Peixoto de Mello
11 Glaucus Cajaty dos Santos Martins
12 André Raposo Heringer
13 Raphael Barbosa Gamallo
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Luiz Felippe dos Santos Martins Filho
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Antônio Vítor de Abreu
17 Antônio Carlos Pires de Carvalho
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Abstract
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Objective
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23 The objective of this research was to evaluate the prevalence of cervical and lumbar
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25 pain in obese patients eligible for bariatric surgery, and to investigate possible changes
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27 in sagittal spine alignment in these patients.
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29 Methods
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31 The following parameters were compared in 30 obese patients and a control group of
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25 non-obese volunteers: body mass index (BMI), prevalence of cervical and lumbar
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34 pain assessed by visual analog scale (VAS), Neck Disability Index [NDI] and Oswestry
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36 Disability Index [ODI], as well as radiographic parameters of the spine and pelvis
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38 measured with Surgimap software.
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40 Results
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42 The cervical and lumbar VAS and the NDI and ODI were significantly worse in obese
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patients. Compared with the control group, the cervical sagittal vertical axis (cSVA) of
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45 the obese group had higher variance (p-value = 0.0006) and the cervical lordosis was
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47 diminished (p-value = 0.0078). Thoracic kyphosis, lumbar lordosis, and the pelvic
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49 parameters were not significantly different between the groups.
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51 Conclusions
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53 Obese patients demonstrated lower functional performance compared with their non-
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obese counterparts, while cervical lordosis was diminished and the cSVA was
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56 increased in obese patients.
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58 Keywords
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5 obesity, neck pain, low back pain, sagittal alignment parameters, parameters
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7 spinopelvic
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9 Introduction
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11 Obesity is one of the most important public health problems, currently responsible for
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approximately 7.1% of all global deaths (1). In 2016, according to the World Health
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14 Organization (WHO) criteria, 13% of the adult population was obese, including 11% of
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16 men and 15% of women. The worldwide prevalence of obesity nearly tripled between
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18 1975 and 2016 (2). The global economic impact of obesity is about $2.0 trillion, or 2.8%
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20 of the global gross domestic product (GDP), roughly equivalent to the global impact of
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22 smoking or armed violence, war, and terrorism (3).
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The incidence of musculoskeletal disorders (4,5), including back pain (6,7), is high in
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25 obese patients. However, still no definition in the literature exists about the cause-and-
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27 effect association between obesity and back pain. Classically, obesity is associated
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29 with degenerative joint disease due to the mechanical stress placed on the cartilage
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31 by increased local pressure, stress, tension, shear forces, and/or increased hydrostatic
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33 pressure within the cartilage (8), and it is natural to believe that the same would happen
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in the vertebral structures. However, more recent studies involving visceral fat proteins
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36 point to adipokines as playing an important role in the development of joint injury (9).
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38 Adipokines are a group of proteins produced by white adipose tissue that are believed
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40 to induce a state of systemic low-grade inflammation (10,11). A recent review of the
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42 literature that evaluated overweight and obesity alone revealed that there were
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44 substantial costs due to lost productivity among affected workers (12). Also, a recent
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study projected that if current trends continue, the global prevalence of obesity will
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47 reach 18% in men and surpass 21% in women by 2025 (13).
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49 Back pain is an important public health problem. A study of the global impact of the
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51 disease showed that back pain is the factor that most contributes to disability
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53 worldwide, adding 10.7% of the total years lost through disability, a percentage that
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55 tends to increase as the population gets older (14). It is the second leading cause of
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absenteeism at work (14–16). Additionally, it is responsible for a significant proportion
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58 of long-term absenteeism, with an estimated 32% of patients not returning to work
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60 within 1 month (17). It is estimated that 54% to 80% of the adult population will have

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5 at least one episode of back pain during their lifetime (18,19). There is an apparent
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7 relationship between obesity and back pain, but the details remain poorly understood
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9 (20,21).
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11 Additionally, the change in physiological sagittal curves in the spine (cervical and
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lumbar lordosis and thoracic kyphosis) (22,23) and decreased mobility of the spine
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14 (24) are related both to obesity and to back pain. Currently, a value is assigned to the
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16 sagittal spinal balance in the genesis of pain (22). While there is no normal sagittal
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18 balance, it is important to maintain an appropriate balance between the curvatures of
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20 the spine and the pelvis (25).
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22 The objective of this study was to evaluate the prevalence of cervical and lumbar pain
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in obese patients eligible for bariatric surgery, and to investigate possible changes of
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25 parameters of sagittal alignment in these patients and the role of these changes in the
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27 origination of the pain.
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29 Materials and Methods
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31 A cross-sectional study registered and approved by the Committee on Ethics in
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33 Research (66439416.1.0000.5646) was performed with informed consent of
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participants.
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36 A group of 30 patients in the Bariatric Surgery Outpatient Clinic of the Hospital of
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38 Ipanema was randomly selected for the study. The group was selected as the patients
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40 elected for bariatric surgery in the outpatient clinic between January and June of 2017.
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42 Another group of 25 volunteers from the health team was selected to serve as a control
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44 group, while those who were obese or who had back pain were excluded (Table 1). The
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control group was structured to be similar in gender composition and mean age to the
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47 study group. Individuals who had previously undergone surgical procedures for spine
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49 issues or fractures of the lower limbs were excluded.
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51 Obesity was determined by the body mass index (BMI), as recommended by the WHO
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53 (26).
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55 Participants were questioned about their cervical and lumbar pain and were presented
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with a ruler depicting a visual analog scale of pain. The answer was classified as 0 (no
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58 pain) to 10 (no more intense pain possible); with mild pain being 0–3, moderate pain
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60 being 4–6, and severe pain being 7–10.

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5 Functional involvement and limitations associated with back pain have been assessed
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7 by the Neck Disability Index (NDI) (27) and the Oswestry Disability Index (ODI)
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9 (28). These scales evaluate the impact of pain on the life of the patient by assessing
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11 main activities of daily living. Each question is given a value, resulting in a score for
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each activity (domain) and an overall score (sum of items).
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14 X-rays of the spine were taken in the standing position.
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16 Using the software Surgimap Spine (Nemaris Inc., New York-NY, USA) (29), the
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18 following parameters were measured on digital radiographs of the groups:
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20 • cervical lordosis was measured from the lower plateau of C2 to the C7 lower
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22 plateau;
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• thoracic kyphosis was measured from the upper plateau of T5 to the T12 lower
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25 plateau;
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27 • lumbar lordosis was measured from the upper plateau of L1 to the upper plateau
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29 of S1;
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31 • pelvic incidence (PI) was measured as the angle between a line perpendicular
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33 to the ground at the midpoint of the sacral plateau, and a line connecting this
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point to the central axis of the femoral head, on a lateral radiograph of the pelvis;
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36 • pelvic tilt (PT) was measured as the angle between a line perpendicular to the
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38 ground and a vertical line connecting the midpoint of the top plateau of S1, to
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40 the midpoint of the line that connects the center of the femoral heads, on a
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42 lateral radiograph of the pelvis;
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44 • sacral slope (SS) was measured as the angle between the upper plateau of S1
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and a line parallel to the ground, on a lateral radiograph of the pelvis;
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47 • cervical sagittal vertical axis (cSVA) was measured as the distance between the
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49 line perpendicular to the ground passing through the center of C2 and the
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51 posterior superior border of C7, on a lateral radiograph of the cervical spine.
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53 We used the D’Agostino-Pearson test to access the normality of the groups. We then
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55 used the Student’s t-test or the Mann–Whitney U test to evaluate the difference
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between the groups, using the first for normally distributed groups and the second for
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58 the others. P-values were considered significant when they were lower than 0.05. The
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60 correlation between the two groups was assessed with Pearson’s correlation for

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5 normally distributed and Spearman’s correlation test for non-normally distributed
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Results
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The groups were not significantly different in composition with regard to sex, with five
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14 (17%) men in the group of obese patients and five (20%) in the control group. Although
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16 they were not normally distributed, their distribution was equivalent, as shown by
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18 Student’s t-test. The groups were also equivalent with respect to age, with the mean
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20 age being 51 years in the obese group and 50 years in the control group. Only BMI
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22 showed a statistically significant difference, as shown in Table 1.
23 Group Obese Control
24 total 5 5
25 Male
26 percentage 17% 20%
27 total 25 20
28 Sex Female
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percentage 83% 80%
30 D'Agostino-Pearson p-value < 0.0001 < 0.0001
31 Mann-Whitney p-value 0.833
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33 Mean 51 50
34 Standard deviation 7 13
35 Age
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D'Agostino-Pearson p-value 0.451 0.281
37 Student's t p-value 0.784
38 Mean 39.5 23.5
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40 Standard deviation 4.6 3.3
BMI
41 D'Agostino-Pearson p-value 0.009 0.004
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Student's t p-value < 0.0001
Table 1
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46 In relation to measures of spinal curvature, the only significant differences between the
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48 groups were in cervical lordosis and in cervical sagittal vertical axis (cSVA), as shown
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50 in Chart 1 and 2.
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22 Chart 1
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Chart 2
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40 Although they were significantly different, the Pearson correlation coefficients could
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42 not establish a definite relationship between BMI and the cervical lordosis and cSVA.
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44 Thoracic kyphosis, lumbar lordosis, and pelvic parameters showed no statistically
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46 significant differences between the groups. The results are shown in Table 2.
47 Group Obese Control
48 Mean -13 -22
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50 Standard deviation 12 12
Cervical Lordosis
51 D'Agostino-Pearson p-value 0 1
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Mann-Whitney p-value 0 0
54 Mean 23 12
55 Standard deviation 12 10
56 cSVA
57 D'Agostino-Pearson p-value 0 0
58 Mann-Whitney p-value 0 0
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Mean 31 31
Thoracic Kyphosis
Standard deviation 10 10

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5 D'Agostino-Pearson p-value < 0.0001 0
6 Student's t p-value 1 0
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Mean -46 -49
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9 Standard deviation 12 13
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Lumbar Lordosis
D'Agostino-Pearson p-value 0 0
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12 Student's t p-value 1 0
13 Mean 15.13 13.11
14 Standard deviation 6.25 8.48
15 PT
16 D'Agostino-Pearson p-value 0.67 0.51
17 Student's t p-value 0.31 0.00
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19 Mean 49.97 50.54
20 Standard deviation 8.38 11.58
21 PI
D'Agostino-Pearson p-value 0.16 0.58
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23 Student's t p-value 0.83 0.00
24 Mean 35.00 37.38
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Standard deviation 9.32 10.90
SS
27 D'Agostino-Pearson p-value 0.26 0.40
28 Student's t p-value 0.39 0.00
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30 Mean 0.50 0.16
31 Standard deviation 0.11 0.07
32 NDI
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D'Agostino-Pearson p-value 0.42 0.46
34 Student's t p-value < 0.0001 0.00
35 Mean 0.48 0.08
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37 Standard deviation 0.11 0.06
ODI
38 D'Agostino-Pearson p-value 0.52 0.45
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Student's t p-value < 0.0001 0.00
41 Mean 4.20 0.32
42 Standard deviation 1.69 0.75
43 VAS cervical
44 D'Agostino-Pearson p-value 0.65 < 0.0001
45 Student's t p-value < 0.0001 0.00
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Mean 4.40 0.32
48 Standard deviation 1.92 0.75
49 VAS lumbar
D'Agostino-Pearson p-value 0.94 < 0.0001
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51 Student's t p-value < 0.0001 0.00
52 Table 2
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54 All the disability scores showed statistically significant differences (p<0.05) between
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56 the two groups, but no definite correlation could be established between BMI and these
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58 scores by Pearson correlation coefficients (p<0.05). These results are shown in Table
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5 2, while in Table 3 we show the results of the Pearson correlation. Charts 3 and 4 also
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8 Pearson Correlation with BMI r p
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10 Obese -0.07 0.72
Cervical Lordosis
11 Normal 0.35 0.08
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Obese -0.09 0.64
13 cSVA
14 Normal 0.09 0.69
15 Obese 0.16 0.39
16 NDI
17 Normal 0.00 1.00
18 Obese 0.26 0.16
19 ODI
Normal 0.02 0.91
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21 Obese 0.02 0.90
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VAS cervical
Normal -0.03 0.90
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24 Obese 0.08 0.67
VAS lumbar
25 Normal 0.23 0.27
26 Table 3
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43 Chart 3
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5 A sample size calculation made after the study showed that our group numbers were
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7 inadequate in drawing a robust conclusion about the measurement of cervical lordosis,
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9 but adequate on the conclusion on cSVA. The sample size calculation showed that 41
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11 individuals were necessary in the obese and 34 in the control group for cervical
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lordosis, and 24 in the obese and 20 in the control group for the cSVA.
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14 Discussion
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16 Individuals in the obese group presented with painful symptoms in the cervical and
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18 lumbar spine more often than those in the control group. In addition, the group of obese
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20 individuals exhibited worse functional performance of the cervical and lumbar spine in
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22 the activities of daily living as evaluated by NDI and ODI, respectively, compared with
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the control group.
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25 Although some studies (4,30) have indicated that obese individuals have a higher
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27 incidence of musculoskeletal pain, including lumbago, it has not yet been defined if
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29 increased weight has a direct relationship with the prevalence and onset of back pain
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31 (21,35).
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33 Some studies have shown a correlation between obesity and back pain (6,18,21),
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suggesting that obesity is a risk factor for causing back pain. Other studies have
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36 determined that this relationship is weak or non-existent, raising the possibility that
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38 other factors are causing the pain (31,20,32).
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40 Some studies have also noted a direct relationship between obesity and low back pain
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42 (20,32,33). Other authors have found that environmental factors and genetics should
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44 be considered in the pathophysiology of low back pain (20). Others, however, have
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concluded that overweight and obesity increase the risk of chronic pain (34).
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47 The present study showed an increase in pain reported in the group of obese patients
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49 compared with the control patients. Similarly, the obese patients also had worse
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51 functional outcomes compared with the control patients, as measured by the NDI and
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53 ODI. This result does not agree with other studies (35,36), suggesting that other factors
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55 may be related to the back pain.
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There are few publications regarding alterations in sagittal spine balance associated
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58 with obesity. In a bibliographic survey, we identified few articles that describe the
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60 angular values in physiological curves in the cervical, dorsal, and lumbar spine in

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5 obese subjects, and even fewer in patients with morbid obesity. González-Sánchez et
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7 al. (37) found no difference in sagittal curvature of the spine between obese and non-
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9 obese individuals, but they used an electromagnetic apparatus and no radiographic
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11 examinations. To our knowledge, it has not been described in the literature how the
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spine curves behave and their compensatory mechanisms in severe obesity (BMI >
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14 40).
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16 An important finding of our study was the existence of significantly smaller values of
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18 cervical lordosis in obese subjects compared with the control group. We also found a
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20 significantly larger cSVA in obese subjects. The average value of the cSVA was 2.2
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22 cm in the obese group, which is significantly greater than that of the control group (0.63
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cm). However, this value did not indicate severe cervical sagittal imbalance (greater
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25 than 4 cm) (38).
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27 The study of cervical spine alignment is gaining greater importance as it relates to the
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29 postural compensation mechanisms after large surgeries for thoracolumbar
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31 deformities and cervical myelopathy. The importance of the cervical spine in the global
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33 compensation of sagittal balance has also been increasingly valued (39,40).
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The difference in the cervical measures that we observed between the obese and
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36 control groups have not been shown in the literature. The importance of these findings
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38 requires further research with a larger group of patients, and merits re-evaluation and
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40 additional analyses in the future.
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42 No differences were observed between the average values of the pelvic measures
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44 between the obese and control groups. This conflicted with the results of Kulcheski et
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al. (41), who observed increased values of pelvic incidence and pelvic tilt in obese
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47 patients. However, these authors did not have a control group, and compared their
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49 results with values in the literature, which may have created bias in the comparison
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51 and analysis of the data. Roussouly et al. (42) and Romero-Vargas et al. (43)
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53 reinforced the importance of this topic, given the absence of definitive findings and the
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55 importance of the subject.
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In addition, weight loss in patients with osteoarthritis has been shown to have a positive
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58 impact (44). Weight loss in patients with severe obesity (i.e., BMI between 35 and 40),
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60 and a reduction in the clinical complications related to obesity, such as diabetes,

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5 obstructive sleep apnea, and other cardiovascular risk factors, can be achieved with
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7 surgical treatment (45). However, a clear benefit in relation to back pain has not yet
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9 been demonstrated.
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11 This study, as with all cross-sectional studies, cannot unequivocally determine cause
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and effect, and the results cannot be extrapolated to the general population because
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14 of the small sample size. A larger study with a greater number of subjects is necessary
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16 to validate our results. However, the originality of the approach of evaluating
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18 radiographic patterns of the spine segments, as well as pain and functional parameters
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20 in severely obese individuals, makes this study a valuable contribution to the literature.
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22 This research sought to evaluate the prevalence of cervical and lumbar pain and
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analyze whether there would be abnormalities in sagittal spine alignment in obese
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25 patients. These results may be useful in guiding the treatment of obese patients with
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27 back pain.
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30
31 Acknowledgment
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33 We thank Peter Mittwede, MD, PhD, from Edanz Group (www.edanzediting.com/ac)
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for editing a draft of this manuscript.
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36
37
38
39
40 References
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43 1. Kushner RF, Kahan S. Introduction: the state of obesity in 2017. Medical
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