The lumbar disc and low back pain.

The lumbar disc serves to sustain compression loads and is subject to tension and shear in forward bending and rotation. Its outer third is innervated and can be a source of pain. The annulus fibrosus may be injured in rotation and flexion of the lumbar spine and may become symptomatic as a ligamentous injury. Compression injuries of the disc are initially asymptomatic but may set in train a degradative process that, in time, leads to internal disc disruption, which becomes symptomatic as a result of chemical or mechanical irritation of nociceptors in the annulus fibrosus. Disc prolapse is but one possible end stage of internal disc disruption and represents the culmination of a series of destructive processes affecting the disc. This condition can be symptomatic while the external appearance of the disc remains normal and before nerve roots are affected in any way.     

Morphometry of the lower lumbar vertebrae in patients with and without low back pain

The authors made several measurements in the lower lumbar vertebrae of patients with and without low back pain. Our objective was to determine the allometric relationships between different dimensions of the lumbar canal, the effects on these from degenerative disease, and differences between the symptomatic and asymptomatic populations. We compared 119 patients suffering from low back and sciatic pain and 39 subjects without lumbar symptoms as determined by computed tomography (CT). The following measurements were made: sagittal diameter of the canal, interpedicular distance, interarticular distance, and anteroposterior diameter of lateral recess and foramen. With respect to the patients with lumbar pain, the asymptomatic group proved to have wider foramina from L3 to L5 and wider sagittal diameters in S1. The patients with canal stenosis revealed lower figures for all diameters of the central canal, lateral recess of L4, and foramina of L4 and L5. Patients with lumbarization showed smaller diameters of the central canal. CONCLUSION: There is an allometric relationship between the dimensions of the central canals. This relationship is less evident with lateral canals. The patients without lumbar symptoms had wider foramina and sagittal diameters in S1 than those with lumbar symptoms. Of these, patients who developed symptoms of canal stenosis demonstrated smaller diameters in central and lateral canals. Of the developmental anomalies, lumbarization proved to be associated with canal stenosis due to smaller diameters of the central canals.     

Serial lumbar dynamometry in low back pain.

To determine the significance of changes in motor performance as measured by lumbar dynamometry, serial lumbar dynamometry was performed on a group of 45 male Workers' Compensation patients with chronic "mechanical" low back pain and in a group of 20 healthy male volunteers. The patients were men aged 20-60 years, whose current episode of low back pain had lasted for at least 3 months (mean 19.5 weeks, range 12-47 weeks). Testing was performed at entry into a "back school" program of therapy and again 2 weeks and 4 weeks later. The control group showed a slight improvement in almost all variables of strength and range of motion between the first and second tests but no significant change between the second and third tests. This was consistent with a learning effect. The patient group was analyzed as a whole and also in two groups based on their response to the Waddell maneuvers at entry: Waddell score 0-2 (no excessive illness behavior) and 3-5 (excessive illness behavior). As a whole, the patients showed significant progressive improvement in most variables on successive tests. The group with the low Waddell score had significantly greater strength and range of motion than the group with the high Waddell score but the trend of improvement with time was similar in the two groups. The authors conclude that in this sample of patients with low back pain, serial lumbar dynamometry reveals a progressive improvement in performance, which is greater than the improvement expected from the natural history of physical recovery and greater than the improvement expected from an increase in strength and range of motion attributable to the therapeutic exercises performed and is much larger than any learning effect related to the test procedure.     

The relationship between degree of facet tropism and amount of dynamic disc bulge in lumbar spine of patients symptomatic for low back pain

Facet tropism has been investigated as a predisposing factor for degenerative changes in the lumbar spine; however, no prior study has evaluated the relationship between disc bulge and facet tropism. In this study, we used kinetic magnetic resonance imaging (kMRI) to investigate the association between degree of facet tropism and amount of disc bulge in the lumbar spine in relation to age. kMRIs in the flexion, neutral, and extension positions were performed on 410 consecutive patients with low back pain. T2-weighted midsagittal and axial mid-disc cuts were analyzed to measure disc bulge and facet angle. Facet asymmetry was calculated and classified as: no facet tropism, <6°; mild facet tropism, 6–11°; or severe facet tropism, ≥11°. Maximal static bulge (MSB), maximal dynamic bulge (MDB), and age in the facet tropism groups were compared by age subpopulations and MDB categories, defined by the positions between which the largest change in disc bulge occurs. We found the severe facet tropism group to be associated with a nearly significant increase in MSB and MDB over the no facet tropism group in the older subpopulation at the L4–L5 level only, and a larger MDB in the L4–L5 MDB category [E–N], where the greatest change in disc bulge occurs between neutral and extension positions (p = 0.013). Our findings suggest that severe facet tropism is associated with increased disc bulge at L4–L5 in only a subset of older age patients, but may in large part be due to biomechanical factors that define the [E–N] category.     

The crunch factor's role in golf-related low back pain

Background contextThe golf swing exposes the spine to complex torsional, compressive, and shearing loads that increase a player's risk of injury. The crunch factor (CF) has been described as a measure to evaluate the risk of low back injuries in golfers and is based on the notion that lateral flexion and axial trunk rotation jointly contribute to spinal degeneration. However, few studies have evaluated the appropriateness of this measure in golfers with low back pain (LBP).PurposeTo objectively examine the usefulness of the CF as a measure for assessing the risk of low back injury in golfers.Study designField-based research using a cross-sectional design.MethodsThis research used three-dimensional motion analysis to assess the golf swings of 12 golfers with LBP and 15 asymptomatic controls. Three-dimensional kinematics were derived using Vicon Motus, and the CF was calculated as the instantaneous product of axial trunk rotation velocity and lateral trunk flexion angle.ResultsMaximum CFs and their timings were not significantly different between the symptomatic and asymptomatic groups. Furthermore, for those golfers who produced higher CFs (irrespective of the group), the increased magnitude could not be attributed to an increased axial angular trunk velocity or lateral flexion angle, but rather to a concomitant increase in both of these variables.ConclusionsThe findings suggested that although the fundamental concepts that underpin the CF seem sensible, this measure does not appear to be sensitive enough to distinguish golfers with LBP from the asymptomatic players.     

Radiologic abnormalities and low back pain in elite skiers

Lumbar radiographs of 120 adolescent elite skiers were evaluated for radiologic abnormalities by two independent observers. All athletes had no symptoms before the study. Radiographs were taken before enrollment of the students in elite level training. To determine the clinical significance of these abnormalities, all athletes were observed prospectively during the subsequent 2-year period for development of low back pain under high performance training. Anterior end plate lesions, Schmorl's nodes, posterior end plate lesions, spondylolysis, scoliosis, and spina bifida occulta were found. The depth of anterior end plate lesions showed a two-peak distribution, with peaks at 11% and 22% and a valley at 18% vertebral body height. The overall low back pain incidence was 12.5%. Students with severe anterior lesions (greater than 18% vertebral body height, n = 25) had significantly more low back pain (incidence, 32%) than did students without severe anterior lesions (incidence, 7.4%). Accordingly, students with severe anterior lesions had a significantly higher risk of having low back pain develop. Moderate end plate lesions and other abnormalities were not related to an increased incidence of low back pain. Adolescent students of elite sports with severe lumbar anterior end plate lesions have an increased risk of having low back pain develop under high performance training.     

应用椎间盘造影判断腰椎间盘突出症腰痛的来源

[目的]应用椎间盘造影术探讨腰椎间盘突出症患者临床腰痛来源.[方法]137例椎间盘突出症患者根据造影术前MRI表现将椎间盘分为:正常、突出和退变.患者腰痛和腿痛的严重程度应用疼痛视觉模拟评分(VAS评分)判定,分为三组:(1)腰痛为主组;(2)腿痛为主组;(3)腰腿痛并重组.对所有退变的腰椎间盘及至少1个作对照的正常椎间盘进行椎间盘造影检查,如造影过程中诱发一致性腰痛,即认为椎间盘造影阳性.[结果]137例患者总共427个椎间盘行造影检查,其中104个造影阳性.椎间盘造影阳性患者腰痛与腿痛VAS评分无明显差异(P＞0.05),而阴性者腿痛评分高于腰痛评分(P＜0.05).腰痛为主组,腿痛为主组,腰腿痛并重组其造影阳性率分别为79.2%,18.6%,71. 7%.MRI表现为正常、突出和退变的椎间盘其造影阳性率分别是1.4%、48.3%、21.6%(P＜0.05).[结论]盘源性腰痛可能是腰痛明显的椎间盘突出症患者腰痛的主要原因,这种腰痛主要来源于椎间盘突出节段和或邻近退变节段.     

Reliability of lumbar dynamometry measurements in patients with chronic low back pain with test-retest measurements on different days

Lumbar dynamometry is a potentially useful method for assessing the state of trunk muscles in low back pain (LBP) patients. The purpose of this study was to assess the reliability of lumbar dynamometry measurements in chronic LBP patients by conducting test-retest measurements on different days. Thirtyone men and 14 women with chronic LBP participated in this study. The experiments consisted of three sets of lumbar dynamometry measurements (Isostation B200) carried out on three different days with a 2- to 3-day interval. A standard protocol was administered to all subjects, consisting of a range-of-motion measurement about each axis, a 5 s maximum isometric trial about each axis and five dynamic repetitions about each axis against a resistance set at 25% and at 50% of the maximum isometric torque. Correlation coefficients and regression analysis were used to detect possible learning effects. One-way anova and regression analysis were used to assess the reliability of the measurements. High coefficients were found for the correlation between the first and second lumbar dynamometry measurements. Regression analysis showed that the differences between those measurements were not significant. This means that there was no learning effect operating between the first and second lumbar dynamometry measurements. One-way anova showed a reliability higher than 0.90 for the torque and velocity parameters. Reliability for the range-of-motion parameters was somewhat lower: between 0.76 and 0.94. Regression analysis showed no significant differences between the second and third measurements for the torque and velocity parameters. For range-of-motion parameters significant differences were found. From this study it can be concluded that the Isostation B200 provides reliable measures of torque and velocity parameters, but measures of the range-of-motion parameters are unreliable. No learning effect operates between the first and second lumbar dynamometry measurements, which means that a single measurement, with prior warming up and practice, is sufficient to assess the performance of the LBP patient.     

雷火灸对原发性骨质疏松症腰背疼痛患者自发性脑活动影响的观察

目的采用静息态功能磁共振(RS-fMRI)观察雷火灸干预原发性骨质疏松症腰背疼痛患者自发性脑活动的影响,并分析自发性脑活动与疼痛改善的相关性。方法入组原发性骨质疏松症腰背痛患者18例,给予雷火灸治疗,取穴肝俞、肾俞、大肠俞、命门、腰阳关,每组腧穴治疗30 min,每周3次,隔日1次,持续4周。治疗4周前后采用视觉模拟评分(VAS)和RS-fMRI进行评估。结果 (1)VAS治疗后较治疗前显著改善(P0.05);(2)与治疗前比较,治疗后以左侧岛叶、左侧颞下回、左侧海马为代表的脑区低频振幅(ALFF)值显著降低,且ALFF值与VAS评分差值具有显著正相关。结论雷火灸治疗能缓解原发性骨质疏松症(POP)患者慢性腰背疼痛,其调节自发性脑活动可能是重要的作用机制之一。     

The role of fusion for chronic low back pain

The demonstration of a rich nerve supply in the outer half of the disc and the occurrence of deep pain referred from the vertebral column to the leg without nerve root compression are both important aspects in understanding low back pain and in making a decision regarding its surgical management. Discography is invaluable as a diagnostic test in patients with chronic back pain if one is to demonstrate discogenic lesions. For sufferers of postlaminectomy syndrome, a difficult patient group, a simultaneous combined anterior and posterior fusion offers a real hope for relief of pain and rehabilitation.     

Changes in lumbar lordosis in young patients with low back pain during a 10-year period

 Height and muscle strength have reportedly changed among Japanese youth during the past 10 years. Height has increased, and the back muscles have become weaker than 10 years ago. We compared the lumbar lordosis of youth today (113 men and 76 women) and of 10 years ago (85 men and 62 women). Lumbar lordosis and sacral inclination were measured on lateral standing radiographs of the lumbar spine. We also measured the same parameters among adults today (63 men and 63 women) and 10 years ago (56 men and 73 women) to study postural changes in another generation. In both men and women, the lumbar lordosis and the sacral inclination of youth today were approximately 10° larger than they were 10 years ago (P < 0.0001). However, there was no significant difference between the values among adults today and those of the same generation 10 years ago. Received: March 25, 2002 / Accepted: June 12, 2002 Offprint requests to: Y. Murata, Linnégatan 45, Apartment nr: 107 SE-413 08 Gothenburg, Sweden     

Predictors of isokinetic back muscle strength in patients with low back pain

STUDY DESIGN: Testing for trunk muscle strength was performed on 105 patients with chronic low back pain. OBJECTIVES: To investigate prediction of isokinetic back muscle strength in patients with low back pain. SUMMARY OF BACKGROUND DATA: The clinical evaluation of patients with chronic low back pain often in difficult because of discrepancy between disability and impairment. The isokinetic trunk device was developed as a tool for objective assessment of back muscle strength. However, the performance of patients depends on radiologic abnormalities of the spine, conditions of the back muscles, and various psychosocial factors. Studies are warranted that address how these variables influence back muscle strength. METHODS: The patients with chronic low back pain were tested by an isokinetic trunk muscle strength test (Cybex TEF, Ronkonkoma, NY). In addition, the following variables were recorded: gender, age, body mass index, emotional distress, pain on exertion, self-efficacy for pain, degenerative changes of the lumbar spine, cross-sectional area, and density of the erector spinae muscles. The three latter variables were estimated by computed tomography scans. The sum of the total work performed during isokinetic extension strength test was the dependent variable in a multiple regression analysis, and anthropometric, demographic, psychological, and radiologic factors were independent variables. RESULTS: Gender, cross-sectional muscle area, and pain on exertion were the most powerful predictors of isokinetic back muscle strength. The final regression model, which included these variables, could account for approximately 40% of the variability in back muscle strength. CONCLUSION: For assessing the results of an isokinetic trunk muscle strength test, cross-sectional muscle area, gender, and pain on exertion should be taken into account.     

不同年龄非特异性腰痛患者腰椎曲度相关因素分析

目的 分析不同年龄段非特异性腰痛患者人口学因素、临床特征及竖脊肌形态与腰椎曲度的相关性.方法 选取2016年1月—2019年12月首都医科大学附属北京安贞医院和国家电网北京电力医院收治的临床影像学资料完整的非特异性腰痛患者99例,记录患者年龄、性别、体质量指数(BMI)、腰痛持续时间、腰痛视觉模拟量表(VAS)评分.于腰椎侧位X线片测量腰椎前凸角,于腰椎横断面MRI测量L4,5节段去除脂肪信号后的双侧竖脊肌横截面积(CSA)及L4 CSA.依据患者年龄分为≥65岁组(16例)和<65岁组(83例),比较2组人口学因素、腰痛持续时间、VAS评分、竖脊肌参数和腰椎前凸角的差异,并分析腰椎前凸角与其他指标的相关性.结果 <65岁组L4,5节段竖脊肌CSA/L4 CSA高于≥65组,差异有统计学意义(P<0.05).2组性别、BMI、VAS评分、腰痛持续时间及腰椎前凸角差异无统计学意义(P>0.05).在<65岁组中,相关性检验显示性别和L4,5节段竖脊肌CSA/L4 CSA与腰椎前凸角存在相关性,多元线性回归分析显示腰椎前凸角与L4,5节段竖脊肌CSA/L4 CSA呈正线性相关.在≥65岁组中,相关性检验显示腰椎前凸角与年龄和L4,5节段竖脊肌CSA/L4 CSA存在相关性,多元线性回归分析显示年龄与腰椎前凸角呈负线性相关、与L4,5节段竖脊肌CSA/L4 CSA呈正线性相关.结论 非特异性腰痛患者性别、年龄、L4,5节段竖脊肌CSA/L4 CSA与腰椎曲度均存在相关性,<65岁的患者腰椎曲度与性别相关,≥65岁的患者腰椎曲度与年龄相关,而腰椎曲度与L4,5节段竖脊肌CSA/L4 CSA的相关性不依赖于年龄.     

The role of rehabilitation in the treatment of low back pain

The frequency of symptoms that manifest in low back pain (LBP), whatever if its immediate cause, makes pain back an important medical, and also an socio-economical theme. Rehabilitation is an important factor in the medical and curing process of such patients. Evaluation of the effect of medical rehabilitation is being monitored with a number of specific questionnaires, in which one of the most used is the Oswestry LBP Questionnaire, Roland-Morris Questionnaire and non-specific WHOQOL. All the already mentioned mechanisms for LBP have its disadvantages but they also fit in well in the bio-psycho-social model of treatment, for which the LBP is a good example. LBP is not only a problem for itself, but also the cause of stress, disability and reduced functional ability of each patient.     

唑来膦酸改善骨质疏松患者后路腰椎椎间融合术后腰痛

目的了解唑来膦酸对骨质疏松患者行后路腰椎椎间融合术(PLIF)后腰痛的影响,评价唑来膦酸的安全性与有效性。方法选取2013年6月—2015年6月在中国人民解放军西部战区总医院因腰椎退行性疾病接受PLIF治疗的63例骨质疏松症患者,按照随机数字表法分为对照组和治疗组,术后均给予相同的抗骨质疏松基础治疗(口服碳酸钙D3片),治疗组联合应用唑来膦酸治疗。记录并比较2组患者术前及术后随访期疼痛视觉模拟量表(VAS)评分及Oswestry功能障碍指数(ODI)。结果术前及术后1周,2组腰痛VAS评分无显著差异;术后各时间点2组腰痛VAS评分较术前均明显下降,差异有统计学意义(P 0.05);治疗组术后1、3、6和12个月的腰痛VAS评分低于对照组,差异有统计学意义(P 0.05)。术前2组ODI无明显差异;术后各时间点2组ODI均较术前明显改善,且治疗组优于对照组,差异均有统计学意义(P 0.05)。结论骨质疏松患者PLIF后应用唑来膦酸,有助于减轻患者术后中远期腰痛,改善患者术后腰椎功能。     

The role of anticipation and fear of pain in the persistence of avoidance behavior in patients with chronic low back pain

STUDY DESIGN: A correlative design using stepwise regression analysis. OBJECTIVE: To explore the variation in spinal isometric strength that can be accounted for by anticipation of pain, sensory perception of pain, functional disability belief, and the fear-avoidance belief in chronic low back pain patients. SUMMARY OF THE BACKGROUND DATA: Several biobehavioral factors contribute to the persistence of pain behavior in chronic patients. Recent studies suggest a need to explore the relation between reduced physical performance and the sensory and cognitive perception of pain. METHODS: Sixty-three patients with chronic low back pain 20 to 56 years of age participated in this study. Visual Analogs Scales, the Fear-Avoidance Belief questionnaire, and the Disability Belief questionnaire were used to measure the sensory and cognitive dimensions of pain. Spinal isometric strength was measured by the Medx lumbar extension machine. RESULTS: Analysis of variance and the stepwise regression analysis demonstrated that anticipation of pain and the fear-avoidance belief about physical activity significantly predicted variation in the spinal isometric strength deficit P < 0. 001. True pain experienced during the testing and answers to the Disability Belief questionnaire were not related. CONCLUSION: The results of this study strongly support the hypothesis that spinal physical capacity in chronicity is not explained solely by the sensory perception of pain. The anticipation of pain and the fear-avoidance belief about physical activities were the strongest predictors of the variation in physical performance.