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Wang S, Shi J. Three Stages on Magnetic Resonance Imaging of Lumbar Degenerative Spine. World Neurosurg 2024:S1878-8750(24)00706-X. [PMID: 38679375 DOI: 10.1016/j.wneu.2024.04.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 04/21/2024] [Indexed: 05/01/2024]
Abstract
PURPOSES To propose a new lumbar degenerative staging system using the current radiological classification system. METHODS A cross-sectional analysis of retrospective databases between January 2018 and December 2022 was performed. Total of 410 patients for Modic changes, paravertebral muscle fat infiltration, disc degeneration, articular process degeneration, vertebral endplate degeneration and other structures, and disc displacement, Spondylolisthesis, and stenosis, and grouped patients according to stage were assessed. Visual analog scale, Japanese Orthopaedic Association, and Oswestry Disability Index scores were used to assess low back pain strength, neurological function, and quality of life, respectively. RESULTS The lumbar degeneration staging system consists of 8 variables, which can be divided into 3 steps: early, middle and late, and the correlation between each variable is strong (P < 0.05). The later the staging, the worse the Japanese Orthopaedic Association, visual analog scale, and Oswestry Disability Index scores. CONCLUSIONS Patients with later stages have worse clinical scores. This staging system recommends a uniform classification to assess lumbar degeneration.
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Affiliation(s)
- Shunmin Wang
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Naval Medical University, Shanghai, People's Republic of China; 910 Hospital of China Joint Logistics Support Force, Quanzhou City, People's Republic of China
| | - Jiangang Shi
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Naval Medical University, Shanghai, People's Republic of China.
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Köhli P, Schönnagel L, Hambrecht J, Zhu J, Chiapparelli E, Güven AE, Evangelisti G, Amoroso K, Duculan R, Michalski B, Shue J, Tsuchiya K, Burkhard MD, Sama AA, Girardi FP, Cammisa FP, Mancuso CA, Hughes AP. The relationship between paraspinal muscle atrophy and degenerative lumbar spondylolisthesis at the L4/5 level. Spine J 2024:S1529-9430(24)00157-8. [PMID: 38570036 DOI: 10.1016/j.spinee.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND/CONTEXT Degenerative lumbar spondylolisthesis (DLS) is a prevalent spinal condition that can result in significant disability. DLS is thought to result from a combination of disc and facet joint degeneration, as well as various biological, biomechanical, and behavioral factors. One hypothesis is the progressive degeneration of segmental stabilizers, notably the paraspinal muscles, contributes to a vicious cycle of increasing slippage. PURPOSE To examine the correlation between paraspinal muscle status on MRI and severity of slippage in patients with symptomatic DLS. STUDY DESIGN/SETTING Retrospective cross-sectional study at an academic tertiary care center. PATIENT SAMPLE Patients who underwent surgery for DLS at the L4/5 level between 2016-2018 were included. Those with multilevel DLS or insufficient imaging were excluded. OUTCOME MEASURES The percentage of relative slippage (RS) at the L4/5 level evaluated on standing lateral radiographs. Muscle morphology measurements including functional cross-sectional area (fCSA), body height normalized functional cross-sectional area (HI) of Psoas, erector spinae (ES) and multifidus muscle (MF) and fatty infiltration (FI) of ES and MF were measured on axial MR. Disc degeneration and facet joint arthritis were classified according to Pfirrmann and Weishaupt, respectively. METHODS Descriptive and comparative statistics, univariable and multivariable linear regression models were utilized to examine the associations between RS and muscle parameters, adjusting for confounders sex, age, BMI, segmental degeneration, and back pain severity and symptom duration. RESULTS The study analyzed 138 out of 183 patients screened for eligibility. The median age of all patients was 69.5 years (IQR 62 to 73), average BMI was 29.1 (SD±5.1) and average preoperative ODI was 46.4 (SD±16.3). Patients with Meyerding-Grade 2 (M2, N=25) exhibited higher Pfirrmann scores, lower MFfCSA and MFHI, and lower BMI, but significantly more fatty infiltration in the MF and ES muscles compared to those with Meyerding Grade 1 (M1). Univariable linear regression showed that each cm2 decrease in MFfCSA was associated with a 0.9%-point increase in RS (95% CI -1.4 to - 0.4, p<.001), and each cm2/m2 decrease in MFHI was associated with an increase in slippage by 2.2%-points (95% CI -3.7 to -0.7, p=.004). Each 1%-point rise in ESFI and MFFI corresponded to 0.17%- (95% CI 0.05-0.3, p=.01) and 0.20%-point (95% CI 0.1-0.3 p<.001) increases in relative slippage, respectively. Notably, after adjusting for confounders, each cm2 increase in PsoasfCSA and cm2/m2 in PsoasHI was associated with an increase in relative slippage by 0.3% (95% CI 0.1-0.6, p=.004) and 1.1%-points (95% CI 0.4-1.7, p=.001). While MFfCSA tended to be negatively associated with slippage, this did not reach statistical significance (p=.105). However, each 1%-point increase in MFFI and ESFI corresponded to increases of 0.15% points (95% CI 0.05-0.24, p=.002) and 0.14% points (95% CI 0.01-0.27, p=.03) in relative slippage, respectively. CONCLUSION This study found a significant association between paraspinal muscle status and severity of slippage in DLS. Whereas higher degeneration of the ES and MF correlate with a higher degree of slippage, the opposite was found for the psoas. These findings suggest that progressive muscular imbalance between posterior and anterior paraspinal muscles could contribute to the progression of slippage in DLS.
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Affiliation(s)
- Paul Köhli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Charitéplatz 1, Berlin 10117, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, Charitéplatz 1, Berlin 10117, Germany
| | - Lukas Schönnagel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Charitéplatz 1, Berlin 10117, Germany
| | - Jan Hambrecht
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA; Department of Trauma Surgery, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
| | - Jiaqi Zhu
- Department of Epidemiology and Biostatistics, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71th Street, New York, NY 10021, USA
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA
| | - Ali E Güven
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA
| | - Gisberto Evangelisti
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA; Instituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, Bologna, BO, 40136, Italy
| | - Krizia Amoroso
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA
| | | | - Bernhard Michalski
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Charitéplatz 1, Berlin 10117, Germany
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA
| | - Koki Tsuchiya
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA; Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Marco D Burkhard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA
| | - Carol A Mancuso
- Hospital for Special Surgery, New York City, NY, USA; Weill Cornell Medical College, New York, NY, USA
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA.
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Haueise T, Schick F, Stefan N, Machann J. Comparison of the accuracy of commercial two-point and multi-echo Dixon MRI for quantification of fat in liver, paravertebral muscles, and vertebral bone marrow. Eur J Radiol 2024; 172:111359. [PMID: 38325186 DOI: 10.1016/j.ejrad.2024.111359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/03/2024] [Indexed: 02/09/2024]
Abstract
PURPOSE Excess fat accumulation contributes significantly to metabolic dysfunction and diseases. This study aims to systematically compare the accuracy of commercially available Dixon techniques for quantification of fat fraction in liver, skeletal musculature, and vertebral bone marrow (BM) of healthy individuals, investigating biases and sex-specific influences. METHOD 100 healthy White individuals (50 women) underwent abdominal MRI using two-point and multi-echo Dixon sequences. Fat fraction (FF), proton density fat fraction (PDFF) and T2* values were calculated for liver, paravertebral muscles (PVM) and vertebral BM (Th8-L5). Agreement and systematic deviations were assessed using linear correlation and Bland-Altman plots. RESULTS High correlations between FF and PDFF were observed in liver (r = 0.98 for women; r = 0.96 for men), PVM (r = 0.92 for women; r = 0.93 for men) and BM (r = 0.97 for women; r = 0.95 for men). Relative deviations between FF and PDFF in liver (18.92 % for women; 13.32 % for men) and PVM (1.96 % for women; 11.62 % for men) were not significant. Relative deviations in BM were significant (38.13 % for women; 27.62 % for men). Bias correction using linear models reduced discrepancies. T2* times were significantly shorter in BM (8.72 ms for women; 7.26 ms for men) compared to PVM (13.45 ms for women; 13.62 ms for men) and liver (29.47 ms for women; 26.35 ms for men). CONCLUSION While no significant differences were observed for liver and PVM, systematic errors in BM FF estimation using two-point Dixon imaging were observed. These discrepancies - mainly resulting from organ-specific T2* times - have to be considered when applying two-point Dixon approaches for assessment of fat content. As suitable correction tools, linear models could provide added value in large-scale epidemiological cohort studies. Sex-specific differences in T2* should be considered.
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Affiliation(s)
- Tobias Haueise
- Institute for Diabetes Research and Metabolic Diseases, Helmholtz Munich at the University of Tübingen, Tübingen, Germany; German Center for Diabetes Research (DZD), Tübingen, Germany
| | - Fritz Schick
- Institute for Diabetes Research and Metabolic Diseases, Helmholtz Munich at the University of Tübingen, Tübingen, Germany; German Center for Diabetes Research (DZD), Tübingen, Germany; Section on Experimental Radiology, Department of Diagnostic and Interventional Radiology, University Hospital Tübingen, Tübingen, Germany
| | - Norbert Stefan
- German Center for Diabetes Research (DZD), Tübingen, Germany; Section on Experimental Radiology, Department of Diagnostic and Interventional Radiology, University Hospital Tübingen, Tübingen, Germany; Department of Diabetology, Endocrinology and Nephrology, University Hospital Tübingen, Tübingen, Germany
| | - Jürgen Machann
- Institute for Diabetes Research and Metabolic Diseases, Helmholtz Munich at the University of Tübingen, Tübingen, Germany; German Center for Diabetes Research (DZD), Tübingen, Germany; Section on Experimental Radiology, Department of Diagnostic and Interventional Radiology, University Hospital Tübingen, Tübingen, Germany.
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Lee H, Yun JS, Park S, Kwack KS. Physiological gradient in lumbar spine fat fraction and R2* and its impact on osteoporosis diagnosis. Spine J 2024; 24:479-487. [PMID: 37918572 DOI: 10.1016/j.spinee.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/04/2023] [Accepted: 10/28/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Bone marrow adiposity and R2* have been explored as an imaging biomarker for osteoporosis. Chemical shift-encoded MRI (CSE-MRI) is a method that allows for relatively accurate measurement of adiposity and R2* in bone marrow in a simple manner. Additionally, there are reports of a physiological gradient of fat distribution in the lumbar spine. This physiological gradient of fat distribution can potentially impact the prediction of osteoporosis. Furthermore, the distribution of R2* is not well understood. PURPOSE This study examined how lumbar spine fat fraction (FF) and R2* change with different levels of the lumbar spine, how they influence osteoporosis prediction, and how they change according to measurement methods. STUDY DESIGN/SETTING Cross-sectional study using retrospectively collected data. PATIENT SAMPLE The study included patients who underwent dual-energy X-ray absorptiometry and lumbar spine CSE-MRI within one-month intervals between 2017 and 2022. OUTCOME MEASURES Reproducibility of FF and R2* based on measurement techniques, changes in FF and R2* according to vertebral level and osteoporosis status, and diagnostic power of osteoporosis based on vertebral level. METHODS Patients were categorized into the normal bone density, osteopenia, and osteoporosis groups based on bone mineral density. The relationship between groups and spine level before and after BMD adjustment was investigated using generalized estimating equations. Comparisons between the three groups and various measures of reliability were conducted using intraclass correlation coefficient. The diagnostic performance for predicting osteoporosis was evaluated with a receiver operating characteristic curve. RESULTS Comparing the three groups, FF increased with osteoporosis severity, while R2* decreased (p<.001). The intra/inter-rater agreement for FF and R2* was excellent. A physiological gradient within individuals was observed, where FF increased towards the lower lumbar spine (p=.002). R2* tended to decrease, but it was not statistically significant (p=.218). There was no statistically significant difference in the diagnosis of osteoporosis based on FF or R2* across different lumbar spine levels. CONCLUSIONS There was an increase in FF and a decrease in R2* from T12 to L5. However, the predictive power of osteoporosis did not significantly differ between each level.
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Affiliation(s)
- Haein Lee
- Department of Radiology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, South Korea; Musculoskeletal Imaging Laboratory, Ajou University Medical Center, 164, World cup-ro, Yeongtong-gu, Suwon, South Korea
| | - Jae Sung Yun
- Department of Radiology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, South Korea; Musculoskeletal Imaging Laboratory, Ajou University Medical Center, 164, World cup-ro, Yeongtong-gu, Suwon, South Korea.
| | - Sunghoon Park
- Department of Radiology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, South Korea; Musculoskeletal Imaging Laboratory, Ajou University Medical Center, 164, World cup-ro, Yeongtong-gu, Suwon, South Korea
| | - Kyu-Sung Kwack
- Department of Radiology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, South Korea; Musculoskeletal Imaging Laboratory, Ajou University Medical Center, 164, World cup-ro, Yeongtong-gu, Suwon, South Korea
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Li S, Du J, Huang Y, Gao S, Zhao Z, Chang Z, Zhang X, He B. From hyperglycemia to intervertebral disc damage: exploring diabetic-induced disc degeneration. Front Immunol 2024; 15:1355503. [PMID: 38444852 PMCID: PMC10912372 DOI: 10.3389/fimmu.2024.1355503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/05/2024] [Indexed: 03/07/2024] Open
Abstract
The incidence of lumbar disc herniation has gradually increased in recent years, and most patients have symptoms of low back pain and nerve compression, which brings a heavy burden to patients and society alike. Although the causes of disc herniation are complex, intervertebral disc degeneration (IDD) is considered to be the most common factor. The intervertebral disc (IVD) is composed of the upper and lower cartilage endplates, nucleus pulposus, and annulus fibrosus. Aging, abnormal mechanical stress load, and metabolic disorders can exacerbate the progression of IDD. Among them, high glucose and high-fat diets (HFD) can lead to fat accumulation, abnormal glucose metabolism, and inflammation, which are considered important factors affecting the homeostasis of IDD. Diabetes and advanced glycation end products (AGEs) accumulation- can lead to various adverse effects on the IVD, including cell senescence, apoptosis, pyroptosis, proliferation, and Extracellular matrix (ECM) degradation. While current research provides a fundamental basis for the treatment of high glucose-induced IDD patients. further exploration into the mechanisms of abnormal glucose metabolism affecting IDD and in the development of targeted drugs will provide the foundation for the effective treatment of these patients. We aimed to systematically review studies regarding the effects of hyperglycemia on the progress of IDD.
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Affiliation(s)
- Shuai Li
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Youyidong Road, Xi’an, Shaanxi, China
- Medical College, Yan’an University, Yan’an, Shaanxi, China
- Shaanxi Key Laboratory of Spine Bionic Treatment, Xi’an, Shaanxi, China
| | - Jinpeng Du
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Youyidong Road, Xi’an, Shaanxi, China
- Shaanxi Key Laboratory of Spine Bionic Treatment, Xi’an, Shaanxi, China
| | - Yunfei Huang
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Youyidong Road, Xi’an, Shaanxi, China
- Shaanxi Key Laboratory of Spine Bionic Treatment, Xi’an, Shaanxi, China
| | - Shenglong Gao
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Youyidong Road, Xi’an, Shaanxi, China
- Medical College, Yan’an University, Yan’an, Shaanxi, China
- Shaanxi Key Laboratory of Spine Bionic Treatment, Xi’an, Shaanxi, China
| | - Zhigang Zhao
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Youyidong Road, Xi’an, Shaanxi, China
- Shaanxi Key Laboratory of Spine Bionic Treatment, Xi’an, Shaanxi, China
| | - Zhen Chang
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Youyidong Road, Xi’an, Shaanxi, China
- Shaanxi Key Laboratory of Spine Bionic Treatment, Xi’an, Shaanxi, China
| | - Xuefang Zhang
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Youyidong Road, Xi’an, Shaanxi, China
- Shaanxi Key Laboratory of Spine Bionic Treatment, Xi’an, Shaanxi, China
| | - BaoRong He
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Youyidong Road, Xi’an, Shaanxi, China
- Shaanxi Key Laboratory of Spine Bionic Treatment, Xi’an, Shaanxi, China
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Minetama M, Kawakami M, Nakatani T, Teraguchi M, Nakagawa M, Yamamoto Y, Matsuo S, Sakon N, Nakagawa Y. Lumbar paraspinal muscle morphology is associated with spinal degeneration in patients with lumbar spinal stenosis. Spine J 2023; 23:1630-1640. [PMID: 37394143 DOI: 10.1016/j.spinee.2023.06.398] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/27/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND CONTEXT Lumbar spinal stenosis (LSS) has been reported to induce changes in paraspinal muscle morphology, but objective physical function and degenerative spine conditions are rarely assessed. PURPOSE To identify factors associated with paraspinal muscle morphology using objective physical and degenerative spine assessments in patients with LSS. STUDY DESIGN/SETTING Cross-sectional design. PATIENT SAMPLE Seventy patients with neurogenic claudication caused by LSS, receiving outpatient physical therapy. OUTCOME MEASURES Cross-sectional area (CSA) and functional CSA (FCSA) of the multifidus, erector spinae, and psoas muscles, the severity of stenosis, disc degeneration, and endplate abnormalities were evaluated by magnetic resonance imaging, as well as sagittal spinopelvic alignment by X-ray. Objective physical assessments included pedometry and claudication distance. Patient-reported outcomes included the numerical rating scale of low back pain, leg pain, and leg numbness, and the Zurich Claudication Questionnaire. METHODS To assess the impact of LSS on paraspinal muscles, FCSA and FCSA/CSA were compared between the dominant and nondominant sides based on the patients' neurogenic symptoms, and multivariable regression analyses adjusted for age, sex, height, and weight were performed; p<.05 was considered significant. RESULTS Seventy patients were analyzed. At one level below the maximum stenotic level, erector spinae FCSA on the dominant side was significantly lower than that on the nondominant side. In the multivariable regression analyses, at one level below the symptomatic level, disc degeneration, endplate abnormalities, and lumbar spinopelvic alignment, such as decreased lumbar lordosis and increased pelvic tilt, were negatively associated with multifidus FCSA and FCSA/CSA ratio. A significant association was observed between dural sac CSA and erector spinae FCSA. Throughout L1/2 to L5/S, disc degeneration, endplate abnormalities, and lumbar spinopelvic alignment were negatively associated with multifidus and erector spinae FCSA or FCSA/CSA. CONCLUSIONS Lumbar paraspinal muscle asymmetry caused by LSS was observed only in erector spinae. Disc degeneration, endplate abnormalities, and lumbar spinopelvic alignment, rather than spinal stenosis and LSS symptoms, were more associated with paraspinal muscle atrophy or fat infiltration.
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Affiliation(s)
- Masakazu Minetama
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan.
| | - Mamoru Kawakami
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan; Department of Orthopedic Surgery, Saiseikai Wakayama Hospital, 45 Jyunibancho, Wakayama city, Wakayama, 640-8158, Japan
| | - Tomohiro Nakatani
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Masatoshi Teraguchi
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Masafumi Nakagawa
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Yoshio Yamamoto
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Sachika Matsuo
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Nana Sakon
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Yukihiro Nakagawa
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
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