Association of Incident,Clinically Undiagnosed Radiographic Vertebral Fractures With Follow‐Up Back Pain Symptoms in Older Men: the Osteoporotic Fractures in Men (MrOS) Study

Prior data in women suggest that incident clinically undiagnosed radiographic vertebral fractures (VFs) often are symptomatic, but misclassification of incident clinical VF may have biased these estimates. There are no comparable data in men. To evaluate the association of incident clinically undiagnosed radiographic VF with back pain symptoms and associated activity limitations, we used data from the Osteoporotic Fractures in Men (MrOS) Study, a prospective cohort study of community‐dwelling men aged ≥65 years. A total of 4396 men completed spine X‐rays and symptom questionnaires at baseline and visit 2, about 4.6 years later. Incident clinical VFs during this interval were defined by self‐reported clinical diagnosis plus community imaging showing a centrally adjudicated ≥1 increase in semiquantitative (SQ) grade in any thoracic or lumbar vertebra versus baseline study X‐rays. Incident radiographic VFs (≥1 increase in SQ grade between baseline and visit 2 study X‐rays) were categorized as radiographic‐only (not clinically diagnosed) or radiographic plus clinical (also clinically diagnosed). Multivariable‐adjusted log binomial regression was used to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs). Men with incident radiographic plus clinical VF were most likely to have back pain symptoms and associated activity limitation at follow‐up. However, versus men without incident VF, those with incident radiographic‐only VF also were significantly more likely at follow‐up to report any back pain (70% versus 59%; PR, 1.2 [95% CI, 1.1 to 1.3]), severe back pain (8% versus 4%; PR, 1.9 [95% CI, 1.1 to 3.3]), bother from back pain most/all the time (22% versus 13%; PR, 1.7 [95% CI, 1.3 to 2.2]), and limited usual activity from back pain (34% versus 18%; PR, 1.9 [95% CI, 1.5 to 2.4]). Clinically undiagnosed, incident radiographic VFs were associated with an increased likelihood of back pain symptoms and associated activity limitation. Results suggest incident radiographic‐only VFs often were symptomatic, and were associated with both new and worsening back pain. Preventing these fractures may reduce back pain and related disability in older men. © 2017 American Society for Bone and Mineral Research.     

Sitting position does not alter minimum alveolar concentration for desflurane

PURPOSE: Hypotension is a common complication of the sitting position during anesthesia, and is often counteracted by decreasing anesthetic depth, thereby exposing patients to the risk of being inadequately anesthetized. Baroreceptor unloading and the consequent sympathoexcitation, as during head up tilt, decreases pain threshold and arouses the central nervous system (CNS), whereas hypotension exerts a direct CNS depressant effect. We estimated the minimal alveolar concentration (MAC) of desflurane for immobility in patients undergoing surgery in the sitting position, in comparison to MAC desflurane for patients having a similar type of surgery in the supine position. METHODS: The Dixon up-and-down method was used to evaluate the MAC for desflurane in patients undergoing cervical spine laminoplasty (n = 24) or discectomy (n = 24) in the sitting and supine positions, respectively. Logistic regression with co-variate adjustment was employed to examine if the two positions (sitting and supine) have different or share the same concentration vs response relationship for immobility. Monte Carlo simulation was used to calculate 95% confidence intervals (CI) for the MAC in each position, and to estimate the difference in MAC (delta MAC) between the sitting and supine positions. RESULTS: Modeling both sitting [6.54% (6.50-6.66, 95% CI)] and supine [6.70 (6.55-6.81)] patients as having different MAC concentrations did not significantly improve our simplified model, which treats the two patient groups as one [6.61 (6.52-6.70), delta -2 log likelihood = 2.735, P = 0.098]. Mean delta MAC (95% CI) was -0.14 (-0.30, 0.03). CONCLUSION: The sitting position does not change desflurane anesthetic requirements for immobility.     

Timed Loaded Standing: A Measure of Combined Trunk and Arm Endurance Suitable for People with Vertebral Osteoporosis

Chronic back tiredness or fatigue is a common complaint of people who have a history of osteoporotic vertebral fracture. Trunk muscle endurance has not been studied in people with vertebral osteoporosis, partly due to the lack of assessment tools. We developed a measure of combined trunk and arm endurance suitable for people with vertebral osteoporosis, timed loaded standing (TLS). TLS measures the time a person can stand while holding a two-pound dumbbell in each hand with the arms at 90° of shoulder flexion and the elbows extended. Intraclass correlation coefficients (ICCs) for same day inter-trial and six to ten day test-retest reliability were 0.89 (lower bound 95% confidence interval [LB 95% CI] 0.79) and 0.84 (LB 95% CI 0.68), respectively, in a sample of 21 older women with no known osteoporosis. In 127 women with vertebral fractures, the ICC for same day inter-trial reliability was 0.81 (LB 95% CI 0.75). In a sub-sample of 30 of these women with vertebral fractures, the six to ten day test-retest reliability was 0.85 (LB 95% CI 0.75). Moderately strong and statistically significant (p≤0.05) correlations were found between TLS and sixteen of eighteen measures of physical impairment and function. Functional reach distance, gait velocity, MOS-36 Physical Function Subscale, shoulder flexion strength, and six minute walk distance were most strongly associated with TLS time. Women with vertebral fractures who endorsed having back tiredness when standing and working with the arms in front of the body, sitting to rest because of back tiredness or pain, and planning rest periods because of back tiredness or pain had significantly lower TLS times. TLS is a simple, safe physical performance measure of combined trunk and arm endurance that demonstrates acceptable reliability (inter-trial and test- retest) and concurrent validity. Received: 27 October 1999 / Accepted: 4 April 2000     

Using self-reports of pain and other variables to distinguish between older women with back pain due to vertebral fractures and those with back pain due to degenerative changes

Summary

Women with back pain and vertebral fractures describe different pain experiences than women without vertebral fractures, particularly a shorter duration of back pain, crushing pain and pain that improves on lying down. This suggests a questionnaire could be developed to identify older women who may have osteoporotic vertebral fractures.

Introduction

Approximately 12 % of postmenopausal women have vertebral fractures (VFs), but less than a third come to clinical attention. Distinguishing back pain likely to relate to VF from other types of back pain may ensure appropriate diagnostic radiographs, leading to treatment initiation. This study investigated whether characteristics of back pain in women with VF are different from those in women with no VFs.

Methods

A case control study was undertaken with women aged ≥60 years who had undergone thoracic spinal radiograph in the previous 3 months. Cases were defined as those with VFs identified using the algorithm-based qualitative (ABQ) method. Six hundred eighty-three potential participants were approached. Data were collected by self-completed questionnaire including the McGill Pain Questionnaire. Chi-squared tests assessed univariable associations; logistic regression identified independent predictors of VFs. Receiver operating characteristic (ROC) curves were used to evaluate the ability of the combined independent predictors to differentiate between women with and without VFs via area under the curve (AUC) statistics.

Results

One hundred ninety-seven women participated: 64 cases and 133 controls. Radiographs of controls were more likely to show moderate/severe degenerative change than cases (54.1 vs 29.7 %, P?=?0.011). Independent predictors of VF were older age, history of previous fracture, shorter duration of back pain, pain described as crushing, pain improving on lying down and pain not spreading down the legs. AUC for combination of these factors was 0.85 (95 % CI 0.79 to 0.92).

Conclusion

We present the first evidence that back pain experienced by women with osteoporotic VF is different to back pain related solely to degenerative change.

     

Endplate defects,not the severity of spinal stenosis,contribute to low back pain in patients with lumbar spinal stenosis

BACKGROUND CONTEXTIt is controversial whether lumbar spinal stenosis (LSS) itself contributes to low back pain (LBP). Lower truncal skeletal muscle mass, spinopelvic malalignment, intervertebral disc degeneration, and endplate abnormalities are thought to be related to LBP. However, whether these factors cause LBP in patients with LSS is unclear.PURPOSETo identify factors associated with LBP in patients with LSS.STUDY DESIGN/SETTINGCross-sectional design.PATIENT SAMPLEA total of 260 patients (119 men and 141 women, average age 72.8 years) with neurogenic claudication caused by LSS, as confirmed by magnetic resonance imaging (MRI).OUTCOME MEASURESRatings of LBP, buttock and leg pain, and numbness on a numerical rating scale (NRS), 36-Item Short Form Survey (SF-36) scores, muscle mass measured by bioelectrical impedance analysis, and radiographic measurements including slippage and lumbopelvic alignment. The severity of LSS, endplate defects, Modic endplate changes, intervertebral disc degeneration, and facet joint osteoarthritis were assessed on MRI.METHODSThe presence of LBP was defined as an NRS score ≥3. The demographic data, patient-reported outcomes, and radiological and MRI findings were compared between patients with and without LBP. Multivariate logistic regression analysis was used to identify the factors that were independently associated with the presence of LBP.RESULTSThere were significant differences between patients with and without LBP for buttock and leg pain and numbness on the NRS, general health on the SF-36, presence of endplate defects, presence of Modic changes, disc degeneration grading, and disc height grading (all p < .05). Multivariate logistic regression analysis showed significant associations between LBP and diabetes (OR 2.43; 95% CI 1.07–5.53), buttock and leg numbness on the NRS (OR 1.34; 95% CI 1.17–1.52), general health on the SF-36 (OR 0.97; 95% CI 0.95–0.99), and the presence of erosive endplate defects (OR 3.04; 95% CI 1.51–6.11) (all p < .05).CONCLUSIONSThese results suggest that LBP in patients with LSS should be carefully assessed not only for spinal stenosis but also clinical factors and endplate defects.     

Utility of Natural Sitting Lateral Radiograph in the Diagnosis of Segmental Instability for Patients with Degenerative Lumbar Spondylolisthesis

BackgroundSegmental instability in patients with degenerative lumbar spondylolisthesis is an indication for surgical intervention. The most common method to evaluate segmental mobility is lumbar standing flexion-extension radiographs. Meanwhile, other simple radiographs, such as standing upright radiograph, a supine sagittal magnetic resonance imaging (MRI) or supine lateral radiograph, or a slump or natural sitting lateral radiograph, have been reported to diagnose segmental instability. However, those common posture radiographs have not been well characterized in one group of patients. Therefore, we measured slip percentage in a group of patients with degenerative lumbar spondylolisthesis using radiographs of patients in standing upright, natural sitting, standing flexion, and standing extension positions as well as supine MRI.Questions/purposesWe asked: (1) Does the natural sitting radiograph have a larger slip percentage than the standing upright or standing flexion radiograph? (2) Does the supine sagittal MRI reveal a lower slip percentage than the standing extension radiograph? (3) Does the combination of the natural sitting radiograph and the supine sagittal MRI have a higher translational range of motion (ROM) and positive detection rate of translational instability than traditional flexion-extension mobility using translational instability criteria of greater than or equal to 8%?MethodsWe retrospectively performed a study of 62 patients (18 men and 44 women) with symptomatic degenerative lumbar spondylolisthesis at L4 who planned to undergo a surgical intervention at our institution between September 2018 and June 2019. Each patient underwent radiography in the standing upright, standing flexion, standing extension, and natural sitting positions, as well as MRI in the supine position. The slip percentage was measured three times by single observer on these five radiographs using Meyerding’s technique (intraclass correlation coefficient 0.88 [95% CI 0.86 to 0.90]). Translational ROM was calculated by absolute values of difference between two radiograph positions. Based on the results of comparison of slip percentage and translational ROM, we developed the diagnostic algorithm to evaluate segmental instability. Also, the positive rate of translational instability using our diagnostic algorithms was compared with traditional flexion-extension radiographs.ResultsThe natural sitting radiograph revealed a larger mean slip percentage than the standing upright radiograph (21% ± 7.4% versus 17.7% ± 8.2%; p < 0.001) and the standing flexion radiograph (21% ±7.4% versus 18% ± 8.4%; p = 0.002). The supine sagittal MRI revealed a lower slip percentage than the standing extension radiograph (95% CI 0.49% to 2.8%; p = 0.006). The combination of natural sitting radiograph and the supine sagittal MRI had higher translational ROM than the standing flexion and extension radiographs (10% ± 4.8% versus 5.4% ± 3.7%; p < 0.001). More patients were diagnosed with translational instability using the combination of natural sitting radiograph and supine sagittal MRI than the standing flexion and extension radiographs (61% [38 of 62] versus 19% [12 of 62]; odds ratio 3.9; p < 0.001).ConclusionOur results indicate that a sitting radiograph reveals high slip percentage, and supine sagittal MRI demonstrated a reduction in anterolisthesis. The combination of natural sitting and supine sagittal MRI was suitable to the traditional flexion-extension modality for assessing translational instability in patients with degenerative lumbar spondylolisthesis.Level of EvidenceLevel III, diagnostic study.     

Pseudoarthrosis of vertebral fracture: radiographic and characteristic clinical features and natural history

Background We examined mobility based on radiographic appearance, clinical appearance, and the natural course of osteoporotic vertebral pseudoarthrosis (VPA) in a prospective study in 34 consecutive cases of VPA in 27 patients with osteoporosis. Methods Conventional lateral, lateral flexion, and extension stress radiography (XP) and supine cross-table lateral XP were performed. Anterior vertebral body height and vertebral kyphotic angle were measured to assess vertebral mobility. If vertebral cleft or vertebral instability, which means a difference in vertebral body height between conventional and supine cross-table lateral XP, was present, VPA was diagnosed. Back pain was classified into five grades. Results The average anterior vertebral height was 9.9 ± 5.6 mm on conventional lateral XP; it increased to 11.4 ± 6.5 mm on extension stress XP (not significant) and 18.3 ± 5.7 mm on cross-table lateral XP (significant). The verte-bral kyphotic angle was 24.1° ± 9.7° on conventional lateral XP; it decreased to 21.6° ± 9.8° on extension stress XP (not significant) and 11.8° ± 8.5° on cross-table lateral XP (significant). Intravertebral clefts were detected by conventional lateral XP, extension stress XP, and supine cross-table XP in 3 of 34 (8.8%), 7 of 21 (33.3%), and 28 of 34 (82.4%) vertebral compression fractures (VCFs), respectively. Surgical treatment was performed in seven patients (two because of severe pain and five because of neurological deficits) and in one patient who died. Except in these eight patients, back pain decreased by at least one grade with time in 18 of 19 patients (95%) in whom the clinical course was analyzed. Radiographic follow-up using supine cross-table XP was performed in 15 of 19 patients. Although 11 of these 15 patients (73%) showed vertebral instability on supine cross-table lateral XP, 10 of 11 patients (91%) did not complain of intolerable back pain during daily activity at the final follow-up. Conclusions VPA is often detected on supine cross-table lateral XP but not usually on extension stress XP. Despite the presence of vertebral instability, many patients did not complain of intolerable back pain during their daily activity. Surgical treatment to alleviate back pain should be performed for painful VPA after conservative treatment for about 4 months.     

Ground truth generalizability affects performance of the artificial intelligence model in automated vertebral fracture detection on plain lateral radiographs of the spine

BACKGROUND CONTEXTComputer-aided diagnosis with artificial intelligence (AI) has been used clinically, and ground truth generalizability is important for AI performance in medical image analyses. The AI model was trained on one specific group of older adults (aged≧60) has not yet been shown to work equally well in a younger adult group (aged 18–59).PURPOSETo compare the performance of the developed AI model with ensemble method trained with the ground truth for those aged 60 years or older in identifying vertebral fractures (VFs) on plain lateral radiographs of spine (PLRS) between younger and older adult populations.STUDY DESIGN/SETTINGRetrospective analysis of PLRS in a single medical institution.OUTCOME MEASURESAccuracy, sensitivity, specificity, and interobserver reliability (kappa value) were used to compare diagnostic performance of the AI model and subspecialists’ consensus between the two groups.METHODSBetween January 2016 and December 2018, the ground truth of 941 patients (one PLRS per person) aged 60 years and older with 1101 VFs and 6358 normal vertebrae was used to set up the AI model. The framework of the developed AI model includes: object detection with You Only Look Once Version 3 (YOLOv3) at T0-L5 levels in the PLRS, data pre-preprocessing with image-size and quality processing, and AI ensemble model (ResNet34, DenseNet121, and DenseNet201) for identifying or grading VFs. The reported overall accuracy, sensitivity and specificity were 92%, 91% and 93%, respectively, and external validation was also performed. Thereafter, patients diagnosed as VFs and treated in our institution during October 2019 to August 2020 were the study group regardless of age. In total, 258 patients (339 VFs and 1725 normal vertebrae) in the older adult population (mean age 78±10.4; range, 60–106) were enrolled. In the younger adult population (mean age 36±9.43; range, 20–49), 106 patients (120 VFs and 728 normal vertebrae) were enrolled. After identification and grading of VFs based on the Genant method with consensus between two subspecialists’, VFs in each PLRS with human labels were defined as the testing dataset. The corresponding CT or MRI scan was used for labeling in the PLRS. The bootstrap method was applied to the testing dataset.RESULTSThe model for clinical application, Digital Imaging and Communications in Medicine (DICOM) format, is uploaded directly (available at: http://140.113.114.104/vght_demo/svf-model (grading) and http://140.113.114.104/vght demo/svf-model2 (labeling). Overall accuracy, sensitivity and specificity in the older adult population were 93.36% (95% CI 93.34%–93.38%), 88.97% (95% CI 88.59%–88.99%) and 94.26% (95% CI 94.23%–94.29%), respectively. Overall accuracy, sensitivity and specificity in the younger adult population were 93.75% (95% CI 93.7%–93.8%), 65.00% (95% CI 64.33%–65.67%) and 98.49% (95% CI 98.45%–98.52%), respectively. Accuracy reached 100% in VFs grading once the VFs were labeled accurately. The unique pattern of limbus-like VFs, 43 (35.8%) were investigated only in the younger adult population. If limbus-like VFs from the dataset were not included, the accuracy increased from 93.75% (95% CI 93.70%–93.80%) to 95.78% (95% CI 95.73%–95.82%), sensitivity increased from 65.00% (95% CI 64.33%–65.67%) to 70.13% (95% CI 68.98%–71.27%) and specificity remained unchanged at 98.49% (95% CI 98.45%–98.52%), respectively. The main causes of false negative results in older adults were patients’ lung markings, diaphragm or bowel airs (37%, n=14) followed by type I fracture (29%, n=11). The main causes of false negatives in younger adults were limbus-like VFs (45%, n=19), followed by type I fracture (26%, n=11). The overall kappa between AI discrimination and subspecialists’ consensus in the older and younger adult populations were 0.77 (95% CI, 0.733–0.805) and 0.72 (95% CI, 0.6524–0.80), respectively.CONCLUSIONSThe developed VF-identifying AI ensemble model based on ground truth of older adults achieved better performance in identifying VFs in older adults and non-fractured thoracic and lumbar vertebrae in the younger adults. Different age distribution may have potential disease diversity and implicate the effect of ground truth generalizability on the AI model performance.     

Minimally-invasive percutaneous treatments for low back pain and leg pain: a randomized controlled study of thermal disc decompression versus mechanical percutaneous disc decompression

BACKGROUND CONTEXTMinimally invasive techniques have recently been developed as alternative treatments to surgical interventions, especially for small or contained herniated disc.PURPOSEAim of our study is to assess the efficacy of the mechanical percutaneous disc decompression (PDD) in comparison with the percutaneous radiofrequency targeted disc decompression (TDD).STUDY DESIGNWe conducted a single-center noninferiority trial in which patients who had low back pain with radicular leg pain (RLP) from a contained herniated disc were randomly assigned in a 1:1 ratio to undergo either PDD or TDD.PATIENT SAMPLEFrom January 2016 to January 2017 a total of 327 patients were assessed for eligibility of whom 200 underwent randomization in the trial; 100 patients underwent the PDD and 100 underwent the TDD.OUTCOME MEASURESThe primary outcome measure was the proportion of patients who reported >50% reduction in Numeric Rating Scale (NRS) leg pain score. Secondary outcome measure included the proportion of patients who reported >30% improvement in Oswestry Disability Index (ODI) score.METHODSOutcomes of this trial were measured with the use of patient-reported data obtained from validated questionnaires to assess the low back pain with RLP before intervention and at 6 and 12 months after interventions. MRI was performed before intervention and at 6 and 12 months after interventions. In addition to NRS and ODI scores, we collected the following data: age, gender, length of hospitalizations and return to work rate.RESULTSWhen using an intention to treat analysis with those lost to follow-up and requiring a second procedure counting as failures, there were no statistically significant difference between the two treatment groups in the primary and secondary outcomes at 6 months: >50% reduction in NRS leg pain (PDD vs. TDD)=67% versus 65%; >30% ODI improvement (PDD vs. TDD)=57% versus 55%. Similarly, there were no statistically significant differences between groups in outcomes at 12 months: >50% reduction in NRS leg pain (PDD vs. TDD)=51% (95% CI 41%–60%) versus 40% (95% CI: 30%–49%); >30% ODI improvement (PDD vs. TDD)=42% (95% CI 32%–51%) versus 30% (95% CI: 21%–39%). A nonintention to treat analysis which discounted those lost to follow-up showed the only statistically significant finding was the percentage of those reporting >30% ODI at the 12 month follow-up time, favoring the PDD group: (PDD vs. TDD)=58% (95% CI 46%–69%) versus 42% (95% CI: 22%–43%).CONCLUSIONSPDD and TDD are comparable treatments for patients presenting with low back pain with RLP unresponsive to medical therapy caused by contained disc herniations.     

The spinal curvature irregularity index independently identifies vertebral fractures

Introduction and hypothesis The spinal curvature irregularity index (SCII) is a quantitative measure of the irregularity of the spinal curvature. We evaluated the predictive ability of SCII to identify subjects with vertebral fractures (VF). Methods Vertebral heights were measured by quantitative vertebral morphometry in 461 Lebanese women 20–89 years of age and VFs were ascertained by the grade 1 Eastell method. SCII scores were log-transformed and expressed as Z-SCII, the number of standard deviations above or below the mean ln(SCII) of young patients without VF. Univariate and multivariate binary logistic regression models were used to identify clinical predictors of VF. Results Women with a higher SCII were more likely to have prevalent VF. A higher SCII was associated with a greater prevalence of VF within each category of femoral neck BMD (normal, osteopenia, osteoporosis). In univariate analysis, predictors of VF included Z-SCII (odds ratio, OR: 2.21, 95% CI: 1.80–2.71) and femoral neck T-score (OR: 1.35, 95% CI: 1.12–1.63). In multivariate analysis, predictors of VF were: Z-SCII (OR: 1.54, 95% CI: 1.02–2.32), femoral neck T-score (OR: 1.41, 95% CI: 1.11–1.78) and age³ (OR: 1.40, 95% CI 1.10–1.82). At a cutoff SCII of 9.5%, the sensitivity and specificity of SCII for VF were 71 and 64% respectively, and higher SCII cutoffs identified VFs with greater specificity. Conclusion The SCII is a robust, simple and independent indicator of the presence of VFs.     

Magnetic resonance-detected subchondral bone marrow and cartilage defect characteristics associated with pain and X-ray-defined knee osteoarthritis

OBJECTIVE: To assess whether the presence of subchondral bone marrow abnormalities (bone marrow edema (BME)) and cartilage defects, determined by magnetic resonance imaging (MRI), would explain the difference between painful osteoarthritis of the knee (OAK) compared with painless OAK or pain without OAK. METHOD: Four groups of women (30 per group), aged 35-55 years, were recruited from the southeast Michigan Osteoarthritis cohort (group 1: painful OAK; group 2: painless OAK; group 3: knee pain without OAK; and group 4: no OAK or knee pain). OAK was defined by a Kellgren-Lawrence score of 2 or greater, while pain was based on self-report. BME and cartilage defects were identified from MRI. RESULTS: BME lesions were identified in 56% of all knees. BME lesions were four times (95% CI=1.7, 8.7) more likely to occur in the painless OAK group as compared with the group with pain, but no OAK. BME lesions >1cm were more frequent (OR=5.0; 95% CI=1.4, 10.5) in the painful OAK group than all other groups. While the frequency of BME lesions was similar in the painless OAK and painful OAK groups, there were more lesions, >1cm, in the painful OAK group.About 75% of all knees had evidence of some cartilage defect, of which 35% were full-thickness defects. Full-thickness cartilage defects occurred frequently in painful OAK. One-third of knees with full-thickness defects and 47% of knees with cartilage defects involving bone had BME >1cm. Women with radiographic OA, full-thickness articular cartilage defects, and adjacent subchondral cortical bone defects were significantly more likely to have painful OAK than other groups (OR=3.2; 95% CI=1.3, 7.6). CONCLUSION: The finding on MRI of subchondral BME cannot satisfactorily explain the presence or absence of knee pain. However, women with BME and full-thickness articular cartilage defects accompanied by adjacent subchondral cortical bone defects were significantly more likely to have painful OAK than painless OAK.     

Positional MRI changes in supine versus sitting postures in patients with degenerative lumbar spine

INTRODUCTION: Back pain is associated with a degree of alteration in the alignment and movement of the lumbar spine. The purpose of this study is to investigate how the degree of lumbar segmental degeneration affects sagittal changes in the lumbar spine as it shifts from the supine to the sitting (load-bearing) posture. MATERIALS AND METHODS: Thirty patients with chronic low back pain were enrolled (14 male and 16 female patients); mean age 44.5 years. Their lumbar spines were initially investigated by conventional supine magnetic resonance imaging (MRI) followed later by positional MRI in the seated posture. Of the 150 discs studied, 87 were classified as healthy grade 1, 16 as grade 2, 34 as grade 3, and 13 as grade 4. RESULTS: As the lumbar spine was loaded from the supine to the sitting position, the end-plate angles were decreased significantly as the degeneration was increased. There were also significant changes in the anterior and middle disc heights between the supine and the sitting postures irrespective of the degree of degeneration. The overall lumbar lordosis did not significantly change between the two postures. CONCLUSIONS: We have found that the changes in the segmental motion were related to the degree of degeneration. With positional MRI, we were able to demonstrate changes in healthy and degenerative discs in the weight-bearing position. More similar studies are needed to understand the complex kinematics of the lumbar spine.     

Once‐yearly zoledronic acid and days of disability,bed rest,and back pain: Randomized,controlled HORIZON Pivotal Fracture Trial

The objective of this study was to determine the effect of once‐yearly zoledronic acid on the number of days of back pain and the number of days of disability (ie, limited activity and bed rest) owing to back pain or fracture in postmenopausal women with osteoporosis. This was a multicenter, randomized, double‐blind, placebo‐controlled trial in 240 clinical centers in 27 countries. Participants included 7736 postmenopausal women with osteoporosis. Patients were randomized to receive either a single 15‐minute intravenous infusion of zoledronic acid (5 mg) or placebo at baseline, 12 months, and 24 months. The main outcome measures were s elf‐reported number of days with back pain and the number of days of limited activity and bed rest owing to back pain or a fracture, and this was assessed every 3 months over a 3‐year period. Our results show that although the incidence of back pain was high in both randomized groups, women randomized to zoledronic acid experienced, on average, 18 fewer days of back pain compared with placebo over the course of the trial (p = .0092). The back pain among women randomized to zoledronic acid versus placebo resulted in 11 fewer days of limited activity (p = .0017). In Cox proportional‐hazards models, women randomized to zoledronic acid were about 6% less likely to experience 7 or more days of back pain [relative risk (RR) = 0.94, 95% confidence interval (CI) 0.90–0.99] or limited activity owing to back pain (RR = 0.94, 95% CI 0.87–1.00). Women randomized to zoledronic acid were significantly less likely to experience 7 or more bed‐rest days owing to a fracture (RR = 0.58, 95% CI 0.47–0.72) and 7 or more limited‐activity days owing to a fracture (RR = 0.67, 95% CI 0.58–0.78). Reductions in back pain with zoledronic acid were independent of incident fracture. Our conclusion is that in women with postmenopausal osteoporosis, a once‐yearly infusion with zoledronic acid over a 3‐year period significantly reduced the number of days that patients reported back pain, limited activity owing to back pain, and limited activity and bed rest owing to a fracture. © 2011 American Society for Bone and Mineral Research.     

Long-term outcomes of a large,prospective observational cohort of older adults with back pain

Background Context

Although back pain is common among older adults, there is relatively little research on the course of back pain in this age group.

Low back pain among medical students

Low back pain (LBP) is known to affect both older and younger adults. Medical schools tend to have time-consuming curricula, possibly perpetuating a sedentary lifestyle, and a high prevalence of LBP among medical students. The purpose of this study was to evaluate the extent of sedentary lifestyle and the 12-month prevalence of LBP in a sample group of medical students in comparison to a random sample of physical education students. A retrospective study involving a questionnaire-based inquiry of 103 medical students showed that they were approximately 2.5 times less physically active than the 107 physical education students (p < 0.001) and spent 3 more hours per day sitting (p < 0.001). The 12-month prevalence of (sub)acute and chronic LBP in the sample group of medical students was 53.4% (95% CI: 43.8%-63.0%), as compared to 60.7% (95% CI: 51.4% -70.0%) in the sample group of physical education students, yielding no statistically significant difference (p = 0.329). These data reveal a high prevalence of low back pain among students, which is rather alarming considering their young age. Strangely, the prevalence of LBP was not higher in medical students than in physically more active students, in spite of their sedentary lifestyle. According to the literature, the sitting position is no longer considered as a risk factor for low back pain.     

Prevalence of Vertebral Deformity and its Associations with Physical Impairment among Japanese Women: The Hizen-Oshima Study

Vertebral fractures are a hallmark of postmenopausal osteoporosis and an important end point in trials of osteoporosis treatment, but the clinical significance of vertebral deformities remains uncertain. We examined the prevalence of vertebral deformity and associations of vertebral deformities and other characteristics with physical functioning among 584 Japanese women ages 40 to 89 years. Lateral spine radiographs were obtained and radiographic vertebral deformities were assessed by quantitative morphometry, defined as vertebral heights more than 3 SD below the normal mean. A self-administered questionnaire was used to survey participants about difficulty in performing selected basic and instrumental activities of daily living (ADL). Overall, 15% of women had at least one vertebral deformity, and 8% had 2 or more. The prevalence of vertebral deformities increased progressively with age. Half of women ages 80 and over had vertebral deformities. Impaired function was defined as difficulty performing 3 or more ADLs. After adjusting for age, the odds of impaired function were increased by 1.4 times (95% CI: 0.7, 2.9) in women with a single vertebral deformity, and 3.1 times (1.4, 6.8) in those with two or more deformities. Additional adjustment for number of painful joints, number of comorbidities, body mass index, and back pain did not materially alter these findings. In conclusion, women with multiple vertebral deformities had significantly greater impaired function. The association was independent of age, back pain and the number of painful joints, suggesting that deformities may impair function even when back pain is not present. Received: 29 October 2001 / Accepted: 11 April 2002     

Prevalence of low back pain and factors associated with chronic disabling back pain in Japan

Purpose

This study aimed to report lifetime and 4-week low back pain (LBP) prevalence and examine factors associated with chronic LBP and back pain disability over a lifetime in a Japanese adult population.

Methods

In February 2011, 1,063,083 adults aged 20–79 years registered as internet research volunteers were randomly selected to participate in a questionnaire survey. The data from 65,496 respondents were analyzed to calculate age-standardized lifetime and 4-week prevalence. Chronic LBP and back pain disability were defined as LBP lasting for ≥3 months and a consecutive ≥4-day-long absence, respectively. Factors associated with chronic disabling back pain over a lifetime were examined by multiple logistic regression modeling.

Results

The lifetime LBP prevalence was 83 % and 4-week prevalence was 36 %; majority of the respondents had disability-free LBP. Smoking [adjusted odds ratio (aOR): 1.17; 95 % CI: 1.05, 1.30], lower educational level (aOR: 1.21; 95 % CI: 1.09, 1.34), history of disabling back pain among family members and/or significant others (aOR: 1.46; 95 % CI: 1.27, 1.67), occupational LBP (aOR: 1.34; 95 % CI: 1.16, 1.55), traffic injury (aOR: 2.81; 95 % CI: 2.07, 3.81), compensated work injury (aOR: 2.42; 95 % CI: 1.92, 3.05), radiating pain (aOR: 4.94; 95 % CI: 4.45, 5.48), low back surgery (aOR: 10.69; 95 % CI: 9.02, 12.68), and advice to rest upon back pain consultation (aOR: 3.84; 95 % CI: 3.36, 4.40) were associated with chronic disabling back pain over a lifetime.

Conclusions

LBP is common in Japan as in other industrialized countries. The association between the advice to rest and chronic disabling back pain supports recent treatment guidelines emphasizing continuation of daily activities.     

瞳孔直径变化对术后疼痛评估的价值

目的通过观察术后患者瞳孔直径变化对数字疼痛强度量表评分的反应性,探讨瞳孔直径变异度对术后疼痛评估的评判价值。方法选择择期全麻下手术术后患者80例,男43例,女37例,年龄24~79岁,ASAⅠ~Ⅲ级。入PACU后评估数字疼痛强度量表(numerical rating scale,NRS)评分。当NRS评分为0~3分时,不作镇痛处理;NRS评分为4~10分5min后静脉单次注射芬太尼50μg。记录NRS评分开始20min内每分钟的NRS、瞳孔直径(pupillary diameter,PD)、SBP和HR值,计算NRS评分均为0~3分10min内时,NRS评分由0~3分变为4~10分后5min内时,NRS评分由4~10分变为0~3分后5min内时,NRS评分均为4~10分10min内时的最大变化率(Δmax),分别记为ΔPD、ΔSBP、ΔHR。以NRS评分变化作为评判标准,通过受试者工作特征曲线(ROC曲线)分析ΔPD、ΔSBP和ΔHR对NRS的反应性,寻找诊断临界值(cutoff值)。结果与NRS评分为0~3分时比较,NRS评分为4~10分时的PD明显增大、SBP明显升高、HR明显增快(P0.05)。ΔPD、ΔSBP和ΔHR的曲线下面积(AUC)分别为:AUCΔPD0.904(95%CI 0.822~0.987)、AUCΔSBP0.651(95%CI 0.510~0.781)和AUCΔHR0.588(95%CI 0.444~0.733);AUCΔPD明显大于AUCΔSBP和AUCΔHR(P0.05);当ΔPD的cutoff值为41.3%时,敏感度80.0%,特异度93.5%;当ΔSBP的cutoff值为10.3%时,敏感度62.4%,特异度71.5%。结论ΔPD比ΔSBP、ΔHR对术后疼痛/镇痛的评价具有更高的准确性,是评估术后疼痛/镇痛平衡的有价值指标。     

Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography

The vertebral end-plate has been identified as a possible source of discogenic low back pain. MRI demonstrates end-plate (Modic) changes in 20–50% of patients with low back pain. The aim of this study was to investigate the association between Modic changes on MRI and discogenic back pain on lumbar discography. The MRI studies and discograms of 58 patients with a clinical diagnosis of discogenic back pain were reviewed and the presence of a Modic change was correlated with pain reproduction at 152 disc levels. Twenty-three discs with adjacent Modic changes were injected, 21 of which were associated with pain reproduction. However, pain was also reproduced at 69 levels where no Modic change was seen. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for a Modic change as a marker of a painful disc were 23.3%, 96.8%, 91.3% and 46.5% respectively. Modic changes, therefore, appear to be a relatively specific but insensitive sign of a painful lumbar disc in patients with discogenic low back pain. Received: 24 October 1997 Revised: 11 March 1998 Accepted: 21 April 1998