Disc degeneration. Its frequency and relationship to symptoms

Cervical myelopathy: clinical and neurophysiological evaluation

The overall frequency of troublesome neck pain is estimated to be about 34%, and it was observed that the frequency of complaints lasting 1 month or longer was higher in women than in men. The prevalence increased with age, with regard to both pain duration and chronic pain. Approximately 14% of a randomly selected population meets the criterion for chronic neck pain: complaints lasting more than 6 months. Epidemiologic data substantiate the importance of morphologic, age-related changes of the cervical spine; however, the incidence and prevalence of cervical myelopathy is not known. It could be that the structural transformation of the intervertebral disc, the uncovertebral processes and the zygapophyseal joints is a process accompanied by disturbed function that ultimately not only induces pain, but can lead to narrowing of spinal canal, with symptoms and signs of cervical myelopathy. For a diagnosis of radicular and myelopathic syndromes, the functional and neurological examination is enhanced by neurophysiological assessment. Electromyography (EMG) performed with needle electrodes is the oldest method for diagnosing nerve root compression and anterior horn cell syndromes, and is claimed to have no false-positive results. For cervical myelopathy, as a routine examination sensory evoked potentials (SEPs) by stimulation of tibial nerve and motor evoked potentials (MEPs) from the upper and lower extremities are recommended.

COL9A3 gene polymorphism and obesity in intervertebral disc degeneration of the lumbar spine: evidence of gene-environment interaction

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To evaluate the interaction between the COL9A3 gene polymorphism and persistent obesity in relation to lumbar disc degeneration.

SUMMARY OF BACKGROUND DATA

Obesity has been suggested to be a risk factor for disc degeneration. There is some indication for an association between collagen IX genes and lumbar disc disease characterized by sciatica. However, the interaction between those factors in their influences on the risk of disc degeneration has not been studied.

METHODS

Blood samples from 135 middle-aged men who had undergone magnetic resonance imaging (MRI) of the lumbar spine were analyzed for the presence of an arginine to tryptophan change in the COL9A3 gene (Trp3 allele). The men represented three occupations: 41 were machine drivers, 42 were carpenters, and 52 were office workers. The discs L2/L3-L5/S1 were evaluated on MRI, using decreased signal intensity of the nucleus pulposus, posterior disc bulges, and decreased disc height as signs of disc degeneration. Based on self-reports on body height and weight currently and at the age of 25 years, obesity history was classified as no obesity, persistent obesity, and other. Rothman's synergy index was used as a measure of interaction between two factors.

RESULTS

The Trp3 allele and persistent obesity acted synergistically to increase the risk of dark nucleus pulposus, posterior disc bulge, and decreased disc height at L4/L5; of multilevel posterior disc bulges; and of decreased disc height. From 45% to 71% of disc degeneration among persistently obese individuals with the Trp3 allele could be attributed to the synergism of these two factors.

CONCLUSION

The effect of obesity on lumbar disc degeneration seems to be modified by the collagen IX gene polymorphism, so that people who carry the Trp3 allele are at increased risk if they are persistently obese.

Spinal degenerative disk disease (DDD) in female macaque monkeys: epidemiology and comparison with women

Spinal degenerative disk disease (DDD) in a radiographic, cross-sectional sample of 192 female macaque monkeys, approximately 5-30 years old, is described. The presence and extent of disk space narrowing (DSN) and anterior osteophytosis were assessed with reference to age, average lifetime body mass. and distribution within the thoracolumbar spine. Age was a strong correlate of disk narrowing and osteophytosis, with early signs appearing at equivalent ages in both species and increasing in prevalence thereafter. Macaques showed a far greater prevalence of DDD, especially in the oldest age group, than has been reported in the human data. Body mass was associated with disk narrowing in the macaque, but not with osteophytosis. The two species differed little in the pattern of distribution of DDD along the spine. Our results suggest that bipedality is not the singular, or even the most important, biomechanical factor in the development of human DDD. Rather, others shared postural regimes, e.g., sitting, may be responsible for the onset and progression of DDD in both species. The macaque model could substantially add to the understanding and, potentially, treatment of this oftentimes debilitating condition.

Cervical disc disease in the athlete

The purpose of this article is to review the basic principles of cervical disc disease, and to outline strategies for the evaluation and treatment of this disorder. It is also intended to outline some guidelines regarding the difficult return-to-play decision for athletes with cervical disc disease.

Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study

STUDY DESIGN

A prospective study randomized by patient choice from the private practice of a single physician affiliated with a major teaching hospital was conducted.

OBJECTIVES

To compare transforaminal epidural steroid injections with saline trigger-point injections used in the treatment of lumbosacral radiculopathy secondary to a herniated nucleus pulposus.

SUMMARY OF BACKGROUND DATA

Epidural steroid injections have been used for more than half a century in the management of lumbosacral radicular pain. At this writing, however, there have been no controlled prospective trials of transforaminal epidural steroid injections in the treatment of lumbar radiculopathy secondary to a herniated nucleus pulposus.

METHODS

Randomized by patient choice, patients received either a transforaminal epidural steroid injection or a saline trigger-point injection. Treatment outcome was measured using a patient satisfaction scale with choice options of 0 (poor), 1 (fair), 2 (good), 3 (very good), and 4 (excellent); a Roland-Morris low back pain questionnaire that showed improvement by an increase in score; a measurement of finger-to-floor distance with the patient in fully tolerated hip flexion; and a visual numeric pain scale ranging from 0 to 10. A successful outcome required a patient satisfaction score of 2 (good) or 3 (very good), improvement on the Roland-Morris score of 5 or more, and pain reduction greater than 50% at least 1 year after treatment. The final analysis included 48 patients with an average follow-up period of 16 months (range, 12-21 months).

RESULTS

After an average follow-up period of 1.4 years, the group receiving transforaminal epidural steroid injections had a success rate of 84%, as compared with 48% for the group receiving trigger-point injections (P < 0.005).

CONCLUSION

Fluoroscopically guided transforaminal injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus.

The role of cumulative physical work load in lumbar spine disease: risk factors for lumbar osteochondrosis and spondylosis associated with chronic complaints

OBJECTIVES

To investigate the relation with a case-control study between symptomatic osteochondrosis or spondylosis of the lumbar spine and cumulative occupational exposure to lifting or carrying and to working postures with extreme forward bending.

METHODS

From two practices and four clinics were recruited 229 male patients with radiographically confirmed osteochondrosis or spondylosis of the lumbar spine associated with chronic complaints. Of these 135 had additionally had acute lumbar disc herniation. A total of 197 control subjects was recruited: 107 subjects with anamnestic exclusion of lumbar spine disease were drawn as a random population control group and 90 patients admitted to hospital for urolithiasis who had no osteochondrosis or spondylosis of the lumbar spine radiographically were recruited as a hospital based control group. Data were gathered in a structured personal interview and analysed using logistic regression to control for age, region, nationality, and other diseases affecting the lumbar spine. To calculate cumulative forces to the lumbar spine over the entire working life, the Mainz-Dortmund dose model (MDD), which is based on an overproportional weighting of the lumbar disc compression force relative to the respective duration of the lifting process was applied with modifications: any objects weighing >or=5 kg were included in the calculation and no minimum daily exposure limits were established. Calculation of forces to the lumbar spine was based on self reported estimates of occupational lifting, trunk flexion, and duration.

RESULTS

For a lumbar spine dose >9 x 10(6) Nh (Newton x hours), the risk of having radiographically confirmed osteochondrosis or spondylosis of the lumbar spine as measured by the odds ratio (OR) was 8.5 (95% confidence interval (95% CI) 4.1 to 17.5) compared with subjects with a load of 0 Nh. To avoid differential bias, forces to the lumbar spine were also calculated on the basis of an internal job exposure matrix based on the control subjects' exposure assessments for their respective job groups. Although ORs were lower with this approach, they remained significant.

CONCLUSIONS

The calculation of the sum of forces to the lumbar spine is a useful tool for risk assessment for symptomatic osteochondrosis or spondylosis of the lumbar spine. The results suggest that cumulative occupational exposure to lifting or carrying and extreme forward bending increases the risk for developing symptomatic osteochondrosis or spondylosis of the lumbar spine.

Prognosis following a second whiplash injury

Five percent of the population have suffered a whiplash injury. Of these, 43% suffer long-term symptoms. We undertook a retrospective study of 79 patients who had suffered two whiplash injuries. The severity of each patient's symptoms was assessed after the first and second injuries using the Gargan and Bannister classification. Overall, 84% of patients reported increased symptoms following the second injury. Ninety-seven percent of patients who had been symptom free before the second injury reported persisting discomfort.

Physical medicine modalities for mechanical neck disorders

OBJECTIVES

Multiple physical medicine modalities are commonly included as part of therapeutic interventions for mechanical neck disorders (neck pain). The objective of this review was to assess the effects of physical medicine modalities for pain in adults with mechanical neck disorders.

SEARCH STRATEGY

We searched Medline, Embase, Chirolars, Index to Chiropractic Literature, Cinahl, Science Citation Index, Conference Proceedings Index, National Technical Information Services and reference lists of the retrieved articles from 1985 to December 1993 and we contacted content experts.

SELECTION CRITERIA

Randomised trials and controlled trials of physical medicine modalities in adults with mechanical neck disorder.

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed trial quality and two reviewers independently extracted data. Investigators were contacted to obtain information or data that could not be found in the published reports.

MAIN RESULTS

Thirteen trials were included. The overall quality of the included trials was generally good. Two trials using electromagnetic therapy produced a significant reduction in pain (p <0.01) with three to four weeks of daily (eight hours per day) therapy sessions; and three using laser therapy did not differ significantly from a placebo (p=0.20) for six to 10 sessions of treatment. Not enough scientific testing exists to clearly determine the effectiveness of other therapies. This includes treatments such as exercise, traction, acupuncture, heat / cold applications, electrotherapies, cervical orthoses and chronic pain / cognitive behavioural rehabilitation strategies.

REVIEWER'S CONCLUSIONS

There is little information available from trials to support the use of physical medicine modalities for mechanical neck pain. There is some support for the use of electromagnetic therapy and against the use of laser therapy with respect to pain reduction.

The Southampton examination schedule for the diagnosis of musculoskeletal disorders of the upper limb

OBJECTIVES

Following a consensus statement from a multidisciplinary UK workshop, a structured examination schedule was developed for the diagnosis and classification of musculoskeletal disorders of the upper limb. The aim of this study was to test the repeatability and the validity of the newly developed schedule in a hospital setting.

METHOD

43 consecutive referrals to a soft tissue rheumatism clinic (group 1) and 45 subjects with one of a list of specific upper limb disorders (including shoulder capsulitis, rotator cuff tendinitis, lateral epicondylitis and tenosynovitis) (group 2), were recruited from hospital rheumatology and orthopaedic outpatient clinics. All 88 subjects were examined by a research nurse (blinded to diagnosis), and everyone from group 1 was independently examined by a rheumatologist. Between observer agreement was assessed among subjects from group 1 by calculating Cohen's kappa for dichotomous physical signs, and mean differences with limits of agreement for measured ranges of joint movement. To assess the validity of the examination, a pre-defined algorithm was applied to the nurse's examination findings in patients from both groups, and the sensitivity and specificity of the derived diagnoses were determined in comparison with the clinic's independent diagnosis as the reference standard.

RESULTS

The between observer repeatability of physical signs varied from good to excellent, with kappa coefficients of 0.66 to 1.00 for most categorical observations, and mean absolute differences of 1.4 degrees -11.9 degrees for measurements of shoulder movement. The sensitivity of the schedule in comparison with the reference standard varied between diagnoses from 58%-100%, while the specificities ranged from 84%-100%. The nurse and the clinic physician generally agreed in their diagnoses, but in the presence of shoulder capsulitis the nurse usually also diagnosed shoulder tendinitis, whereas the clinic physician did not.

CONCLUSION

The new examination protocol is repeatable and gives acceptable diagnostic accuracy in a hospital setting. Examination can feasibly be delegated to a trained nurse, and the protocol has the benefit of face and construct validity as well as consensus backing. Its performance in the community, where disease is less clear cut, merits separate evaluation, and further refinement is needed to discriminate between discrete pathologies at the shoulder.

Prevalence of back, neck and shoulder problems in the inner city: implications for the provision of physiotherapy services in primary healthcare

BACKGROUND AND PURPOSE

More general practitioners are offering physiotherapy services within primary healthcare; however, this provision may result in increased demand. Resource allocation, based on previous patterns of consultation for musculoskeletal conditions, may be inadequate since the need for treatment in the community may not have been met in the past. Therefore the aim of this study was to determine the prevalence of back, neck and shoulder problems that had restricted normal activity for more than one week during the last year and which health professionals (if any) patients had consulted about their symptoms.

METHOD

A postal survey of 2400 adult patients selected at random from four general practices in Newcastle upon Tyne (600 from each practice).

RESULTS

A total of 1546 questionnaires were returned, a 64% response rate. Overall, 40% of respondants reported having at least one back, neck and/or shoulder problem. Back problems were most common (30%), followed by those with neck (21%) and shoulder (20%) problems. Approximately one-third of those with problems consulted no one, a further third consulted a general practitioner and only one in six consulted a physiotherapist.

CONCLUSIONS

There is a high prevalence of substantial back, neck and shoulder problems in the community and thus a wider provision of physiotherapy services within primary healthcare may be required to manage the considerable levels of potentially unmet need.

The influence of occupation on lumbar degeneration

In many countries, back problems have been defined as occupational injuries. The belief underlying this injury model is that back symptoms are caused primarily by work-related mechanical factors that damage the structures of the spine, either through a single incident or repeated loading. Although the etiopathogenesis of degenerative findings in the disc and their relation to pain are poorly understood, changes in the disc are suspected of underlying many back symptoms. The focus of this article is on examining the relation between occupational factors and disc degeneration. Occupational factors suspected of accelerating spinal degeneration include accident-related trauma; heavy physical loading and materials handling, including lifting, bending, and twisting; prolonged sitting; and sustained nonneutral work postures and vehicular driving. There is evidence to suggest that occupational exposures have an effect on disc degeneration. However, these factors explain little of the variability in degeneration found in the adult population. Furthermore, the lack of a clear dose-response relation between time spent in various occupational loading conditions and degenerative findings adds to doubts about a strong causal link. The contribution of suspected occupational risk factors appears to be particularly modest when compared with familial influences, which reflect the combined effects of genes and early childhood environment. These findings challenge the dominant role assumed for occupational loading in disc degeneration and associated back problems, and suggest a more complex etiology.

Laparoscopic fusion of the lumbar spine: minimally invasive spine surgery. A prospective multicenter study evaluating open and laparoscopic lumbar fusion

STUDY DESIGN

Two hundred-forty consecutive patients underwent laparoscopic instrumented interbody fusion using custom-designed instrumentation and BAK (Sulzer Spine Tech, Minneapolis, MN) fusion cages. The surgeries were performed at eight spine centers during U.S. Food and Drug Administration investigational device evaluation clinical trials. This cohort was compared with 591 consecutive patients undergoing open anterior fusion with the same device.

OBJECTIVES

To investigate the feasibility and safety of the laparoscopic approach compared with that of open procedures.

SUMMARY OF BACKGROUND DATA

In other areas of medicine, advances in laparoscopic surgical procedures have resulted in reduced morbidity, expense, and pain when compared with results of the open counterpart.

METHODS

The open anterior procedure was performed using a retroperitoneal approach. The laparoscopic procedure was performed transperitoneally with carbon dioxide insufflation to provide visualization using a 10-mm endoscope. Two hollow, titanium, threaded interbody implants packed with autologous bone were inserted into the diseased interspace.

RESULTS

The laparoscopy group had a shorter hospital stay and reduced blood loss but had increased operative time. Operative time improved in the laparoscopy group as surgeons' experience increased. Operative complications were comparable in both groups, with an occurrence of 4.2% in the open approach and 4.9% in the laparoscopic approach. Overall, the device-related reoperation rate was higher in the laparoscopy group (4.7% vs. 2.3%), primarily as a result of intraoperative disc herniation. Conversion to open procedure in the laparoscopy group was 10%, with most cases predictable and preventable.

CONCLUSIONS

The laparoscopic procedure is associated with a learning curve, but once mastered, it is effective and safe when compared with open techniques of fusion.

What are the age-related changes in the spine?

Degenerative changes of the spinal column have long been and continue to be confused with the presence of spinal distress and pain. All parts of the spine undergo degenerative changes as we age. The purpose of this chapter is to describe the degenerative process and its clinical consequences. The disc degenerative process will be discussed; its consequences on the facet joint and osteophyte formation are considered. The prevalence of disc degeneration, the role of physically demanding work and leisure and the interference of spinal deformity is clarified. A section particularly important for the clinician deals with the clinical consequences of the degenerative process in disc herniation, degenerative spondylolisthesis, spondylolysis and stenosis. This chapter tries to put the degenerative changes of the spine into the context of a normal ageing process.

Disc degeneration/back pain and calcification of the abdominal aorta. A 25-year follow-up study in Framingham

STUDY DESIGN

A 25-year follow-up study of 606 members of the population-based Framingham cohort, who had received lateral lumbar radiographs in 1967-1968 and 1992-1993, and completed an interview on back symptoms at the second examination.

OBJECTIVES

To evaluate whether calcific lesions in the posterior wall of the abdominal aorta, the source of the feeding arteries of the lumbar spine, are associated with disc degeneration or back pain, which would suggest that ischemia of the lumbar spine leads to disc degeneration.

METHODS

The presence of radiographic aortic calcification was ascertained in front of each lumbar segment from L1 through L4, and disc degeneration at intervertebral spaces from L1-L2 through L4-L5. The associations between aortic calcification, disc degeneration, and back pain were tested using logistic regression with adjustment for age and sex.

RESULTS

At the baseline examination, aortic calcification was significantly associated with general disc degeneration, that is, disc space narrowing or endplate sclerosis at any lumbar level (odds ratio 1.6; 95% confidence interval 1.0-2.5; P = 0.034). In longitudinal, level-specific analyses, comparing local aortic calcifications with disc degeneration at the matching level, aortic calcifications predicted disc deterioration, that is, a decrease in disc space or appearance of endplate sclerosis, between the examinations (odds ratio 1.5; 95% confidence interval 1.3-1.8; P < 0.001). Furthermore, subjects in whom aortic calcifications developed between the examinations had disc deterioration twice as frequently as those in whom aortic calcifications did not develop (odds ratio 2.0; 96% confidence interval 1.2-3.5; P = 0.013). Also, individuals with severe (Grade 3) posterior aortic calcification in front of any lumbar segment were more likely than others to report back pain during adult life (odds ratio 1.6; 95% confidence interval 1.1-2.2; P = 0.014).

CONCLUSIONS

Advanced aortic atherosclerosis, presenting as calcific deposits in the posterior wall of the aorta, increases a person's risk for development of disc degeneration and is associated with the occurrence of back pain.

Correlates of back problems and back-related disability in the United States

The purpose of this study is to identify correlates of back problems and back disability in the adult population of the United States. Cross-sectional analyses were performed using data from the 1989 National Health Interview Survey (NHIS). Weighted polytomous logistic regression modeling was performed to estimate odds ratios adjusted for the effects of covariates. The prevalence of a disabling back condition, vs. no back condition, was relatively higher among subjects aged 25-64 years, male, non-high-school graduates, unemployed, living in the West, with disabling non-back morbidities, and with body mass index and weight above the 50th percentile. Among workers, those in technical, sales, clerical, private household, service, precision production and repair, or transportation occupations were relatively more likely to report disabling back conditions, compared to workers in professional occupations. Among adults with back problems, age greater than 34 years, weight above the 50th percentile, and history of back trauma were associated with chronic back disability. Although the magnitudes of the associations are not large, they may have enormous public health implications because of the high prevalence of back problems and related disability.

Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies

STUDY DESIGN

A systematic review of published observational studies.

OBJECTIVES

To examine the causal relationship between radiographic findings and nonspecific low back pain.

SUMMARY OF BACKGROUND DATA

The causal relationship between radiographic findings and nonspecific low back pain still is controversial.

METHODS

Two reviewers independently scored the methodologic quality of all relevant, available studies using a standardized set of criteria. The association between radiographic findings and nonspecific low back pain was expressed as an odds ratio with a corresponding 95% confidence interval.

RESULTS

Degeneration, defined by the presence of disc space narrowing, osteophytes, and sclerosis, turned out to be associated with nonspecific low back pain with odds ratios ranging from 1.2 to 3.3. Spondylolysis and spondylolisthesis, spina bifida, transitional vertebrae, spondylosis, and Scheuermann's disease did not appear to be associated with low back pain. The validity scores of the observational studies ranged from 0% to 91% of the maximum score. Only two studies used a prospective design, and most studies lacked control for confounding, an appropriate test for nonspecific low back pain, and blinded assessment of radiographs and low back pain status.

CONCLUSIONS

There is no firm evidence for the presence or absence of a causal relationship between radiographic findings and nonspecific low back pain.

Classification systems of soft tissue disorders of the neck and upper limb: do they satisfy methodological guidelines?

A critical appraisal of existing classifications of soft tissue disorders of the neck and upper limb was performed utilizing methodological criteria including appropriateness for purpose, validity, reliability, feasibility, and generalizability. Five classifications were assessed independently by three raters using standardized forms. For those criteria that can be assessed by inspection of the classification itself, none of the classification systems appeared acceptable for reasons such as failure to be comprehensive, overlap of categories, and lack of demonstration that the criteria for inclusion into the categories are valid and reliable. No judgement could be passed about those criteria that require formal testing, such as reliability and construct validity, because of the absence of data. The overall interrater reliability of the critical appraisal was high, with an intraclass correlation coefficient of 0.82. The validity of studies that have relied upon existing classifications of soft tissue disorders of the neck and upper limb to group the entities under study is questioned in light of the findings of this study. Future work should be directed toward improving existing classification systems and/or developing new ones that fulfil basic measurement criteria.

Degenerative lumbar spinal stenosis. Diagnostic value of the history and physical examination

OBJECTIVE

To assess the value of the history and physical examination findings in the diagnosis of symptomatic degenerative lumbar spinal stenosis (LSS).

METHODS

The study was performed in 3 specialty clinics, and included patients with low back pain who were at least age 40. Findings from a standardized history and physical examination were compared with the diagnostic impression of expert attending clinicians. Imaging studies were available in 88% of those with LSS, and the findings further supported the diagnosis of LSS in each case. The sensitivity, specificity, and likelihood ratio associated with each history and physical examination finding were calculated in bivariate analyses, and independent correlates of LSS were identified with multivariate analyses.

RESULTS

Ninety-three patients were evaluated. History findings most strongly associated with the diagnosis of LSS (likelihood ratio > or = 2) were greater age, severe lower-extremity pain, and absence of pain when seated. Physical examination findings most strongly associated with the diagnosis were wide-based gait, abnormal Romberg test result, thigh pain following 30 seconds of lumbar extension, and neuromuscular deficits. Independent correlates of LSS included advanced age (P = 0.0001), absence of pain when seated (P = 0.006), wide-based gait (P = 0.013), and thigh pain following 30 seconds of lumbar extension (P = 0.002).

CONCLUSION

Specific history and physical examination findings are useful in the diagnosis of LSS and should be ascertained routinely in older patients with low back pain.

Back pain

Classification of back pain is a difficult task. Traditional schemes have focused on the small percentage of cases which have specific causes. Structural anomalies observed on X-ray examination explain only a small proportion of back pain cases, and the emphasis placed on these in the traditional schemes is, as Anderson put it, the tail wagging the dog (Anderson, 1977). Many syndrome classifications are based on arbitrary notions of cause, with little empirical justification and no evidence that they can reliably and usefully be applied in practice. More pragmatic approaches start with the separation of the serious from the less serious, and the distinction between spinal pain and pain arising from outside the spine. The classification of the large majority of back pain cases which are 'non-specific' is best approached by grading the severity of the clinical and psychological features of back pain and their disabling consequences. Such grading schemes also provide the most appropriate outcome measures for clinical and epidemiological back pain research.

Disorders characterised by pain: a methodological review of population surveys

OBJECTIVE--To review a series of conceptual and methodological problems encountered in surveys primarily devoted to pain disorders. CRITERIA FOR INCLUSION AND EXCLUSION OF ARTICLES--Published reports were systematically collected by electronic database searches (Medline), citations in existing publications, and through personal contacts. Relevant articles from clinical and epidemiological research on pain were included and special attention was given to epidemiological research on back pain. CONCLUSIONS--Surveys of pain disorders should be based on a multidimensional pain model that includes nociceptive input, pain perception, suffering, and pain behaviour as major components. Because of the limited applicability of diagnostic procedures or genuine "non-specificity" of pain states, or both, epidemiological surveys may result in a considerable proportion of cases without an identifiable pathophysiological basis. Staging and grading procedures for pain disorders (as distinguished from classification) may comprise various aspects of pain perception: regional distribution, pain intensity, temporal characteristics, sensory qualities, and dimensions of cognitive-emotional appraisal. Description of temporal development and chronification (staging) should refer to different components of the multidimensional pain model. Explicit a posteriori procedures for grading are preferable to implicit grading based on question wording. Evidence from several sources suggests that localistic concepts of pain may be misleading. Identification of complex pain syndromes should be one primary target for epidemiological pain surveys. Of the many factors that may impair the reliability and validity of data collected in pain surveys, recall biases seem to deserve special attention.

The effect of age on intervertebral disc compression during running

Previous studies have shown that intervertebral discs compress under axial loading, yet few studies have examined the relationship between disc age and compressibility. The purpose of this study was to determine if the amount of vertebral column height (VCH) loss induced by running was significantly different between two age groups, 17 males ages 20-27 years and 14 males ages 50-57 years, who could comfortably run 6 miles. The subjects had no previous or current back pathologies. Within 1.5 hours of rising in the morning, each subject's VCH was measured from spinous processes C7 to S2. Immediately following the measurement, each subject ran a predetermined, paved, 6-mile course at a comfortable pace. Within minutes after completing the run, each subject was again measured for VCH. Paired t tests revealed significant decreases in VCH after the run in both groups. An independent t test showed no significant differences between the respective age groups in terms of postrun VCH decreases. Although no significant differences were noted between groups, this study has demonstrated that both age groups experienced significant decreases in VCH after a 6-mile run. These findings have implications for physical therapy for younger and older male patients who may have back pathologies and require an exercise program. Patients may be advised to limit running due to possible exacerbation of back symptoms.

Prevalence of upper extremity neuropathy in a clinical dentist population

When asked about altered sensation in hands or arms, forearms, cervical area or neck, 29 percent of Nebraska dentists surveyed said they felt pain, followed by numbness and tingling. The prevalence suggests the possibility of an occupational concern.

Acute neck sprain after road traffic accident: a long-term clinical and radiological review

A retrospective review of 21 patients between 10 and 19 years after a soft tissue injury to the cervical spine was undertaken. The clinical data showed a persistence of symptoms in 18 (86 per cent) of patients without any deterioration in the clinical signs. The radiological assessment did not show any evidence of injury leading to, or correlating with, the development or progression of degenerative changes in the cervical spine.

Whiplash in Australia: illness or injury?

OBJECTIVE

To provide a perspective on "whiplash" injury in Australia by examining conflicting evidence, which suggests on the one hand that the disorder is a culturally conditioned and legally sanctioned illness and on the other, that it is an occult injury which can cause chronic pain.

DATA SOURCES

The published English language literature derived from MEDLINE covering epidemiological, pathogenetic and psychological aspects of "whiplash" injury, post-traumatic stress disorder, abnormal illness behaviour and iatrogenicity; the Australian legal literature; the printed news media; the Transport Accident Commission of Victoria and the State Government Insurance Commission of South Australia.

DATA SYNTHESIS AND CONCLUSIONS

Comparative studies suggest that "whiplash" is an illness reinforced by legal and social sanction. Evidence from Victoria indicates that the reported incidence of "whiplash" can be reduced by minor legislative change. Occult injury to cervical intervertebral discs, vertebral end plates and cervical zygapophysial joints may be responsible for "whiplash" symptoms in some who are involved in motor vehicle accidents. This is likely to be confined to a small number of those involved in unexpected rear-end collisions.

A longitudinal study of back pain and radiological changes in the lumbar spines of middle aged women. II. Radiographic findings

The natural history of radiological changes in the lumbar spine was evaluated in two groups of middle aged Dutch women selected from the general population. One group (n = 236) had recurrent back pain and the other (n = 241) had never experienced back pain. At the beginning of the study disc degeneration was more common in the group with back pain. Osteoporotic vertebral fractures were equally common in both groups. Nine years later both groups showed an increase in prevalence of disc degeneration and osteoporotic fractures. The strongest predictor for change in disc degeneration was the presence of degeneration at the beginning of the study. The development of disc degeneration for the first time was related to body mass index.

Risk factors for low back pain and sciatica

So far, eight prospective studies and 50 cross-sectional or retrospective studies have focused on risk factors for low back syndromes. Half of these have been published during the 1980s. Hard physical work and, in particular, frequent lifting and postural stress are likely to result in disc degeneration, low back pain and sciatica. Physical strain may also have prophylactic effects, as physical leisure activity and muscular strength are negatively associated with the risk of low back pain. Much evidence points to driving motor vehicles being causally associated with low back pain and sciatica. A probably causal relationship exists between body height and risk of sciatica, but height is not necessarily predictive of other types of low back pain. Obesity, smoking, psychological distress and poor general health also carry increased risk of low back pain, but their causal role is questionable. Although none of the suspected risk factors can be described as having been conclusively investigated epidemiologically, the results of published studies show that there are modifiable factors contributing to low back pain. The overall potential of primary prevention is great if adequate tools for intervention can be developed.

Developmental spinal canal stenosis and somatotype

The hypothesis that somatotype and cervical spine developmental canal stenosis may be associated has been investigated by anthropometry and measurement of lateral projection cervical spine radiographs. A significant association of canal size with somatotype has been found such that those with developmentally narrow canals are more likely to have relatively shorter long-bones, particularly in the upper arm, and longer trunks.

Epidemiology of osteoarthritis: Zoetermeer survey. Comparison of radiological osteoarthritis in a Dutch population with that in 10 other populations

The prevalence of mild and severe radiological osteoarthritis was investigated in a random sample of 6585 inhabitants of a Dutch village. Radiographs were graded 0-4 according to the criteria described by Kellgren and Lawrence. The prevalence of radiological osteoarthritis increased strongly with age and was highest for cervical spine (peak: men 84.8%, women 84.3%), lumbar spine (peak: 71.9%, women 67.3%), and distal interphalangeal joints of the hands (peak: men 64.4%, women 76%). Prevalence did not exceed 10% in sacroiliac joints, lateral carpometacarpal joints, and tarsometatarsal joints. Severe radiological osteoarthritis (grade 3 or grade 4) was uncommon under age 45; in elderly persons the prevalence of severe radiological osteoarthritis did not exceed 20% except for the cervical and lumbar spine, distal interphalangeal joints of the hands and, in women only, metacarpophalangeal joints, first carpometacarpal joints, first metatarsophalangeal joints, and knees. Overall, differences between men and women were small except for hips and knees; however, severe radiological osteoarthritis was found in a higher proportion in most of the joints in women. Our data were compared with data from similar population surveys. The slope between joint involvement and age was strikingly constant for most of the joints. Differences between populations were mainly differences in level. These differences of prevalence of radiological osteoarthritis may be attributed to interobserver differences--that is, different criteria used to establish radiological osteoarthritis, in addition to genetic or environmental factors, or both.

Occurrence of spinal pain syndromes in a group of apparently healthy and physically fit sportsmen (orienteers)

The prevalence of three spine-related pain syndromes was assessed in 739 apparently healthy leisure-time sportsmen (orienteers). The three syndromes were (i) low back pain or stiffness, (ii) thoracic inter-scapular back pain or stiffness, and (iii) frontal chest pain or discomfort. The mean age of the sportsmen was 32.7 years (range 10-65). For low back pain or stiffness the cumulative occurrence was 471 per 1,000, for thoracic back problems it was 146 per 1,000, and for chest pain or discomfort 85 per 1,000. The three pain syndromes were highly associated, i.e. they tended to occur in the same individual.

Prevalence rates and odds ratios of shoulder-neck diseases in different occupational groups

The aim of the present study was to evaluate the association and impact of occupational exposure and diseases of the shoulder and neck. Prevalence rates, odds ratios, aetiological fractions, and their confidence intervals were computed for pooled and non-pooled data of previous published reports. By comparison with office workers and farmers, dentists had an increased odds ratio for cervical spondylosis (two studies) and for shoulder joint osteoarthrosis. Meat carriers, miners, and "heavy workers" also had significantly higher rates of cervical spondylosis compared with referents. Compared with iron foundry workers, civil servants had a significant odds ratio (4.8) of cervical disc disease and a 0.79 aetiological fraction. Whether this was due to exposure or healthy worker effect was not clear. In four occupational groups with high shoulder-neck load an odds ratio of 4.0 was found for thoracic outlet syndrome with an aetiological fraction of 0.75. Rotator cuff tendinitis in occupational groups with work at shoulder level (two studies) showed an odds ratio of 11 and an aetiological fraction of 0.91. Keyboard operators had an odds ratio of 3.0 for tension neck syndrome (five studies). Unfortunately, owing to the scanty description of the work task, the exposure could be analysed only by job title. Examination of published reports shows clearly that certain job titles are associated with shoulder-neck disorders. High rates and aetiological fractions for rotator cuff tendinitis and tension neck syndrome suggest that preventive measures could be effective. Although job descriptions are brief, the associations noted suggest that highly repetitive shoulder muscle contractions, static contractions, and work at shoulder level are hazardous exposure factors. In reports of cross sectional studies of occupational shoulder-neck disorders presentation of age, exposure, and effect distribution may help for future meta-analysis.

Occupation and risk of herniated lumbar intervertebral disc or sciatica leading to hospitalization

Various occupations were studied for the prediction of herniated lumbar intervertebral disc or sciatica in 592 men and women who had been discharged from hospital with these diagnoses during an 11-year follow-up after a health examination. The cases were compared with 2140 controls matched individually for sex, age and place of residence. Subjects who, at the initial examination before the follow-up, had reported a history of back pain or sciatica were excluded. In men, the risk of being hospitalized due to herniated lumbar disc or sciatica was lowest in professional and related occupations, significantly higher in all other groups and highest among blue-collar workers in industry and among motor vehicle drivers. The variation in the risk between occupational groups of women proved less but was nevertheless still apparent. However, in women, but not in men, the risk was significantly associated with self-assessed strenuousness of work.

Guidelines for use of lumbar spine radiography

In deciding whether to obtain lumbosacral spine films, the emergency physician must not ask whether a diagnosis can be established, but whether obtaining films will affect management. Low back pain is a considerable problem for society with cost in billions of dollars. Gonadal radiation from lumbosacral radiographs is significant, and thus ordering films should be minimized. Plain radiographs are rarely indicated in otherwise healthy patients 20 to 50 years old with mechanical or root pain on initial presentation. In other patients alternative diagnostic methodologies such as computed tomography may be superior, with less radiation risk. Specific recommendations for emergency radiographic evaluation of the lumbosacral spine are offered.

Age changes in lumbar intervertebral discs

Measurements of disc thickness, shape and degeneration, using the criteria described by Rolander (1966), were recorded from 204 post-mortem lumbar spines. The "true average disc height" increased with age as the discs "sink" into the vertebrae. These results add information to previous studies which indicate that the loss of transverse trabeculae of lumbar vertebrae is primarily responsible for the change in shape of both vertebrae and discs in the elderly. While the incidence of disc degeneration does increase in old age, the majority of the discs examined did not show evidence of any such change.

Low back pain

Low back pain is one of the most common and costly afflictions of our Society. The majority of adults will have at least one episode of acute low back pain that will likely resolve regardless of treatment. Lumbar spine radiographs are overused and there is little scientific support for many of the therapeutic interventions advocated. Even for those patients with symptomatic herniated disc, only a small fraction will ultimately require surgical intervention.