Associations between back pain history and lumbar MRI findings

Type 1 Modic changes was a significant risk factor for 1-year outcome in sick-listed low back pain patients: a nested cohort study using magnetic resonance imaging of the lumbar spine

BACKGROUND CONTEXT

It is not clear whether Modic changes (MC) is associated with low back pain (LBP) outcome.

PURPOSE

To study associations between baseline degenerative manifestations and outcome in sick-listed LBP patients.

STUDY DESIGN

Prospective nested cohort study based on a randomized controlled trial.

PATIENT SAMPLE

Out of 325 sick-listed LBP patients, 141 were consecutively examined by magnetic resonance imaging (MRI) and included and 140 completed the study.

OUTCOME MEASURES

Degenerative manifestations of the lumbar spine were quantified; associations were studied in relation to the three primary outcomes: change of back+leg pain, change of function as measured by Roland-Morris questionnaire, and 1-year unsuccessful return to work (U-RTW).

METHODS

By using a previously validated MRI protocol, a specialist in radiology, who had no access to clinical data, described the images. Associations were studied by linear and logistic regression with adjustment for previously identified prognostic factors for 1-year pain and function and for U-RTW.

RESULTS

Clinically, 43% of the patients had radiculopathy. Degenerative changes were prevalent with altered disc contours in 84%, high-intensity zones in 70%, and nerve root touch or impingement in 63% of the patients. MC was identified in 60% of the patients, 18% with Type 1 changes and 42% with Type 2 changes, Type 1 including both Type 1 and Type 1 in combination with Type 2. Patients with Type 1 changes reported more back pain and did not improve in pain or disability. They increased to include 30% of the patients with U-RTW at 1 year. Patients with Type 2 changes did not differ significantly from patients without MC but differed significantly from patients with Type 1 changes in all three outcomes. Other degenerative manifestations were not significantly associated with any of the three outcomes.

CONCLUSIONS

The only degenerative manifestation negatively associated with outcome was Type 1 MC that affected 18% of the cohort at baseline and implied an increased risk for no improvement in pain and function and for U-RTW, even after adjustment for other prognostic factors.

Prevalence of radiographic findings in individuals with chronic low back pain screened for a randomized controlled trial: secondary analysis and clinical implications

OBJECTIVE

The purpose of this study is to measure the prevalence of graded disc degeneration, spondylolisthesis, transitional segmentation, and the distribution of sacral slope in patients 21 to 65 years of age with chronic low back pain (CLBP).

METHODS

This retrospective study analyzed 247 digital lumbar radiographic series obtained during a randomized controlled trial of chiropractic patients with CLBP. Chronic low back pain was defined as pain in the low back lasting 12 weeks or longer. Radiographic findings of disc degeneration, spondylolisthesis, and lumbosacral transitional segmentation were graded by 2 authors using established classification criteria. Sacral slope was measured with a digital tool contained within imaging software.

RESULTS

Lumbosacral transitional segments graded I to IV (Castellvi classification) were present in 14% of cases. Lumbar disc degeneration was most prevalent at L3-4 (49%), followed by L4-5 (42%), L2-3 (41%), L5-S1 (37%), and L1-2 (29%). Isthmic spondylolisthesis was present in 5% of cases, with L5 the most common location. Degenerative spondylolisthesis demonstrated a prevalence of 18%, most commonly occurring at L4. The prevalence of degenerative spondylolisthesis was 51% for women aged 50 to 59 years and 24% for men in the same age range.

CONCLUSIONS

Moderate-severe disc degeneration, multilevel disc narrowing, and degenerative spondylolisthesis were common in individuals with CLBP with age more than 40 years. Isthmic spondylolisthesis was not more prevalent than what has been reported in other populations. Transitional segmentation was identified in a minority of participants, with some of these exhibiting accessory joints or fusion. Mean sacral slope in individuals with CLBP was not substantially different from mean slopes reported in other populations.

Short-term effect of spinal manipulation on pain perception, spinal mobility, and full height recovery in male subjects with degenerative disk disease: a randomized controlled trial

OBJECTIVE

To evaluate the short-term effect on spinal mobility, pain perception, neural mechanosensitivity, and full height recovery after high-velocity, low-amplitude (HVLA) spinal manipulation (SM) in the lumbosacral joint (L5-S1).

DESIGN

Randomized, double-blind, controlled clinical trial with evaluations at baseline and after intervention.

SETTING

University-based physical therapy research clinic.

PARTICIPANTS

Men (N=40; mean age ± SD, 38 ± 9.14 y) with diagnosed degenerative lumbar disease at L5-S1 were randomly divided into 2 groups: a treatment group (TG) (n=20; mean age ± SD, 39 ± 9.12 y) and a control group (CG) (n=20; mean age ± SD, 37 ± 9.31 y). All participants completed the intervention and follow-up evaluations.

INTERVENTIONS

A single L5-S1 SM technique (pull-move) was performed in the TG, whereas the CG received a single placebo intervention.

MAIN OUTCOME MEASURES

Measures included assessing the subject's height using a stadiometer. The secondary outcome measures included perceived low back pain, evaluated using a visual analog scale; neural mechanosensitivity, as assessed using the passive straight-leg raise (SLR) test; and amount of spinal mobility in flexion, as measured using the finger-to-floor distance (FFD) test.

RESULTS

The intragroup comparison indicated a significant improvement in all variables in the TG (P<.001). There were no changes in the CG, except for the FFD test (P=.008). In the between-group comparison of the mean differences from pre- to postintervention, there was statistical significance for all cases (P<.001).

CONCLUSIONS

An HVLA SM in the lumbosacral joint performed on men with degenerative disk disease immediately improves self-perceived pain, spinal mobility in flexion, hip flexion during the passive SLR test, and subjects' full height. Future studies should include women and should evaluate the long-term results.

Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK)

Background

There are few longitudinal cohort studies examining associations between incident MRI findings and incident spine-related symptom outcomes. Prior studies do not discriminate between the two distinct outcomes of low back pain (LBP) and radicular symptoms. To address this gap in the literature, we conducted a secondary analysis of existing data from the Longitudinal Assessment of Imaging and Disability of the Back (LAIDBACK). The purpose of this study was to examine the association of incident lumbar MRI findings with two specific spine-related symptom outcomes: 1) incident chronic bothersome LBP, and 2) incident radicular symptoms such as pain, weakness, or sensation alterations in the lower extremity.

Methods

The original LAIDBACK study followed 123 participants without current LBP or sciatica, administering standardized MRI assessments of the lumbar spine at baseline and at 3-year follow-up, and collecting information on participant-reported spine-related symptoms and signs every 4 months for 3 years. These analyses examined bivariable and multivariable associations between incident MRI findings and symptom outcomes (LBP and radicular symptoms) using logistic regression.

Results

Three-year cumulative incidence of new MRI findings ranged between 2 and 8%, depending on the finding. Incident annular fissures were associated with incident chronic LBP, after adjustment for prior back pain and depression (adjusted odds ratio [OR] 6.6; 95% confidence interval [CI] 1.2-36.9). All participants with incident disc extrusions (OR 5.4) and nerve root impingement (OR 4.1) reported incident radicular symptoms, although associations were not statistically significant. No other incident MRI findings showed large magnitude associations with symptoms.

Conclusions

Even when applying more specific definitions for spine-related symptom outcomes, few MRI findings showed large magnitude associations with symptom outcomes. Although incident annular fissures, disc extrusions, and nerve root impingement were associated with incident symptom outcomes, the 3-year incidence of these MRI findings was extremely low, and did not explain the vast majority of incident symptom cases.

Correlation of pain with objective quantification of magnetic resonance images in older adults with chronic low back pain

STUDY DESIGN

Cross sectional study.

OBJECTIVE

The goal of this study is to identify relationships between objectively measured and subjectively scored parameters and reported pain.

SUMMARY OF BACKGROUND DATA

Studies have demonstrated the unreliability of magnetic resonance imaging (MRI)-based parameters to identify pathological pain generators of chronic low back pain, but they were based on visual inspection and subjective assessment of lumbar disc features. Advancements in computer image analysis provide objective measurements of lumbar disc features.

METHODS

Two radiologists evaluated 39 axial and sagittal T1- and T2-weighted MR images of patients with chronic axial low back pain (age, >65 yr) and graded 4 subjective lumbar disc parameters (T2 signal intensity, nucleus shape, Modic changes, and osteophyte formation) whose sum is the cumulative MRI score. Objective parameter, MRI index, was calculated as the product of the measured lumbar disc area and total disc MRI signal intensity. Discs were sorted from least to the most degenerated relative to each parameter. Pearson correlation coefficient and multiple linear regression analysis were performed between the reported pain score and each parameter.

RESULTS

The most and least degenerated discs in each patient, as assessed by MRI index, had the highest negative and positive correlation coefficient and regression weight contribution, respectively. All subjective parameters had low correlation coefficients and regression goodness of fit.

CONCLUSION

Although limited by small sample size, the objective parameter, MRI index, can be a potential imaging biomarker used to identify possible pain generators. This study presents a potential new application of MR imaging in identifying pain generators of patients with chronic low back pain.

Do more MRI findings imply worse disability or more intense low back pain? A cross-sectional study of candidates for lumbar disc prosthesis

OBJECTIVE

To examine whether combined magnetic resonance imaging (MRI) findings are related to the degree of disability and low back pain (LBP) in candidates for lumbar disc prosthesis surgery.

MATERIALS AND METHODS

This cross-sectional study included 170 disc prosthesis candidates (mean age 41 years; 88 women) with chronic non-radicular LBP and localized disc degeneration. Experienced radiologists rated Modic changes and disc findings at L4-S1 on pre-treatment MRIs. An MRI total score (0-10) for findings at L4/L5 plus L5/S1 was calculated for Modic type I and/or II changes, a posterior high intensity zone (HIZ) in the disc, dark/black nucleus pulposus signal, and ≥40 % disc height decrease. We analyzed the relationship of the MRI total score to the Oswestry Disability Index (ODI) (n = 170) and LBP intensity scores (0-100 visual analogue scale, n = 165) using multiple linear regression and adjusting for age, gender, body mass index, smoking, and anxiety/depression.

RESULTS

The MRI total score was not related to ODI (regression coefficient 0.12, p = 0.79) or LBP intensity (regression coefficient 0.64, p = 0.37). When individual MRI findings were analyzed, patients with HIZ at L5/S1 had slightly lower ODI scores (4.7 points, p = 0.02). In post hoc analyses, results remained unchanged after adding facet arthropathy to the MRI total score and adjusting also for physical workload and physical leisure-time activity.

CONCLUSIONS

The combined MRI findings were not related to the degree of disability or the intensity of LBP. These degenerative MRI findings cannot explain variation in pre-treatment disability and pain in patients with chronic LBP accepted for disc prosthesis surgery.

Factors associated with paraspinal muscle asymmetry in size and composition in a general population sample of men

BACKGROUND

Paraspinal muscle asymmetry in cross-sectional area (CSA) and composition have been associated with low back pain and pathology. However, substantial multifidus muscle asymmetry also has been reported in men who were asymptomatic, and little is known about other factors influencing asymmetry.

OBJECTIVE

The goal of this study was to identify behavioral, environmental, and constitutional factors associated with paraspinal muscle asymmetry.

DESIGN

A cross-sectional study of 202 adult male twins was conducted.

METHODS

Data were collected through a structured interview, physical examination, and magnetic resonance imaging. Measurements of multifidus and erector spinae muscle CSA and the ratio of fat-free CSA to total CSA were obtained from T2-weighted axial images at L3-L4 and L5-S1.

RESULTS

In multivariable analyses, greater asymmetry in multifidus CSA at L3-L4 was associated with lower occupational physical demands and less disk height narrowing. Handedness was the only factor associated with multifidus muscle CSA asymmetry at L5-S1. For the erector spinae muscle, greater age, handedness, and disk height narrowing were associated with CSA asymmetry at L3-L4, and sports activity, handedness, disk height narrowing, and familial aggregation were associated with CSA asymmetry at L5-S1. In multivariable analyses of asymmetry in muscle composition, familial aggregation explained 7% to 20% of the variance in multifidus and erector spinae muscle side-to-side differences at both levels measured. In addition, handedness and pain severity entered the model for erector spinae muscle asymmetry at L5-S1, and disability, handedness, and disk height narrowing entered the model for multifidus muscle asymmetry at L5-S1.

LIMITATIONS

Reliance on participants' recall for low back pain history, occupation, and physical activity levels was a limitation of this study.

CONCLUSIONS

Few of the factors investigated were associated with paraspinal muscle asymmetry, and associations were inconsistent and modest, explaining little of the variance in paraspinal muscle asymmetry.

Presence and extent of severe facet joint osteoarthritis are associated with back pain in older adults

OBJECTIVE

To determine whether the presence and extent of severe lumbar facet joint osteoarthritis (OA) are associated with back pain in older adults, accounting for disc height narrowing and other covariates.

DESIGN

Two hundred and fifty-two older adults from the Framingham Offspring Cohort (mean age 67 years) were studied. Participants received standardized computed tomography (CT) assessments of lumbar facet joint OA and disc height narrowing at the L2-S1 interspaces using four-grade semi-quantitative scales. Severe facet joint OA was defined according to the presence and/or degree of joint space narrowing, osteophytosis, articular process hypertrophy, articular erosions, subchondral cysts, and intraarticular vacuum phenomenon. Severe disc height narrowing was defined as marked narrowing with endplates almost in contact. Back pain was defined as participant report of pain on most days or all days in the past 12 months. We used multivariable logistic regression to examine associations between severe facet joint OA and back pain, adjusting for key covariates including disc height narrowing, sociodemographics, anthropometrics, and health factors.

RESULTS

Severe facet joint OA was more common in participants with back pain than those without (63.2% vs 46.7%; P = 0.03). In multivariable analyses, presence of any severe facet joint OA remained significantly associated with back pain (odds ratio (OR) 2.15 [95% confidence interval (CI) 1.13-4.08]). Each additional joint with severe OA conferred greater odds of back pain [OR per joint 1.20 (95% CI 1.02-1.41)].

CONCLUSIONS

The presence and extent of severe facet joint OA on CT imaging are associated with back pain in community-based older adults, independent of sociodemographics, health factors, and disc height narrowing.

Military rank and the symptoms of lumbar disc herniation in young Korean soldiers

OBJECTIVE

There are many factors associated with the symptom presentation of lumbar disc herniation (LDH). However, there are only few reports regarding the clinical feature of LDH in military medicine. The objective of this study is to determine the factors that affected the symptoms of LDH in young Korean soldiers.

METHODS

One hundred thirty male soldiers, diagnosed with LDH, were enrolled in this study. They were divided into four groups, according to their military ranks: private, private first class, corporal, and sergeant. The visual analog scale for low back pain (VAS-LBP), the VAS for leg pain (VAS-LP), and the Oswestry Disability Index (ODI) were evaluated. The education level and military rank were also reviewed and their relationship with the degree of symptoms was investigated.

RESULTS

The mean age for the male subjects enrolled was 20.7 ± 1.2. The mean VAS-LBP, VAS-LP, and ODI were 6.6% ± 1.7%, 7.1% ± 1.9%, and 46.0% ± 16.3%, respectively. There was no statistically significant relationship between the degree of symptoms and the radiologic findings. However, the military rank had an inverse correlation with the VAS scores and the ODI (P < 0.05).

CONCLUSION

Our data showed that the military rank was associated with the symptom presentation of LDH and reflected the characteristics of military life.

Magnetic resonance imaging of the lumbar spine in young arabs with low back pain

Study Design

A prospective study.

Purpose

To Investigate the prevalence of magnetic resonance imaging (MRI) changes of the lumbar spine in low back pain (LBP) and the associated risk factors in young Arab population.

Overview of Literature

Studies on the prevalence of MRI findings and their relationship with LBP have been conducted; these have occurred in adult populations in developed countries. The prevalence of MRI changes in the young Arab population with LBP is not known.

Methods

Two hundred and fourteen patients of Arab origin in the 16 to 29 year age group with LBP symptoms underwent MRI examinations. The prevalence of MRI changes in the lumbar spine and associated risk factors were determined and compared to age, race, and gender-matched controls.

Results

A majority (64%) of the patients with LBP (138 out of 214) were found to have MRI evidence of degenerative disc disease (DD) compared to 10% (22 out of 214) in the control group. The majority (61%) of patients had multiple level disease, most commonly involving the lowest 2 disc levels. Reduced signal of the disc followed by disc bulge was the most common MRI features seen in the symptomatic subjects. Obesity correlated with MRI prevalence of abnormalities, while activity demonstrated a positive trend.

Conclusions

The MRI prevalence of DD among the young Arab patients with LBP is high when compared to other reports in literature. Obesity correlated with MRI prevalence of abnormalities while activity demonstrated a positive trend.

The spinal curvature of three different sitting positions analysed in an open MRI scanner

Sitting is the most frequently performed posture of everyday life. Biomechanical interactions with office chairs have therefore a long-term effect on our musculoskeletal system and ultimately on our health and wellbeing. This paper highlights the kinematic effect of office chairs on the spinal column and its single segments. Novel chair concepts with multiple degrees of freedom provide enhanced spinal mobility. The angular changes of the spinal column in the sagittal plane in three different sitting positions (forward inclined, reclined, and upright) for six healthy subjects (aged 23 to 45 years) were determined using an open magnetic resonance imaging (MRI) scanner. An MRI-compatible and commercially available office chair was adapted for use in the scanner. The midpoint coordinates of the vertebral bodies, the wedge angles of the intervertebral discs, and the lumbar lordotic angle were analysed. The mean lordotic angles were 16.0 ± 8.5° (mean ± standard deviation) in a forward inclined position, 24.7 ± 8.3° in an upright position, and 28.7 ± 8.1° in a reclined position. All segments from T10-T11 to L5-S1 were involved in movement during positional changes, whereas the range of motion in the lower lumbar segments was increased in comparison to the upper segments.

Are facet joint bone marrow lesions and other facet joint features associated with low back pain? A pilot study

OBJECTIVE

To determine the frequency of facet joint (FJ) bone marrow lesions, high FJ periarticular signal intensity, and FJ effusions in a convenience sample of patients with axial low back pain (LBP).

DESIGN

A cross-sectional pilot study with retrospective data collection.

SETTING

Outpatient spine clinics.

PATIENTS

Sixty-four adults with axial LBP scheduled to receive an FJ intra-articular corticosteroid injection.

METHODS

Clinical data were abstracted from the medical record by 1 physician, who was blinded to results of the magnetic resonance imaging evaluations. A musculoskeletal radiologist blinded to clinical information performed standardized assessments of the L1-S1 spinal levels for FJ bone marrow lesions, effusions, and high periarticular signal intensity on lumbar magnetic resonance imaging, including short tau inversion recovery sequences. We calculated the frequency of these FJ features and used generalized estimating equations to examine side-specific associations between the location of FJ features and the side on which LBP was experienced.

RESULTS

The sample included 64 participants with a mean (standard deviation) age of 59.9 ± 14.5 years. FJ bone marrow lesions were present in 64.1%, effusions in 70.3%, and high periarticular signal intensity in 65.6% of participants. All the features were most common at the L4-L5 level. These FJ features showed significant associations with the side on which LBP was experienced or statistical trends toward an association, with or without adjustment for age, gender, and body mass index. The strongest side-specific associations were seen for the number of bone marrow lesions (odds ratio [OR] 1.60 [95% confidence interval {CI},1.05-2.43]), any FJ effusion (OR 2.23 [95% CI, 1.02-4.85]), and the number of joints with high periarticular signal intensity (OR 1.75 [95% CI, 1.16-2.63]).

CONCLUSIONS

FJ bone marrow lesions, effusions, and high periarticular signal intensity were common in this sample of patients with axial LBP and substantially more frequent than in prior reports from unselected samples of patients with or without radicular pain. These FJ features demonstrate side-specific associations with LBP. Further study of associations between these FJ features and LBP are warranted.

Intervertebral disc degeneration: evidence for two distinct phenotypes

We review the evidence that there are two types of disc degeneration. 'Endplate-driven' disc degeneration involves endplate defects and inwards collapse of the annulus, has a high heritability, mostly affects discs in the upper lumbar and thoracic spine, often starts to develop before age 30 years, usually leads to moderate back pain, and is associated with compressive injuries such as a fall on the buttocks. 'Annulus-driven' disc degeneration involves a radial fissure and/or a disc prolapse, has a low heritability, mostly affects discs in the lower lumbar spine, develops progressively after age 30 years, usually leads to severe back pain and sciatica, and is associated with repetitive bending and lifting. The structural defects which initiate the two processes both act to decompress the disc nucleus, making it less likely that the other defect could occur subsequently, and in this sense the two disc degeneration phenotypes can be viewed as distinct.

T1rho and T2 relaxation times for lumbar disc degeneration: an in vivo comparative study at 3.0-Tesla MRI

OBJECTIVE

To determine the relative performance of T1rho and T2 relaxation times in disc degeneration assessment.

METHODS

Lumbar sagittal MRI was performed at 3 T in 52 subjects. With a spin-lock frequency of 500 Hz, T1rho was measured using a rotary echo spin-lock pulse embedded in a three-dimensional (3D) balanced fast field echo sequence. A multi-echo TSE sequence was used for T2 mapping. Regions of interest (ROIs) were drawn over the T1rho and T2 maps, including nucleus pulposus (NP) and annulus fibrosus (AF). Eight- and five-level disc degeneration semi-quantitative grading was performed.

RESULTS

For NP, T1rho and T2 decreased quadratically with disc degeneration grades and had no significant trend difference (P = 0.40). For AF, T1rho decreased linearly as the disc degenerated and had a slope of -3.02 and -4.56 for eight- and five-level gradings respectively; while the slopes for T2 values were -1.43 and -1.84 respectively, being significantly flatter than those of T1rho (P < 0.001). There was no significant difference in T1rho and T2 values for both NP and AF among discs of grade 5/8 to 8/8 degeneration.

CONCLUSION

T1rho is better suited for evaluating AF in degenerated disc than T2. In NP, T1rho and T2 decrease in a similar pattern following disc degeneration.

Genetic contribution of catechol-O-methyltransferase variants in treatment outcome of low back pain: a prospective genetic association study

Background

Treatment outcome of low back pain (LBP) is associated with inter-individual variations in pain relief and functional disability. Genetic variants of catechol-O-methyltransferase (COMT) gene have previously been shown to be associated with pain sensitivity and pain medication. This study examines the association between COMT polymorphisms and 7–11 year change in Oswestry Disability Index (ODI) and Visual Analog Score (VAS) for LBP as clinical outcome variables in patients treated with surgical instrumented lumbar fusion or cognitive intervention and exercise.

Methods

93 unrelated patients with chronic LBP for duration of >1 year and lumbar disc degeneration (LDD) were treated with lumbar fusion (N = 60) or cognitive therapy and exercises (N = 33). Standardised questionnaires assessing the ODI, VAS LBP, psychological factors and use of analgesics, were answered by patients both at baseline and at 7–11 years follow-up. Four SNPs in the COMT gene were successfully genotyped. Single marker as well as haplotype association with change in ODI and VAS LBP, were analyzed using Haploview, linear regression and R-package Haplostats. P-values were not formally corrected for multiple testing as this was an explorative study.

Results

Association analysis of individual SNPs adjusted for covariates revealed association of rs4633 and rs4680 with post treatment improvement in VAS LBP (p = 0.02, mean difference (β) = 13.5 and p = 0.02, β = 14.2 respectively). SNPs, rs4633 and rs4680 were found to be genotypically similar and in strong linkage disequilibrium (LD). A significant association was found with covariates, analgesics (p = 0.001, β = 18.6); anxiety and depression (p = 0.008, β = 15.4) and age (p = 0.03, mean difference per year (β) = 0.7) at follow-up. There was a tendency for better improvement among heterozygous patients compared to the homozygous. No association was observed for the analysis of the common haplotypes, these SNPs were situated on.

Conclusions

Results suggest an influence of genetic variants of COMT gene in describing the variation in pain after treatment for low back pain. Replication in large samples with testing for other pain related genes is warranted.

An Association Study of Interleukin 18 Receptor Genes (IL18R1 and IL18RAP) in Lumbar Disc Degeneration

Objectives:

To examine association of candidate genetic variants in structural, inflammatory, matrix modifying, vitamin D receptor genes and variants associated with osteoarthritis, with surgical candidates and surgical patients with lumbar disc degeneration (LDD), in light of their previously reported susceptibility for LDD.

Methods:

Genotyping of 146 Norwegian LDD patients and 188 Norwegian controls was performed for 20 single-nucleotide polymorphisms (SNPs) from collagen, aggrecan, interleukin, VDR, MMP3 and COX2 genes and 7 SNPs from osteoarthritic genes.

Results:

The neighboring genes IL18R1 and IL18RAP polymorphisms (rs2287037 and rs1420100), showed a statistically non-significant risk for developing LDD (OR 1.36 [95 % CI 0.99 – 1.87]; p=0.06 and OR 1.33 [95 % CI 0.98-1.81]; p=0.07). Homozygosity of these risk alleles was associated with LDD (p=0.023 and p=0.027). The non-risk alleles at these SNPs were situated on a haplotype negatively associated with LDD (p=0.008). Carriage of at least one non-risk allele at both loci also reduces the risk of developing LDD (OR 0.51 [95 % CI 0.33-0.80]; p=0.003).

Conclusion:

Our findings support the polygenic nature of LDD and suggest that variation in interleukin 18 receptor genes could affect the risk of severe LDD and associated low back pain.

Understanding Chronic Pain in a Lifestyle Context

This article reviews both traditional and emerging aspects of pain medicine within the context of a “whole-person,” lifestyle-based approach. This is consistent with contemporary systems theory formulations of chronic disease in general. A traditional approach sees ongoing pain as a fixed biological disorder and much of its management as the task of medically palliating or learning to cope. Within this framework, chronic pain has been conceptualized by some authors as a disease in its own right based on underlying alterations in nervous system processing. This explains the stronger correlation of chronic pain with neural sensitization than with structural change in bodily tissues. However, recent research findings are expanding current views of causation and management, and there is now a growing recognition that pain-related nervous system changes are potentially reversible. The so-called paradox of plasticity proposes that the same property of changeability in the nervous system that allows chronic pain to develop can also lead to its resolution. Nutrition and personal story are key aspects of an emerging whole-person approach and can be combined with traditional biomedical and cognitive behavioral interventions to enhance therapeutic gains. An interesting hypothesis deriving from recent research is that multiple unhelpful aspects of lifestyle contribute to systemic metaflammation, which in turn spills over to sensitize the nervous system and facilitate pain-related transmission. Therefore, addressing lifestyle factors therapeutically has the potential to desensitize the nervous system and reduce pain.

Quantitative assessment of abdominal aortic calcification and associations with lumbar intervertebral disc height loss: the Framingham Study

BACKGROUND CONTEXT

Vascular disease has been proposed as a risk factor for disc height loss (DHL).

PURPOSE

To examine the relationship between quantitative measures of abdominal aortic calcifications (AACs) as a marker of vascular disease, and DHL, on computed tomography (CT).

STUDY DESIGN

Cross-sectional study in a community-based population.

PATIENT SAMPLE

Four hundred thirty-five participants from the Framingham Heart Study.

OUTCOME MEASURES

Quantitative AAC scores assessed by CT were grouped as tertiles of "no" (reference), "low," and "high" calcification. Disc height loss was evaluated on CT reformations using a four-grade scale. For analytic purposes, DHL was dichotomized as moderate DHL of at least one level at L2-S1 versus less than moderate or no DHL.

METHODS

We examined the association of AAC and DHL using logistic regression before and after adjusting for cardiovascular risk factors and before and after adjusting for age, sex, and body mass index (BMI).

RESULTS

In crude analyses, low AAC (odds ratio [OR], 2.05 [1.27-3.30]; p=.003) and high AAC (OR, 2.24 [1.38-3.62]; p=.001) were strongly associated with DHL, when compared with the reference group of no AAC. Diabetes, hypercholesterolemia, hypertension, and smoking were not associated with DHL and did not attenuate the observed relationship between AAC and DHL. Adjustment for age, sex, and BMI markedly attenuated the associations between DHL and low AAC (OR, 1.20 [0.69-2.09]; p=.51) and high AAC (OR, 0.74 [0.36-1.53]; p=.42).

CONCLUSIONS

Abdominal aortic calcification was associated with DHL in this community-based population. This relationship was independent of cardiovascular risk factors. However, the association of AAC with DHL was explained by the effects of age, sex, and BMI.

Nucleus pulposus deformation following application of mechanical diagnosis and therapy: a single case report with magnetic resonance imaging

BACKGROUND

The McKenzie management strategy of mechanical diagnosis and therapy (MDT) is commonly used for the assessment and management of spinal problems. Within this system, 'derangement syndrome' is the most common classification, for which the conceptual model is an intra-discal displacement. However, the reduction of an intra-discal displacement by MDT has never been documented. The purpose of this study was to compare, using magnetic resonance imaging (MRI), the nucleus pulposus (NP) profiles before and after the use of this approach.

PATIENT CHARACTERISTICS

The patient was a 34-year-old female with a long history of right sided low back and buttock pain classified with 'derangement syndrome'.

EXAMINATION

T2-weighted images of the L4-5 disc at initial assessment were compared with that at final assessment 1 month later. Initially, the MRI showed a portion of the NP displaced right and posteriorly towards the side of pain, and an overall NP position in the coronal plane shifted to the left.

INTERVENTION

The patient was managed with a 1-month course of the McKenzie management strategy treatment.

OUTCOMES

One month later, the displaced portion of the NP was no longer present and the left-shifted NP was centrally located.

DISCUSSION

These intervertebral disc changes coincided with centralization and abolition of symptoms. This case may support the conceptual model of MDT.

Reliability of MRI findings in candidates for lumbar disc prosthesis

Introduction

Limited reliability data exist for localised magnetic resonance imaging (MRI) findings relevant to planning of treatment with lumbar disc prosthesis and later outcomes. We assessed the reliability of such findings in chronic low back pain patients who were accepted candidates for disc prosthesis.

Methods

On pretreatment MRI of 170 patients (mean age 41 years; 88 women), three experienced radiologists independently rated Modic changes, disc findings and facet arthropathy at L3/L4, L4/L5 and L5/S1. Two radiologists rerated 126 examinations. For each MRI finding at each disc level, agreement was analysed using the kappa statistic and differences in prevalence across observers using a fixed effects model.

Results

All findings at L3/L4 and facet arthropathy at L5/S1 had a mean prevalence <10% across observers and were not further analysed, ensuring interpretable kappa values. Overall interobserver agreement was generally moderate or good (kappa 0.40–0.77) at L4–S1 for Modic changes, nucleus pulposus signal, disc height (subjective and measured), posterior high-intensity zone (HIZ) and disc contour, and fair (kappa 0.24) at L4/L5 for facet arthropathy. Posterior HIZ at L5/S1 and severely reduced subjective disc height at L4/L5 differed up to threefold in prevalence between observers (p < 0.0001). Intraobserver agreement was mostly good or very good (kappa 0.60–1.00).

Conclusion

In candidates for disc prosthesis, mostly moderate interobserver agreement is expected for localised MRI findings.

Diurnal variation in stature: do those with chronic low-back pain differ from asymptomatic controls?

BACKGROUND

Stature loss is a commonly used measure of spinal load. The aim of this study was to investigate the pattern of diurnal stature change in those with and without chronic low-back pain, over a 24-h period.

METHODS

Eight participants with chronic low-back pain (age 24.6 (SD 4.3) years, height 1.76 (SD 0.08) m, body mass 72.8 (SD 11.1) kg) and eight controls (age 21.8 (SD 2.0) years, height 1.75 (SD 0.10) m, body mass 71.8 (SD 11.6) kg) participated in this investigation. Twenty-four stature measurements were performed over a 24-h period.

FINDINGS

The trough to peak variation in stature of 17.9 mm (low-back pain group) and 17.6mm (control group) did not differ between groups (P>0.05). Both groups experienced greatest stature change in the 1st hour after rising (31.3% [low-back pain] and 44.6% [control] of total stature change). At approximately 18:00h the LBP group reached a plateau whilst the control group continued to lose stature. Between 14:00 and 18:00h both groups demonstrated a previously unreported recovery of stature. A significant correlation was found between low-back discomfort and stature change in the low-back pain group only.

INTERPRETATION

No significant difference existed between groups in relation to total stature loss; however the low-back pain group appeared to reach their nadir earlier, possibly exposing other spinal structures to loading for a greater duration. This is supported by the relationship found between stature loss and discomfort. The reversal in stature loss in the afternoon may be of clinical significance and warrants further investigation.

Comparative study of lumbar magnetic resonance imaging and myelography in young soldiers with herniated lumbar disc

OBJECTIVE

This study was undertaken to compare the diagnostic performances of magnetic resonance imaging (MRI), MR myelography (MRM) and myelography in young soldiers with a herniated lumbar disc (HLD).

METHODS

Sixty-five male soldiers with HLD comprised the study cohort. A visual analogue scale for low back pain (VAS-LBP), VAS for leg radiating pain (VAS-LP), and Oswestry disability index (ODI) were applied. Lumbar MR, MRM, and myelographic findings were checked and evaluated by four independent radiologists, respectively. Each radiologist was asked to score (1 to 5) the degree of disc protrusion and nerve root compression using modified grading systems devised by the North American Spine Society and Pfirrmann and the physical examination rules for conscription in the Republic of Korea. Correlated coefficients between clinical and radiological factors were calculated. Interpretational reproducibility between MRI and myelography by four bases were calculated and compared.

RESULTS

Mean patient age was 20.5 ± 1.1. Mean VAS-LBP and VAS-LP were 6.7 ± 1.6 and 7.4 ± 1.7, respectively. Mean ODI was 48.0 ± 16.2%. Mean MRI, MRM, and myelography scores were 3.3 ± 0.9, 3.5 ± 1.0, and 3.9 ± 1.1, respectively. All scores of diagnostic performances were significantly correlated (p < 0.05). However, none of these scores reflected the severity of patients' symptoms. There was no statistical difference of interpretational reproducibility between MRI and myelography.

CONCLUSION

Although MRI and myelography are based on different principles, they produce similar interpretational reproducibility in young soldiers with a HLD. However, these modalities do not reflect the severity of symptoms.

Labeling of lumbar discs using both pixel- and object-level features with a two-level probabilistic model

Backbone anatomical structure detection and labeling is a necessary step for various analysis tasks of the vertebral column. Appearance, shape and geometry measurements are necessary for abnormality detection locally at each disc and vertebrae (such as herniation) as well as globally for the whole spine (such as spinal scoliosis). We propose a two-level probabilistic model for the localization of discs from clinical magnetic resonance imaging (MRI) data that captures both pixel- and object-level features. Using a Gibbs distribution, we model appearance and spatial information at the pixel level, and at the object level, we model the spatial distribution of the discs and the relative distances between them. We use generalized expectation-maximization for optimization, which achieves efficient convergence of disc labels. Our two-level model allows the assumption of conditional independence at the pixel-level to enhance efficiency while maintaining robustness. We use a dataset that contains 105 MRI clinical normal and abnormal cases for the lumbar area. We thoroughly test our model and achieve encouraging results on normal and abnormal cases.

Injuries to the lower back in elite fast bowlers

In our study, the aims were to describe the changes in the appearance of the lumbar spine on MRI in elite fast bowlers during a follow-up period of one year, and to determine whether these could be used to predict the presence of a stress fracture of the posterior elements. We recruited 28 elite fast bowlers with a mean age of 19 years (16 to 24) who were training and playing competitively at the start of the study. They underwent baseline MRI (season 1) and further scanning (season 2) after one year to assess the appearance of the lumbar intervertebral discs and posterior bony elements. The incidence of low back pain and the amount of playing and training time lost were also recorded.

In total, 15 of the 28 participants (53.6%) showed signs of acute bone stress on either the season 1 or season 2 MR scans and there was a strong correlation between these findings and the later development of a stress fracture (p < 0.001). The prevalence of intervertebral disc degeneration was relatively low. There was no relationship between disc degeneration on the season 1 MR scans and subsequent stress fracture. Regular lumbar MR scans of asymptomatic elite fast bowlers may be of value in detecting early changes of bone stress and may allow prompt intervention aimed at preventing a stress fracture and avoiding prolonged absence from cricket.

Healing of a painful intervertebral disc should not be confused with reversing disc degeneration: implications for physical therapies for discogenic back pain

BACKGROUND

Much is known about intervertebral disc degeneration, but little effort has been made to relate this information to the clinical problem of discogenic back pain, and how it might be treated.

METHODS

We re-interpret the scientific literature in order to provide a rationale for physical therapy treatments for discogenic back pain.

INTERPRETATION

Intervertebral discs deteriorate over many years, from the nucleus outwards, to an extent that is influenced by genetic inheritance and metabolite transport. Age-related deterioration can be accelerated by physical disruption, which leads to disc "degeneration" or prolapse. Degeneration most often affects the lower lumbar discs, which are loaded most severely, and it is often painful because nerves in the peripheral anulus or vertebral endplate can be sensitised by inflammatory-like changes arising from contact with blood or displaced nucleus pulposus. Surgically-removed human discs show an active inflammatory process proceeding from the outside-in, and animal studies confirm that effective healing occurs only in the outer anulus and endplate, where cell density and metabolite transport are greatest. Healing of the disc periphery has the potential to relieve discogenic pain, by re-establishing a physical barrier between nucleus pulposus and nerves, and reducing inflammation.

CONCLUSION

Physical therapies should aim to promote healing in the disc periphery, by stimulating cells, boosting metabolite transport, and preventing adhesions and re-injury. Such an approach has the potential to accelerate pain relief in the disc periphery, even if it fails to reverse age-related degenerative changes in the nucleus.

Degeneration and regeneration of the intervertebral disc: lessons from development

Degeneration of the intervertebral discs, a process characterized by a cascade of cellular, biochemical, structural and functional changes, is strongly implicated as a cause of low back pain. Current treatment strategies for disc degeneration typically address the symptoms of low back pain without treating the underlying cause or restoring mechanical function. A more in-depth understanding of disc degeneration, as well as opportunities for therapeutic intervention, can be obtained by considering aspects of intervertebral disc development. Development of the intervertebral disc involves the coalescence of several different cell types through highly orchestrated and complex molecular interactions. The resulting structures must function synergistically in an environment that is subjected to continuous mechanical perturbation throughout the life of an individual. Early postnatal changes, including altered cellularity, vascular regression and altered extracellular matrix composition, might set the disc on a slow course towards symptomatic degeneration. In this Perspective, we review the pathogenesis and treatment of intervertebral disc degeneration in the context of disc development. Within this scope, we examine how model systems have advanced our understanding of embryonic morphogenesis and associated molecular signaling pathways, in addition to the postnatal changes to the cellular, nutritional and mechanical microenvironment. We also discuss the current status of biological therapeutic strategies that promote disc regeneration and repair, and how lessons from development might provide clues for their refinement.

Assessment of nerve involvement in the lumbar spine: agreement between magnetic resonance imaging, physical examination and pain drawing findings

Background

Detection of nerve involvement originating in the spine is a primary concern in the assessment of spine symptoms. Magnetic resonance imaging (MRI) has become the diagnostic method of choice for this detection. However, the agreement between MRI and other diagnostic methods for detecting nerve involvement has not been fully evaluated. The aim of this diagnostic study was to evaluate the agreement between nerve involvement visible in MRI and findings of nerve involvement detected in a structured physical examination and a simplified pain drawing.

Methods

Sixty-one consecutive patients referred for MRI of the lumbar spine were - without knowledge of MRI findings - assessed for nerve involvement with a simplified pain drawing and a structured physical examination. Agreement between findings was calculated as overall agreement, the p value for McNemar's exact test, specificity, sensitivity, and positive and negative predictive values.

Results

MRI-visible nerve involvement was significantly less common than, and showed weak agreement with, physical examination and pain drawing findings of nerve involvement in corresponding body segments. In spine segment L4-5, where most findings of nerve involvement were detected, the mean sensitivity of MRI-visible nerve involvement to a positive neurological test in the physical examination ranged from 16-37%. The mean specificity of MRI-visible nerve involvement in the same segment ranged from 61-77%. Positive and negative predictive values of MRI-visible nerve involvement in segment L4-5 ranged from 22-78% and 28-56% respectively.

Conclusion

In patients with long-standing nerve root symptoms referred for lumbar MRI, MRI-visible nerve involvement significantly underestimates the presence of nerve involvement detected by a physical examination and a pain drawing. A structured physical examination and a simplified pain drawing may reveal that many patients with "MRI-invisible" lumbar symptoms need treatment aimed at nerve involvement. Factors other than present MRI-visible nerve involvement may be responsible for findings of nerve involvement in the physical examination and the pain drawing.

Computed tomography-evaluated features of spinal degeneration: prevalence, intercorrelation, and association with self-reported low back pain

BACKGROUND CONTEXT

Although the role of radiographic abnormalities in the etiology of nonspecific low back pain (LBP) is unclear, the frequent identification of these features on radiologic studies continues to influence medical decision making.

PURPOSE

The primary purposes of the study were to evaluate the prevalence of lumbar spine degeneration features, evaluated on computed tomography (CT), in a community-based sample and to evaluate the association between lumbar spine degeneration features. The secondary purpose was to evaluate the association between spinal degeneration features and LBP.

STUDY DESIGN

This is a cross-sectional community-based study that was an ancillary project to the Framingham Heart Study.

SAMPLE

A subset of 187 participants were chosen from the 3,529 participants enrolled in the Framingham Heart Study who underwent multidetector CT scan to assess aortic calcification.

OUTCOME MEASURES

Self-report measures: LBP in the preceding 12 months was evaluated using a Nordic self-report questionnaire. Physiologic measures: Dichotomous variables indicating the presence of intervertebral disc narrowing, facet joint osteoarthritis (OA), spondylolysis, spondylolisthesis, and spinal stenosis and the density (in Hounsfield units) of multifidus and erector spinae muscles were evaluated on CT.

METHODS

We calculated the prevalence of spinal degeneration features and mean density of multifidus and erector spinae muscles in groups of individuals with and without LBP. Using the chi(2) test for dichotomous and t test for continuous variables, we estimated the differences in spinal degeneration parameters between the aforementioned groups. To evaluate the association of spinal degeneration features with age, the prevalence of degeneration features was calculated in four age groups (less than 40, 40-50, 50-60, and 60+ years). We used multiple logistic regression models to examine the association between spinal degeneration features (before and after adjustment for age, sex, and body mass index [BMI]) and LBP, and between all degeneration features and LBP.

RESULTS

In total, 104 men and 83 women, with a mean age (+/-standard deviation) of 52.6+/-10.8 years, participated in the study. There was a high prevalence of intervertebral disc narrowing (63.9%), facet joint OA (64.5%), and spondylolysis (11.5%) in the studied sample. When all spinal degeneration features as well as age, sex, and BMI were factored in stepwise fashion into a multiple logistic regression model, only spinal stenosis showed statistically significant association with LBP, odds ratio (OR) (95% confidence interval [CI]): 3.45 [1.12-10.68]. Significant association was found between facet joint OA and low density of multifidus (OR [95% CI]: 3.68 [1.36-9.97]) and erector spinae (OR [95% CI]: 2.80 [1.10-7.16]) muscles.

CONCLUSIONS

Degenerative features of the lumbar spine were extremely prevalent in this community-based sample. The only degenerative feature associated with self-reported LBP was spinal stenosis. Other degenerative features appear to be unassociated with LBP.

Correlations between radiographic, magnetic resonance and histological examinations on the degeneration of human lumbar intervertebral discs

CONTEXT AND OBJECTIVE

There is controversy regarding which imaging method is best for identifying early degenerative alterations in intervertebral discs. No correlations between such methods and histological finds are presented in the literature. The aim of this study was to correlate the thickness of intervertebral discs measured on simple radiographs with the degree of degeneration seen on magnetic resonance images and the histological findings relating to nerve ends inside the discs.

DESIGN AND SETTING

Cross-sectional correlation study on the lumbar spines of human cadavers, at Universidade Federal de São Paulo (Unifesp), São Paulo, Brazil.

METHODS

Ten lumbar spinal columns were extracted from human cadavers and subjected to magnetic resonance imaging and simple radiography. They were classified according to the degree of disc degeneration seen on magnetic resonance, and the thickness of the discs was measured on radiographs. The intervertebral discs were then extracted, embedded in paraffin and analyzed immunohistochemically with protein S100, and the nerve fibers were counted and classified.

RESULTS

No correlation was observed between the thickness of the intervertebral discs and the degree of degeneration seen on magnetic resonance images. Only the uppermost lumbar discs (L1/L2 and L2/L3) presented a correlation between their thickness and type I and IV nerve endings.

CONCLUSION

Reduced disc thickness is unrelated to increased presence of nerve ends in intervertebral discs, or to the degree of disc degeneration.

Changes in paraspinal muscles and their association with low back pain and spinal degeneration: CT study

The objectives of the study were to evaluate the association between lumbar paraspinal muscle density, evaluated on computed tomography (CT) and age, sex and BMI; and to evaluate the association of those changes with low back pain (LBP) and spinal degeneration features in a community-based sample. This study was an ancillary project to the Framingham Study. A sample of 3,529 participants aged 40-80 years had a CT scan performed to assess aortic calcification. 187 individuals were randomly enrolled in this study. LBP in the last 12 months was evaluated using self-report questionnaire. Density (in Hounsfield units) of multifidus and erector spinae was evaluated on CT. The prevalence of intervertebral disc narrowing, facet joint osteoarthritis (FJOA), spondylolysis, spondylolisthesis and spinal stenosis were also evaluated. We used linear regression models to examine the association of paraspinal muscles density with age, sex, BMI, LBP, and spinal degeneration features. The results show that in our study, men have higher density of paraspinal muscles than women, younger individuals have higher density than older ones and individuals with lower weight have higher muscle density than overweight. No differences between individuals with and without LBP were found. Significant association was found between L4 multifidus/erector spinae density and FJOA at L4-L5; between multifidus at L4 and spondylolisthesis at L4-5; and between erector spinae at L4 and L5 with disc narrowing at L4-5 and L5-S1, respectively. We conclude that the paraspinal muscle density decreases with age, and increases BMI. It is associated with at some levels FJOA, spondylolisthesis and disc narrowing at the same level, but not associated with occurrence of LBP.

The Twin Spine Study: contributions to a changing view of disc degeneration

BACKGROUND CONTEXT

Disc degeneration was commonly viewed over much of the last century as a result of aging and "wear and tear" from mechanical insults and injuries. Thus, prevention strategies and research in lumbar degenerative changes and associated clinical conditions focused largely on mechanical factors as primary causes using an "injury model." The Twin Spine Study, a research program on the etiology and pathogenesis of disc degeneration, has contributed to a substantial revision of this view of determinants of lumbar disc degeneration.

PURPOSE

To provide a review of the methods and findings of the Twin Spine Study project.

STUDY DESIGN/SETTING

Narrative review of the Twin Spine Study.

METHODS

The Twin Spine Study, which started in 1991, is a multidisciplinary, multinational research project with collaborators primarily in Canada, Finland, and the United States. The most significant investigations related to determinants of disc degeneration included occupational exposures, driving and whole-body vibration exposure, smoking exposure, anthropomorphic factors, heritability, and the identification of genotypes associated with disc degeneration.

RESULTS

Among the most significant findings were a substantial influence of heredity on lumbar disc degeneration and the identification of the first gene forms associated with disc degeneration. Conversely, despite extraordinary discordance between twin siblings in occupational and leisure-time physical loading conditions throughout adulthood, surprisingly little effect on disc degeneration was observed. Studies on the effects of smoking on twins with large discordance in smoking exposure demonstrated an increase in disc degeneration associated with smoking, but this effect was small. No evidence was found to suggest that exposure to whole-body vibration through motorized vehicles leads to accelerated disc degeneration in these well-controlled studies. More recent results indicate that the effect of anthropometric factors, such as body weight and muscle strength on disc degeneration, although modest, appear in this work to be greater than those of occupational physical demands. In fact, some indications were found that routine loading may actually have some benefits to the disc.

CONCLUSIONS

The once commonly held view that disc degeneration is primarily a result of aging and "wear and tear" from mechanical insults and injuries was not supported by this series of studies. Instead, disc degeneration appears to be determined in great part by genetic influences. Although environmental factors also play a role, it is not primarily through routine physical loading exposures (eg, heavy vs. light physical demands) as once suspected.

New concept for backache: biopsychosocial pain syndrome

Recently a new concept for explaining backache, "biopsychosocial pain syndrome," has been suggested. Psychosocial factors play an important role in the development and persistence of backache from an early stage. Diagnosis and treatment of backache should be based on the new concept. A good relationship between doctors and patients influences treatment outcome and patient satisfaction. Treatment should be decided by patients themselves, after being informed of the natural history of the disease and the merit and demerit of the treatment.

Spinal injection procedures: a review of concepts, controversies, and complications

The field of spinal injection procedures is growing at a tremendous rate. Many disciplines are involved, including radiology, anesthesiology, orthopedics, physiatry and rehabilitation medicine, as well as other specialties. However, there remains tremendous variability in the assessment of patients receiving these therapies, methods for evaluation of outcome, and in the understanding of where these procedures belong in the triaging of those who require surgery. In this article, we attempt to highlight the biologic concepts on which these therapies are based, controversies that have arisen with their increasing use, and a description of complications that have been reported.

Value of the Magnetic Resonance Imaging in Patients With Painful Lumbar Spinal Stenosis (LSS) Undergoing Lumbar Epidural Steroid Injections

OBJECTIVES

Purpose of this study is to examine the relationship between the magnetic resonance imaging (MRI) findings, pain scores, and opiates use in patients with lumbar spinal stenosis (LSS) undergoing lumbar epidural steroid (LES) injections by retrospective review of 719 patients' electronic medical records.

METHODS

Reviewed were Visual Analog Scale (VAS) pain scores and opioid use before and 8 to 12 weeks after series of LES injections. The stenosis pain index (SPI) was produced by adding an assigned numerical value of severity (1=mild, 2=moderate, 3=severe) to the number of lumbar vertebral levels affected by LSS on MRI (lateral or central).

RESULTS

The average age of patients was 68.4 years. There was no relationship between the pretreatment age, sex, or number of vertebral levels affected on MRI with pretreatment VAS pain scores or opioid use. The degree of LSS present on MRI, categorized as a mild, moderate, or severe, correlated clearly with initial VAS pain scores (P=0.017). The improvement in VAS pain scores after LES injections correlated well with number of levels affected (P=0.003) and the severity of stenosis (P=0.12). Positive correlation was observed between change in VAS pain score 8 to 12 weeks after the series of LES injections and the SPI (P=0.001). There were no differences found in opioid use.

DISCUSSION

The improvement in VAS pain scores after LES injections correlated well with the changes in the SPI except in those patients classified on MRI as severe LSS and more than 3 lumbar levels affected. That patient group is unlikely to benefit from LES injections.

Neck and low back pain: neuroimaging

Spine imaging accounts for a major share of expenses related to neck and back pain. Improving image quality translates into better morphologic evaluation of the spine. Unfortunately, the morphologic abnormalities on spine imaging are common and nonspecific, obscuring the relevance to patient symptomatology. Furthermore, distinction between degenerative and age-related changes is not clear. The key is clinical correlation of imaging findings. This article presents a concise and illustrated discussion of spinal neuroimaging related to neck and back pain, with emphasis on degenerative disease.

The association between cervical spine curvature and neck pain

Degenerative changes of the cervical spine are commonly accompanied by a reduction or loss of the segmental or global lordosis, and are often considered to be a cause of neck pain. Nonetheless, such changes may also remain clinically silent. The aim of this study was to examine the correlation between the presence of neck pain and alterations of the normal cervical lordosis in people aged over 45 years. One hundred and seven volunteers, who were otherwise undergoing treatment for lower extremity problems in our hospital, took part. Sagittal radiographs of the cervical spine were taken and a questionnaire was completed, enquiring about neck pain and disability in the last 12 months. Based on the latter, subjects were divided into a group with neck pain (N = 54) and a group without neck pain (N = 53). The global curvature of the cervical spine (C2-C7) and each segmental angle were measured from the radiographs, using the posterior tangent method, and examined in relation to neck complaints. No significant difference between the two groups could be found in relation to the global curvature, the segmental angles, or the incidence of straight-spine or kyphotic deformity (P > 0.05). Twenty-three per cent of the people with neck pain and 17% of those without neck pain showed a segmental kyphosis deformity of more than 4 degrees in at least one segment--most frequently at C4/5, closely followed by C5/6 and C3/4. The average segmental angle at the kyphotic level was 6.5 degrees in the pain group and 6.3 degrees in the group without pain, with a range of 5-10 degrees in each group. In the group with neck pain, there was no association between any of the clinical characteristics (duration, frequency, intensity of pain; radiating pain; sensory/motor disturbances; disability; healthcare utilisation) and either global cervical curvature or segmental angles. The presence of such structural abnormalities in the patient with neck pain must be considered coincidental, i.e. not necessarily indicative of the cause of pain. This should be given due consideration in the differential diagnosis of patients with neck pain.

Heritability of low back pain and the role of disc degeneration

Twin studies suggest that both disc degeneration and back pain have a genetic component. We were interested in estimating the heritability of low back pain in men and examining whether genetic influences on back pain are mediated through genetic influences on disc degeneration. Thus, we conducted a classic twin study with multivariate quantitative genetic models to estimate the degree to which genetic (or environmental) effects on back pain were correlated with genetic (or environmental) effects on disc degeneration. Subjects included 147 monozygotic and 153 dizygotic male twin pairs (N=600 subjects) from the population-based Finnish Twin Cohort. All subjects underwent lumbar magnetic resonance imaging and completed an extensive interview, including back pain history and exposure to suspected risk factors. Disc height narrowing was the degenerative finding most associated with pain history, and was used to index disc degeneration in the models. Statistically significant genetic correlations were found for disc height narrowing and different definitions of back pain, such as duration of the worst back pain episode (r(g)=0.46) and hospitalization for back problems (r(g)=0.49), as well as disability in the previous year from back pain (r(g)=0.33). The heritability estimates for these back pain variables ranged from 30% to 46%. There also were statistically significant, but weaker, environmental correlations for disc height narrowing with back symptoms over the prior year. A substantial minority of the genetic influences on pain was due to the same genetic influences affecting disc degeneration. This suggests that disc degeneration is one pathway through which genes influence back pain.

Are first-time episodes of serious LBP associated with new MRI findings?

BACKGROUND

Magnetic resonance (MR) imaging is frequently used to evaluate first-time episodes of serious low back pain (LBP). Common degenerative findings are often interpreted as recent developments and the probable anatomic cause of the new symptoms. To date no prospective study has established a baseline MR status of the lumbar spine in subjects without significant LBP problems and prospectively surveyed these subjects for acute changes shortly after new and serious LBP episodes. This method can identify new versus old MR findings possibly associated with the acute symptomatic episode.

PURPOSE

To determine if new and serious episodes of LBP are associated with new and relevant findings on MRI.

STUDY DESIGN

Prospective observational study with baseline and post-LBP MRI monitoring of 200 subjects over 5 years.

OUTCOME MEASURES

Clinical outcomes: LBP intensity (visual analogue scale), Oswestry Disability Index, and work loss. MRI outcomes: disc degeneration, herniation, annular fissures, end plate changes, facet arthrosis, canal stenosis, spondylolisthesis, and root impingement.

METHODS

200 subjects with a lifetime history of no significant LBP problems, and a high risk for new LBP episodes were studied at baseline with physical examination, plain radiographs, and MR imaging. Subjects were followed every 6 months for 5 years with a detailed telephone interview. Subjects with a new severe LBP episode (LBP>or=6/10,>1 week) were assessed for new diagnostic tests. New MR imaging, taken within 6 to 12 weeks of the start of a new LBP episode, was compared with baseline (asymptomatic) images. Two independent and blinded readers evaluated each baseline and follow-up study.

RESULTS

During the 5-year observation period of 200 subjects, 51 (25%) subjects were evaluated with a lumbar MRI for clinically serious LBP episodes, and 3/51 (6%) had a primary radicular complaint. These 51 subjects had 67 MR scans. Of 51 subjects, 43 (84%) had either unchanged MR or showed regression of baseline changes. The most common progressive findings were disc signal loss (10%), progressive facet arthrosis (10%), or increased end plate changes (4%). Only two subjects, both with primary radicular complaints, had new findings of probable clinical significance (4%). Subjects having another MR were more likely to have had chronic pain at baseline (odds ratio [OR]=3.19; 95% confidence interval [CI] 1.61-6.32), to smoke (OR=5.81; 95% CI 1.99-16.45), have baseline psychological distress (OR 2.27; 95% CI 1.15-4.49), and have previous disputed compensation claims (OR=2.35; 95% CI 0.97-5.69). Subjects involved in current compensation claims were also more likely to have an MR scan to evaluate the LBP episode (risk ratio=4.75, p<.001), but were unlikely to have significant new findings. New findings were not more frequent in subjects with LBP episodes developing after minor trauma than when LBP developed spontaneously.

CONCLUSION

Findings on MR imaging within 12 weeks of serious LBP inception are highly unlikely to represent any new structural change. Most new changes (loss of disc signal, facet arthrosis, and end plate signal changes) represent progressive age changes not associated with acute events. Primary radicular syndromes may have new root compression findings associated with root irritation.

Relationship between low back pain, disability, MR imaging findings and health care provider

OBJECTIVE

To determine the association between the self-report of pain and disability and findings on lumbar MR images, and to compare two different health care providers in Spanish patients with low back pain (LBP).

DESIGN

Cross-sectional

MATERIAL AND METHODS

A total of 278 patients, 137 men and 141 women aged 44+/-14 years submitted with low back pain (LBP) were studied. One hundred and nine patients were from the National Health System (NHS) and 169 from private practice. Patients with previous discitis, surgery, neoplasm or traumatic episodes were excluded. Every patient completed a disability questionnaire with six core items, providing a score of disability from 2 to 28. All patients had sagittal spin-echo T1 and turbo spin-echo T2, axial proton-density and MR myelography weighted images. MR images of the two most affected disc levels were read, offering an MR imaging score from 0 to 30.

RESULTS

Patients with a combination of LBP and sciatica showed the highest levels of disability (p=0.002). MR imaging scores only correlated with pain interference with normal work (p=0.04), but not with other disability questions. Patients from the NHS showed greater disability scores than private ones (p=0.001) and higher MR imaging scores (p=0.01).

CONCLUSION

In patients with LBP, MR imaging only correlates with pain interference with work but not with other disability questions. Differences are found between private and NHS patients, the latter being more physically affected.

Relationship between alterations of the lumbar spine, visualized with magnetic resonance imaging, and occupational variables

Although the effect of physical workload on the occurrence of low back pain (LBP) has been extensively investigated, few quantitative studies have examined the morphological changes visualized via magnetic resonance imaging (MRI) in relation to occupational variables. The relationship between the severity of some abnormalities such as lumbar spinal stenosis or spondylolisthesis and physical or psychosocial occupational risk factors has not been investigated previously. In this cross-sectional study patients fulfilled the following inclusion criteria: (1) long-standing (minimum 1-year) LBP radiating down the leg (or not); (2) age more than 40 years; (3) willingness to undergo an MRI of the lumbar spine; and (4) ability to speak Italian. Primary objective of the study was to investigate the association between occupational exposure and morphological MRI findings, while controlling for the individual risk factors for LBP. Secondarily, we looked at the influence of this exposure and the degenerative changes in the lumbar spine on clinical symptoms and the related disability. Lumbar MRI scans from 120 symptomatic patients were supplemented by the results of structured interviews, which provided personal, medical, and occupational histories. All occupational factors were arranged on scales of increasing exposure, whereas pain and disability were assessed using ad hoc validated questionnaires. Evidence of intervertebral disc narrowing or herniation and the occurrence and severity of spinal stenosis and spondylolisthesis was obtained from the MRI scans and a summative degenerative score was then calculated. We detected a direct association between increasing age and the global amount of degenerative change, the severity of intervertebral disc height loss, the number of narrowed discs, stenosis, the number of stenotic levels, and spondylolisthesis. Physical occupational exposure was not associated with the presence of lumbar disc degeneration and narrowing per se, but a higher degree of such an exposure was directly associated with a higher degree of degeneration (P=0.017). Spondylolistesis and stenosis were positively related to heavy workload (P=0.014) and the manual handling of materials (P=0.023), respectively. Psychosocial occupational discomfort was directly associated to stenosis (P=0.041) and number of stenotic levels (P=0.019). A heavier job workload was the only occupational factor positively related to the degree of disability at the multivariate analysis (P=0.002). Total amount of degeneration in the lumbar spine directly influenced pain duration (P=0.011) and degree of disability (P=0.050). These results suggest that caution should be exercised when symptomatic subjects with evidence of degenerative changes on MRI scans engage in strenuous physical labor.

Can the combination of localized "proliferative therapy" with "minor ozonated autohemotherapy" restore the natural healing process?

Regenerative injection therapy (RIT), also known as proliferative therapy, has been used for over 30 years in the USA in patients with spinal and peripheral joint and ligamentous pathologies. It involves the injection of mildly irritating medications onto ligaments and tendons, most commonly at origins and insertions. These injections cause a mild inflammatory response which "turns on" the normal healing process and results in the regeneration of these structures. At the same time they strengthen and become less sensitive to pain through a combination of neurolysis of small nerve fibers (C-fibers) and increased stability of the underlying structures. Oxygen/ozone therapy is a well established complementary therapy practiced in many European countries. The ozone dissolves in body fluids and immediately reacts with biomolecules generating messengers responsible for biological and therapeutic activities. This results in an anti inflammatory response, which also results in a similar trophic reaction to that of RIT. It is logical to expect that combining these two modalities would result in enhanced healing and therefore improved clinical outcomes. Oxygen/ozone therapy, accomplished by autohemotherapy (AHT), is performed by either administering ozonated blood intravenously (Major AHT) or via intramuscular route (Minor AHT). These procedures result in stimulation of the immune and healing systems. Our concept is that the local injection of this activated blood injected directly to the ligamentous areas that are also being treated with RIT will act as a direct stimulation to the healing process. In addition, combining this with intravenous major AHT should stimulate the immune system to augment and support this process. RIT and oxygen/ozone therapy have been extensively studied separately. We propose a study of lumbosacral ligamentous pain to explore this therapeutic combination. We hope that this paper will stimulate general interest in this area of medicine and result in investigation of the "interface" between these treatment modalities.

Myths and perceptions of back pain in the Norwegian population, before and after the introduction of guidelines for acute back pain

AIM

Deyo's seven "myths" about back pain are based on common misconceptions of causality and therapy of back pain. These myths were alive in the Norwegian population in 2001; this report investigates whether this is true two years later.

METHODS

A representative sample of the Norwegian population in 2003 (n = 1,014) were asked to rate their agreement with the seven myths.

RESULTS

There is significantly less acceptance of all myths except "Most back pain is caused by injuries or heavy lifting" in 2003. Myths concerning the use and importance of X-ray were still common: 43% agreed that "X-ray and newer imaging tests can always identify the cause of pain" and 50% that "Everyone with back pain should have a spine X-ray". Low level of education is still associated with high acceptance of the myths, but the changes from 2001 are most pronounced for these groups.

CONCLUSION

Perceptions in the general population in Norway are slowly changing to be more in accordance with existing knowledge on accurate behaviour and treatment of back pain. This may be related to introduction of new evidence-based guidelines. The difference between educational groups is reduced, but is still a challenge to health professionals and health authorities.

Molecular pathogenic factors in symptomatic disc degeneration

BACKGROUND CONTEXT

Although symptomatic disc degeneration is thought to be the leading cause of chronic low back pain, no available biologic therapy is yet available to treat this highly prevalent condition.

PURPOSE

In this article, the cellular, biomechanical and molecular alterations that occur during disc degeneration are reviewed to provide a better understanding of this pathologic process.

STUDY DESIGN

The cellular and molecular aspects of disc degeneration are reviewed.

METHODS

The available studies detailing the molecular and cellular changes during disc degeneration are reviewed in an effort to provide a basis for understanding the biologic strategies for disc repair.

RESULTS

Disc degeneration begins early in life and involves a cascade of changes at the cellular and molecular level that results in degradation of the extracellular matrix of the disc, leading to biomechanical failure of this complex structure.

CONCLUSION

With a thorough understanding of the cellular and molecular events causing degeneration of the intervertebral disc, rational strategies for disc repair can be understood and evaluated. It appears that biologic disc repair will be feasible in the future although challenges remain in this blossoming field.