Roussouly P, Gollogy S, Berthonnaud E, et al. Classification of the Normal Variation in the Sagittal Alignment of the Human Lumbar Spine and Pelvis in the Standing Position. Spine 1 February 2005; 30(3): 346-353.
As with the other papers, this study used standing, full spine radiographs.“Specific changes in sagittal alignment and the characteristics of the lumbar lordosis are potentially responsible for degenerative changes and symptomatic back pain.”
“Understanding the patterns of variations in the sagittal alignment may help discover the relationship between spinal balance and the development of degenerative changes in the spine.”
“An iatrogenic loss of lumbar lordosis accompanied by an anterior shift of the sagittal vertical axis creates a constellation of symptoms and problems with spinal alignment that is difficult to treat.”
“… There appears to be an association between the loss of lordosis, an anterior shift in the sagittal vertical axis, and the development of symptomatic back pain and degenerative changes in the spine.”