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Lumbar Lordosis and Back Pain

In this case study, the authors review hyperlordosis as a cause of back pain during pregnancy and discuss best practices for pain management before, during, and after pregnancy.
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Case Overview

A 26-year-old female, who was 34 weeks pregnant with her first child, presented with lower back pain. She described the pain as a dull ache that was constantly present. While the pain was relieved when she slept on her side with a pillow in between her legs, the patient reported that the pain disrupted her ability to fall asleep. The patient had no other pain complaints or radiation of pain to the legs and had no apparent abdominal issues. The lower back pain disabled her from walking, thereby affected her daily activities and limited her overall quality of life. On physical exam, she was positive for tenderness to palpation over the sacroiliac joint. There was an increased curvature in the lumbar region. When examining the patient’s gait, there was a slight tilt forward, possibly due to her spine’s posterior shift. The patient exhibited no neurological deficits. 

Introduction and Clinical Overview

The female body experiences many changes during a 40-week pregnancy, some of which increase susceptibility to discomfort and pain during pregnancy (see also, “Mechanical changes in pregnancy” on page 32).1 Back arching and a gradual anterior shift may naturally occur with the added load of a fetus’ weight. At the same time, changes in center of gravity and increased body mass may lead to lengthening and weakening of the abdominal musculature.2,3 These combined changes may lead to back pain.4,5 To compensate, the patient may shift the body frequently, leading to changes in posture, which may further induce strain on the spine and perpetuate pain.4

It has been postulated that there are two patterns of common back pain during pregnancy: lumbar pain (LP) and posterior pelvic pain.4 Specifically, the increased mass distribution of the trunk and center of gravity shift may result in lumbar lordosis. This presents as a tilt in the pelvis, which may then result in lumbar hyperlordosis, an inward curvature of the lumbar spine formed by the wedging of lumbar vertebral bodies and the intervertebral disks, which all contribute to LP. Lumbar hyperlordosis is diagnosed by measuring the curvature of the sagittal plane region of the vertebral spine using the Cobb method.

Mechanical changes in pregnancy
Pregnancy is a time of immense biological change during which every system of the body is affected. The physiological and physical adjustments of the female body during pregnancy have vast implications on the level of comfort. For example, the growth of the fetus shifts the center of mass and causes compensatory postural adjustments, which could be responsible for 
the backache commonly reported among pregnant females.1Although there is a strong correlation between back pain and pregnancy, further research is needed to fully understand the physiological mechanisms of this pain.

Normally, slight curves of the spine serve to absorb impact, decrease vertebral stiffness, and enhance muscle function. However, sources of back pain may result from unnatural variations in these sagittal plane curves. The measurement of lumbar hyperlordosis is influenced by multiple factors, such as age, gender, thoracic curvature, and pelvic bend.6

Lumbar lordosis is a crucial factor of sagittal spinal balance. Evidence indicates hat with increased lumbar lordosis, there is a lack of ability of the pelvis to compensate leading to strain.7 Cobb’s is the uniform measurement method and involves measuring the angle between the superior endplate of the first lumbar vertebra to the superior endplate of the first sacral vertebra.8 For an evaluation of lordosis, placing the patient in a standing position using X-rays is common.8 In this literature review, the authors discuss the parameters of lumbar lordosis and its association with pregnancy-related back pain and pain management The study focuses on hyperlordosis as a cause of back pain during pregnancy and discusses management before, during, and after pregnancy.

Prevalence & Risk

Approximately 50% of pregnant patients suffer from some kind of low back pain, such as pelvic girdle pain and LP, during their pregnancies or post-partum period.9 One-third of pregnant women suffer from severe LP, and most women experience LP during their first pregnancy.9 Approximately 80% of pregnant women report that their daily routine is disturbed due to LP and about 10% report being unable to work as a result.9 Managing LP during pregnancy has significant, even life-altering, health-related and economic implications.

Research is warranted to better understand how the pregnant body may compensate when experiencing LP due to the various complications that can arise and so that an appropriate pain management plan can be provided and function restored.

Etiology

As a pregnant woman compensates for changes in center of gravity and body weight, LP may result, leading to increased levels of relaxin and relaxation of the pelvic ligaments. Biomechanical differences play an even larger role, as an anterior shift in the center of mass has been related to women lacking positional adjustment of lumbar lordosis.10

Last updated on: November 9, 2017
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