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Wesselink EO, Pool-Goudzwaard A, De Leener B, Law CSW, Fenyo MB, Ello GM, Coppieters MW, Elliott JM, Mackey S, Weber KA. Investigating the associations between lumbar paraspinal muscle health and age, BMI, sex, physical activity, and back pain using an automated computer-vision model: a UK Biobank study. Spine J 2024; 24:1253-1266. [PMID: 38417587 DOI: 10.1016/j.spinee.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/06/2024] [Accepted: 02/18/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND CONTEXT The role of lumbar paraspinal muscle health in back pain (BP) is not straightforward. Challenges in this field have included the lack of tools and large, heterogenous datasets to interrogate the association between muscle health and BP. Computer-vision models have been transformative in this space, enabling the automated quantification of muscle health and the processing of large datasets. PURPOSE To investigate the associations between lumbar paraspinal muscle health and age, sex, BMI, physical activity, and BP in a large, heterogenous dataset using an automated computer-vision model. DESIGN Cross-sectional study. PATIENT SAMPLE Participants from the UK Biobank with abdominal Dixon fat-water MRI (N=9,564) were included (41.8% women, mean [SD] age: 63.5 [7.6] years, BMI: 26.4 [4.1] kg/m2) of whom 6,953 reported no pain, 930 acute BP, and 1,681 chronic BP. OUTCOME MEASURES Intramuscular fat (IMF) and average cross-sectional area (aCSA) were automatically derived using a computer-vision model for the left and right lumbar multifidus (LM), erector spinae (ES), and psoas major (PM) from the L1 to L5 vertebral levels. METHODS Two-tailed partial Pearson correlations were generated for each muscle to assess the relationships between the muscle measures (IMF and aCSA) and age (controlling for BMI, sex, and physical activity), BMI (controlling for age, sex, and physical activity), and physical activity (controlling for age, sex, and BMI). One-way ANCOVA was used to identify sex differences in IMF and aCSA for each muscle while controlling for age, BMI, and physical activity. Similarly, one-way ANCOVA was used to identify between-group differences (no pain, acute BP, and chronic BP) for each muscle and along the superior-inferior expanse of the lumbar spine while controlling for age, BMI, sex, and physical activity (α=0.05). RESULTS Females had higher IMF (LM mean difference [MD]=11.1%, ES MD=10.2%, PM MD=0.3%, p<.001) and lower aCSA (LM MD=47.6 mm2, ES MD=350.0 mm2, PM MD=321.5 mm2, p<.001) for all muscles. Higher age was associated with higher IMF and lower aCSA for all muscles (r≥0.232, p<.001) except for LM and aCSA (r≤0.013, p≥.267). Higher BMI was associated with higher IMF and aCSA for all muscles (r≥0.174, p<.001). Higher physical activity was associated with lower IMF and higher aCSA for all muscles (r≥0.036, p≤.002) except for LM and aCSA (r≤0.010, p≥.405). People with chronic BP had higher IMF and lower aCSA than people with no pain (IMF MD≤1.6%, aCSA MD≤27.4 mm2, p<.001) and higher IMF compared to acute BP (IMF MD≤1.1%, p≤.044). The differences between people with BP and people with no pain were not spatially localized to the inferior lumbar levels but broadly distributed across the lumbar spine. CONCLUSIONS Paraspinal muscle health is associated with age, BMI, sex, and physical activity with the exception of the association between LM aCSA and age and physical activity. People with BP (chronic>acute) have higher IMF and lower aCSA than people reporting no pain. The differences were not localized but broadly distributed across the lumbar spine. When interpreting measures of paraspinal muscle health in the research or clinical setting, the associations with age, BMI, sex, and physical activity should be considered.
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Affiliation(s)
- Evert Onno Wesselink
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 9, 1081 BT Amsterdam, The Netherlands; Division of Pain Medicine, Department of Anaesthesiology, Perioperative and Pain Medicine, Stanford University, 1070 Arastradero Road, Palo Alto, CA 94304, USA.
| | - Annelies Pool-Goudzwaard
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 9, 1081 BT Amsterdam, The Netherlands; SOMT University of Physiotherapy, Softwareweg 5, 3821 BN Amersfoort, the Netherlands
| | - Benjamin De Leener
- Department of Computer Engineering and Software Engineering, Polytechnique Montreal, 2900 Edouard Montpetit Blvd, Quebec H3T 1J4, Canada
| | - Christine Sze Wan Law
- Division of Pain Medicine, Department of Anaesthesiology, Perioperative and Pain Medicine, Stanford University, 1070 Arastradero Road, Palo Alto, CA 94304, USA
| | - Meredith Blair Fenyo
- Division of Pain Medicine, Department of Anaesthesiology, Perioperative and Pain Medicine, Stanford University, 1070 Arastradero Road, Palo Alto, CA 94304, USA
| | - Gabriella Marie Ello
- Division of Pain Medicine, Department of Anaesthesiology, Perioperative and Pain Medicine, Stanford University, 1070 Arastradero Road, Palo Alto, CA 94304, USA
| | - Michel Willem Coppieters
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 9, 1081 BT Amsterdam, The Netherlands; School of Health Sciences and Social Work, Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, 170 Kessels Road, 4111 Brisbane, Australia
| | - James Matthew Elliott
- The University of Sydney, Faculty of Medicine and Health and the Northern Sydney Local Health District, The Kolling Institute, Reserve Road, St Leonards NSW Sydney 2065, Australia
| | - Sean Mackey
- Division of Pain Medicine, Department of Anaesthesiology, Perioperative and Pain Medicine, Stanford University, 1070 Arastradero Road, Palo Alto, CA 94304, USA
| | - Kenneth Arnold Weber
- Division of Pain Medicine, Department of Anaesthesiology, Perioperative and Pain Medicine, Stanford University, 1070 Arastradero Road, Palo Alto, CA 94304, USA
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Wesselink E, Elliott J, Pool-Goudzwaard A, Coppieters M, Pevenage P, Di Ieva A, Weber II K. Quantifying lumbar paraspinal intramuscular fat: Accuracy and reliability of automated thresholding models. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 17:100313. [PMID: 38370337 PMCID: PMC10869289 DOI: 10.1016/j.xnsj.2024.100313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 02/20/2024]
Abstract
Background The reported level of lumbar paraspinal intramuscular fat (IMF) in people with low back pain (LBP) varies considerably across studies using conventional T1- and T2-weighted magnetic resonance imaging (MRI) sequences. This may be due to the different thresholding models employed to quantify IMF. In this study we investigated the accuracy and reliability of established (two-component) and novel (three-component) thresholding models to measure lumbar paraspinal IMF from T2-weighted MRI. Methods In this cross-sectional study, we included MRI scans from 30 people with LBP (50% female; mean (SD) age: 46.3 (15.0) years). Gaussian mixture modelling (GMM) and K-means clustering were used to quantify IMF bilaterally from the lumbar multifidus, erector spinae, and psoas major using two and three-component thresholding approaches (GMM2C; K-means2C; GMM3C; and K-means3C). Dixon fat-water MRI was used as the reference for IMF. Accuracy was measured using Bland-Altman analyses, and reliability was measured using ICC3,1. The mean absolute error between thresholding models was compared using repeated-measures ANOVA and post-hoc paired sample t-tests (α = 0.05). Results We found poor reliability for K-means2C (ICC3,1 ≤ 0.38), moderate to good reliability for K-means3C (ICC3,1 ≥ 0.68), moderate reliability for GMM2C (ICC3,1 ≥ 0.63) and good reliability for GMM3C (ICC3,1 ≥ 0.77). The GMM (p < .001) and three-component models (p < .001) had smaller mean absolute errors than K-means and two-component models, respectively. None of the investigated models adequately quantified IMF for psoas major (ICC3,1 ≤ 0.01). Conclusions The performance of automated thresholding models is strongly dependent on the choice of algorithms, number of components, and muscle assessed. Compared to Dixon MRI, the GMM performed better than K-means and three-component performed better than two-component models for quantifying lumbar multifidus and erector spinae IMF. None of the investigated models accurately quantified IMF for psoas major. Future research is needed to investigate the performance of thresholding models in a more heterogeneous clinical dataset and across different sites and vendors.
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Affiliation(s)
- E.O. Wesselink
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences – Program Musculoskeletal Health, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - J.M. Elliott
- The University of Sydney, Faculty of Medicine and Health and the Northern Sydney Local Health District, The Kolling Institute, Sydney, Australia
| | - A. Pool-Goudzwaard
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences – Program Musculoskeletal Health, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- SOMT University of Physiotherapy, Amersfoort, The Netherlands
| | - M.W. Coppieters
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences – Program Musculoskeletal Health, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Menzies Health Institute Queensland, School of Health Sciences and Social Work, Griffith University, Brisbane and Gold Coast, Australia
| | | | - A. Di Ieva
- Computational Neurosurgery (CNS) Lab, Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Level 1, 75 Talavera Road, Sydney, NSW 2109, Australia
| | - K.A. Weber II
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
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Tieppo Francio V, Westerhaus BD, Carayannopoulos AG, Sayed D. Multifidus dysfunction and restorative neurostimulation: a scoping review. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1341-1354. [PMID: 37439698 PMCID: PMC10690869 DOI: 10.1093/pm/pnad098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/14/2023] [Accepted: 07/10/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVE Chronic low back pain (CLBP) is multifactorial in nature, with recent research highlighting the role of multifidus dysfunction in a subset of nonspecific CLBP. This review aimed to provide a foundational reference that elucidates the pathophysiological cascade of multifidus dysfunction, how it contrasts with other CLBP etiologies and the role of restorative neurostimulation. METHODS A scoping review of the literature. RESULTS In total, 194 articles were included, and findings were presented to highlight emerging principles related to multifidus dysfunction and restorative neurostimulation. Multifidus dysfunction is diagnosed by a history of mechanical, axial, nociceptive CLBP and exam demonstrating functional lumbar instability, which differs from other structural etiologies. Diagnostic images may be used to grade multifidus atrophy and assess other structural pathologies. While various treatments exist for CLBP, restorative neurostimulation distinguishes itself from traditional neurostimulation in a way that treats a different etiology, targets a different anatomical site, and has a distinctive mechanism of action. CONCLUSIONS Multifidus dysfunction has been proposed to result from loss of neuromuscular control, which may manifest clinically as muscle inhibition resulting in altered movement patterns. Over time, this cycle may result in potential atrophy, degeneration and CLBP. Restorative neurostimulation, a novel implantable neurostimulator system, stimulates the efferent lumbar medial branch nerve to elicit repetitive multifidus contractions. This intervention aims to interrupt the cycle of dysfunction and normalize multifidus activity incrementally, potentially restoring neuromuscular control. Restorative neurostimulation has been shown to reduce pain and disability in CLBP, improve quality of life and reduce health care expenditures.
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Affiliation(s)
- Vinicius Tieppo Francio
- Department of Physical Medicine & Rehabilitation, The University of Kansas Medical Center, Kansas City, KS 66160, United States
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, United States
| | - Benjamin D Westerhaus
- Cantor Spine Institute at the Paley Orthopedic & Spine Institute, West Palm Beach, FL 33407, United States
| | - Alexios G Carayannopoulos
- Department of Neurosurgery and Neurology, Warren Alpert Medical School of Brown University, Providence, RI 02903, United States
| | - Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, United States
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Han G, Jiang Y, Zhang B, Gong C, Li W. Imaging Evaluation of Fat Infiltration in Paraspinal Muscles on MRI: A Systematic Review with a Focus on Methodology. Orthop Surg 2021; 13:1141-1148. [PMID: 33942525 PMCID: PMC8274185 DOI: 10.1111/os.12962] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/16/2022] Open
Abstract
Purpose Numerous studies have applied a variety of methods to assess paraspinal muscle degeneration. However, the methodological differences in imaging evaluation may lead to imprecise or inconsistent results. This article aimed to provide a pragmatic summary review of the current imaging modalities, measurement protocols, and imaging parameters in the evaluation of paraspinal muscle fat infiltration (FI) in MRI studies. Methods Web of Science, EMBASE, and PubMed were searched from January 2005 to March 2020 to identify studies that examined the FI of paraspinal muscles on MRI among patients with lumbar degenerative diseases. Results Intramyocellular lipids measured by magnetic resonance spectroscopy and FI measured by chemical‐shift MRI were both correlated to low back pain and several degenerative lumbar diseases, whereas results on the relationship between FI and degenerative lumbar pathologies using conventional MRI were conflicting. Multi‐segment measurement of FI at the lesion segment and adjacent segments could be a prognostic indicator for lumbar surgery. Most studies adopted the center of the intervertebral disc or endplate as the level of slice to evaluate the FI. Compared with visual semiquantitative assessment, quantitative parameters appeared to be precise for eliminating individual or modality differences. It has been demonstrated that fat CSA/total CSA (based on area) and muscle–fat index (based on signal intensity) as quantitative FI parameters are associated with multiple lumbar diseases and clinical outcomes after surgery. Conclusion Having a good command of the methodology of paraspinal muscle FI on MRI was effective for diagnosis and prognosis in clinical practice.
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Affiliation(s)
- Gengyu Han
- Third Hospital Orthopaedics Department, Beijing Key Laboratory of Spinal Disease Research, Peking University, Beijing, China
| | - Yu Jiang
- Third Hospital Orthopaedics Department, Beijing Key Laboratory of Spinal Disease Research, Peking University, Beijing, China
| | - Bo Zhang
- Peking University Health Science Center, Beijing, China
| | - Chunjie Gong
- Peking University Health Science Center, Beijing, China
| | - Weishi Li
- Third Hospital Orthopaedics Department, Beijing Key Laboratory of Spinal Disease Research, Peking University, Beijing, China
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Agha O, Mueller‐Immergluck A, Liu M, Zhang H, Theologis AA, Clark A, Kim HT, Liu X, Feeley BT, Bailey JF. Intervertebral disc herniation effects on multifidus muscle composition and resident stem cell populations. JOR Spine 2020; 3:e1091. [PMID: 32613166 PMCID: PMC7323461 DOI: 10.1002/jsp2.1091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 04/14/2020] [Accepted: 04/19/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Paraspinal muscles are crucial for vertebral stabilization and movement. These muscles are prone to develop fatty infiltration (FI), fibrosis, and atrophy in many spine conditions. Fibro-adipogenic progenitors (FAPs), a resident muscle stem cell population, are the main contributors of muscle fibrosis and FI. FAPs are involved in a complex interplay with satellite cells (SCs), the primary myogenic progenitor cells within muscle. Little is known about the stem cell composition of the multifidus. The aim of this study is to examine FAPs and SCs in the multifidus in disc herniation patients. Multifidus muscle samples were collected from 10 patients undergoing decompressive spine surgery for lumbar disc herniation. Hamstring muscle was collected from four patients undergoing hamstring autograft ACL reconstruction as an appendicular control. Multifidus tissue was analyzed for FI and fibrosis using Oil-Red-O and Masson's trichrome staining. FAPs and SCs were visualized using immunostaining and quantified with fluorescence-activated cell sorting (FACS) sorting. Gene expression of these cells from the multifidus were analyzed with reverse transcription-polymerase chain reaction and compared to those from hamstring muscle. FI and fibrosis accounted for 14.2%± 7.4% and 14.8%±4.2% of multifidus muscle, respectively. The multifidus contained more FAPs (11.7%±1.9% vs 1.4%±0.2%; P<.001) and more SCs (3.4%±1.6% vs 0.08%±0.02%; P=.002) than the hamstring. FAPs had greater α Smooth Muscle Actin (αSMA) and adipogenic gene expression than FAPs from the hamstring. SCs from the multifidus displayed upregulated expression of stem, proliferation, and differentiation genes. CONCLUSION The multifidus in patients with disc herniation contains large percentages of FAPs and SCs with different gene expression profiles compared to those in the hamstring. These results may help explain the tendency for the multifidus to atrophy and form FI and fibrosis as well as elucidate potential approaches for mitigating these degenerative changes by leveraging these muscle stem cell populations.
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Affiliation(s)
- Obiajulu Agha
- Department of Orthopaedic SurgeryUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Department of Orthopaedic SurgerySan Francisco Veterans Affair Health Care SystemSan FranciscoCaliforniaUSA
| | - Andreas Mueller‐Immergluck
- Department of Orthopaedic SurgeryUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Department of Orthopaedic SurgerySan Francisco Veterans Affair Health Care SystemSan FranciscoCaliforniaUSA
| | - Mengyao Liu
- Department of Orthopaedic SurgeryUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Department of Orthopaedic SurgerySan Francisco Veterans Affair Health Care SystemSan FranciscoCaliforniaUSA
| | - He Zhang
- Department of Orthopaedic SurgeryUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Department of Orthopaedic SurgerySan Francisco Veterans Affair Health Care SystemSan FranciscoCaliforniaUSA
- Department of Exercise PhysiologyBeijing Sport UniversityBeijingChina
| | - Alekos A. Theologis
- Department of Orthopaedic SurgeryUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Department of Orthopaedic SurgerySan Francisco Veterans Affair Health Care SystemSan FranciscoCaliforniaUSA
| | - Aaron Clark
- Department of NeurosurgeryUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Hubert T. Kim
- Department of Orthopaedic SurgeryUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Department of Orthopaedic SurgerySan Francisco Veterans Affair Health Care SystemSan FranciscoCaliforniaUSA
| | - Xuhui Liu
- Department of Orthopaedic SurgeryUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Department of Orthopaedic SurgerySan Francisco Veterans Affair Health Care SystemSan FranciscoCaliforniaUSA
| | - Brian T. Feeley
- Department of Orthopaedic SurgeryUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Department of Orthopaedic SurgerySan Francisco Veterans Affair Health Care SystemSan FranciscoCaliforniaUSA
| | - Jeannie F. Bailey
- Department of Orthopaedic SurgeryUniversity of CaliforniaSan FranciscoCaliforniaUSA
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Hofste A, Soer R, Hermens HJ, Wagner H, Oosterveld FGJ, Wolff AP, Groen GJ. Inconsistent descriptions of lumbar multifidus morphology: A scoping review. BMC Musculoskelet Disord 2020; 21:312. [PMID: 32429944 PMCID: PMC7236939 DOI: 10.1186/s12891-020-03257-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/31/2020] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Anke Hofste
- Anesthesiology Pain Center, University of Groningen, University Medical Center Groningen, Location Beatrixoord, Dilgtweg 5, Haren, the Netherlands. .,Faculty of Physical Activity and Health, Saxion University of Applied Sciences, Enschede, the Netherlands.
| | - Remko Soer
- Anesthesiology Pain Center, University of Groningen, University Medical Center Groningen, Location Beatrixoord, Dilgtweg 5, Haren, the Netherlands.,Faculty of Physical Activity and Health, Saxion University of Applied Sciences, Enschede, the Netherlands
| | - Hermie J Hermens
- Department of Biomedical Signals & Systems, Faculty of Electrical Engineering, Mathematics and Computer Science, University of Twente, Enschede, the Netherlands.,Telemedicine Group, Roessingh Research and Development, Enschede, the Netherlands
| | - Heiko Wagner
- Department of Movement Science, Institute of Sport and Exercise Sciences, Münster, Germany
| | - Frits G J Oosterveld
- Faculty of Physical Activity and Health, Saxion University of Applied Sciences, Enschede, the Netherlands
| | - André P Wolff
- Anesthesiology Pain Center, University of Groningen, University Medical Center Groningen, Location Beatrixoord, Dilgtweg 5, Haren, the Netherlands
| | - Gerbrand J Groen
- Anesthesiology Pain Center, University of Groningen, University Medical Center Groningen, Location Beatrixoord, Dilgtweg 5, Haren, the Netherlands
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Hou X, Lu S, Wang B, Kong C, Hu H. Morphologic Characteristics of the Deep Cervical Paraspinal Muscles in Patients with Single-Level Cervical Spondylotic Myelopathy. World Neurosurg 2020; 134:e166-e171. [DOI: 10.1016/j.wneu.2019.09.162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 09/29/2019] [Accepted: 09/30/2019] [Indexed: 10/25/2022]
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