Chronic low back pain in individuals with chronic neck pain of traumatic and non-traumatic origin: A population-based study

Background?It is unclear whether the prevalence of chronic low back pain is higher in chronic whiplash patients than in the general population. In a population-based study, we evaluated the prevalence of chronic low back pain in individuals with chronic neck pain of traumatic and non-traumatic origin, with special emphasis on whiplash injury.

Subjects and methods?Additional questions concerning the patient's experience of neck and low back pain were added to the questionnaire of the MONICA health survey. 4,415 subjects aged 25–64 years were randomly selected from a geographically well-defined area in northern Sweden.

Results?The prevalences of chronic low back pain and chronic neck pain were 16% and 17%, respectively. 51% of subjects had both back and neck pain. Of the patients with neck pain, one quarter had a history of neck injury, which was related to whiplash injury in almost one-half of the cases. The prevalence of chronic low back pain in individuals with chronic non-traumatic neck pain was 53%, and it was 48% in those with chronic neck pain and a history of neck trauma. There was no difference in the prevalence of chronic low back pain between whiplash injury and other types of neck trauma. Confounding factors such as sex, age, marital status, BMI, smoking status and level of education were not significantly different between traumatic and non-traumatic groups.

Interpretation?Independently of traumatic or non-traumatic origin of the symptoms, the prevalence of chronic low back pain is 3 times higher in individuals with chronic neck pain than in the general population. Causes other than a history of neck trauma, such as chronic muskuloskeletal pain syndromes, may be important in evaluation of these cases.??     

Relationship between body mass index and spinal pathology in community-dwelling older adults

Purpose

To clarify the relationship between body mass index (BMI) and spinal pathologies including spinal sagittal balance, back extensor strength (BES), paraspinal muscle mass, prevalent vertebral fracture, disc degeneration, Modic changes, low back pain, and quality of life (QOL) in community-dwelling older adults.

Methods

This study included 380 participants (age: ≥ 65 years, male/female: 152/228) from the Shiraniwa Study. Multivariate nonlinear regression analysis was used to investigate the relationship between BMI and sagittal vertical axis (SVA), BES, paraspinal muscle mass, visual analog scale (VAS) for low back pain, Oswestry Disability Index (ODI), and EuroQoL-5 Dimension (EQ5D) score after adjusting for sex, age, Hospital Anxiety and Depression Scale score, and Charlson Comorbidity Index. In addition, multiple logistic regression analysis was used to investigate the association between BMI and prevalent vertebral fracture, disc degeneration, and Modic changes.

Results

BMI was significantly correlated with SVA, BES, paraspinal muscle mass, VAS, ODI, and EQ5D score. The increase in BMI was associated with the deterioration of all outcomes, which accelerated when the BMI increased from approximately 22–23 kg/m². Moreover, overweight/obesity was significantly correlated with disc degeneration and Modic changes.

Conclusion

Increased BMI is significantly associated with spinal pathologies such as SVA, BES, paraspinal muscle mass, VAS, QOL, disc degeneration, and Modic changes. The findings suggest that measures for controlling overweight and obesity among older adults can play an important role in the prevention and treatment of spinal pathologies.

     

Extreme lateral approach to the spine in degenerative and post traumatic lumbar diseases: selection process,results and complications

Purpose of the study

The aim of this study is to describe clinical and radiological outcomes as well as accompanying complications in a series of consecutive lateral transpsoas approaches (XLIF).

Materials and methods

A retrospective study of 39 patients treated for degenerative and post-traumatic lumbar diseases was carried out. Functional status, leg and back pain and radiological outcomes were evaluated pre and post-operatively using the Oswestry disability index score (ODI) visual analog scales (VAS) and X-ray studies.

Results

Mean follow-up was 16 months (range 12–24 months). Mean improvement in back and leg pain on VAS was 6.08 (p < 0.01) and 2.77 (p < 0.01), respectively. Mean improvement in the ODI score was 38 (p < 0.01). Increases in lumbar lordosis (32.8°–39.2°, p < 0.05) and disc height (3.6–4.8 mm, p < 0.05) were noted in the post-operative. Mild, transient strength deficit of the quadriceps muscle was also noted in ten cases with complete regression.

Conclusions

XLIF proved to be a safe, effective, minimally invasive technique that allows valid arthrodesis to be carried out. Patients achieved positive clinical outcomes and satisfactory fusion rates, with sustained restoration of lordosis, spinal alignment and disc height.

     

Lumbar spinal loads and lumbar muscle forces evaluation with various lumbar supports and backrest inclination angles in driving posture

Purpose

The low back pain of professional drivers could be linked to excessive lumbar load. This study aims at developing a musculoskeletal model to study the lumbar spinal loads and lumbar muscle forces of the human body in driving posture, so as to contribute to a better understanding of low back pain and to improve the design of vehicle seats.

Methods

A standing musculoskeletal model, including limbs, head and neck, that can reflect several activities of daily living was established based on the Christophy spine model. The model was then validated by comparing the calculated lumbar loads and muscle forces to the experimental data in the previous studies. Referring to radiology studies, the musculoskeletal model was adjusted into different driving postures with several different lumbar supports (0, 2 and 4 cm) and inclinations of the backrest (from 23° to 33°, by 2° intervals). The lumbar biomechanical load with various lumbar supports and backrest inclination angles was calculated.

Results

The results showed that the overall lumbar spinal load and lumbar muscle force with 4 cm lumbar support were reduced by 11.30 and 26.24%. The lumbar spinal loads and lumbar muscle forces increased first and then decreased with the increase in backrest inclination angles from 23° to 33°. The lumbar biomechanical load varied slightly with the backrest inclination angles from 29° to 33°.

Conclusions

There are two findings: (i) the lumbar spinal loads at the L3–L4, L4–L5 and L5–S1, and lumbar muscle forces decreased obviously with the 4 cm lumbar support, while the seat cushion inclination angle was set to 10°. (ii) The recommended backrest inclination angles are 29° to 33° with a 10° seat cushion to the horizontal, which can keep a low level of the lumbar spinal loads and lumbar muscle forces. This study could be used to explain the association between drivers’ sitting posture and the lumbar load change, and provide a reference for the prevention of low back pain.

     

High degree of kinesiophobia after lumbar disc herniation surgery

Background and purpose Several studies have investigated outcomes after disc surgery. However, the occurrence of kinesiophobia has not been investigated previously in patients after disc herniation surgery. In this cross-sectional study, we investigated kinesiophobia in patients who had been treated surgically for lumbar disc herniation, and we related the results to established outcome measures.

Patients and methods 10–34 months after surgery, questionnaires were sent to 97 patients who had undergone standardized open discectomy. Outcome measures included Tampa scale for kinesiophobia (TSK); Oswestry disability index (ODI); European quality of life in 5 dimensions (EQ-5D); visual analog scale (VAS) for leg and back pain, work disability, and patient satisfaction; Zung self-rating depression scale (ZDS); pain catastrophizing scale (PCS); and a self-efficacy scale (SES).

Results 36 of 80 patients reported having kinesiophobia. There were statistically significant differences in ODI, EQ-5D, VAS leg and back pain, ZDS, PCS, and SES between patients with and without kinesiophobia.

Interpretation Half of the patients suffered from kinesiophobia 10–34 months after surgery for disc herniation. These patients were more disabled, had more pain, more catastrophizing thoughts, more symptoms of depression, lower self-efficacy, and poorer health-related quality of life than patients without kinesiophobia.     

An evidence-based review of the literature on the consequences of conservative versus aggressive discectomy for the treatment of primary disc herniation with radiculopathy

Background contextIt remains unknown whether aggressive disc removal with curettage versus conservative removal of a disc fragment with little disc invasion provides a better outcome for the treatment of lumbar disc herniation with radiculopathy.PurposeDetermine the level of evidence within the clinical literature that supports the performance of a conservative versus aggressive technique for discectomy.Study design/settingSystematic evidence-based review of clinical literature.Patient samplePatients with primary lumbar disc herniation with radiculopathy.Outcome measuresOperative time, return to work status, recurrent disc herniation, self-reported, and functional measures assessed less than 2 years (short term) and greater than 2 years (long term) after surgery.MethodsSystematic Medline search was performed to identify all published studies relating to outcome after aggressive or conservative discectomy. Levels of evidence (I–V) were assessed for each study and grades of recommendation were generated (Good, Fair, Poor, Insufficient evidence) based on the NASS Clinical Guidelines' Levels of Evidence and Grades of Recommendation.ResultsThere is fair evidence that conservative discectomy will result in shorter operative times and a quicker return to work despite similar lengths of hospital stay, similar pain levels at discharge, similar 6-month functional status, and a similar 2-year incidence of persistent/recurrent back and leg pain. There is poor quality evidence that conservative discectomy will result in a lower incidence of recurrent back pain beyond 2 years postoperatively. There is fair quality evidence that conservative discectomy will result in a higher incidence of recurrent disc herniation.ConclusionsThere are no Level I studies to support conservative versus aggressive discectomy for the treatment of primary disc herniation. However, systematic review of the literature suggests that conservative discectomy may result in shorter operative time, quicker return to work, and a decreased incidence of long-term recurrent low back pain but with an increased incidence of recurrent disc herniation. Prospective randomized trails are needed to firmly assess this possible benefit.     

Shared decision-making in back pain consultations: an illusion or reality?

Purpose

Amid a political agenda for patient-centred healthcare, shared decision-making is reported to substantially improve patient experience, adherence to treatment and health outcomes. However, observational studies have shown that shared decision-making is rarely implemented in practice. The purpose of this study was to measure the prevalence of shared decision-making in clinical encounters involving physiotherapists and patients with back pain.

Method

Eighty outpatient encounters (comprising 40 h of data) were observed audio-recorded, transcribed verbatim and analysed using the 12-item OPTION scale. The higher the score, the greater is the shared decision-making competency of the clinicians.

Results

The mean OPTION score was 24.0 % (range 10.4–43.8 %).

Conclusion

Shared decision-making was under-developed in the observed back pain consultations. Clinicians’ strong desire to treat acted as a barrier to shared decision-making and further work should focus on when and how it can be implemented.

     

Prognostic factors in lumbar spinal stenosis surgery

Background and purpose A considerable number of patients who undergo surgery for spinal stenosis have residual symptoms and inferior function and health-related quality of life after surgery. There have been few studies on factors that may predict outcome. We tried to find predictors of outcome in surgery for spinal stenosis using patient- and imaging-related factors.

Patients and methods 109 patients in the Swedish Spine Register with central spinal stenosis that were operated on by decompression without fusion were prospectively followed up 1 year after surgery. Clinical outcome scores included the EQ-5D, the Oswestry disability index, self-estimated walking distance, and leg and back pain levels (VAS). Central dural sac area, number of levels with stenosis, and spondylolisthesis were included in the MRI analysis. Multivariable analyses were performed to search for correlation between patient-related and imaging factors and clinical outcome at 1-year follow-up.

Results Several factors predicted outcome statistically significantly. Duration of leg pain exceeding 2 years predicted inferior outcome in terms of leg and back pain, function, and HRLQoL. Regular and intermittent preoperative users of analgesics had higher levels of back pain at follow-up than those not using analgesics. Low preoperative function predicted low function and dissatisfaction at follow-up. Low preoperative EQ-5D scores predicted a high degree of leg and back pain. Narrow dural sac area predicted more gains in terms of back pain at follow-up and lower absolute leg pain.

Interpretation Multiple factors predict outcome in spinal stenosis surgery, most importantly duration of symptoms and preoperative function. Some of these are modifiable and can be targeted. Our findings can be used in the preoperative patient information and aid the surgeon and the patient in a shared decision making process.     

High-level physical activity in childhood seems to protect against low back pain in early adolescence

BackgroundThe evidence on the impact of physical activity on back pain in children and adolescents has been contradicting. It has also been shown that the physical activity cannot accurately be estimated in children using questionnaires.PurposeThe aim of this study was to establish if physical activity in childhood had any impact on back pain reporting in early adolescence (3 years later), using an objective instrumental measurement of physical activity.Study designProspective cohort study.Patient sampleRepresentative random sample of Danish children from the city of Odense sampled at age 9 years and followed-up at age 12 years.Outcome measuresThe 1-month period prevalence of back pain (neck pain, mid back pain, and low back pain) was established using a structured interview.MethodsPhysical activity was assessed with the MTI-accelerometer. The accelerometer provides a minute-by-minute measure of the physical activity performed. An overall measure of physical activity and time spent in high activity were studied in relation to back pain using logistic regression. The analyses were performed on the total sample and then stratified on back pain (yes/no) at baseline.ResultsHigh physical activity (HPA) levels seem to protect against future low back pain and appear to actually “treat” and reduce the odds of future mid back pain. When comparing the least active children to the most active children, the least active had a multivariate odds ratio of 3.3 of getting low back pain and 2.7 of getting mid back pain 3 years later. When stratified on back pain at baseline, this effect on mid back pain was especially noticeable in children who had had mid back pain already at baseline, with an odds ratio of 7.2.ConclusionsHPA in childhood seems to protect against low back pain and mid back pain in early adolescence. Larger prospective studies with repetitive follow-ups and preferably intervention studies should be performed, to see if these findings can be reproduced.     

骶髂关节紊乱与腰椎间盘退变之间相关性的流行病学研究与生物力学分析

目的：研究骶髂关节紊乱与腰椎间盘退变之间的相关性,为慢性顽固性腰腿痛的防治提供一个新的认识理念和临床治疗途径。方法：自2009年8月至2010年10月,采用流行病学调查的方法研究129例腰椎间盘突出症患者。L4.5椎间盘突出症患者61例,男37例,女24例;年龄20～75岁;病程1～144个月。L5S1椎间盘突出症患者68例,男32例,女36例;年龄18～76岁;病程0．5～240个月。流行病学调查患者的一般临床资料、症状与体征,以及腰椎与骨盆在X线片的表现形式。病例对照研究的方法计算骶髂关节紊乱对腰椎间盘突出症发病的危险度;单因素危险度估计对自变量进行筛选,Logistic回归分析确定腰椎间盘突出症的危险因素,并进行生物力学分析。结果：129例腰椎间盘突出症患者中88例合并有骶髂关节紊乱,骶髂关节紊乱是腰椎间盘突出的危险因素之一（OR=4．61,P=0．00）;61例L5S1椎间盘突出症患者中47例合并骶髂关节紊乱,髂骨旋转移位引起的髂嵴不平为L4．,椎间盘突出症的高危险因素（OR=11．27,P=0．00）;68例L5S1椎间盘突出症患者中41例合并骶髂关节紊乱,骶骨倾斜移位引起的腰骶角异常为L5S1椎间盘突出症的高危险因素（OR=2．31,P=O．03）。结论：骶髂关节紊乱与腰椎间盘突出症是二联症,二者相互影响且有因果关系,任何一方的发生是另一方发生的原因和结果,共同存在于腰腿痛疾病中。     

极外侧型腰椎椎间盘突出致病相关因素分析及防治

目的探讨作为特殊类型的极外侧型腰椎椎间盘突出症(far lateral lumbar disc herniation,FLLDH)的临床表现独特性及其病因、发病危险因素及致病机理,进一步总结提高对该疾病的认识。方法回顾分析本院近10年PLLDH病例资料58例,通过归纳分析该病的症状特点及原因,评价手术后患者恢复情况及手术效果,总结致病相关因素及防治策略。结果 FLLDH主要见于重体力劳动者,具有根性症状重、直腿抬高试验阳性率低、病史短等特点,多数患者非手术治疗无效需手术治疗。结论 FLLDH做为一种特殊类型椎间盘突出症,可以通过各种方法进行早期预防,MRI技术有助提高确诊率,经侧后路植骨融合患者手术后腰椎失稳、腰部疼痛的情况明显少于单纯髓核摘除减压,2种手术均是快速缓解下肢根性症状、提高生活质量的良好选择。     

Self-reported low back symptoms in urban bus drivers exposed to whole-body vibration.

The prevalence of self-reported low back symptoms was investigated by a postal questionnaire in a group of 234 urban bus drivers exposed to whole-body vibration and postural stress and in a control group of 125 maintenance workers employed at the same bus municipal company. The average vertical whole-body vibration magnitude measured on the seat pan of the buses was 0.4 m/s2. After controlling for potential confounders, the prevalence odds ratios for the bus drivers compared to the controls significantly exceeded 1 for several types of low back symptoms (leg pain, acute low back pain, low back pain). The occurrence of low back symptoms increased with increasing whole-body vibration exposure expressed in terms of total (lifetime) vibration dose (years m2/s4), equivalent vibration magnitude (m/s2), and duration of exposure (years of service). The highest prevalence of disc protrusion was found among the bus drivers with more severe whole-body vibration exposure. Frequent awkward postures at work were also related to some types of low back symptoms. It is concluded that bus driving is associated with an increased risk for low back troubles. This excess risk may be due to both whole-body vibration exposure and prolonged sitting in a constrained posture. The findings of this study also indicated that among the bus drivers low back symptoms occurred at whole-body vibration exposure levels that were lower than the health-based exposure limits proposed by the International Standard ISO 2631/1.     

Impact of insurance type on patient-reported outcome measures in patients with lumbar disc herniation

BACKGROUNDLumbar disc herniations (LDH) are among the most common spinal conditions. Despite increased appreciation for the importance of social determinants of health, the role that these factors play in patients with lumbar disc herniations is poorly defined.PURPOSETo elucidate the association between insurance status and baseline patient reported outcome measures (PROMs) in the setting of lumbar disc herniations.STUDY DESIGN/SETTINGRetrospective cohort studyPATIENT SAMPLEBaseline patient-reported outcome measures (PROMS) were reviewed from 924 adult patients presenting for treatment of lumbar disc herniation within our institutional healthcare system (2015–2020).OUTCOME MEASURESThe Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a), PROMIS Global-Mental, PROMIS Global-Physical, and visual analogue scale (VAS) for back and leg pain were assessed.METHODSPROMIS scores at presentation were defined at the primary outcome and insurance status as the primary predictor. Differences in clinical and sociodemographic characteristics between our cohorts, stratified by insurance status, were evaluated using Wilcoxon rank-sum or chi-squared testing. We used multivariable negative binomial regression modeling to adjust for potential confounders including age, gender, race, language, ethnicity, comorbidity index, and median geospatial household income.RESULTSWe included 924 patients, with mean age of 58.4 +/- 15.2 years and 52.6% male prevalence. Patients insured through Medicaid were more likely to be Black, Hispanic, and non-English speaking patients compared with the commercially insured. The Charlson Comorbidity index was significantly higher in the Medicare group. Following adjusted analysis, patients with Medicaid insurance had significantly worse PF10a (IRR, 0.90, 95% CI 0.85–0.96), as well as PROMIS Global-Physical score (IRR 0.88, 95% CI 0.82–0.94), and VAS low back pain (IRR 1.20, 95% CI 1.04–1.40) when compared to the commercially insured.CONCLUSIONSWe encountered worse physical function, mental, and pain-related patient-reported outcomes for those with Medicaid insurance in a population of patients presenting for evaluation of lumbar disc herniation. These findings, including worse depression, anxiety, and higher axial back pain scores, merit further investigation into potential health system asymmetries, and should be accounted for by treating providers.     

腰椎后路椎间植骨融合器后移的危险因素

目的探讨腰椎后路椎间植骨融合器后移的危险因素,以有助于完善预防措施。方法回顾性分析2011年1月—2013年5月在本院接受单节段或多节段腰椎后路减压椎弓根钉棒内固定椎间植骨融合术(简称腰椎后路椎间植骨融合术)治疗的238例患者的完整病历及影像学资料,共280个节段,278枚椎间融合器(Cage)。患者年龄42~76岁,平均56.9岁;平均手术节段1.4个(1~4个);随访时间12~24个月,平均20.3个月。根据术后是否出现突然的腰痛和下肢症状决定非手术治疗或行翻修手术。结果本研究组中Cage后移7例,Cage7枚,均发生在L4/L5节段。Cage后移发生在术后1~3个月,平均1.6个月,7例患者均未因Cage后移出现腰痛或下肢症状,所有患者未行翻修手术。结论 Cage后移的危险因素有使用Cage型号过小、Cage无角度、直线型终板、术前椎间隙前后缘高度过大及合并退行性侧凸等。     

Influences of limited flexibility of the lower extremities and occurrence of low back pain in adolescent baseball players: A prospective cohort study

BackgroundLimited flexibility of the lower extremities, such as hamstring tightness, has long been suggested as a physical risk factor for low back pain among adolescent athletes. However, few prospective cohort studies have examined the direction of causality for this relationship. This prospective cohort study investigated the relationship between limited flexibility of the lower extremities and the occurrence of low back pain among high school baseball players.MethodsParticipants comprised 335 high school baseball players from 43 high school baseball teams who had undergone baseline medical evaluations (a self-completed questionnaire and physical examination). Occurrence of low back pain during a 1-year follow up, and associations with measurements of flexibility of the lower extremities such as straight-leg-raising angle (hamstring tightness), Thomas test (iliopsoas tightness), heel-buttock-distance (quadriceps tightness), and passive range of motion of the hip were investigated.ResultsIn total, 296 players (88.4%) participated in the 1-year follow-up survey, with 147 of the 296 players (49.7%) reporting the occurrence of low back pain during follow-up. The number of players with low back pain during follow-up peaked in November, then decreased and was lowest in June. After adjusting for factors associated with low back pain using logistic regression modeling, a significant association between hamstring tightness on the non-throwing arm side and low back pain (odds ratio 2.86, 95% confidence interval 1.17–6.94; P = 0.018) was found.ConclusionsHamstring tightness on the non-throwing arm side was identified as a potential risk factor for low back pain in high school baseball players. These results may provide guidance in the development of future prevention programs.     

Biomechanical changes in the lumbar spine following spaceflight and factors associated with postspaceflight disc herniation

Background ContextFor chronic low back pain, the causal mechanisms between pathological features from imaging and patient symptoms are unclear. For instance, disc herniations can often be present without symptoms. There remains a need for improved knowledge of the pathophysiological mechanisms that explore spinal tissue damage and clinical manifestations of pain and disability. Spaceflight and astronaut health provides a rare opportunity to study potential low back pain mechanisms longitudinally. Spaceflight disrupts diurnal loading on the spine and several lines of evidence indicate that astronauts are at a heightened risk for low back pain and disc herniation following spaceflight.PurposeTo examine the relationship between prolonged exposure to microgravity and the elevated incidence of postflight disc herniation, we conducted a longitudinal study to track the spinal health of twelve NASA astronauts before and after approximately 6 months in space. We hypothesize that the incidence of postflight disc herniation and low back complaints associates with spaceflight-included muscle atrophy and pre-existing spinal pathology.Study DesignThis is a prospective longitudinal study.Patient SampleOur sample included a cohort of twelve astronaut crewmembers.Outcome MeasuresFrom 3T MRI, we quantified disc water content (ms), disc degeneration (Pfirrmann grade), vertebral endplate irregularities, facet arthropathy and/ fluid, high intensity zones, disc herniation, multifidus total cross-sectional area (cm²), multifidus lean muscle cross-sectional area (cm²), and muscle quality/composition (%). From quantitative fluoroscopy we quantified, maximum flexion-extension ROM (°), maximum lateral bending ROM (°), and maximum translation (%). Lastly, patient outcomes and clinical notes were used for identifying postflight symptoms associated with disc herniations from 3T MRI.MethodsAdvanced imaging data from 3T MRI were collected at three separate time points in relation to spending six months in space: (1) within a year before launch (“pre-flight”), (2) within a week after return to Earth (“post-flight”), and (3) between 1 and 2 months after return to Earth (“recovery”). Fluoroscopy of segmental kinematics was collected at preflight and postflight timepoints. We assessed the effect of spaceflight and postflight recovery on longitudinal changes in spinal structure and function, as well as differences between crew members who did and did not present a symptomatic disc herniation following spaceflight.ResultsHalf of our astronauts (n=6) experienced new symptoms associated with a new or previously asymptomatic lumbar disc protrusion or extrusion following spaceflight. We observed decreased multifidus muscle quality following spaceflight in the lower lumbar spine, with a reduced percentage of lean muscle at L4L5 (-6.2%, p=.009) and L5S1 (-7.0%, p=.006) associated with the incidence of new disc herniation. Additionally, we observed reduced lumbar segment flexion-extension ROM for L2L3 (-17.2%, p=.006) and L3L4 (-20.5%, p=.02) following spaceflight, and furthermore that reduced ROM among the upper three lumbar segments (-24.1%, p=.01) associated with the incidence of disc herniation. Existing endplate pathology was most prevalent in the upper lumbar spine and associated with reduced segmental ROM (-20.5%, p=.02).ConclusionsIn conclusion from a 10-year study investigating the effects of spaceflight on the lumbar spine and risk for disc herniation, we found the incidence of lumbar disc herniation following spaceflight associates with compromised multifidus muscle quality and spinal segment kinematics, as well as pre-existing spinal endplate irregularities. These findings suggest differential effects of spinal stiffness and muscle loss in the upper versus lower lumbar spine regions that may specifically provoke risk for symptomatic disc herniation in the lower lumbar spine following spaceflight. Results from this study provide a unique longitudinal assessment of mechanisms and possible risk factors for developing disc herniations and related low back pain. Furthermore, these findings will help inform physiologic countermeasures to maintain spinal health in astronauts during long-duration missions in space.     

Advances in the diagnosis of degenerated lumbar discs and their possible clinical application

Purpose

One possible source of chronic low back pain is a degenerated intervertebral disc. In this review, various diagnostic methods for the assessment of the presence of degenerative changes are described. These include clinical MRI, a number of novel MRI techniques and nuclear magnetic resonance spectroscopy.

Methods

Non-systematic literature review.

Results

Clinical MRI is the most commonly employed technique to determine the general “health status” of the intervertebral disc. Novel MRI techniques, such as quantitative MRI, T1ρ MRI, sodium MRI and nuclear magnetic resonance spectroscopy, are more sensitive in quantifying the biochemical changes of disc degeneration, as measured by alteration in collagen structure, as well as water and proteoglycan loss. As potential future diagnostic alternatives, miniature sensors are currently being developed to measure parameters associated with the disc degeneration cascade, such as intradiscal pressure and PG concentration. However, none of the methods listed above show sufficient specificity to identify a degenerated disc as the actual source of the pain. Provocative discography is the only test aimed at a direct diagnosis of discogenic pain, but it has a high false positive rate and there is some evidence of long-term adverse effects. Imaging techniques have also been tested for this purpose, but their validity has not been confirmed and they do appear to be problematic.

Conclusions

A reliable diagnostic tool that could help a clinician to determine if a disc is the source of the pain in patients with chronic LBP is still not available. New MRI techniques are under investigation that could result in a significant improvement over current methods, particularly as they can allow monitoring, not only of morphological but also of biochemical changes.

     

Lumbar spine MRI in upright position for diagnosing acute and chronic low back pain: statistical analysis of morphological changes

Background

Patients with low back pain frequently demonstrate recumbent magnetic resonance imaging (MRI) alterations not always related to homogeneous clinical symptoms. The purpose of this study was to evaluate and quantify the statistical significance of variations of some anatomical parameters of the lumbosacral spine and reveal occult disc pathologies from recumbent to upright position in patients with acute and chronic low back pain.

Materials and methods

Fifty-seven patients complaining of low back pain (27 women, 30 men) underwent dynamic lumbosacral MRI with a 0.25-T tilting system (G-scan Esaote). We settled five parameters for which variations have been evaluated: lumbosacral angle, lordosis angle, L3–L4 intersomatic disc height, L3–L4 interspinous processes distance, and widest anteroposterior dural sac diameter. Images were obtained in both recumbent and upright positions.

Results

Statistically significant differences [one-way analysis of variance (ANOVA), p = 0.0043] were found between each pair of values of parameters sampled in recumbent and upright positions. In 70 % of patients, on visual qualitative analysis only, an increment of disc protrusions and/or spondylolisthesis was found in the upright position; in three cases, in the upright position only, an interarticular pseudocyst was found.

Conclusions

Dynamic MRI with an open-configuration, low-field tilting MRI system is a feasible and promising tool to study degenerative pathology of the spine. Moreover, in cases of low back pain with negative MRI in the recumbent position or in patients with pain in the upright position only, tilting MRI permits visualization of occult spine and disc pathologies in patients with acute or chronic low back pain.     

The role of intense athletic activity on structural lumbar abnormalities in adolescent patients with symptomatic low back pain

Purpose

To determine if adolescent athletics increases the risk of structural abnormalities in the lumbar spine.

Methods

A retrospective review of patients (ages 10–18) between 2004 and 2012 was performed. Pediatric patients with symptomatic low back pain, a lumbar spine MRI, and reported weekly athletic activity were included. Patients were stratified to an “athlete” and “non-athlete” group. Lumbar magnetic resonance and plain radiographic imaging was randomized, blinded, and evaluated by two authors for a Pfirrmann grade, herniated disc, and/or pars fracture.

Results

A total of 114 patients met the inclusion criteria and were stratified into 66 athletes and 48 non-athletes. Athletes were more likely to have abnormal findings compared to non-athletes (67 vs. 40 %, respectively, p = 0.01). Specifically, the prevalence of a spondylolysis with or without a slip was higher in athletes vs. non-athletes (32 vs. 2 %, respectively, p = 0.0003); however, there was no difference in the average Pfirrmann grade (1.19 vs. 1.14, p = 0.41), percentage of patients with at least one degenerative disc (39 vs. 31 %, p = 0.41), or disc herniation (27 vs. 33 %, p = 0.43). Body mass index, smoking history, and pelvic incidence (51.5° vs. 48.7°, respectively, p = 0.41) were similar between the groups.

Conclusion

Adolescents with low back pain have a higher-than-expected prevalence of structural pathology regardless of athletic activity. Independent of pelvic incidence, adolescent athletes with low back pain had a higher prevalence of spondylolysis compared to adolescent non-athletes with back pain, but there was no difference in associated disc degenerative changes or herniation.

     

Segmental spinal canal volume in patients with degenerative spondylolisthesis

Background contextLumbar degenerative spondylolisthesis (DS), typically characterized by the forward slippage of the superior vertebra of a lumbar motion segment, is a common spinal pathological condition in elderly individuals. Significant deformation and volume changes of the spinal canal can occur because of the vertebral slippage, but few data have been reported on these anatomic variations in DS patients. Whether to restore normal anatomy, such as reduction of the slippage and restoration of disc height, is still not clear in surgery.PurposeThis study was designed to determine the volume change of the spinal canal and detect specific anatomic factors affecting the spinal canal volume in DS patients.Study design/settingA case-control study.MethodsNine asymptomatic volunteers (mean age 54.4) and 9 patients with L4/L5 DS (mean age 73.4) were recruited. All patients had intermittent claudication and different extent low back pain, and two patients also had leg pain. L4/L5 vertebral motion segment unit of each subject was reconstructed using three-dimensional computed tomography or magnetic resonance images in a solid modeling software. In vivo lumbar vertebral motion during functional postures (supine, standing upright, flexion, and extension) was determined using a dual fluoroscopic imaging technique. The volume of the spinal canal was measured at each functional posture. Various anatomic parameters (disc height, cross-sectional area of the canal, left-right diameter of the canal, anterior-posterior diameter of the canal, slippage, posture, intervertebral disc angle [DA], etc.) that may potentially affect the canal volume were also measured, and their correlations with the volume change of spinal canal were analyzed. This study was funded by a 2-year, $275,000 grant from the National Institutes of Health.ResultsOn average, spinal canal volume was larger at supine and flexion postures than at stand and extension postures in both the DS and the asymptomatic groups. Spinal canal volume of the DS patients were significantly lower than that of the asymptomatic subjects under all the four postures (p<.05). Correlation analysis showed that spinal canal volume was strongly affected by the posterior disc height (Pearson correlation coefficient γ_b=0.822) and the slippage percentage (γ_b=?0.593) and moderately affected by the anterior disc height (γ_b=0.300) and the DA (γ_b=?0.237).ConclusionsThe volume of spinal canal is affected by multiple factors. Increased spinal canal volume at supine and flexion positions may explain the clinical observations of relief of symptoms at these postures in DS patients. The data also suggest that reduction of slipped vertebral body, decrease of DA, intervertebral distraction, and decompression could all be effective to increase the canal volume of DS patients thus to relieve clinical symptoms.