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Kunow A, Freyer Martins Pereira J, Chenot JF. Extravertebral low back pain: a scoping review. BMC Musculoskelet Disord 2024; 25:363. [PMID: 38714994 PMCID: PMC11075250 DOI: 10.1186/s12891-024-07435-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 04/11/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Low back pain (LBP) is one of the most common reasons for consultation in general practice. Currently, LBP is categorised into specific and non-specific causes. However, extravertebral causes, such as abdominal aortic aneurysm or pancreatitis, are not being considered. METHODS A systematic literature search was performed across MEDLINE, Embase, and the Cochrane library, complemented by a handsearch. Studies conducted between 1 January 2001 and 31 December 2020, where LBP was the main symptom, were included. RESULTS The literature search identified 6040 studies, from which duplicates were removed, leaving 4105 studies for title and abstract screening. Subsequently, 265 publications were selected for inclusion, with an additional 197 publications identified through the handsearch. The majority of the studies were case reports and case series, predominantly originating from specialised care settings. A clear distinction between vertebral or rare causes of LBP was not always possible. A range of diseases were identified as potential extravertebral causes of LBP, encompassing gynaecological, urological, vascular, systemic, and gastrointestinal diseases. Notably, guidelines exhibited inconsistencies in addressing extravertebral causes. DISCUSSION Prior to this review, there has been no systematic investigation into extravertebral causes of LBP. Although these causes are rare, the absence of robust and reliable epidemiological data hinders a comprehensive understanding, as well as the lack of standardised protocols, which contributes to a lack of accurate description of indicative symptoms. While there are certain disease-specific characteristics, such as non-mechanical or cyclical LBP, and atypical accompanying symptoms like fever, abdominal pain, or leg swelling, that may suggest extravertebral causes, it is important to recognise that these features are not universally present in every patient. CONCLUSION The differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. Clinicians should maintain a high index of suspicion for extravertebral aetiologies, especially in patients presenting with atypical accompanying symptoms.
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Affiliation(s)
- Anna Kunow
- Department of General Practice, University Medicine Greifswald, 17475, Fleischmannstraße, Greifswald, Germany.
| | | | - Jean-François Chenot
- Department of General Practice, University Medicine Greifswald, 17475, Fleischmannstraße, Greifswald, Germany
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Schönnagel L, Muellner M, Suwalski P, Guven AE, Camino-Willhuber G, Tani S, Caffard T, Zhu J, Haffer H, Arzani A, Chiapparelli E, Amoroso K, Shue J, Duculan R, Sama AA, Cammisa FP, Girardi FP, Mancuso CA, Hughes AP. Association of abdominal aortic calcification and lower back pain in patients with degenerative spondylolisthesis. Pain 2024; 165:376-382. [PMID: 37856648 DOI: 10.1097/j.pain.0000000000003018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/28/2023] [Indexed: 10/21/2023]
Abstract
ABSTRACT Abdominal aortic calcification (AAC) is hypothesized to lead to ischemic pain of the lower back. This retrospective study aims to identify the relationship between AAC and lower back pain (LBP) in patients with degenerative lumbar spondylolisthesis. Lower back pain was assessed preoperatively and 2 years after surgery using the numeric analogue scale. Abdominal aortic calcification was assessed according to the Kauppila classification and was grouped into no, moderate, and severe. A multivariable regression, adjusted for age, sex, body mass index, hypertension, and smoking status, was used to assess the association between AAC and preoperative/postoperative LBP as well as change in LBP after surgery. A total of 262 patients were included in the final analysis. The multivariable logistic regression demonstrated an increased odds ratio (OR) for preoperative LBP ≥ 4 numeric analogue scale (OR = 9.49, 95% confidence interval [CI]: 2.71-40.59, P < 0.001) and postoperative LBP ≥ 4 (OR = 1.72, 95% CI: 0.92-3.21, P = 0.008) in patients with severe AAC compared with patients with no AAC. Both moderate and severe AAC were associated with reduced improvement in LBP after surgery (moderate AAC: OR = 0.44, 95% CI: 0.22-0.85, P = 0.016; severe AAC: OR = 0.41, 95% CI: 0.2-0.82, P = 0.012). This study demonstrates an independent association between AAC and LBP and reduced improvement after surgery. Evaluation of AAC could play a role in patient education and might be considered part of the differential diagnosis for LBP, although further prospective studies are needed.
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Affiliation(s)
- Lukas Schönnagel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Muellner
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Phillip Suwalski
- Medical Heart Center of Charité CBF-Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ali E Guven
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gaston Camino-Willhuber
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Soji Tani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Thomas Caffard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
- Universitätsklinikum Ulm, Klinik für Orthopädie, Ulm, Germany
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY, United States
| | - Henryk Haffer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Artine Arzani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Krizia Amoroso
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Roland Duculan
- Hospital for Special Surgery, New York City, NY, United States
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Carol A Mancuso
- Hospital for Special Surgery, New York City, NY, United States
- Weill Cornell Medical College, New York, NY, United States
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
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Atypical patterns of spinal segment degeneration in patients with abdominal aortic aneurysms. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:8-19. [PMID: 35835893 DOI: 10.1007/s00586-022-07276-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 05/13/2022] [Accepted: 05/25/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Abdominal aortic aneurysms (AAAs) affect the vascular perfusion of the lumbar spine. The treatment of AAAs with endovascular aortic aneurysm repair (EVAR) completely occludes the direct vascular supply to the lumbar spine. We hypothesized that patients with AAA who undergo EVAR show a different pattern of spinal degeneration than individuals without AAA. METHODS In this retrospective institutional review board-approved study, 100 randomly selected patients with AAA who underwent EVAR with computed tomography (CT) scans between 2005 and 2017 were compared with age- and gender-matched controls without AAA. In addition, long-term follow-up CT images (> 6 months before EVAR, at the time of EVAR, and > 12 months after EVAR) of the patients were analysed to compare the progression of degeneration from before to after EVAR. Degeneration scores, lumbar levels with the most severe degeneration, and lumbar levels with progressive degeneration were analysed in all CT images. Fisher's exact test, Wilcoxon signed-rank test, and Mann-Whitney U test were performed for statistical analyses. RESULTS Compared with the control group (n = 94), the most severe degeneration was more commonly detected in the mid-lumbar area in the patient group (n = 100, p = 0.016), with significantly more endplate erosions being detected in the lumbar spine (p = 0.015). However, EVAR did not result in significant additional acceleration of the degenerative process in the long-term follow-up analysis (n = 51). CONCLUSION AAA is associated with atypical, more cranially located spinal degradation, particularly in the mid-lumbar segments; however, EVAR does not seem to additionally accelerate the degenerative process. This observation underlines the importance of disc and endplate vascularization in the pathomechanism of spinal degeneration. LEVEL OF EVIDENCE I Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.
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Gahier M, Hersant J, Hamel JF, Sempore Y, Bruneau A, Henni S, Abraham P. A Simple Scale for Screening Lower-Extremity Arterial Disease as a Possible Cause of Low Back Pain: a Cross-sectional Study Among 542 Subjects. J Gen Intern Med 2020; 35:1963-1970. [PMID: 32367389 PMCID: PMC7351938 DOI: 10.1007/s11606-020-05670-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/13/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Epidemiological, imaging, and anatomical studies suggest an association between proximal arterial atherosclerosis and development of low back pain (LBP). OBJECTIVES We aimed to define (1) the frequency and (2) factors associated with exercise-induced proximal ischemia (EIPI) in individuals with LBP and (3) develop a clinical screening scale. DESIGN Monocentric cross-sectional study. PARTICIPANTS All patients with history of ongoing LBP referred to our exercise investigation laboratory for exercise transcutaneous oximetry (ex-tcPO2) between January 2011 and December 2017 (n = 542; mean age, 65.4 ± 10.9; 83.9% men). MAIN MEASURES EIPI was defined as a decrease from rest of oxygen pressure (DROP) below - 15 mmHg on the lumbar and/or buttock probes. Ex-tcPO2 is a reliable validated tool for diagnosing EIPI in comparison with arteriography and computed tomography angiography. Ex-tcPO2 was performed on a treadmill until symptom manifestation or exhaustion. Clinical data were collected using interview questionnaires, medical file review, and clinical examination. KEY RESULTS EIPI was diagnosed in 282 patients (52%). Age ≤ 70 years (OR, 2.22; 95% CI, 1.35-3.57; p = 0.002), a history of proximal revascularization (OR, 2.64; 95% CI, 1.50-4.65; p = 0.001), use of antiplatelet medication (OR, 1.71; 95% CI, 0.96-3.06; p = 0.069), a relationship between exercise and LBP (OR, 2.61; 95% CI, 1.49-4.57; p = 0.001), and an abnormal ankle to brachial index (OR, 2.87; 95% CI, 1.77-4.66; p < 0.0001) were identified as EIPI predictors. Using these items, we developed a screening scale that showed an area under the receiver operating characteristics curve of .756. At a score of ≥ 3, the sensitivity, specificity, and accuracy for EIPI were 84%, 55%, and 71%, respectively. CONCLUSIONS EIPI was common among our patients with LBP undergoing ex-TcPO2. Our screening scale could help better select the patients who require angiography.
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Affiliation(s)
- M Gahier
- Sports Medicine and Exercise Investigations, University Hospital, Angers, France.
| | - J Hersant
- Vascular Medicine, University Hospital, Angers, France
| | - J F Hamel
- Methodology and Biostatistics Department, Angers University Hospital, Angers, France
| | - Y Sempore
- Sports Medicine and Exercise Investigations, University Hospital, Angers, France
| | - A Bruneau
- Sports Medicine and Exercise Investigations, University Hospital, Angers, France
| | - S Henni
- Vascular Medicine, University Hospital, Angers, France
- UMR INSERM 1083 - CNRS 6015, Angers University Hospital, Angers, France
| | - P Abraham
- Sports Medicine and Exercise Investigations, University Hospital, Angers, France
- Vascular Medicine, University Hospital, Angers, France
- UMR INSERM 1083 - CNRS 6015, Angers University Hospital, Angers, France
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The Association Between Atherosclerosis and Low Back Pain: A Systematic Review. PM R 2017; 9:1144-1156. [PMID: 28461227 DOI: 10.1016/j.pmrj.2017.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 04/08/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To assess the evidence of association between atherosclerosis and low back pain (LBP). TYPE: Focused systematic review. LITERATURE SURVEY PubMed, Web of Science, CINAHL, and EMBASE were searched for original research articles, not limited by language, from January 1, 1990, to October 31, 2016. METHODOLOGY Titles and then abstracts were identified using predefined search terms and excluded based on lack of relevancy. This was followed by full-text reviews. Two authors independently assessed methodological quality based on Cochrane Handbook for Systematic Reviews of Interventions. SYNTHESIS A total of 26 studies met the inclusion criteria. The quality of the studies was low to moderate. There was significant heterogeneity across articles with respect to methodology. There was insufficient evidence to support an association between ischemia and low back pain. CONCLUSIONS The cause of LBP remains poorly understood. Better insight into how intervertebral disk changes relate to LBP is needed to guide future research. High-quality prospective studies are needed to answer the question of whether atherosclerosis is a risk factor for LBP. LEVEL OF EVIDENCE II.
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Ha IH, Lee J, Kim MR, Kim H, Shin JS. The association between the history of cardiovascular diseases and chronic low back pain in South Koreans: a cross-sectional study. PLoS One 2014; 9:e93671. [PMID: 24751659 PMCID: PMC3994023 DOI: 10.1371/journal.pone.0093671] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 03/08/2014] [Indexed: 11/19/2022] Open
Abstract
Background Cardiovascular disease and related risk factors have been suggested as a mechanism leading to atherosclerosis of the lumbar vessels and consequent lumbar pain or sciatica. But there is continued controversy concerning its generalization. This study examined whether cardiovascular disease or its risk factors were associated with chronic low back pain (cLBP) in Koreans. Methods Health surveys and examinations were conducted on a nationally representative sample (n = 23,632) of Koreans. A total of 13,841 eligible participants (aged 20 to 89 years) were examined to determine the association between cardiovascular disease, the Framingham risk score, major cardiovascular risk factors (blood pressure, diabetes, cholesterol, and smoking habits) and chronic LBP. Results The total prevalence of cLBP was 16.6% (men: 10.8%, women: 21.1%) and that in patients with a history of cardiovascular diseases was 36.6% (men: 26.5%, women: 47.1%). The results showed that patients’ medical history of cardiovascular disease was significantly associated with cLBP in both men and women when adjusted for covariates (men: OR 2.16; 95%CI 1.34∼3.49; women: OR 2.26; 95%CI 1.51∼3.38). No association was observed between cLBP and the Framingham risk score, medication for hyperlipemia, hypertension, diabetes, and major cardiovascular risk factors (systolic blood pressure, total cholesterol, high density lipoprotein cholesterol, triglycerides, glucose and smoking habits) in either men or women. Conclusions The prevalence of cLBP is correlated to a history of cardiovascular disease, but not to the major cardiovascular risk factors from the Framingham study. Further studies on whether these results were affected by psychological factors in patients with a history of cardiovascular diseases or whether new potential risk factors from the artery atherosclerosis hypothesis applying to Koreans exist are needed.
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Affiliation(s)
- In-Hyuk Ha
- Jaseng Medical Foundation, Jaseng Hospital of Korean Medicine, Seoul, Republic of Korea
- Graduate School of Public Health & Institute of Health and Environment, Seoul National University, Gwanak-ro, Gwanak-gu, Seoul, Korea
- * E-mail:
| | - Jinho Lee
- Jaseng Medical Foundation, Jaseng Hospital of Korean Medicine, Seoul, Republic of Korea
- Department of Herbology, Graduate School of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Me-riong Kim
- Jaseng Medical Foundation, Jaseng Hospital of Korean Medicine, Seoul, Republic of Korea
| | - Hyejin Kim
- Jaseng Medical Foundation, Jaseng Hospital of Korean Medicine, Seoul, Republic of Korea
| | - Joon-Shik Shin
- Jaseng Medical Foundation, Jaseng Hospital of Korean Medicine, Seoul, Republic of Korea
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Kim NS, Kang SH, Park SY. Coexistence of expanding abdominal aortic aneurysm and aggravated intervertebral disc extrusion -a case report-. Korean J Anesthesiol 2013; 65:345-8. [PMID: 24228150 PMCID: PMC3822029 DOI: 10.4097/kjae.2013.65.4.345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 12/18/2012] [Accepted: 12/30/2012] [Indexed: 11/10/2022] Open
Abstract
Abdominal aortic aneurysm is included in the differential diagnosis of lower back pain. Although rare, this important disease can cause potentially lethal complications. In this case, expanding abdominal aortic aneurysm coexisted with intervertebral disc extrusion. The diagnosis of abdominal aortic aneurysm was delayed, putting the patient at risk of aneurysmal rupture. In the management of patients with degenerative spinal diseases, we should not overlook the possibility of comorbidities such as an abdominal aortic aneurysm. We also suggest the importance of interpreting images more carefully, especially for elderly male patients.
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Affiliation(s)
- Nan Seol Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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Tsuchie H, Miyakoshi N, Kasukawa Y, Nishi T, Abe H, Takeshima M, Shimada Y. High prevalence of abdominal aortic aneurysm in patients with chronic low back pain. TOHOKU J EXP MED 2013; 230:83-86. [PMID: 23759898 DOI: 10.1620/tjem.230.83] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Low back pain (LBP) is one of the most common symptoms in outpatient clinics, and abdominal aortic aneurysm (AAA) is one of the causes of LBP. In the present study, we examined the prevalence of chronic LBP in patients with aortic aneurysm. The study included 23 patients with AAA and 23 patients with thoracic aortic aneurysm (TAA); all of them visited a regional center hospital in Akita, Japan. A total of 207 hypertension patients were also enrolled as a control. Chronic LBP was defined in patients who visited the orthopedic outpatient clinic for the LBP treatment for more than three months. The prevalence of chronic LBP in the AAA group (52.2%) was significantly higher than that in the TAA (17.4%, P < 0.05) or hypertension patients (11.6%, P < 0.01). The rate of a trigger point (TP) injection was significantly higher in the AAA group or the TAA group than that in hypertension patients (P < 0.01, P < 0.05), but there was no significant difference between the AAA and TAA groups. The TP injection represents an injection of local anesthesia to the low back muscles. We also evaluated the involvement of various factors in LBP caused by AAA, such as age, gender, blood pressure, the existence of dissection, and the maximum diameter of AAA, but none of them showed significant relationship to LBP. The prevalence of LBP is high in AAA patients, and doctors who treat chronic LBP should be aware of AAA as a potential cause of LBP.
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Shi S, Wang C, Yuan W, Wang X, Zhou X. Potential prevention: Orally administered statins may retard the pathologic process of disc degeneration. Med Hypotheses 2011; 76:125-7. [DOI: 10.1016/j.mehy.2010.08.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Revised: 08/26/2010] [Accepted: 08/28/2010] [Indexed: 11/30/2022]
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Heuch I, Heuch I, Hagen K, Zwart JA. Associations Between Serum Lipid Levels and Chronic Low Back Pain. Epidemiology 2010; 21:837-41. [DOI: 10.1097/ede.0b013e3181f20808] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kauppila L. Atherosclerosis and Disc Degeneration/Low-Back Pain – A Systematic Review. Eur J Vasc Endovasc Surg 2009; 37:661-70. [DOI: 10.1016/j.ejvs.2009.02.006] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Accepted: 02/17/2009] [Indexed: 10/21/2022]
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