BIOMEDIKA
ISSN: 2085-8345.
E-ISSN: 2541-2582
Vol 18.
No.
1 Februari 2026 doi: 10.
23917/biomedika.
Dynamic Lumbosacral Radiograph in Comparison with Conventional Lumbosacral Radiograph in Finding Degenerative Disease of The Lumbar Spine Fityay Adzhani1.
Muchtar Hanafi1*.
Amelia Tjandra Irawan1,2.
Hari Wujoso3
AFFILIATIONS
Radiology Department.
Faculty of Medicine.
Universitas Sebelas Maret Musculoskeletal Subdivision.
Dr.
Moewardi General Hospital.
Surakarta Forensic Department.
Dr.
Moewardi General Hospital.
Surakarta This work is licensed under a Creative Commons AttributionNonCommercial 4.
International License.
ABSTRACT
Degenerative lumbar spine disease is a leading cause of disability, reducing patient's quality of life.
However.
Magnetic Resonance Imaging (MRI), the primary diagnostic modality, is not routinely feasible due to high cost and limited availability.
Routine anteroposterior (AP) and lateral plain radiographs remain inferior to MRI, highlighting the need for alternative modalities such as vertebral dynamic radiography .
lexion-extension view.
to assess intervertebral instability.
This analytic observational study used a cross-sectional design analyzing 42 patients at RSUD Dr.
Moewardi (February 2019 - February 2.
with MRI-confirmed degenerative disease, the study compared findings of spondylolisthesis, vacuum disk phenomenon, osteophytes, and intervertebral space narrowing.
Statistical analysis obtained p-value <0.
05, demonstrating that dynamic radiographs possess higher sensitivity for detecting degenerative diseases of the spine than conventional Furthermore, the vacuum disk phenomenon was most prevalent in extension radiographs and least frequent in flexion.
While osteophyte detection and intervertebral space narrowing remained consistent across both modalities, the dynamic study proved superior in assessing joint instability.
The study concludes that there was a significant difference in the findings of spondylolisthesis on dynamic lateral radiographs and conventional lateral radiographs.
KEYWORDS:
Degenerative Disease.
Spine.
Dynamic Lumbosacral.
Plain Radiograph CORRESPONDING AUTHOR:
Muchtar Hanafi hanafi@staff.
INTRODUCTION
compress the spinal cord or nerve root causing Degenerative disease of the lumbar spine is an radiating pain and limb weakness.
More than 90% important and significant cause of disability (Astuti cases of disc herniation occur in the lumbosacral et al.
, 2.
This disease has a variety of The incidence of degenerative lumbar symptoms, such as lower limb pain, limb weakness, disease is 4.
18 per 1000 population (Deane and and low back pain (LBP), which can reduce the McGregor, 2016.
Ravindra et al.
, 2018.
Modic and quality of life.
Low back pain is a disease with a Ross, 2007.
Zylbersztejn et al.
, 2.
prevalence of life time 70-85%.
The Global Burden Radiological examination plays an important role of Disease (GBD) study reported that LBP ranks the in diagnosing degenerative diseases of the spine, highest to cause disability, with 83 million incidents especially with magnetic resonance imaging (MRI) of disability in 2010.
Degenerative diseases include which can provide a noninvasive evaluation of the spondylolisthesis, joint degeneration, and spinal vertebrae and spinal joints.
However.
MRI cannot be Disruption of the normal disc can cause used as a routine check-up due to high costs and retropulsion of the nucleus pulposus, which can Avalaible online at https://journals2.
id/index.
php/biomedika Meanwhile.
Dynamic Lumbosacral Radiograph in Comparison with Conventional A (Fityay Adzhan.
anteroposterior (AP) and lateral plain radiographs Hospital Ethics Committee with registration number are routine examinations performed in assessing 322/II/HREC/2020.
However.
MRI examination was performed with a 1.
5-tesla examination is still far from being compared to MRI.
(HDxt 1.
GE Healthcar.
comprising T1 and T2- Therefore, other plain radiographs are needed which weighted image sagittal sequences focusing on T2- are expected to support the diagnosis, such as weighted image to diagnose the degenerative dynamic plain radiographs .
lexion-extensio.
to disease of the subjects, and to rule out any other visualize the instability of the intervertebral joints (Hiyama et al.
, 2019.
Kim et al.
, 2018.
Tannor, dynamic lumbosacral plain radiographs of the 8 subjects were made with digital measuring tools of In order to find out the difference between radiographs in finding degenerative disease of the PACS DICOM Viewer.
Meanwhile, the other 34 subjects were reviewed from the picture of radiographs films.
Two lumbar spine we performed this study.
Measurements musculoskeletal and neuroradiology reviewed the METHODS We conducted an analytic observational study with a cross-sectional approach in patient with degenerative disc disease admitted to Dr.
Moewardi General Hospital.
Surakarta.
Indonesia February 2019 to February 2020.
The data were taken from secondary data of radiology installation The diagnosis of spinal degenerative disc disease was confirmed clinically and radiologically with lumbosacral MRI.
We excluded patients with any other diseases, such us trauma, tumor, metastasis and surgical history.
Forty-two patients included to this study underwent conventional as well as dynamic lumbosacral plain radiographs.
This study had been approved ethically by Dr.
Moewardi BIOMEDIKA.
Vol.
No.
Februari 2026, 60 - 67 The presence of spondylolisthesis intervertebral joint was recorded as the degree of It was measured by the distance between posterior-inferior superior vertebrae and posteriorsuperior inferior vertebrae on the lateral projection lumbosacral plain radiographs, both conventional and dynamic.
This distance was divided by the width of the superior endplate of the vertebral body underneath which showed the percentage value of the displacement.
Measurement of listhesis from two radiologist was calculated with interclass correlation coefficient (ICC) to test the reliability of the measurement.
Dynamic Lumbosacral Radiograph in Comparison with Conventional A (Fityay Adzhan.
used paired t-test to evaluate the difference All of the subjects included in the study were between conventional and dynamic radiograph between 40 and 58 years old, comprising 23 .
%) lumbosacral if the data were normally distributed.
females and 19 .
%) males.
Degenerative disease Wilcoxon rank test was used if the data were not of the lumbar spine confirmed by MRI examination normally distributed.
The statistical analysis was showed various degrees of severity based on Pfirmann classification.
According to this study, most calculated using SPSS software, version 23.
of the degenerative patients were in grade 4
RESULT AND DISCUSSION
In assessing conventional lateral lumbosacral .
3%), meanwhile the least patients were in grade plain radiographs, radiologist 1 obtained the mean 2 and grade 5 .
4% respectivel.
value of spondylolisthesis was 6.
99 A 7.
53%, while Table 1.
The findings of spondylolisthesis based on conventional and dynamic lateral lumbosacral Dynamic Spondylolisthe Conventio Flexi Extensi Yes Total radiologist 2 had mean value of 6.
95 A 7.
ANOVA test comparing those outcomes found no significant difference findings on conventional lateral lumbosacral plain radiograph .
= 0.
meaning it (ICC = 1.
The assessment of lumbosacral lateral flexion plain radiographs performed by radiologist 1 obtained mean value of spondylolisthesis was 13.
64 A 8.
spondylolisthesis was 13.
64 A 8.
Lateral lumbosacral extension plain radiographs assessed by radiologist 1 and 2 had the mean values of spondylolisthesis of 8.
78 A 6.
77%, and 9.
64%, respectively.
The ANOVA test obtained a pvalue = 0.
972 and 0.
> 0.
for lateral lumbosacral flexion and extension plain radiographs, respectively, thus there was no significant difference with ICC values of 1.
000 and 0.
937 for lateral lumbosacral flexion and extension plain radiographs, respectively, demonstrating excellent reliability.
(Koo and Li, 2.
BIOMEDIKA.
Vol.
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Februari 2026, 60 - 67 This conventional and dynamic lateral lumbosacral plain degenerative disease of the lumbar spine.
Flexion dynamic lateral radiographs found spondylolisthesis in 34 subjects, while extension dynamic lateral Conventional lateral radiographs found spondylolisthesis in 22 subjects.
Thus 12 subjects were detected spondylolisthesis on flexion dynamic lateral radiographs and 7 subjects were detected spondylolisthesis on extension dynamic lateral radiographs, but were not detected on conventional lateral radiographs (Table .
Table 2.
The distribution of spondylolisthesis subjects based on discus intervertebral level Level L3-4
L4-5
L5-S1
Total Dynamic Lumbosacral Radiograph in Comparison with Conventional A (Fityay Adzhan.
The distribution of intervertebral disc levels in 34 Wilcoxon rank test comparing conventional with subjects with spondylolisthesis is shown in Table 2.
Most radiographs in degenerative spondylolisthesis of the spondylolisthesis were at the level of L4-5 .
5%),
lumbar spine obtained p value of < 0.
001 with the followed by the level of L3-4 .
7%) and L5-S1 level mean values of 6.
99 A 7.
53% on conventional and .
8%).
64 A 8.
32% on flexion lateral lumbosacral Table 3.
Other radiologic findings on conventional and dynamic lateral lumbosacral radiograph.
Yes Findings Osteophyte Conventional Flexion Extension Narrowing of spinal joint Conventional Flexion Extension Vacuum disk phenomenon Conventional Flexion Extension The other findings of degenerative disease of the lumbar spine on plain radiographs were radiograph (Table .
It means that degenerative spondylolisthesis was found more on lateral dynamic flexion radiograph, the statistical analysis showed significant differences.
Table 5.
Difference between conventional and dynamic extension lateral lumbosacral radiographs in finding Conventio nal (%) 99A 7.
Extension
(%)
78A 6.
p-value Spon Notes: Wilcoxon rank test, 5% level of significance narrowing of the spinal joints, sclerotics and The spondylolisthesis finding on conventional osteophytes in the vertebral body endplate, as well lateral lumbosacral radiograph and extension lateral as the formation of the vacuum disk phenomenon.
lumbosacral radiograph obtained mean values of Both conventional and dynamic lateral radiograph 99 A 7.
53% and 8.
78 A 6.
77%, respectively .
= .
lexion and extensio.
revealed osteophytes in 42 subjects .
%) and narrowing of the spinal joint in spondylolisthesis was found more on lateral dynamic 32 subjects .
2%).
Meanwhile the formation of extension radiograph, the statistical analysis showed vacuum disk phenomenon, was found most on significant differences (Table .
lateral extension radiograph (N = 15.
7%),
Degenerative disease of the spine is a spinal followed by lateral flexion radiograph (N = 5.
disease that occurs due to a degenerative process.
9%) (Table .
Degenerative cascade process explains lumbar Table 4.
The difference between conventional and dynamic flexion lateral lumbosacral radiograph in finding Conventio Flexion nal (%) (%) p-value Spondylolis 6.
99 A 7.
<0.
Notes: Wilcoxon rank test, 5% level of significance BIOMEDIKA.
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dehydration of the disc so that it can form the more frequently at the L4-5 level, where the vacuum disc phenomenon, the instability phase with presence of the iliolumbar ligament at the L5 level laxity of the facet capsule laxity and disc disruption limits the movement of L5, so that the L4-5 level becomes relatively easier to move.
The more sagittal degenerative spondylolisthesis, and the last phase is orientation of the facet joints at the L4-5 level is also the stabilization phase by forming the osteophytes an additional predisposing factor for instability at and thickening flavum ligament compressing the that level.
(Garvin et al.
, 2.
spinal canal.
Therefore, the radiological image on Anatomy of the spine based on Denis as shown the lateral plain radiograph shows the appearance of in Figure 1, is divided into three compartments, osteophytes on the edge of the vertebral body anterior, media and posterior, in which degenerative endplate, narrowing of the intervertebral space, disease of the spine starting from the intervertebral vacuum disc phenomenon, and instability with disc, which is the anterior and media structure MRI changes, leading to spondylolisthesis caused by examination can find degenerative spinal joints in instability of the posterior compartment.
This the form of changes in the intensity of the disc, as degenerative process also involves three joint well as in the ligament around the spine and complexes, the intervertebral disc and two facet compression of the spinal canal.
(Garvin et al.
, 2018.
Initiation of degenerative processes is in the Herring, 2016.
Devlin, 2.
intervertebral discs.
This can also be the basic Meanwhile In this study, we found differences in several findings of spondylolisthesis in degenerative patients findings obtained on conventional and dynamic which most commonly found on dynamic lateral radiograph .
, because in the flexion position, spondylolisthesis and vacuum disk phenomenon.
the facet joints seem to be moved away so the loose addition, the intervertebral space narrowing and the condition of facet joints .
with instable condition of intervertebral disc will be easily visible These conventional and dynamic lateral radiographs.
as a spondylolisthesis.
(Garvin et al.
, 2018.
Devlin.
The spondylolisthesis which was mostly found at the Steinmetz and Benzel, 2.
L4-5 level .
5%) is in line with the theory of The instability due to degenerative changes can result in translation or spondylolisthesis, this condition occurs BIOMEDIKA.
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examinations that represent instability are important as these can influence the operator's decision in choosing the surgical option which can affect the patient's prognosis.
(Garvin et al.
, 2018.
(Devlin.
Figure 1.
Anatomy of the spine based on Denis.
(Devlin.
Treatment options for degenerative disease of Steinmetz and Benzel, 2016.
Dharma et al.
In this study, we found that spondylolisthesis the spine are non-surgical and surgical therapy.
Surgical therapy comprises several surgical options according to clinical and radiological examinations.
Spondylolisthesis which represents the degenerative instability can be an indicator of degenerative severity and a pain generator, thus it is a determining factor in choosing of surgery for degenerative patients of the spinal joints.
(Garvin et Several previous studies comparing therapy with or without the combination of interbody fusion .
ither posterolateral or transforaminal lumba.
in cases of degenerative spondylolisthesis, found that the combination of interbody fusion therapy has a radiographs with the average of 13.
64% listhesis.
Then radiographs in 29 patients and conventional lateral radiographs in 22 patients, with mean listhesis of 78% and 6.
99%, respectively.
The statistical analysis of our findings demonstrated a significant difference, in which spondylolisthesis indicating the , 2018.
Devlin, 2.
was mostly detected on flexion dynamic lateral reoperation, as compared to therapy without the presence of degenerative instability can be detected more through dynamic lateral radiographs .
lexion Thus, dynamic lateral radiographs can affect decision in determining of treatment options for patients with degenerative spinal joints (Figure 2 and Figure .
interbody fusion combination.
A study by Dharma AS, et al in Surakarta also reported that the procedure of Posterior Lumbar Interbody Fusion (PLIF) on the management of lumbar spinal stenosis with instability showed better functional results.
Spondylolisthesis is also an indication for Lumbar Total Disc Arthroplasty surgery.
Therefore, the BIOMEDIKA.
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The conventional lateral radiograph of one of our samples (A) shows osteophytes in the vertebral body and there is no spondylolisthesis.
On the flexion (B) and extension (C) lateral radiographs, there is posterolisthesis at the level of L4-5.
Dynamic Lumbosacral Radiograph in Comparison with Conventional A (Fityay Adzhan.
cervical spine, not the lumbosacral region.
(Kim et , 2.
Study by Spina N, et al examining instability in surgeonAos point of view revealed that it was necessary to assess instability with the finding of spondylolisthesis on dynamic lateral radiographs.
Figure 3.
The conventional lateral radiograph of one of the study subjects (A) shows osteophytes and there is no The extension lateral radiograph (B) demonstrates no spondylolisthesis, but the flexion lateral radiograph (C) reveals antherolisthesis at the level of L45.
and the finding of spondylolisthesis on conventional lateral radiographs was not meaningful unless it was more than 4 mm.
Previous study by Pieper CC, et al Other findings of degenerative disease of the examining radiological evaluation of instability with spine such as osteophytes and spinal joint narrowing lumbar spondylolisthesis, found that flexion dynamic on both conventional lateral and dynamic lateral lateral radiographs were significantly needed to .
lexion and extensio.
lumbosacral radiographs assess spondylolisthesis compared to conventional where similar, in which osteophytes were found in lateral radiographs.
However, extension dynamic all subjects .
%), and spinal joint narrowing were lateral radiographs were not required because they seen in 83.
3% of subjects.
However, another finding were considered not significantly different from in the form of vacuum disc phenomenon was conventional lateral radiograph.
(Spina et al.
, 2019.
We found that vacuum disc phenomenon Pieper et al.
, 2.
was more common on extension lateral radiographs CONCLUSION .
7%) than on conventional lateral radiograph This .
6%) and flexion lateral radiographs .
9%).
radiograph examination is also required to diagnose Previous study by Kim CH, et al examining degenerative disease of the lumbar spine because dynamic .
lexion and extensio.
radiographs to there are findings which may not be obtained from predict the severity of spinal joint degeneration on conventional lateral radiographs.
Both dynamic MRI compared with conventional lateral radiographs lateral radiographs .
lexion and extensio.
are reported that there was a significant correlation of important because they have significant differences the severity of spinal joint degeneration with to evaluate degenerative instability compared to extension dynamic plain radiographs as compared conventional lateral radiographs, especially in the with conventional lateral radiographs.
However, this case of patients with degenerative lumbosacral study examined degenerative diseases of the These findings can certainly be considered by clinicians to add dynamic lateral radiographs as a BIOMEDIKA.
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package of examinations that must be carried out in patients with degenerative of the lumbar spine, whether MRI is available or not available because it FUNDING This study was fully funded independently and received no external financial support from public, commercial, or non-profit funding institution.
ACKNOWLEDGEMENT
The authors would like to express sincere gratitude to the Radiology Department of Dr.
Moewardi General Hospital for the technical support provided throughout the research process.
REFERENCES