Multifidus muscle fatty infiltration as an index of dysfunction in patients with single-segment degenerative lumbar spinal stenosis: A case-control study based on propensity score matching

Goutallier Grading of Psoas Major and Lumbar Extensor Muscles as a Predictor of Cage Subsidence and Reoperation Following Transforaminal and Posterior Lumbar Interbody Fusion

BACKGROUND CONTEXT

Cage subsidence after transforaminal or posterior lumbar interbody fusion (TLIF/PLIF) is a complication that can lead to recurrence of radiculopathy, loss of correction, and poor patient outcomes. A reliable method to predict subsidence has not yet been established. One recently proposed method involves measuring the degree of fatty degeneration and Goutallier grading of the psoas major (PM) and lumbar extensors (LE) muscle groups, as well as the cross-sectional area (CSA) ratio between these muscle groups and the corresponding vertebrae.

PURPOSE

The purpose of this study was to determine the relationship between (1) Goutallier grading of PM/LE and subsidence, (2) CSA ratio and subsidence, (3) identify the most predictive vertebral level, (4) examine the relationship between these measurements and rates of reoperation, and (5) examine the relationship between these measurements and patient reported outcome measures (PROMs).

STUDY DESIGN/SETTING

This study is a retrospective chart review.

PATIENT SAMPLE

This study included one hundred and sixty-two patients who underwent elective single level TLIF/PLIF from 2007-2022.

OUTCOME MEASURES

Outcome data collected included cage subsidence rates, reoperation rates, Oswestry disability index (ODI), and Patient-Reported Outcomes Measurement Information System (PROMIS) Global scores.

METHODS

A retrospective analysis was performed identifying patients who underwent elective single level TLIF/PLIF from 2007-2022. Muscle parameters collected include the CSA ratio and Goutallier grade of the PM/LE muscle groups at L3/L4, L4/L5, and L5/S1 based on axial CT and MRI. Clinical and radiographic data collected include cage subsidence, osteoporosis diagnosis, reoperation rates, and PROMs.

RESULTS

One hundred sixty-two patients met inclusion criteria. Average follow-up time was 1.6±1.1 years (range:0.13-7.3 years). 81 (50%) patients experienced cage subsidence. Compared to the non-subsidence group, the subsidence group had higher mean Goutallier grade at L3/4 measured in the PM (1.10±1.05 vs. 0.60±0.84, p< 0.001) and LE (1.40±0.89 vs. 1.18±0.76, p=0.047) muscle groups. A Goutallier grade ≥ 2 at L3/4 was associated with an increased risk of subsidence based on PM (OR=4.585, p< 0.001; AUC=0.635; r=0.258, p=0.001) measurements. Increased risk of reoperation was observed in patients with higher Goutallier grades at L3/L4, L4/L5, and L5/S1 based on PM parameters (OR=3.997, p=0.004; OR=3.516, p=0.008; and OR=3.124, p=0.016, respectively), and at L3/4 based on LE parameters (OR 3.462, p=0.009). A significant correlation was found between worse ODI and a higher Goutallier grade at L3-L4 for PM (B= 2.105, p= 0.043). Worse PROMIS Global scores were significantly correlated with higher Goutallier grades at L3-L4 for LE (B= -4.455, p= 0.002). CSA ratios for PM/LE were not strongly correlated with subsidence, PROMs, or reoperation.

CONCLUSION

Our results demonstrated that the degree of fat degeneration of PM and LE is correlated with increased risk of cage subsidence, worse PROMs, and reoperation rates following single level TLIF/PLIF. A Goutallier grade of ≥ 2 of both PM and LE parameters at L3/4 was found to be most predictive of subsidence risk. CSA ratios were not as strongly correlated nor predictive of subsidence. These findings suggest that Goutallier grading of PM and LE show promise as a tool to predict risk of cage subsidence and the need for potential reoperation.

Impact of myosteatosis on prognosis in multiple myeloma patients: A subgroup analysis of 182 cases and development of a nomogram

Background

This study aims to explore the prognostic value of myosteatosis in multiple myeloma (MM) and to analyze the factors influencing myosteatosis.

Methods

A retrospective analysis was conducted on 182 patients treated for MM at our institution from 2009 to 2020 who underwent MRI examinations. The fatty infiltration rate (FIR) of the erector spinae and multifidus muscles at the L3 level was measured to assess the degree of myosteatosis. Patients were grouped based on fracture presence and median FIR, and group differences were compared, with P < 0.05 considered statistically significant. Survival and fractures were used as prognostic indicators, and regression analysis was performed to determine the impact of FIR on these outcomes in MM patients. The factors influencing FIR were analyzed, and the relationship between myosteatosis and MM prognosis was further analyzed within its sensitive subgroups. Finally, a nomogram based on FIR was established and validated.

Results

Significant differences were observed between the fracture and non-fracture groups in lactate dehydrogenase, serum phosphorus, visual analogue scale, oswestry disability index and FIR (P < 0.05). When patients were grouped based on the median FIR (28.89 %), there were significant differences in age, sex, body mass index (BMI), red blood cell (RBC) count, hemoglobin, hematocrit, albumin, visual analogue scale, oswestry disability index, and fracture incidence (P < 0.05). Univariate COX regression analysis indicated that myosteatosis had no significant impact on survival prognosis in MM patients (HR = 0.999, P = 0.852), with a log-rank test P value of 0.11 when grouped by the cut-off FIR value of 33.67 %. Multivariate logistic regression indicated that FIR is an independent predictor of fractures (OR = 1.054, P = 0.000). Multivariate linear regression revealed that age, sex, RBC count, and BMI are independent factors influencing FIR (P < 0.05). When not grouped, FIR's prediction of fractures showed no significant interaction with age, sex, RBC count, or BMI (P for interaction > 0.05). In subgroups with BMI ≥ 25 kg/m2 or RBC count > 3.68 × 10^12/L, FIR lost its predictive significance for fractures. The FIR nomogram model had a C-index of 0.777, and the calibration curve, decision curve analysis, and clinical impact curve all validated its effectiveness.

Conclusions

Myosteatosis characterized by FIR is not a reliable predictor of survival in MM patients but is effective in predicting fractures and is closely related to back pain and functional impairment. FIR is significantly associated with age, sex, RBC count, and BMI.

Are paraspinal muscle morphology and composition associated with lumbar spinal stenosis? A systematic review

BACKGROUND

There has been increasing interest in associations between paraspinal muscle phenotypes and common spinal disorders, including lumbar spinal stenosis (LSS). However, the relation of paraspinal muscle morphology and composition with LSS is unclear.

OBJECTIVES

To provide a systematic overview and synthesis of current evidence on the association of paraspinal muscle morphology and composition with LSS presence, pain and disability or function.

DESIGN

Systematic review.

METHODS

Relevant studies were identified from a search of EMBASE, PubMed, SPORTDiscuss, Cinahl, Web of Science and PEDro. Relevant studies were selected, data were extracted, and risk of bias was assessed by 2 independent reviewers prior to conducting a narrative synthesis to summarize evidence using GRADE considerations. The study protocol was prospectively registered (Prospero: CRD42021246492).

RESULTS

Of 33 studies included in the review, multifidus (n=22) was most frequently studied, followed by psoas (n=10). Fatty infiltration (20 studies), CSA (n=11) and relative CSA (n=10) were the most studied paraspinal phenotypes. Most studies (n=31) had low risk of bias, with selection and confounding bias (n=13) most common. High variability in approaches used to measure muscle morphology and composition and LSS disability and pain, and variable control of confounding factors, created challenges in synthesizing findings. The only association identified for which there was moderate certainty of evidence was between increased multifidus fatty infiltration and the presence of LSS (4 of 6 studies). All other associations studied with high or moderate strength of evidence demonstrated no association, including no association between multifidus fatty infiltration and pain severity (8 studies), multifidus CSA and LSS disability (7 studies), psoas morphology and LSS anatomical severity (4 studies), or psoas composition and LSS pain severity (4 studies) for which there was high certainty. There was moderate certainty of no association between multifidus morphology and LSS pain severity (5 of 7 studies), and erector spinae morphology and pain severity (3 studies), and erector spinae composition and LSS pain severity (3 studies) and function (3 studies). Other associations remain more unclear.

CONCLUSION

Largely consistent results suggest multifidus fatty infiltration is associated with the presence of LSS. However, other specific associations examined with high or moderate certainty of evidence demonstrated no association, and others remain largely undetermined. Although interest has grown in paraspinal muscle morphology and composition for improved phenotyping, prognosis and treatment of common spinal disorders, the clinical utility of paraspinal muscle imaging in LSS remains unclear.

Lumbar paraspinal muscle morphology is associated with spinal degeneration in patients with lumbar spinal stenosis

BACKGROUND CONTEXT

Lumbar spinal stenosis (LSS) has been reported to induce changes in paraspinal muscle morphology, but objective physical function and degenerative spine conditions are rarely assessed.

PURPOSE

To identify factors associated with paraspinal muscle morphology using objective physical and degenerative spine assessments in patients with LSS.

STUDY DESIGN/SETTING

Cross-sectional design.

PATIENT SAMPLE

Seventy patients with neurogenic claudication caused by LSS, receiving outpatient physical therapy.

OUTCOME MEASURES

Cross-sectional area (CSA) and functional CSA (FCSA) of the multifidus, erector spinae, and psoas muscles, the severity of stenosis, disc degeneration, and endplate abnormalities were evaluated by magnetic resonance imaging, as well as sagittal spinopelvic alignment by X-ray. Objective physical assessments included pedometry and claudication distance. Patient-reported outcomes included the numerical rating scale of low back pain, leg pain, and leg numbness, and the Zurich Claudication Questionnaire.

METHODS

To assess the impact of LSS on paraspinal muscles, FCSA and FCSA/CSA were compared between the dominant and nondominant sides based on the patients' neurogenic symptoms, and multivariable regression analyses adjusted for age, sex, height, and weight were performed; p<.05 was considered significant.

RESULTS

Seventy patients were analyzed. At one level below the maximum stenotic level, erector spinae FCSA on the dominant side was significantly lower than that on the nondominant side. In the multivariable regression analyses, at one level below the symptomatic level, disc degeneration, endplate abnormalities, and lumbar spinopelvic alignment, such as decreased lumbar lordosis and increased pelvic tilt, were negatively associated with multifidus FCSA and FCSA/CSA ratio. A significant association was observed between dural sac CSA and erector spinae FCSA. Throughout L1/2 to L5/S, disc degeneration, endplate abnormalities, and lumbar spinopelvic alignment were negatively associated with multifidus and erector spinae FCSA or FCSA/CSA.

CONCLUSIONS

Lumbar paraspinal muscle asymmetry caused by LSS was observed only in erector spinae. Disc degeneration, endplate abnormalities, and lumbar spinopelvic alignment, rather than spinal stenosis and LSS symptoms, were more associated with paraspinal muscle atrophy or fat infiltration.

The association between morphological characteristics of paraspinal muscle and spinal disorders

BACKGROUND

Spinal disorders affect millions of people worldwide, and can cause significant disability and pain. The paraspinal muscles, located on either side of the spinal column, play a crucial role in the movement, support, and stabilization of the spine. Many spinal disorders can affect paraspinal muscles, as evidenced by changes in their morphology, including hypertrophy, atrophy, and degeneration.

OBJECTIVES

The objectives of this review were to examine the current literature on the relationship between the paraspinal muscles and spinal disorders, summarize the methods used in previous studies, and identify areas for future research.

METHODS

We reviewed studies on the morphological characteristics of the paravertebral muscle and discussed their relationship with spinal disorders, as well as the current limitations and future research directions.

RESULTS

The paraspinal muscles play a critical role in spinal disorders and are important targets for the treatment and prevention of spinal disorders. Clinicians should consider the role of the paraspinal muscles in the development and progression of spinal disorders and incorporate assessments of the paraspinal muscle function in clinical practice.

CONCLUSION

The findings of this review highlight the need for further research to better understand the relationship between the paraspinal muscles and spinal disorders, and to develop effective interventions to improve spinal health and reduce the burden of spinal disorders.

Age-related radiographic parameters difference between the degenerative lumbar spinal stenosis patients and healthy people and correlation analysis

OBJECTIVES

To identify age-related radiographic risk factors for degenerative lumbar spinal stenosis (DLSS) and analyze correlations among them.

METHODS

A total of 180 cases were enrolled in this study, and lumbar magnetic resonance was performed. Among them, 93 cases suffered DLSS and lumbar dynamic X-ray was examined. And following parameters were measured and evaluated: intervertebral disk height (IDH), the ratio of IDH(IDH_L4-5/L3-4), initial IDH of L4-5(iIDH_L4-5) in the DLSS group, disk degeneration (DD), cartilaginous endplate failure (CEF), Modic changes, the thickness of ligamentum flavum (LF), range of intervertebral motion (ROM), facet joint opening (FJO), facet joint angle (FJA), the standard cross-sectional area (SCSA) of the multifidus, erector spinae, and psoas major muscles. The data of two groups were compared, and the possible risk factors of DLSS were analyzed.

RESULTS

Compared with the control group, the DLSS group had higher IDH except for L4-5 and larger iIDH_L4-5 (P < 0.05). Significant differences were shown in CEF and the thickness of LF at L1-S1 and DD at L4-5 (P < 0.05). The DLSS group had smaller SCSA of multifidus, erector spinae, and psoas major muscles but greater FJA, FJO (P < 0.05). And the risk of DLSS increased when iIDH_L4-5 ≥ 10.73 mm, FJA ≥ 52.03° , or FJO ≥ 3.75 mm. IDH positively correlated with SCSA of multifidus and psoas major muscles and ROM at L1-S1 (P < 0.05). DD showed negative linear relations with SCSA of multifidus and psoas muscle and positive linear relation with CEF at L1-2, L2-3, and L5-S1 (P < 0.05).

CONCLUSION

Larger initial disk height and excessive CEF may induce DLSS by increasing intervertebral mobility to promote DD, and atrophied paravertebral muscles by weakening the stability of lumbar spine.

Spinal degeneration is associated with lumbar multifidus morphology in secondary care patients with low back or leg pain

Associations between multifidus muscle morphology and degenerative pathologies have been implied in patients with non-specific low back pain, but it is unknown how these are influenced by pathology severity, number, or distribution. MRI measures of pure multifidus muscle cross-sectional area (CSA) were acquired from 522 patients presenting with low back and/or leg symptoms in an outpatient clinic. We explored cross-sectional associations between the presence, distribution, and/or severity of lumbar degenerative pathologies (individually and in aggregate) and muscle outcomes in multivariable analyses (beta coefficients [95% CI]). We identified associations between lower pure multifidus muscle CSA and disc degeneration (at two or more levels): − 4.51 [− 6.72; − 2.3], Modic 2 changes: − 4.06 [− 6.09; − 2.04], endplate defects: − 2.74 [− 4.58; − 0.91], facet arthrosis: − 4.02 [− 6.26; − 1.78], disc herniations: − 3.66 [− 5.8; − 1.52], and when > 5 pathologies were present: − 6.77 [− 9.76; − 3.77], with the last supporting a potential dose–response relationship between number of spinal pathologies and multifidus morphology. Our findings could hypothetically indicate that these spinal and muscle findings: (1) are part of the same degenerative process, (2) result from prior injury or other common antecedent events, or (3) have a directional relationship. Future longitudinal studies are needed to further examine the complex nature of these relationships.

Electromyography of the Multifidus Muscle in Horses Trotting During Therapeutic Exercises

Thoracolumbar pain has been identified in both human and equine patients. Rehabilitation and conditioning programs have focused specifically on improving trunk and abdominal muscle function (1–5). Equine exercise programs routinely incorporate ground poles and training devices for the similar goals of increasing spinal and core stability and strength (6–8). The multifidus muscle has been an area of focus due to atrophy associated with disease (9). To date, there have been no reports on the activity of the multifidus muscle in horses in relation to therapeutic exercises. Our objectives were to use electromyography to determine the average work performed and peak muscle activity of the multifidus in horses trotting, trotting over ground poles, trotting while wearing a resistance band-based training device and trotting while wearing the training device over ground poles. We hypothesized that ground poles and the training device would each increase average work performed and peak multifidus muscle activity. Right and left cranial thoracic locations showed significant increased muscle work and peak activation when horses were trotted over ground poles versus without. The peak activation was significantly greater in horses trotting over poles in both lumbar regions, but there was no significant change in peak activation in either location due to the training device. When the influence of the training device was investigated without ground poles, left caudal thoracic muscle work and peak activity, and right lumbar muscle work were significantly lower when using the training device, as compared to without. When the training device was combined with trotting over ground poles, both left and right caudal thoracic regions showed significantly lower muscle work and peak activity when the device was used. There was no significant difference between with and without the device in either left or right lumbar muscle work. In conclusion, implementing ground poles can be an effective strategy to increase the activation of the multifidus muscle, however, caution should be taken when incorporating the use of a resistance band training device as muscle work and peak activation were significantly reduced in most locations. Further study should be performed in regards to the training device to determine its effects on epaxial musculature.