Sagittal balance parameters in choice of surgical strategy for degenerative lumbosacral spinal stenosis

OBJECTIVE: To determine the indications for surgical correction of lumbar lordosis in patients with multilevel degenerative lumbosacral spinal stenosis. MATERIAL AND METHODS: A prospective pilot study was conducted at the Perm City Clinical Hospital No. 4 between 2022 and 2025. Patients with multilevel degenerative lumbosacral spinal stenosis presenting with clinical manifestations of compressive syndromes, as well as persistent back pain refractory to conservative treatment, were enrolled. All patients underwent the following additional examinations: pain assessment (VAS scores), functional status (the Oswestry Disability Index and the Roland-Morris Disability Questionnaire), standing full-spine radiography with calculation of sagittal balance parameters. RESULTS: The study group consisted of 22 patients with multilevel lumbar spinal stenosis at the following levels: L3-L4-L5 in 6 (27.3%) patients, L4-L5-S1 in 13 (59.1%) patients, and L2-L3-L4-L5 in 3 (13.6%) patients. Mean pathological reduction of lumbar lordosis relative to individual normative value was 17.8° (min 8.3°, max 22.6°). All patients underwent surgical intervention. After 3 postoperative months, standing radiographs demonstrated achievement of target lumbar lordosis along with regression of neurological symptoms in all patients. VAS score of pain decreased by 2.8 times (95% CI 1.7-4.2). Disability according to the Roland-Morris questionnaire improved by 3.3 times (95% CI 2.1-4.7). Quality of life across various domains assessed by the Oswestry Disability Index improved by 3.1 times (95% CI 1.1-3.8). CONCLUSION: In patients with multilevel degenerative lumbosacral spinal stenosis (Schizas grade C or D) accompanied by compressive syndromes and drug-resistant back pain, surgical interventions are indicated for reduced lumbar lordosis and impairment of at least one sagittal balance parameter, including pelvic angle, pelvic tilt, ThI pelvic angle, sagittal vertical axis. Correction of lumbar lordosis in this patient population results in significant reduction of back pain and QoL improvement.