Multifidus atrophy is localized and bilateral in active persons with chronic unilateral low back pain

The Turkish minimum dataset for chronic low back pain research: a cross-cultural adaptation of the National Institutes of Health Task Force Research Standards

BACKGROUND

The US National Institutes of Health (NIH) has produced a minimal data set to promote more accurate and consistent reporting of clinical trials, facilitating easier comparison of research on low back pain patients worldwide. The NIH-minimal dataset has not been previously translated into Turkish, and its features are currently unknown. This study aimed to adapt the NIH-Minimal Data Set into Turkish and investigate its validity and reliability in Turkish-speaking patients with chronic low back pain (CLBP).

METHODS

In the study, 245 patients with CLBP were included. Test-retest and internal consistency analyzes were performed to evaluate the reliability of the NIH-minimal dataset. The intraclass correlation coefficient (ICC2,1) value was used to assess test-retest analysis. Cronbach's alpha value was calculated for internal consistency. Total impact scores of the NIH-minimal dataset were compared with total scores of the Roland Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI) to assess construct validity. The minimal detectable change (MDC95) was calculated based on the standard error of measurement (SEM95).

RESULTS

The NIH-Minimal Data Set was found to have high test-retest reliability (ICC2,1 = 0.928) and high internal consistency (Cronbach α = 0.905). The NIH-minimal dataset correlated well with RMDQ and ODI (r = 0.750 and 0.810, respectively). There were no floor or ceiling effects. Also, SEM95 and MDC95 for the total score were 4.57 and 12.55, respectively.

CONCLUSION

Considering all these data, it was concluded that the Turkish version of the NIH-minimal dataset is a valid and reliable outcome measure for evaluating patients with CLBP.

Contraction ratio of multifidus and erector spinae muscles in unilateral sacroiliac joint pain: A cross-sectional trial

Sacroiliac joint (SIJ) pain is one of the most prevalent reasons for disability, it affects the contraction ratio of the muscles of the back. Imaging is critical for diagnosing back muscles. The purpose of this study was to look at changes in the muscle contraction ratio of the lumbar multifidus (LM) and erector spinae (ES) in unilateral SIJ pain. This research included 60 individuals (30 with unilateral SIJ pain and 30 healthy people (who served as matching controls). The contraction ratio of back muscles such as ES and LM was assessed using real-time ultrasonography, and the results were compared between the affected and non-affected sides in patients with unilateral SIJ pain, and healthy participants as well. In the study group, the contraction ratio of ES and LM muscles on the non-affected side was significantly higher than on the affected side (p < 0.05). as well as a significant increase in contraction ratio of the ipsilateral side (affected matched control side) LM of the healthy group compared with that of the non-affected side of the study group (p < 0.001), while there was no significant difference in contraction ratio of the contralateral (unaffected matched control side) ES of the healthy group compared with that of the non-affected side of the study group. The results of this trial demonstrate that patients with unilateral SIJ pain exhibited a substantially lower muscle contraction ratio in the ES and LM of the affected side than the non-affected side in the study group, as well as a significant increase in the contraction ratio of the ES and MF on the ipsilateral side of the control group compared with that of the study group. However, there was no significant change in the contraction ratio of the contralateral ES in healthy individuals compared to the non-affected side of the study group. The findings of the study may help in designing an appropriate exercise program to deal with patients with SIJ pain.

Age-Related Association Between Unilateral Single-Channel and Double-Channel Surgery and Postoperative Multifidus Muscle Atrophy and Fat Infiltration

BACKGROUND

Unilateral biportal endoscopic laminotomy (UBE) and percutaneous endoscopic laminotomy (PEL) are minimally invasive spinal surgery (MISS) techniques used for unilateral and dual-channel endoscopic laminectomy. However, limited research has been conducted on lumbosacral multifidus muscle injuries in elderly individuals undergoing MISS for lumbar spinal canal stenosis. The objective of this study was to investigate the impact of single-channel and double-channel MISS on the multifidus muscle in elderly patients.

MATERIALS AND METHODS

A total of 107 patients who underwent MISS were stratified into two cohorts: group A (<65 years) and group B (≥65 years). Preoperative imaging data, including magnetic resonance imaging, were gathered to classify the degree of stenosis based on the nerve root compression. The extent of multifidus muscle atrophy and fat infiltration was assessed by calculating the fat-free cross-sectional area (FCSA)/cross-sectional area (CSA) ratio before and after surgery through measurements of CSA and FCSA. Total cross-sectional area/FCSA were calculated using MRI cross-sectional T2WI.

RESULTS

The degree of atrophy and fat infiltration did not change between procedures in group A (P>.05), but changed significantly in group B (P<.05).

CONCLUSION

Unilateral single-channel and double-channel surgery had no significant effect on the degree of multifidus muscle atrophy and fat infiltration in patients younger than 65 years. However, in patients 65 years and older, the degree of multifidus muscle atrophy and fat infiltration significantly increased with the increasing incidence of lateral recess stenosis, which was positively correlated with the duration of surgery. [Orthopedics. 2025;48(1):12-19.].

FAPs orchestrate homeostasis of muscle physiology and pathophysiology

As a common clinical manifestation, muscle weakness is prevalent in people with mobility disorders. Further studies of muscle weakness have found that patients with muscle weakness present with persistent muscle inflammation, loss of muscle fibers, fat infiltration, and interstitial fibrosis. Therefore, we propose the concept of muscle microenvironment homeostasis, which explains the abnormal pathological changes in muscles through the imbalance of muscle microenvironment homeostasis. And we identified an interstitial progenitor cell FAP during the transition from normal muscle microenvironment homeostasis to muscle microenvironment imbalance caused by muscle damage diseases. As a kind of pluripotent stem cell, FAPs do not participate in myogenic differentiation, but can differentiate into fibroblasts, adipocytes, osteoblasts, and chondrocytes. As a kind of mesenchymal progenitor cell, it is involved in the generation of extracellular matrix, regulate muscle regeneration, and maintain neuromuscular junction. However, the muscle microenvironment is disrupted by the causative factors, and the abnormal activities of FAPs eventually contribute to the complex pathological changes in muscles. Targeting the mechanisms of these muscle pathological changes, we have identified appropriate signaling targets for FAPs to improve and even treat muscle damage diseases. In this review, we propose the construction of muscle microenvironmental homeostasis and find the key cells that cause pathological changes in muscle after homeostasis is broken. By studying the mechanism of abnormal differentiation and apoptosis of FAPs, we found a strategy to inhibit the abnormal pathological changes in muscle damage diseases and improve muscle regeneration.

Low Back Pain During and After Spaceflight: A Systematic Review with Meta-Analysis

Space flights can produce physiological changes in the spine, leading to the development of acute and chronic pain in passengers. However, there is a lack of comprehensive literature exploring physiological spine changes and acute and chronic pain in space passengers (astronauts and animals). The first aim of this study was to identify the physiological changes experienced by passengers (humans and animals) after space flight. The second aim was to identify the incidence of low back pain during and after space flight. This systematic review was conducted following PRISMA guidelines and was pre-registered in PROSPERO (ID 451144). We included Randomized Controlled Trials or longitudinal studies in humans and animals, and the variables must be assessed either in-flight or post-flight. We conducted a literature search in major databases combining the keywords: Pain; Space; Low Back Pain; Astronauts; Spine Changes; Microgravity; Physiological Changes; Humans; Animals. Risk of bias and quality of studies were analyzed, and the level of evidence was assessed using the GRADE system. After duplicates were removed, 115 abstracts were screened by two reviewers, and finally, 11 articles were included in this review. The evidence indicates that astronauts experience muscle atrophy in the lumbar multifidus with a moderate to large effect, especially in the L4-L5 and L5-S1 segments. Space flights also decrease the range of motion with a moderate effect, along with disc herniations and disc dehydration. 77% of astronauts experience pain during spaceflight, and 47% develop acute pain after spaceflight. Chronic pain was reported by 33% of the astronauts. After space flights, astronauts suffer from lumbar muscle atrophy, reduced range of motion, disc herniations, and disc dehydration, with a high incidence of both acute and chronic pain.

Relation Between Abnormal Spontaneous Brain Activity and Altered Neuromuscular Activation of Lumbar Paraspinal Muscles in Chronic Low Back Pain

OBJECTIVE

To investigate the neural mechanism underlying functional reorganization and motor coordination strategies in patients with chronic low back pain (cLBP).

DESIGN

A case-control study based on data collected during routine clinical practice.

SETTING

This study was conducted at a university hospital.

PARTICIPANTS

Fifteen patients with cLBP and 15 healthy controls.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Whole brain blood oxygen level-dependent signals were measured using functional magnetic resonance imaging and amplitude of low-frequency fluctuation (ALFF) method to identify pain-induced changes in regional spontaneous brain activity. A novel approach based on the surface electromyogram (EMG) system and fine-wire electrodes was used to record EMG signals in the deep multifidus, superficial multifidus, and erector spinae.

RESULTS

In cLBP, compared with healthy groups, ALFF was higher in the medial prefrontal, primary somatosensory, primary motor, and inferior temporal cortices, whereas it was lower in the cerebellum and anterior cingulate and posterior cingulate cortices. Furthermore, the decrease in the average EMG activity of the 3 lumbar muscles in the cLBP group was positively correlated with the ALFF values of the primary somatosensory cortex, motor cortex, precuneus, and middle temporal cortex but significantly negatively correlated with the ALFF values of the medial prefrontal and inferior temporal cortices. Interestingly, the correlation between the functional activity in the cerebellum and the EMG activity varied in the lumbar muscles.

CONCLUSIONS

These findings suggest a functional association between changes in spontaneous brain activity and altered voluntary neuromuscular activation patterns of the lumbar paraspinal muscles, providing new insights into the mechanisms underlying pain chronicity as well as important implications for developing novel therapeutic targets of cLBP.

Age-dependent flexion relaxation phenomenon in chronic low back pain patients

Background

The flexion relaxation phenomenon (FRP) is characterized by suddenly reduced paraspinal muscle activity during full flexion. Previous studies showed significant differences in FRP and flexion angles in chronic low back pain (cLBP) patients compared to individuals without back pain (no-BP). However, the relationship between FRP and flexion angles remains insufficiently understood in older populations. Thus, this study investigated the relationship between FRP and flexion angles concerning to the age and presence of cLBP.

Methods

Forty no-BP subjects (20m/20f; mean age 41.5 years) and thirty-eight cLBP patients (19m/19f; mean age 43.52 years) performed maximum full upper body flexion task. Electromyographic (EMG) measurements were conducted to assess the activity of lumbar erector spinae (ESL), thoracic erector spinae (EST), and multifidus (MF). Lumbar, thoracic, and pelvic angles at the onset (OnsetL/T/P) and offset of the FRP (OffsetL/T/P) and maximum trunk inclination (MaxL/T/P) were calculated. The FRP was evaluated using a flexion relaxation ratio (FRR).

Results

cLBP patients showed smaller FRR in MF and right ESL compared to no-BP individuals (p < 0.05), while no differences were found in flexion angles between two groups. Subjects over 40 showed smaller FRR in MF and ESL, and smaller flexion angles on OffsetL and MaxL (p < 0.05). Age-related analysis in the cLBP group revealed that patients over 40, compared to younger ones, had smaller FRR in MF and ESL, and smaller values in all thoracic and lumbar flexion angles (p < 0.05). While in no-BP group, significant larger flexion angles in OnsetL and OffsetT (p < 0.05) were observed in participants over 40. Pain-related analysis in the older group revealed that the cLBP patients, compared to no-BP individuals, had smaller FRR in right MF and right ESL, and smaller values in all lumbar and thoracic flexion angles (p < 0.05), while in younger group, there were no significant pain-related differences in FRR, with larger values in all lumbar flexion angles (p < 0.05).

Conclusion

Our findings indicate a reduction or absence of FRP in cLBP patients compared to no-BP individuals, with age being a significant factor as those over 40 showed smaller FRP and flexion angles compared to younger individuals.

Comparisons of postural control, proprioception, muscle strength, pain and disability between individuals with acute, subacute and chronic low back pain

PURPOSE/AIM

Postural control, proprioception and lower extremity muscle strength are affected in individuals with low back pain (LBP). However, it is yet unknown whether these variables differentiate between acute, subacute and chronic stages of LBP. The aim was to investigate if there were any differences in postural control, proprioception, lower extremity muscle strength, pain intensity and disability between individuals in the different stages of LBP.

MATERIALS AND METHODS

In this cross-sectional study, 124 individuals with LBP were grouped as acute LBP (ALBP) (n = 38), subacute LBP (SLBP) (n = 30) and chronic LBP (CLBP) (n = 56) groups. Postural control was assessed via computerised technology. Lumbar proprioception, lower extremity muscle strength, pain intensity and disability were assessed using Joint Repositioning Error Test, hand-held dynamometer, Numeric Rating Scale and Oswestry Disability Index (ODI), respectively. Kruskal-Wallis Tests, ANCOVA and post hoc Mann-Whitney U-Test with Bonferroni correction were performed.

RESULTS

While there were no significant differences in terms of postural control, proprioception and pain intensity (p > 0.05), significant differences were found in terms of lower extremity muscle strength and ODI scores between groups when adjusted for age (p < 0.05). Individuals with CLBP demonstrated poorer lower extremity muscle strength than those with ALBP and SLBP, and higher disability than those with ALBP (p < 0.017).

CONCLUSIONS

Although postural control, proprioception and pain intensity were similar between individuals with acute, subacute and chronic LBP, muscle strength and disability seem to worsen stepwise as the pain becomes chronic. Muscle strength and disability should be taken into account while evaluating and/or managing individuals with acute and subacute stages of LBP.

Understanding the Biering-Sørensen test: Contributors to extensor endurance in young adults with and without a history of low back pain

The Biering-Sørensen test is commonly used to assess paraspinal muscle endurance. Research using a single repetition of the test has provided conflicting evidence for the contribution of impaired paraspinal muscle endurance to low back pain (LBP). This study investigated how Sørensen test duration, muscle activation, and muscle fatigability are affected by multiple repetitions of the test and determined predictors of Sørensen test duration in young adults with and without a history of LBP. Sixty-four young individuals performed three repetitions of the Sørensen test. Amplitude of activation and median frequency slope (fatigability) were calculated for the lumbar and thoracic paraspinals and hamstrings. Duration of the test was significantly less for the 3rd repetition in individuals with LBP. In individuals without LBP, test duration was predicted by fatigability of the lumbar paraspinals. In individuals with LBP, Sørensen test duration was predicted by fatigability of the hamstrings and amplitude of activation of the thoracic and lumbar paraspinals. Our findings demonstrate that it is necessary to amplify the difficulty of the Sørensen test to reveal impairments in young, active adults with LBP. Training programs aiming to improve lumbar paraspinal performance should monitor performance of other synergist muscles during endurance exercise.

Age-Dependent Differences of Paraspinal Muscle Endurance and Morphology in Chinese Community Population Without Chronic Low Back Pain

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

Our aim was to describe age-dependent changes of lumbar paraspinal muscle endurance and morphology in Chinese healthy population. We also explored the relationship between paraspinals endurance and morphology.

METHODS

A total of 181 participants from Chinese community population without chronic low back pain were included. The participants were divided into three groups: young (20-39 years old, n = 29), middle (40-59 years old, n = 93), and elderly (≥ 60 years old, n = 59). The Ito test was performed to evaluate the isometric endurance of paraspinal muscles. The total cross-sectional area (TCSA) and fat infiltration (FI) of multifidus (MF) and erector spinae (ES) were measured at L1-L5 levels on magnetic resonance imaging. Physical activity level was evaluated using the physical activity index and comorbidities were assessed by the modified 5-item frailty index.

RESULTS

The elderly group had a shorter performance time of endurance test than the young group and middle-aged group. Correlation analysis showed that age had a significant correlation with endurance test, the average MF TCSA, MF FI, ES TCSA and ES FI of L1-5. In addition, PAI had a significant correlation with endurance test and MF FI. In multiple linear regression analysis, paraspinals endurance was associated with MF FI, ES FI, physical activity level and comorbidities.

CONCLUSION

Age-related decreases in paraspinals endurance and TCSA, and an increase in FI were revealed. Besides, paraspinal muscles FI, but not TCSA, was negatively associated with the endurance of paraspinals.

Importance of Lumbar Instability in the Study of Associations Between Muscle Morphology, Pain, and Disability in Chronic Low Back Pain

OBJECTIVE

The purpose of this study was to (1) evaluate the relationship between lumbar extensor muscle morphology, with pain and disability in patients with chronic low back pain and (2) compare these relationships in subgroup of chronic low back pain with and without lumbar structural segmental instability.

DESIGN AND METHODS

This cross-sectional study included 183 patients with chronic low back pain. Standing lateral lumbar flexion/extension radiographs were used to assess lumbar structural segmental instability. Lumbar multifidus, erector spinae, and psoas major morphology were determined from axial magnetic resonance imaging. Associations between lumbar muscle morphologies and patient pain and disability were evaluated in two groups with and without lumbar instability.

RESULTS

Patients' disability was negatively associated with psoas major total cross-sectional area (beta = -22.82, 95% CI = -37.05 to -8.59) and functional cross-sectional area (beta = -23.45, 95% CI = -37.81 to -9.09). Multifidus morphology was negatively associated with disability in the lumbar instability group. Pain intensity was only associated to psoas major total cross-sectional area (beta = -3.33, 95% CI = -6.43 to -2.24) and functional cross-sectional area (beta = -3.22, 95% CI = -6.40 to -0.05) only in the lumbar instability group.

CONCLUSIONS

Psoas major atrophy was associated with greater disability and pain in chronic low back pain, but multifidus atrophy was associated with greater disability in chronic low back pain patients with lumbar structural segmental instability.

Cortical excitability and multifidus activation responses to transcranial direct current stimulation in patients with chronic low back pain during remission

Evidence indicates that patients with chronic low back pain (CLBP) have lumbar multifidus muscle (LM) activation deficit which might be caused by changes in cortical excitability. Anodal transcranial direct current stimulation (a-tDCS) can be used to restore cortical excitability. This study aimed to (1) determine the immediate effects of a-tDCS on the cortical excitability and LM activation and (2) explore the relationship between cortical excitability and LM activation. Thirteen participants with CLBP during remission and 11 healthy participants were recruited. Cortical excitability (peak-to-peak motor evoked potential amplitude; P2P and cortical silent period; CSP) and LM activation were measured at pre- and post-intervention. We found significant difference (P < 0.05) in P2P between groups. However, no significant differences (P > 0.05) in P2P, CSP and LM activation were found between pre- and post-intervention in CLBP. The CLBP group demonstrated significant correlation (P = 0.05) between P2P and LM activation. Although our finding demonstrates change in P2P in the CLBP group, one-session of a-tDCS cannot induce changes in cortical excitability and LM activation. However, moderate to strong correlation between P2P and LM activation suggests the involvement of cortical level in LM activation deficit. Therefore, non-significant changes could have been due to inadequate dose of a-tDCS.

Magnetic Resonance Imaging Evaluation of Multifidus Muscle in Patients with Low Back Pain after Microlumbar Discectomy Surgery

Cross-sectional area (CSA) and signal intensity ratio (SIR) of the multifidus muscle (MFM) on magnetic resonance imaging (MRI) was used to evaluate the extent of injury and atrophy of the MFM in patients with negative treatment outcomes following microlumbar discectomy (MLD). Negative treatment outcome was determined by pain score improvement of <50% compared to baseline. Patients in groups 1, 2, and 3 were evaluated at <4 weeks, 4-24 weeks, and >24 weeks postoperatively, respectively. The associations between the follow-up, surgery time and the changes in the MFM were evaluated. A total of 79 patients were included, with 22, 27, and 30 subjects in groups 1, 2, and 3, respectively. The MFM SIR of the ipsilateral side had significantly decreased in groups 2 (p = 0.001) and 3 (p < 0.001). The ipsilateral MFM CSA significantly decreased postoperatively in groups 2 (p = 0.04) and 3 (p = 0.006). The postoperative MRI scans found significant MFM changes on the ipsilateral side in patients with negative treatment outcomes regarding pain intensity following MLD. As the interval to the postoperative MRI scan increased, the changes in CSA of the MFM and change in T2 SIR of the MFM showed a tendency to increase.

The Role of Back Muscle Dysfunctions in Chronic Low Back Pain: State-of-the-Art and Clinical Implications

Changes in back muscle function and structure are highly prevalent in patients with chronic low back pain (CLBP). Since large heterogeneity in clinical presentation and back muscle dysfunctions exists within this population, the potential role of back muscle dysfunctions in the persistence of low back pain differs between individuals. Consequently, interventions should be tailored to the individual patient and be based on a thorough clinical examination taking into account the multidimensional nature of CLBP. Considering the complexity of this process, we will provide a state-of-the-art update on back muscle dysfunctions in patients with CLBP and their implications for treatment. To this end, we will first give an overview of (1) dysfunctions in back muscle structure and function, (2) the potential of exercise therapy to address these dysfunctions, and (3) the relationship between changes in back muscle dysfunctions and clinical parameters. In a second part, we will describe a framework for an individualised approach for back muscle training in patients with CLBP.

Does paraspinal muscle morphometry predict functional status and re-operation after lumbar spinal surgery? A systematic review and meta-analysis

OBJECTIVES

Whether paraspinal muscle degeneration is related to poor clinical outcomes after lumbar surgery is still indistinct, which limits its clinical application. This study aimed to evaluate the predictive value of paraspinal muscle morphology on functional status and re-operation after lumbar spinal surgery.

METHODS

A review of the literature was conducted using a total of 6917 articles identified from a search of PubMed, EMBASE, and Web of Science databases through September 2022. A full-text review of 140 studies was conducted based on criteria including an objective assessment of preoperative paraspinal muscle morphology including multifidus (MF), erector spinae (ES), and psoas major (PS) in addition to measuring its relationship to clinical outcomes including Oswestry disability index (ODI), pain and revision surgery. Meta-analysis was performed when required metrics could be calculated in ≥ three studies, otherwise vote counting model was a good alternative to show the effect direction of evidence. The standardized mean difference (SMD) and 95% confidence interval (CI) were calculated.

RESULTS

A total of 10 studies were included in this review. Of them, five studies with required metrics were included in the meta-analysis. The meta-analysis suggested that higher preoperative fat infiltration (FI) of MF could predict higher postoperative ODI scores (SMD = 0.33, 95% CI 0.16-0.50, p = 0.0001). For postoperative pain, MF FI could also be an effective predictor for persistent low back pain after surgery (SMD = 0.17, 95% CI 0.02-0.31, p = 0.03). However, in the vote count model, limited evidence was presented for the prognostic effects of ES and PS on postoperative functional status and symptoms. In terms of revision surgery, there was conflicting evidence that FI of MF and ES could predict the incidence of revision surgery in the vote count model.

CONCLUSION

The assessment of MF FI could be a viable method to stratify patients with lumbar surgery by the risk of severe functional disability and low back pain.

KEY POINTS

• The fat infiltration of multifidus can predict postoperative functional status and low back pain after lumbar spinal surgery. • The preoperative evaluation of paraspinal muscle morphology is conducive for surgeons.

The Cross-Sectional Area Assessment of Pelvic Muscles Using the MRI Manual Segmentation among Patients with Low Back Pain and Healthy Subjects

The pain pathomechanism of chronic low back pain (LBP) is complex and the available diagnostic methods are insufficient. Patients present morphological changes in volume and cross-sectional area (CSA) of lumbosacral region. The main objective of this study was to assess if CSA measurements of pelvic muscle will indicate muscle atrophy between asymptomatic and symptomatic sides in chronic LBP patients, as well as between right and left sides in healthy volunteers. In addition, inter-rater reliability for CSA measurements was examined. The study involved 71 chronic LBP patients and 29 healthy volunteers. The CSA of gluteus maximus, medius, minimus and piriformis were measured using the MRI manual segmentation method. Muscle atrophy was confirmed in gluteus maximus, gluteus minimus and piriformis muscle for over 50% of chronic LBP patients (p < 0.05). Gluteus medius showed atrophy in patients with left side pain occurrence (p < 0.001). Muscle atrophy occurred on the symptomatic side for all inspected muscles, except gluteus maximus in rater one assessment. The reliability of CSA measurements between raters calculated using CCC and ICC presented great inter-rater reproducibility for each muscle both in patients and healthy volunteers (p < 0.95). Therefore, there is the possibility of using CSA assessment in the diagnosis of patients with symptoms of chronic LBP.

Understanding the Biering-Sørensen test: contributors to extensor endurance in young adults with and without low back pain

Impaired paraspinal muscle endurance may contribute to persistent low back pain (LBP) and is frequently assessed using a single repetition of the Biering-Sørensen test. This study investigated how Sørensen test duration, muscle activation, and muscle fatigability are affected by multiple repetitions of the test, and determined predictors of Sørensen test duration in young, active adults with and without a history of LBP. Sixty-four individuals with and without persistent LBP performed 3 repetitions of the Sørensen test. Amplitude of activation and median frequency slope (fatigability) were calculated for the lumbar and thoracic paraspinals and the hamstrings. Duration of the test was significantly less for the 2nd and 3rd repetitions in individuals with LBP. In individuals without LBP, fatigability of the lumbar paraspinals was the best predictor of test duration. In individuals with LBP, Sørensen test duration was predicted by fatigability of the hamstrings and amplitude of activation of the thoracic and lumbar paraspinals. Our findings demonstrate that it is necessary to amplify the difficulty of the Sørensen test to elucidate impairments in young, active adults with LBP. Training programs aiming to improve lumbar paraspinal performance in individuals with LBP should monitor performance of other synergist muscles during endurance exercise.

Are serum thyroid hormone, parathormone, calcium, and vitamin D levels associated with lumbar spine degeneration? A cross-sectional observational clinical study

PURPOSE

Low back pain (LBP) impairs the quality of life and rises healthcare costs. The association of spine degeneration and LBP with metabolic disorders have been reported, previously. However, metabolic processes related with spine degeneration remained unclear. We aimed to analyze whether serum thyroid hormones, parathormone, calcium, and vitamin D levels were associated with lumbar intervertebral disc degeneration (IVDD), Modic changes, and fatty infiltration in the paraspinal muscles.

METHODS

We cross-sectionally analyzed a retrospective database. Patients who visited internal medicine outpatient clinics with suspect of endocrine disorders and chronic LBP were searched. Patients with biochemistry results within 1 week before lumbar spine magnetic resonance imaging (MRI) were included. Age- and gender-matched cohorts were made-up and analyzed.

RESULTS

Patients with higher serum free thyroxine levels were more likely to have severe IVDD. They were also more likely to have fattier multifidus and erector spinae at upper lumbar levels, less fatty psoas and less Modic changes at lower lumbar levels. Higher PTH levels were observed in patients with severe IVDD at L4-L5 level. Patients with lower serum vitamin D and calcium levels had more Modic changes and fattier paraspinal muscles at upper lumbar levels.

CONCLUSION

Serum hormone, vitamin D, and calcium levels were associated with not only IVDD and Modic changes but also with fatty infiltration in the paraspinal muscles, mainly at upper lumbar levels in patients with symptomatic backache presenting to a tertiary care center. Complex inflammatory, metabolic, and mechanical factors present in the backstage of spine degeneration.

Lumbar multifidus muscle ultrasound imaging: Is handheld technology reliable?

BACKGROUND

Advancement in ultrasound imaging technology has led to the development of handheld devices that are more accessible to physical therapists due to decreased cost, reduced size, and improved ease of use relative to current established units. Physical therapists use ultrasound imaging of the lumbar multifidus muscle (LMM) to assist in rehabilitation of patients with lumbar pathology.

OBJECTIVES

To identify the inter-device reliability of measuring the LMM thickness during a sustained contraction when comparing handheld (Butterfly iQ+) and established (SonoSite M-Turbo) ultrasound units. A secondary purpose was to determine the reliability of a student physical therapist using both devices.

DESIGN

A reliability measurement study METHOD: A blinded examiner identified the LMM at the L4 vertebral level and measured the thickness of the contracted muscle utilizing both the handheld and established ultrasound devices. ICC values were calculated to determine the inter-device and intra-rater reliability.

RESULTS

The study included 42 healthy participants, 30 females and 12 males, with a mean age of 38.5 years. The inter-device reliability during a sustained LMM contraction was excellent (ICC = 0.92, 95% CI: 0.87-0.94) and the intra-rater reliability was good for both the handheld (ICC = 0.85, 95% CI: 0.73-0.92) and established (ICC = 0.89, 95% CI: 0.82-0.93) ultrasound units.

CONCLUSION

Results support the use of handheld ultrasound by physical therapists and students to measure the LMM thickness. Future studies could investigate the reliability of handheld ultrasound in a variety of musculoskeletal and pathological structures important to PT practice.

Evaluation of the degeneration of the multifidus and erector spinae muscles in patients with low back pain and healthy individuals

BACKGROUND

Although several studies have been conducted to determine the cause of low back pain (LBP), a sufficient correlation has not been found between research findings and symptoms. Therefore there seems to be a need for studies to explain the relationship between pain and morphological changes in the paraspinal muscles of patients with LBP through comparisons with healthy control subjects.

OBJECTIVE

The aim of this study was to examine degeneration in the lumbar musculus multifidus (LMF) and lumbar musculus erector spinae (LES) muscles in patients with chronic LBP with non-radiculopathy lumbar disc herniation (LDH), patients with mechanical LBP, and healthy individuals.

METHODS

The study included 35 patients with mechanical LBP, 38 patients with non-radiculopathy LDH, and a control group of 36 healthy participants. In all patients and the control group, evaluations were made on axial magnetic resonance imaging slices at L3-S1 level of the LMF and LES cross-sectional areas (CSA), total CSA (TCSA = LMF+LES), fat infiltrations and asymmetries.

RESULTS

The mean CSA values of the right and left LMF and LES showed significant differences between the groups (p< 0.001, p= 0.002, p= 0.002, p= 0.010, respectively). Fat infiltrations showed a difference between the right-left LMF and left LES groups (p= 0.007, p< 0.001, p= 0.026, respectively). Asymmetry was not observed between the CSA and TCSA of the right and left sides.

CONCLUSION

A correlation was found between fat infiltration in the LMF and mechanical LBP and LDH. However, no significant correlation was determined between LBP and the CSA and TCSA of the LMF and LES. This was thought to be due to an incorrect result of CSA and TCSA in the evaluation of muscle mass. Therefore, for a more accurate evaluation of muscle mass, it can be considered necessary to measure muscle atrophy associated with fat infiltration or functional CSA.

Comprehensive analysis of muscles wasting in disc herniation

Neuromuscular reeducation of the muscles that stabilize the spine is the basis of conservative treatment of disc herniation. Therefore, it is important to investigate how these muscles are affected by disc herniation. The aim of this study was to investigate the effect of disc herniation, herniation severity, patient age, and biomechanics on the lumbar stabilizer muscles. A total of 330 individuals, including 261 patients with disc herniations and 69 without disc herniation participated in this study. The cross-sectional areas (CSAs) of the lumbar stabilizer muscles and the lumbar lordosis angle were evaluated by magnetic resonance imaging (MRI), according to the severity of the disc herniation and the patient's age. In the patients with disc herniation, the CSAs of the quadratus lumborum (QL) and the multifidus (MF) muscles were decreased. The psoas major (PM) muscle CSA was higher in the patients with sequestered discs than in those with protruded and extruded discs. A negative relationship between the sagittal curve and the PM muscle CSA was found. In addition, MF muscle CSA was found to decrease at age 45 years and over. Although disc herniation negatively affects muscle CSAs, no linear relationship was found between the severity of the herniation and the muscle CSA. In addition, the PM muscle was found to be a strong compensatory muscle in disc herniation.

A new equation for correlation of clinical and radiological factors affecting multifidus muscle degeneration in magnetic resonance imaging

Background

Multifidus muscle (MF) is one of the back muscles of the spine that is involved in the pathogenesis of low back pain. Its role as a stabilizer of the spine continues to present diagnostic and therapeutic challenges. The degree of MF degeneration is dependent on multiple clinical and radiological factors. We proposed a new equation to predict MF degeneration based upon clinical and radiological changes in magnetic resonance imaging.

Methods

Clinical factors associated with MF degeneration include visual analogue scale (VAS) for pain, body mass index, duration of complaint, age of the patients and the presence of sciatica. Other radiological factors include the number of disc pathologies, neural canal stenosis and facet joint arthropathies, by building a module of a univariate and multivariate linear regression analysis for the parameters affecting MF degeneration score as a dependent variable.

Results

Regarding the univariate and multivariate linear regression for factors affecting MF degeneration, the most common factors associated with increased multifidus score were the duration in years and VAS score in the multivariate analysis model with B value equal to 0.184 according to duration in years and equal to 0.287 with VAS score according to 95% confidence interval.

Conclusion

The equation for multifidus score is a helpful method to predict the degree of MF degeneration in relation to clinical variable.

Pain-side related difference in cross-sectional area of the longus colli muscle and its relationship with standing balance in persons with non-specific neck pain

BACKGROUND

Longus colli muscle has a significant role in postural control. A reduction of longus colli cross-sectional area (CSA) has been demonstrated in neck pain patients. However, pain-side related difference and its relationship with clinical features and standing balance remain unclear.

OBJECTIVE

To investigate side-to-side difference in the longus colli CSA and to determine the relationships of the CSA with clinical characteristics and standing balance in neck pain patients.

STUDY DESIGN

Cross-sectional study.

MATERIALS AND METHODS

Fifty participants with chronic non-specific neck pain (20 unilateral and 30 bilateral) were recruited. CSA of the longus colli muscle was measured using ultrasound imaging. Balance was measured using a force platform during a narrow stance with eyes open, eyes closed, and neck torsion (left and right). Balance outcomes were sway area and displacement in anterior-posterior (AP) and medial-lateral (ML) directions. Clinical characteristics were neck pain intensity, disability, and duration.

RESULTS

The longus colli CSA was reduced on the painful side in patients with unilateral neck pain (p < 0.01). There was a trend towards reduced CSA on the more painful side in those with bilateral neck pain (p = 0.08). The reduced CSA was mostly correlated with the greater AP sway displacement and sway area (r ranged from -0.27 to -0.54, p < 0.05). The longus colli CSA was not correlated with pain intensity, disability, and duration (p > 0.05).

CONCLUSION

The longus colli CSA was reduced on the painful side of neck pain. The reduced CSA was correlated with impaired standing balance, but not with clinical characteristics of neck pain.

Investigation of the relationship between the clinical evaluation results of lumbar region muscles with cross-sectional area and fat infiltration

BACKGROUND

The relationship between the endurance of the lumbar paraspinal muscles and morphological changes needs to be clarified. In this context, the importance can be revealed of increasing the endurance level of the paraspinal muscles in the prevention and treatment of low back diseases.

OBJECTIVE

The aim of this study was to examine the relationship between the clinical evaluation results of the cross-sectional area (CSA) and fat infiltration of the lumbar deep paraspinal muscles.

METHODS

The study included 37 patients with mechanical low back pain (mechanical), 41 patients with lumbar hernia without root compression (discopathy) and 36 healthy individuals as a control group. The functional status of the lumbar deep paraspinal muscles was evaluated clinically with muscle endurance tests. The fat infiltration and CSA of the muscles were evaluated on axial MRI sections at the L3-S1 level.

RESULTS

The mean values of the prone bridge, Biering-Sorenson, and trunk flexion tests were seen to be highest in the control group and lowest in the discopathy group (p< 0.001). In all tests, the longest test period was obtained at < 10% fat infiltration and the shortest at > 50% fat infiltration. It was observed that as the amount of fat infiltration of the muscles increased, the test times were shortened. There was no significant relationship between the endurance level and the CSA of the groups.

CONCLUSION

The study results demonstrated that the endurance of the paraspinal muscles is associated with the fat infiltration of the muscles. In patients with chronic low back pain, information about muscle morphology and degeneration can be obtained with simple endurance tests without the need for further measurements. On clinical examination, a weak endurance level of the paraspinal muscles indicates the presence of a low back problem and an increase in the amount of fat infiltration.

Association between muscle health and patient-reported outcomes after lumbar microdiscectomy: early results

BACKGROUND CONTEXT

Poor muscle health has been implicated as a source of back pain among patients with lumbar spine pathology. Recently, a novel magnetic resonance imaging (MRI)-based lumbar muscle health grade was shown to correlate with health-related quality of life scores. However, the impact of muscle health on postoperative functional outcomes following spine surgery remains to be investigated.

PURPOSE

To determine whether muscle health grade measured by preoperative psoas and paralumbar muscle cross-sectional areas impact the achievement of minimal clinically important difference (MCID) following lumbar microdiscectomy.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

Consecutive patients who underwent 1-level lumbar microdiscectomy in a single institution between 2017 and 2021.

OUTCOME MEASURES

Rate of MCID achievement, time to MCID achievement, PROMs including Oswestry Disability Index (ODI), visual analog scale for back pain (VAS back), VAS leg, Short Form 12 Physical Component Summary (SF-12 PCS), SF-12 Mental Component Summary (SF-12 MCS), and Patient Reported Outcomes Measurement Information System Physical Function (PROMIS PF).

METHODS

Two previously validated methods for muscle health grading were applied. Axial T2 MRI were analyzed for muscle measurements. The psoas-based method utilized the normalized total psoas area (NTPA), which is the psoas cross-sectional area divided by the square of patient height (mm2/m2). Patients were divided into low and high NTPA groups based on sex-specific lowest quartile NTPA thresholds. The paralumbar-based method incorporated the paralumbar cross-sectional area normalized by body mass index (PL-CSA/BMI) and Goutallier classification. Score of 1 was added for either PL-CSA/BMI >130 or Goutallier class of ≤2. "Good" muscle health was defined as score of 2, and "poor" muscle health was defined as score of 0 to 1. Prospectively collected PROMs were analyzed at 2-week, 6-week, 3-month, 6-month, 1-year, and 2-year postoperative timepoints. The rate of and time to MCID achievement were compared among the cohorts. Bivariate analyses were performed to assess for correlations between psoas/paralumbar cross-sectional areas and change in PROM scores from baseline.

RESULTS

The total cohort included 163 patients with minimum follow-up of 6 months and mean follow-up of 16.5 months. 40 patients (24.5%) were categorized into the low NTPA group, and 55 patients (33.7%) were categorized into the poor paralumbar muscle group. Low NTPA was associated with older age, lower BMI, and greater frequencies of Charlson Comorbidity Index (CCI) ≥1. Poor paralumbar muscle health was associated with older age, female sex, higher BMI, and CCI ≥1. There were no differences in rates of MCID achievement for any PROMs between low versus high NTPA groups or between poor versus good paralumbar groups. Low NTPA was associated with longer time to MCID achievement for ODI, VAS back, VAS leg, and SF-12 MCS. Poor paralumbar muscle health was associated with longer time to MCID achievement for VAS back, VAS leg, and SF-12 PCS. NTPA negatively correlated with change in VAS back (6-week, 12-week) and VAS leg (6-month). PL-CSA/BMI positively correlated with change in PROMIS-PF at 3 months follow-up.

CONCLUSIONS

Among patients undergoing lumbar microdiscectomy, patients with worse muscle health grades achieved MCID at similar rates but required longer time to achieve MCID. Lower NTPA was weakly correlated with larger improvements in pain scores. PL-CSA/BMI positively correlated with change in PROMIS-PF. Our findings suggest that with regards to functional outcomes, patients with worse muscle health may take longer to recuperate postoperatively compared to those with better muscle health.

Correlations between paraspinal extensor muscle endurance and clinical outcomes in preoperative LSS patients and clinical value of an endurance classification

Background

Few study has investigated how paraspinal muscle endurance deteriorates in lumbar spinal stenosis (LSS) patients. In addition, little information is available on the relationship between clinical outcomes and the endurance of paraspinal muscles.

Objective

To explore the correlation between paraspinal extensor muscle endurance, quality of life (QOL) and sagittal spinopelvic alignment. Besides, we attempted to propose a paraspinal extensor muscle endurance test (PEMET) classification for identifying the severity of clinical symptoms and sagittal imbalance in LSS patients.

Methods

171 hospitalized LSS patients and 100 healthy controls from the community were prospectively enrolled in this study. The paraspinal extensor endurance test was performed at baseline according to Ito test. The LSS patients were stratified into three groups based on the performance time of endurance test: grade I (<10s); grade II (10–60s); and grade III (>60s). Clinical measures of QOL included the visual analog scale scores (VAS) for back pain and leg pain and the Oswestry Disability Index (ODI). Sagittal alignment was analysed by standing posteroanterior and lateral whole spine X-ray in LSS patients.

Results

The LSS group had a significantly shorter performance time of the endurance test than the control group. The paraspinal muscle endurance significantly correlated with VAS-back, VAS-leg, ODI, pelvic tilt, lumbar lordosis and sagittal vertical axis (SVA; all p < 0.05). In binary logistic regression, the performance time of the endurance test was an independent factor of both poor functional status (ODI >40; p = 0.005, OR = 0.985) and global sagittal imbalance (SVA >50 mm; p = 0.019, OR = 0.985). Based on PEMET classification, moving from the grade III group to the grade I group, there was progressive worsening in VAS-back and ODI (all adjusted p < 0.05). Moreover, the grade I group had significantly greater VAS- leg, less LL and greater SVA than the other two groups (all adjusted p < 0.05).

Conclusion

Paraspinal muscle endurance was associated with QOL and sagittal spinopelvic alignment in LSS patients. A PEMET classification system has been constructed and has shown a correlation with QOL and sagittal imbalance.

Translational potential statement

The PEMET classification system proposed in this study could be available for identifying the severity of clinical symptoms and sagittal imbalance during preoperative evaluation in LSS patients.

Reliability and agreement of lumbar multifidus volume and fat fraction quantification using magnetic resonance imaging

INTRODUCTION

Magnetic resonance imaging (MRI) is the standard to quantify size and structure of lumbar muscles. Three-dimensional volumetric measures are expected to be more closely related to muscle function than two-dimensional measures such as cross-sectional area. Reliability and agreement of a standardized method should be established to enable the use of MRI to assess lumbar muscle characteristics.

OBJECTIVES

This study investigates the intra- and inter-processor reliability for the quantification of (1) muscle volume and (2) fat fraction based on chemical shift MRI images using axial 3D-volume measurements of the lumbar multifidus in patients with low back pain.

METHODS

Two processors manually segmented the lumbar multifidus on the MRI scans of 18 patients with low back pain using Mevislab software following a well-defined method. Fat fraction of the segmented volume was calculated. Reliability and agreement were determined using intra-class correlation coefficients (ICC), Bland-Altman plots and calculation of the standard error of measurement (SEM) and minimal detectable change (MDC).

RESULTS

Excellent ICCs were found for both intra-processor and inter-processor analysis of lumbar multifidus volume measurement, with slightly better results for the intra-processor reliability. The SEMs for volume were lower than 4.1 cm³. Excellent reliability and agreement were also found for fat fraction measures, with ICCs of 0.985-0.998 and SEMs below 0.946%.

CONCLUSION

The proposed method to quantify muscle volume and fat fraction of the lumbar multifidus on MRI was highly reliable, and can be used in further research on lumbar multifidus structure.

Can fat infiltration in the multifidus muscle be a predictor of postoperative symptoms and complications in patients undergoing lumbar fusion for degenerative lumbar spinal stenosis? A case-control study

Purpose

This study aimed to explore whether 25% as the cutoff value of fat infiltration (FI) in multifidus (MF) could be a predictor of clinical outcomes of lumbar spinal stenosis (LSS) patients.

Methods

A total of 461 patients undergoing posterior lumbar interbody fusion for LSS with 1-year follow-up were identified. After sex- and age-match, 160 pairs of patients were divided into a FI < 25% group and a FI ≥ 25% group according to FI of MF at L4 on preoperative magnetic resonance imaging. Patient-reported outcomes including the visual analog scale scores (VAS) for back pain and leg pain and the Oswestry disability index (ODI) scores were evaluated. Bone nonunion and screw loosening were evaluated by dynamic X-ray.

Results

After matching, there was no significant difference in age, sex, body mass index, fusion to S1, number of fusion levels, osteoporosis, spondylolisthesis, smoking and diabetes. FI ≥ 25% group had significantly higher VAS for back pain, VAS for leg pain and ODI than FI < 25% group at 1-year follow-up. However, there was no significant difference in the change of them from baseline to 1-year follow-up between the two groups. In light of complications, FI ≥ 25% group had a significantly higher rate of bone nonunion than FI < 25% group, whereas there was no significant difference of screw loosening rates between the two groups.

Conclusion

MF FI might be a pragmatic cutoff value to predict bone nonunion in LSS patients, but it has little predictive value on screw loosening and postoperative improvement of symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03186-2.

The relationships between physical activity, lumbar multifidus muscle morphology, and low back pain from childhood to early adulthood: a 12-year longitudinal study

We investigated the longitudinal associations between physical activity (PA), lumbar multifidus morphology, and impactful low back pain (LBP) in young people. Nine-year-old children were recruited from 25 primary schools and followed up at age 13, 16, and 21 years. We measured PA with accelerometers at age 9, 13, and 16; quantified patterns of lumbar multifidus intramuscular adipose tissue (IMAT) change from 13 to 16 years using magnetic resonance imaging; and recorded LBP and its impact with standardised questionnaires and interviews. Associations were examined with crude and adjusted logistic or multinomial models and reported with odds ratios (OR) or relative risk ratios (RRR). We included data from 364 children (mean[SD] age = 9.7[.4] years). PA behaviour was not associated with LBP. Having persistently high IMAT levels at age 13 and 16 was associated with greater odds of LBP (OR[95% CI] = 2.98[1.17 to 7.58]). Increased time in moderate and vigorous intensity PA was associated with a lower risk of higher IMAT patterns (RRR[95% CI] = .67[.46 to .96] to .74[.55 to 1.00]). All associations became non-significant after adjusting for sex and body mass index (BMI). Future studies investigating the relationships between PA behaviour, lumbar multifidus IMAT, and impactful LBP should account for potential confounding by sex and BMI.

A novel use of cone beam CT: flexion and extension weight-bearing imaging to assess spinal stability

PURPOSE

To assess spinal stability in different physiological positions whilst weight-bearing.

METHODS

A cone beam CT scanner (CBCT) was used to identify any abnormal motion in the spine in different physiological positions whilst weight-bearing. The lumbar spine was assessed in 6 different patients with a comfortable neutral standing position and standing flexion and extension images in selected patients. Seated, weight-bearing flexion and extension images of the cervical spine were obtained in a further patient. Clinical indications included stability assessment post-trauma, post-surgical fusion and back pain. The projection images were reconstructed using bone and soft tissue algorithms to give isotropic CT images which could be viewed as per conventional multi-detector CT images. The flexion and extension CBCT data were fused to give a representation of any spinal movement between the extremes of motion.

RESULTS

The flexion and extension weight-bearing images gave anatomical detail of the spine. Detail of the surgical constructs was possible. Dynamic structural information about spinal alignment, facet joints, exit foramina and paraspinal musculature was possible. The effective dose from the neutral position was equal to that of supine, multi-detector CT.

CONCLUSION

CBCT can be used to image the lumbar and cervical spine in physiological weight-bearing positions and at different extremes of spinal motion. This novel application of an existing technology can be used to aid surgical decision making to assess spinal stability and to investigate occult back and leg pain. Its use should be limited to specific clinical indications, given the relatively high radiation dose.

Multifidus Muscle Contractility Deficit Was Not Specific to the Painful Side in Patients with Chronic Low Back Pain During Remission: A Cross-Sectional Study

Purpose

Morphology studies demonstrated that patients with chronic low back pain (CLBP) have bilateral multifidus muscle (LM) atrophy. This atrophy should result in LM contractility deficit bilaterally. Additionally, a recent study showed the effect of sex on LM thickness. Researchers proposed percentage LM contractility (LM_CONT) as standardization to enable the comparison across participants. This study aimed to determine side-to-side difference in LM_CONT and to determine the difference in LM_CONT between males and females.

Patients and Methods

Twenty-five healthy individuals (NoLBP group; 10 males and 15 females) and 35 with CLBP (CLBP group; 16 males and 19 females; 23 unilateral pain and 12 bilateral pain) were recruited. Ultrasound imaging was used to measure LM thickness at rest, during maximum voluntary isometric contraction, and during combined maximum voluntary isometric contraction with electrical stimulation. These data were used to calculate LM_CONT. For unilateral CLBP, right and left LM_CON were renamed to painful and non-painful sides.

Results

Data demonstrated no significant difference (p > 0.05) between right (87.3 ± 13.7%) and left (87.2 ± 14.0%) in NoLBP, right (71.2 ± 15.7%) and left (76.5 ± 19.7%) in bilateral CLBP, and painful (70.3 ± 17.5%) and non-painful (77.7 ± 18.4%) in unilateral CLBP. No difference (p > 0.05) was found between males and females in both NoLBP (male 84.8 ± 6.5%, female 88.9 ± 15.4%) and CLBP groups (male 76.3 ± 15.5%, female 71.9 ± 14.0%).

Conclusion

The findings suggested that LM contractility deficit in CLBP is not specific to painful side. No effect was found of sex on LM contractility. Therefore, we can use averaged LM activation across painful and non-painful sides and across males and females to compare between NoLBP and CLBP groups.

Alteration of lumbar muscle morphology and composition in relation to low back pain: a systematic review and meta-analysis

BACKGROUND CONTEXT

Previous studies have proposed that there is a relationship between low back pain (LBP) and morphology and composition of paraspinal muscles. However, results have been conflicting, especially regarding fatty infiltration of muscles.

PURPOSE

The primary goal of this study was to review and analyze results from imaging studies which investigated morphological and composition changes in the multifidus, erector spinae and psoas major muscles in people with LBP.

STUDY DESIGN/SETTING

Systematic review with meta-analysis.

PATIENT SAMPLE

A patient sample was not required OUTCOME MEASURES: This review did not have outcome measures.

METHODS

PubMed, Scopus, Web of Sciences, EMBASE and ProQuest were searched for eligible studies up to 31st July 2020 (all languages). A systematic search of electronic databases was conducted to identify studies investigating the association between the morphology and fat content of lumbar muscles in people with LBP compared with a (no LBP) control group. 13,795 articles were identified. Based on the screening for inclusion/ exclusion, 25 were included. The quality of the studies was evaluated using the Newcastle-Ottawa Scale. From the 25 articles, 20 were included in the meta-analysis.

RESULTS

Results showed that the total cross-sectional area of the multifidus was smaller in people with LBP (Standardized mean difference, SMD = -0.24, 95% CI = -0.5 to 0.03). Combined SMDs showed a medium effect of LBP on increasing multifidus muscle fat infiltration (SMD = 0.61, 95% CI = 0.30 to 0.91). There were no LBP related differences identified in the morphology or composition of the lumbar erector spine and psoas major muscles.

CONCLUSIONS

People with LBP were found to have somewhat smaller multifidus muscles with a significant amount of intramuscular fat infiltration. Varying sample size, age and BMI of participants, quality of studies and the procedures used to measure fat infiltration are possible reasons for inconsistencies in results of previous studies.

The predictive value of preoperative paraspinal muscle morphometry on complications after lumbar surgery: a systematic review

PURPOSE

The effect of paraspinal muscles atrophy and fat infiltration (FI) on the complications of spinal surgery has not been established.

METHODS

A review of the literature was conducted from a search of the PubMed, EMBASE, and Web of Science databases from inception through January 2021. The literature was searched and assessed by independent reviewers based on criteria that included an assessment of preoperative paraspinal muscle morphology in addition to measuring its relationship to surgical complications. All relevant papers were assessed for risk of bias according to the modified Newcastle Ottawa Scale and the Joanna Briggs Institute Critical Appraisal Tools. A narrative synthesis was conducted.

RESULTS

The initial search yielded 5632 studies, of which 16 studies were included in the analysis. All included studies were at a low risk of bias. There existed strong evidence that the atrophy and FI of paraspinal muscles had an association with the development of bone nonunion (two high quality studies), pedicle screw loosening (two high quality studies), adjacent segment degeneration (three high quality studies) and proximal junctional kyphosis (five high quality studies) after lumbar surgery. Besides, there is also limited evidence for association between atrophy and FI of paraspinal extensor muscles and less local and global curve improvement.

CONCLUSIONS

Strong evidence was found for an association between preoperative paraspinal muscle degeneration and multiple postoperative complications after lumbar surgery. However, the findings should be interpreted with caution due to the small quantity of the available literature and high heterogeneity among studies.

Functional and morphological lumbar multifidus characteristics in subgroups with low back pain in primary care

BACKGROUND

Since the contribution of the lumbar multifidus(LM) is not well understood in relation to non-specific low back pain(LBP), this may limit physiotherapists in choosing the most appropriate treatment strategy.

OBJECTIVES

This study aims to compare clinical characteristics, in terms of LM function and morphology, between subacute and chronic LBP patients from a large clinical practice cohort compared to healthy controls.

DESIGN

Multicenter case control study.

METHOD

Subacute and chronic LBP patients and healthy controls between 18 and 65 years of age were included. Several clinical tests were performed: primary outcomes were the LM thickness from ultrasound measurements, trunk range of motion(ROM) from 3D kinematic tests, and median frequency and root mean square values of LM by electromyography measurements. The secondary outcomes Numeric Rating Scale for Pain(NRS) and the Oswestry Disability Index(ODI) were administered. Comparisons between groups were made with ANOVA, p-values<0.05, with Tukey's HSD post-hoc test were considered significant.

RESULTS

A total of 161 participants were included, 50 healthy controls, 59 chronic LBP patients, and 52 subacute LBP patients. Trunk ROM and LM thickness were significantly larger in healthy controls compared to all LBP patients(p < 0.01). A lower LM thickness was found between subacute and chronic LBP patients although not significant(p = 0.11-0.97). All between-group comparisons showed no statistically significant differences in electromyography outcomes (p = 0.10-0.32). NRS showed no significant differences between LBP subgroups(p = 0.21). Chronic LBP patients showed a significant higher ODI score compared to subacute LBP patients(p = 0.03).

CONCLUSIONS

Trunk ROM and LM thickness show differences between LBP patients and healthy controls.

Efficacy of lumbar kinetic chain training for staged rehabilitation after percutaneous endoscopic lumbar discectomy

BACKGROUND

Percutaneous endoscopic lumbar discectomy (PELD) is a promising minimally invasive treatment for lumbar disc herniation (LDH). Postoperative rehabilitation can improve patient outcomes. Not only rehabilitation for surgical trauma but also rehabilitation for lumbar spine and lower kinetic chain dysfunction should be performed. The aims of this study were to investigate the efficacy of a lumbar kinetic chain training for staged rehabilitation after PELD for LDH.

METHODS

Fifty one LDH patients treated with PELD were studied. After surgery, patients underwent lumbar kinetic chain training for staged rehabilitation( staged group) or regular low back rehabilitation (regular group). The staged rehabilitation programme included three phases from 2 to 6, 7-12, and 13-24 weeks postoperatively, and different physical therapies were performed during these phases. The low back pain visual analogue scale (VAS), JOA score, ODI, SF-36, and cross-sectional area of the lumbar multifidus on MRI were assessed, and gait analysis was performed.

RESULTS

Twenty five patients in staged group and twenty six patients in regular group were included. There were no significant differences in age or sex between the two groups at baseline (p > 0.05). The VAS score decreased and the JOA and SF-36 scores increased in both groups from baseline to 6 weeks (P < 0.05). In the staged group, compared with the regular group, the VAS and ODI scores were lower and the JOA and SF-36 scores were higher at 6 weeks (P < 0.05); the VAS and ODI scores were lower and the SF-36 score was higher at 12 weeks (P < 0.05); the SF-36 score was higher at 24 weeks (P < 0.05); the cross-sectional area of the lumbar multifidus showed no differences at 12 weeks (P > 0.05); and the left-right support ratio of gait was higher at 24 weeks (P < 0.05).

CONCLUSIONS

The staged rehabilitation programme for LDH after PELD promoted postoperative recovery, and the efficacy of lumbar kinetic chain training was higher than that of regular low back muscle exercise.

Individuals with recurrent low back pain exhibit further altered frontal plane trunk control in remission than when in pain

BACKGROUND

Movement alterations due to low back pain (LBP) could lead to long-term adverse consequences if they do not resolve after symptoms subside. This study aims to determine if altered trunk control associated with recurrent low back pain persists beyond symptom duration.

METHODS

Twenty young adults with recurrent LBP were tested once during an LBP episode and once in symptom remission, and twenty matched back-healthy participants served as controls. Participants walked on a treadmill with five prescribed step widths (0.33, 0.67, 1, 1.33, 1.67 × preferred step width). Motion capture and surface electromyography were used to record trunk kinematics and muscle activation. Thorax-pelvis coordination was calculated using vector coding, and longissimus activation and co-activation were analyzed.

FINDINGS

Young adults with recurrent LBP exhibited a "looser" trunk control strategy in the frontal plane during gait that was persistent regardless of pain status across multiple step widths compared to controls. The looser trunk control was demonstrated by a greater pelvis-only, less thorax-only coordination pattern, and decreased bilateral longissimus co-activation in individuals with recurrent LBP compared to controls. The looser trunk control strategy was further amplified when individuals were in symptom remission and exhibited greater trunk excursion and reduced in-phase coordination in the frontal plane.

INTERPRETATION

The amplification of aberrant movement during symptom remission may suggest that movement patterns or anatomical factors existing prior to the tested painful episode underlie altered trunk control in individuals with recurrent LBP. The symptom remission period of recurrent LBP may be a critical window into clinical evaluation and treatment.

Assessing lumbar paraspinal muscle cross-sectional area and fat composition with T1 versus T2-weighted magnetic resonance imaging: Reliability and concurrent validity

Purpose

Studies using magnetic resonance imaging to assess lumbar multifidus cross-sectional area frequently utilize T1 or T2-weighted sequences, but seldom provide the rationale for their sequence choice. However, technical considerations between their acquisition protocols could impact on the ability to assess lumbar multifidus anatomy or its fat/muscle distinction. Our objectives were to examine the concurrent validity of lumbar multifidus morphology measures of T2 compared to T1-weighted sequences, and to assess the reliability of repeated lumbar multifidus measures.

Methods

The lumbar multifidus total cross-sectional area of 45 patients was measured bilaterally at L4 and L5, with histogram analysis determining the muscle/fat threshold values per muscle. Images were later re-randomized and re-assessed for intra-rater reliability. Matched images were visually rated for consistency of outlining between both image sequences. Bland-Altman bias, limits of agreement, and plots were calculated for differences in total cross-sectional area and percentage fat between and within sequences, and intra-rater reliability analysed.

Results

T1-weighted total cross-sectional area measures were systematically larger than T2 (0.2 cm²), with limits of agreement <±10% at both spinal levels. For percentage fat, no systematic bias occurred, but limits of agreement approached ±15%. Visually, muscle outlining was consistent between sequences, with substantial mismatches occurring in <5% of cases. Intra-rater reliability was excellent (ICC: 0.981–0.998); with bias and limits of agreement less than 1% and ±5%, respectively.

Conclusion

Total cross-sectional area measures and outlining of muscle boundaries were consistent between sequences, and intra-rater reliability for total cross-sectional area and percentage fat was high indicating that either MRI sequence could be used interchangeably for this purpose. However, further studies comparing the accuracy of various methods for distinguishing fat from muscle are recommended.

Sources of lumbar back pain during aging and potential therapeutic targets

Lumbar back pain during aging is a major clinical problem, the origins and underlying mechanisms of which are challenging to study. Degenerative changes occur in various parts of the functional spinal unit, such the vertebral endplate and intervertebral disc. The homeostasis of these structural components is regulated by signaling molecules, such as transforming growth factor-β and parathyroid hormone. Previous efforts to understand sources of lumbar back pain focused on sensory innervation in the degenerative intervertebral disc, but intervertebral disc degeneration is frequently asymptomatic. An in vivo mouse model of lumbar spine aging and degeneration, combined with genetic technology, has identified endplate innervation as a major source of lumbar back pain and a potential therapeutic target. In this review, we consider how each structural component of the functional spinal unit contributes to lumbar back pain, how the homeostasis of each component is regulated, and how these findings can be used to develop potential therapies.

Musculature adaption in patients with lumbosacral transitional vertebrae: a matched-pair analysis of 46 patients

OBJECTIVE

Even though lumbosacral transitional vertebrae (LSTV) are one of the most common congenital anomalies of the spine, their effect on surrounding soft tissues is not well-studied. We therefore aimed at analyzing the association between LSTV and changes in volume, mass, symmetry, and degeneration of lumbar and trunk muscles.

MATERIALS AND METHODS

Abdomen-pelvis CT scans were analyzed in patients with LSTV and a matched control group. LSTV were classified according to the Castellvi classification. Muscles were segmented from the remaining soft tissue and their cross-sectional area and volume were examined at five defined levels. Threshold segmentation was used to differentiate between muscle fibers and fat tissue. Matched pairs were compared using Wilcoxon rank sum tests. For comparison of categorical data, chi-squared tests were performed and for associations between the degree of fusion and muscle size and degeneration, Spearman's correlation coefficients were calculated. Inter- and intrarater reliabilities were evaluated by computing intraclass correlation coefficients.

RESULTS

Forty-six patients with LSTV and 46 controls were included. Muscle volume of the paraspinal and trunk muscles was significantly lower (707.0 cm³ vs. 809.7 cm³, p < 0.001) and fatty muscle changes were significantly increased in all but the caudal paravertebral muscles of LSTV patients (M. psoas p < 0.04, M. quadratus lumborum p < 0.001, paravertebral muscles p = 0.011, M. rectus abdominis p < 0.001, M. obliquus abdominis p < 0.001). Correlations between the degree of Castellvi classification and muscle volume were significant (p = 0.001).

CONCLUSION

LSTV are associated with a reduction in muscle volume and an increase in muscle degeneration of both lumbar and trunk muscles.

Effect of Increased Lumbar Lordosis on Lumbar Multifidus and Longissimus Thoracis Activation During Quadruped Exercise in Patients With Chronic Low Back Pain: An EMG Study

The objective was to investigate the electromyographic activity of the lumbar multifidus (MF) muscle and longissimus thoracis muscle, along with their activity ratio (MF longissimus thoracis ratio), during quadruped stabilization exercise performed with neutral posture and with increased lumbar lordosis in patients with chronic low back pain (CLBP). A total of 23 patients with CLBP (12 females and 11 males) were recruited based on inclusion and exclusion criterion. Each patient performed 4 exercises in random order, with surface electromyography electrodes and an electrogoniometer attached. A cross-sectional study design was used to measure the amplitude of muscle activation (as a percentage of maximum voluntary contraction) in each patient across the 2 muscles (MF and longissimus thoracis) during quadruped stabilization exercise with neutral posture and with increased lumbar lordosis. A 2-way analysis of variance was conducted, which demonstrated a statistically significant increase in the recruitment of MF with increased lumbar lordosis in patients with CLBP during quadruped exercise. An increase of 9.7% and 16.9% maximum voluntary contraction in MF electromyographic activity was observed in lumbar lordosis posture during the quadruped leg raise and quadruped leg-arm raise exercise, respectively (P < .01), when compared to the neutral posture. The increased recruitment of MF with lumbar lordosis in the quadruped position has strong implications in the assessment and management of patients with CLBP.

Age-related degeneration of lumbar muscle morphology in healthy younger versus older men

AIM

The aim of this study was to evaluate age-related changes in lumbar paravertebral muscle (LPM) morphology in healthy younger and older adult men.

METHODS

T2-weighted axial MRI of the lumbar spine were obtained for 12 healthy older (67.3 ± 6.0 years) and younger (24.7 ± 3.1 years) men. Normalised muscle volume (NMV) and muscle fat infiltrate (MFI) were determined bilaterally for the psoas (PS), quadratus lumborum (QL), erector spinae (ES) and multifidus (MF). MANOVA was used to compare NMV and MFI between age groups. Follow-up ANOVA compared NMV and MFI for each muscle between age groups, with physical activity (PA) as a covariate. Stepwise regression was used to explore the association between muscle morphology.

RESULTS

NMV of the ES and QL were significantly lower in the older group (OG) (p = 0.040 and p < 0.001, respectively). MFI across all muscles was significantly greater in the OG (p < 0.001). PA did not moderate the relationship between aging and muscle degeneration. Non-dominant handgrip strength was associated with NMV (p = 0.003).

CONCLUSIONS

Age-related atrophy is muscle specific in the lumbar spine; changes in lumbar musculature is independent of PA, handgrip strength may reflect morphological changes in the postural muscles with age. This study supports establishing effective targeted exercise interventions in the lumbar musculature.

Asymmetric atrophy of the multifidus in persons with hemiplegic presentation post-stroke

Objective: To identify the asymmetry of fatty infiltration and cross-sectional areas (CSAs) of individual paravertebral muscles in persons with hemiplegic presentation post-stroke.Methods: We retrospectively reviewed 26 patients with unilateral hemiplegia who underwent lumbar magnetic resonance imaging post-stroke. CSAs and functional CSAs (FCSAs) of individual paraspinal muscles (multifidus, erector spinae, quadratus lumborum, and psoas major) at the mid-disc level were bilaterally measured from L1-L2 to L5-S1 on T2-weighted lumbar axial images. The FCSA-to-total CSA ratio of each paraspinal muscle was also calculated. These parameters were compared between the more-affected and less-affected sides, and between the less chronic and chronic phases.Results: FCSA (p = .049) and FCSA-to-total CSA ratio (p = .044) were significantly smaller at the L5-S1 multifidus on the more-affected side than on the less-affected side in the chronic phase. Other muscles showed no meaningful changes. The erector spinae on the more-affected side and the multifidus on the less-affected side significantly increased in size in the chronic phase compared with the less chronic phase.Conclusions: Persons with hemiplegic presentation may have unilateral atrophy and fatty infiltration of the multifidus on the more-affected side during the chronic phase. The comparison between the less chronic and chronic phases suggested that the recovery pattern of the trunk muscles could differ between sides in unilateral hemiplegia: increased size of the multifidus, a tonic stabilizer, on the less-affected side and of the erector spinae, a phasic muscle, on the more-affected side. This finding could be applied to trunk rehabilitation strategies for persons post-stroke.

Regional differences between superficial and deep lumbar multifidus in patients with chronic lumbar spine pathology

BACKGROUND

Due to its unique arrangement, the deep and superficial fibers of the multifidus may have differential roles for maintaining spine stabilization and lumbar posture; the superficial multifidus is responsible for lumbar extension and the deep multifidus for intersegmental stability. In patients with chronic lumbar spine pathology, muscle activation patterns have been shown to be attenuated or delayed in the deep, but not superficial, multifidus. This has been interpreted as pain differentially influencing the deep region. However, it is unclear if degenerative changes affecting the composition and function of the multifidus differs between the superficial and deep regions, an alternative explanation for these electrophysiological changes. Therefore, the goal of this study was to investigate macrostructural and microstructural differences between the superficial and deep regions of the multifidus muscle in patients with lumbar spine pathology.

METHODS

In 16 patients undergoing lumbar spinal surgery for degenerative conditions, multifidus biopsies were acquired at two distinct locations: 1) the most superficial portion of muscle adjacent to the spinous process and 2) approximately 1 cm lateral to the spinous process and deeper at the spinolaminar border of the affected vertebral level. Structural features related to muscle function were histologically compared between these superficial and deep regions, including tissue composition, fat fraction, fiber cross sectional area, fiber type, regeneration, degeneration, vascularity and inflammation.

RESULTS

No significant differences in fat signal fraction, muscle area, fiber cross sectional area, muscle regeneration, muscle degeneration, or vascularization were found between the superficial and deep regions of the multifidus. Total collagen content between the two regions was the same. However, the superficial region of the multifidus was found to have less loose and more dense collagen than the deep region.

CONCLUSIONS

The results of our study did not support that the deep region of the multifidus is more degenerated in patients with lumbar spine pathology, as gross degenerative changes in muscle microstructure and macrostructure were the same in the superficial and deep regions of the multifidus. In these patients, the multifidus is not protected in order to maintain mobility and structural stability of the spine.

The Implications of Paraspinal Muscle Atrophy in Low Back Pain, Thoracolumbar Pathology, and Clinical Outcomes After Spine Surgery: A Review of the Literature

STUDY DESIGN

Literature review.

OBJECTIVES

Paraspinal muscle integrity is believed to play a critical role in low back pain (LBP) and numerous spinal deformity diseases and other pain pathologies. The influence of paraspinal muscle atrophy (PMA) on the clinical and radiographic success of spinal surgery has not been established. We aim to survey the literature in order to evaluate the impact of paraspinal muscle atrophy on low back pain, spine pathologies, and postoperative outcomes of spinal surgery.

METHODS

A review of the literature was conducted using a total of 267 articles identified from a search of the PubMed database and additional resources. A full-text review was conducted of 180 articles, which were assessed based on criteria that included an objective assessment of PMA in addition to measuring its relationship to LBP, thoracolumbar pathology, or surgical outcomes.

RESULTS

A total of 34 studies were included in this review. The literature on PMA illustrates an association between LBP and both decreased cross-sectional area and increased fatty infiltration of paraspinal musculature. Atrophy of the erector spinae and psoas muscles have been associated with spinal stenosis, isthmic spondylolisthesis, facet arthropathy, degenerative lumbar kyphosis. A number of studies have also demonstrated an association between PMA and worse postoperative outcomes.

CONCLUSIONS

PMA is linked to several spinal pathologies and some studies demonstrate an association with worse postoperative outcomes following spinal surgery. There is a need for further research to establish a relationship between preoperative paraspinal muscle integrity and postoperative success, with the potential for guiding surgical decision making.

Posturography Comparison and Discriminant Analysis Between Individuals With and Without Chronic Low Back Pain

OBJECTIVE

The aims of this study were to evaluate the center of pressure (CoP) in individuals with chronic low back pain (LBP) compared with matched controls and perform discriminant analysis to detect which CoP variables differentiate the groups.

METHODS

Thirty-two participants with LBP and 33 matched controls were evaluated on a force plate in a bipedal static position for 30 seconds in 2 conditions: eyes open (EO) and eyes closed (EC). Two discriminant analyzes were performed to detect which CoP variables could discriminate between groups.

RESULTS

Those with LBP had higher values (ie, poorer balance) for most variables compared with the control group. With EO, total displacement of sway (TDS) was as follows: LBP group (median [25%-75%]) 31.77 (26.39-41.79) cm, control group 27.21 (22.29-31.78) cm, P = .008 and area: LBP group 3.31 (2.33-4.68) cm², control group 1.77 (1.3-2.71) cm². With EC, TDS was as follows: LBP group 49.6 (39.65-68.15) cm, control group 38.77 (30.36; 45.65) cm, P = .003 and area: LBP group 4.68 (2.6-7.28) cm², control group 2.4 (2.1-3.34) cm². The discriminating variables in the EO condition were the TDS for the LBP group and the anteroposterior mean velocity for the control group, while in the EC condition they were mediolateral dispersion and area for the LBP group.

CONCLUSION

Individuals with chronic LBP had worse postural control performance than matched controls, and it is possible to characterize those with and without LBP with CoP variables.

Does Plantar Pressure Distribution Influence the Lumbar Multifidus Muscle Thickness in Asymptomatic Individuals? A Preliminary Study

BACKGROUND

Atrophy can occur in the lumbar multifidus (LM) muscle quickly as a result of various musculoskeletal problems. Knowing factors influencing muscle thickness of the LM will provide important clues about lumbopelvic stability.

OBJECTIVES

Although there are several studies in the literature investigating the adverse effects of foot-ankle postural disorders on the lumbopelvic region, to our knowledge there has been no investigation of plantar pressure distribution (PPD) as a factor influencing muscle thickness of the LM. The aim of this study was to determine whether PPD could affect LM muscle thickness.

METHODS

This observational study consisted of 25 asymptomatic individuals. Ultrasonographic imaging was used to determine the thickness of the LM. All participants were subjected to PPD analysis using the Digital Biometry Scanning System and Milletrix software in 9 different plantar pressure zones. The Pearson product-moment correlation coefficients were used to examine the correlations between the LM muscle thickness and other variables. Stepwise multiple linear regression analysis was used to determine the variables with the greatest influence on LM muscle thickness.

RESULTS

Peak pressures of medial and lateral zones of the heel were the significant and independent factors influencing static LM thickness, with 39.5% of the variance; moreover, the peak pressures of heel medial and fourth metatarsal bone were the significant and independent factors influencing dynamic LM thickness, with 38.7% of the variance.

CONCLUSIONS

Plantar pressure distribution could be an important factor influencing LM thickness, although further research is required. Examining foot-ankle biomechanics may provide information about the stability of the LM.

Inconsistent descriptions of lumbar multifidus morphology: A scoping review

BACKGROUND

Lumbar multifidus (LM) is regarded as the major stabilizing muscle of the spine. The effects of exercise therapy in low back pain (LBP) are attributed to this muscle. A current literature review is warranted, however, given the complexity of LM morphology and the inconsistency of anatomical descriptions in the literature.

METHODS

Scoping review of studies on LM morphology including major anatomy atlases. All relevant studies were searched in PubMed (Medline) and EMBASE until June 2019. Anatomy atlases were retrieved from multiple university libraries and online. All studies and atlases were screened for the following LM parameters: location, imaging methods, spine levels, muscle trajectory, muscle thickness, cross-sectional area, and diameter. The quality of the studies and atlases was also assessed using a five-item evaluation system.

RESULTS

In all, 303 studies and 19 anatomy atlases were included in this review. In most studies, LM morphology was determined by MRI, ultrasound imaging, or drawings - particularly for levels L4-S1. In 153 studies, LM is described as a superficial muscle only, in 72 studies as a deep muscle only, and in 35 studies as both superficial and deep. Anatomy atlases predominantly depict LM as a deep muscle covered by the erector spinae and thoracolumbar fascia. About 42% of the studies had high quality scores, with 39% having moderate scores and 19% having low scores. The quality of figures in anatomy atlases was ranked as high in one atlas, moderate in 15 atlases, and low in 3 atlases.

DISCUSSION

Anatomical studies of LM exhibit inconsistent findings, describing its location as superficial (50%), deep (25%), or both (12%). This is in sharp contrast to anatomy atlases, which depict LM predominantly as deep muscle. Within the limitations of the self-developed quality-assessment tool, high-quality scores were identified in a majority of studies (42%), but in only one anatomy atlas.

CONCLUSIONS

We identified a lack of standardization in the depiction and description of LM morphology. This could affect the precise understanding of its role in background and therapy in LBP patients. Standardization of research methodology on LM morphology is recommended. Anatomy atlases should be updated on LM morphology.

Age-related degeneration of the lumbar paravertebral muscles: Systematic review and three-level meta-regression

BACKGROUND

Morphological changes of the lumbar spine muscles are not well characterised with ageing. To further the understanding of age-related degeneration of the lumbar spine musculature, normative morphological changes that occur within the paravertebral muscles must first be established.

METHODS

A systematic review and meta-regressions were conducted adhering to PRISMA guidelines. Searches for published and unpublished data were completed in June 2019.

RESULTS

Searches returned 4781 articles. 34 articles were included in the quantitative analysis. Three-level meta-analyses showed age-related atrophy (r = -0.26; 95% CI: -0.33, -0.17) and fat infiltration (r = 0.39; 95% CI: 0.28, 0.50) in the lumbar paravertebral muscles. Degenerative changes were muscle-specific and men (r = -0.32; 95% CI: -0.61, 0.01) exhibited significantly greater muscle atrophy than women (r = -0.24; 95% CI: -0.47, 0.03). Imaging modality, specifically ultrasound, also influenced age-related muscle atrophy. Measurements taken across all lumbar levels revealed the greatest fat infiltration with ageing (r = 0.58, 95% CI: 0.35, 0.74). Moderators explained a large proportion of between-study variance in true effects for muscle atrophy (72.6%) and fat infiltration (79.8%) models.

CONCLUSIONS

Lumbar paravertebral muscles undergo age-related degeneration in healthy adults with muscle, lumbar level and sex-specific responses. Future studies should use high-resolution imaging modalities to quantify muscle atrophy and fat infiltration.

Effect of Combined Diclofenac and B Vitamins (Thiamine, Pyridoxine, and Cyanocobalamin) for Low Back Pain Management: Systematic Review and Meta-analysis

BACKGROUND

Cumulative evidence suggests an analgesic effect of thiamine, pyridoxine, and cyanocobalamin (TPC) in monotherapy, and also when combined with nonsteroidal anti-inflammatory drugs (NSAIDs), particularly diclofenac, in a synergistic manner. The aim of this review was to determine the effects of diclofenac combined with TPC compared with diclofenac monotherapy for low back pain (LBP) management.

METHODS

We searched for randomized clinical trials on the MEDLINE, EMBASE, LILACS, and Cochrane databases of records of clinical trials, among other sources. We evaluated the risk of bias regarding randomization, allocation concealment, blinding, incomplete outcome data, selective reporting, and other biases. A random-effects meta-analysis to examine patients with acute LBP (N = 1,108 adults) was performed, along with a subsequent sensitivity analysis.

RESULTS

Five studies in patients with LBP were included in the qualitative synthesis. Four of these studies in acute LBP were included in the first meta-analysis. A sensitivity test based on risk of bias (three moderate- to high-quality studies) found that the combination therapy of diclofenac plus TPC was associated with a significant reduction in the duration of treatment (around 50%) compared with diclofenac monotherapy (odds ratio = 2.23, 95% confidence interval = 1.59 to 3.13, P < 0.00001). We found no differences in the safety profile and patient satisfaction.

CONCLUSIONS

This meta-analysis demonstrated that combination therapy of diclofenac with TPC might have an analgesic superiority compared with diclofenac monotherapy in acute LBP. However, there is not enough evidence to recommend this therapy in other types of pain due to the scarcity of high-quality studies.