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Park S, Hong SH, Chung SG, Kim K. Redundant nerve roots on magnetic resonance imaging can predict ongoing denervation in patients with lumbar spinal stenosis. Muscle Nerve 2024; 69:691-698. [PMID: 38545741 DOI: 10.1002/mus.28094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/12/2024] [Accepted: 03/17/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION/AIMS Redundant nerve roots (RNRs) are abnormally elongated and tortuous nerve roots that develop secondary to degenerative spinal stenosis. RNRs have been associated with poorer clinical outcomes after decompression surgery; however, studies on their clinical characteristics are limited. This study aimed to investigate the association between RNRs and denervation potentials, that is, abnormal spontaneous activity (ASA), on electromyography. METHODS We retrospectively reviewed data of patients who underwent an electrodiagnostic study of the lower extremities between January 2020 and March 2023. Of these, patients with lumbar central spinal stenosis, as seen on magnetic resonance imaging, were included. We analyzed clinical and imaging data, including presence of ASA, and compared them according to the presence of RNRs. Multivariable logistic regression analysis was employed to identify factors associated with development of ASA. RESULTS Among the 2003 patients screened, 193 were included in the study. RNRs were associated with advanced age (p < .001), longer symptom duration (p = .009), smaller cross-sectional area of the dural sac at the stenotic level (p < .001), and higher frequency of ASA (p < .001). Higher probability of ASA was correlated with greater RNR severity (p < .001). In the multivariable logistic regression analysis, ASA occurrence was associated with smaller cross-sectional area, multiple stenotic sites, and severe-grade RNRs. DISCUSSION The presence of RNRs, particularly severe-grade RNRs, was identified as a significant risk factor for the development of ASA on electromyography. This finding may aid physicians in estimating the prognosis of patients with central spinal stenosis.
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Affiliation(s)
- Seoyeong Park
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sung Hwan Hong
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sun Gun Chung
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Institute on Aging, Seoul National University, Seoul, Republic of Korea
| | - Keewon Kim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Matheve T, Hodges P, Danneels L. The Role of Back Muscle Dysfunctions in Chronic Low Back Pain: State-of-the-Art and Clinical Implications. J Clin Med 2023; 12:5510. [PMID: 37685576 PMCID: PMC10487902 DOI: 10.3390/jcm12175510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Changes in back muscle function and structure are highly prevalent in patients with chronic low back pain (CLBP). Since large heterogeneity in clinical presentation and back muscle dysfunctions exists within this population, the potential role of back muscle dysfunctions in the persistence of low back pain differs between individuals. Consequently, interventions should be tailored to the individual patient and be based on a thorough clinical examination taking into account the multidimensional nature of CLBP. Considering the complexity of this process, we will provide a state-of-the-art update on back muscle dysfunctions in patients with CLBP and their implications for treatment. To this end, we will first give an overview of (1) dysfunctions in back muscle structure and function, (2) the potential of exercise therapy to address these dysfunctions, and (3) the relationship between changes in back muscle dysfunctions and clinical parameters. In a second part, we will describe a framework for an individualised approach for back muscle training in patients with CLBP.
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Affiliation(s)
- Thomas Matheve
- Spine, Head and Pain Research Unit Ghent, Department of Rehabilitation Sciences, Ghent University, 9000 Gent, Belgium;
- REVAL—Rehabilitation Research Center, Faculty of Rehabilitation Sciences, UHasselt, 3500 Diepenbeek, Belgium
| | - Paul Hodges
- NHMRC—Centre of Clinical Research Excellence in Spinal Pain, Injury & Health, School of Health & Rehabilitation Sciences, The University of Queensland, Brisbane 4072, Australia;
| | - Lieven Danneels
- Spine, Head and Pain Research Unit Ghent, Department of Rehabilitation Sciences, Ghent University, 9000 Gent, Belgium;
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3
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Banitalebi H, Aaen J, Storheim K, Negård A, Myklebust TÅ, Grotle M, Hellum C, Espeland A, Anvar M, Indrekvam K, Weber C, Brox JI, Brisby H, Hermansen E. A novel MRI index for paraspinal muscle fatty infiltration: reliability and relation to pain and disability in lumbar spinal stenosis: results from a multicentre study. Eur Radiol Exp 2022; 6:38. [PMID: 35854201 PMCID: PMC9296716 DOI: 10.1186/s41747-022-00284-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fatty infiltration of the paraspinal muscles may play a role in pain and disability in lumbar spinal stenosis. We assessed the reliability and association with clinical symptoms of a method for assessing fatty infiltration, a simplified muscle fat index (MFI). METHODS Preoperative axial T2-weighted magnetic resonance imaging (MRI) scans of 243 patients aged 66.6 ± 8.5 years (mean ± standard deviation), 119 females (49%), with symptomatic lumbar spinal stenosis were assessed. Fatty infiltration was assessed using both the MFI and the Goutallier classification system (GCS). The MFI was calculated as the signal intensity of the psoas muscle divided by that of the multifidus and erector spinae. Observer reliability was assessed in 102 consecutive patients for three independent investigators by intraclass correlation coefficient (ICC) and 95% limits of agreement (LoA) for continuous variables and Gwet's agreement coefficient (AC1) for categorical variables. Associations with patient-reported pain and disability were assessed using univariate and multivariate regression analyses. RESULTS Interobserver reliability was good for the MFI (ICC 0.79) and fair for the GCS (AC1 0.33). Intraobserver reliability was good or excellent for the MFI (ICC range 0.86-0.91) and moderate to almost perfect for the GCS (AC1 range 0.55-0.92). Mean interobserver differences of MFI measurements ranged from -0.09 to -0.04 (LoA -0.32 to 0.18). Adjusted for potential confounders, none of the disability or pain parameters was significantly associated with MFI or GCS. CONCLUSION The proposed MFI demonstrated high observer reliability but was not associated with preoperative pain or disability.
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Affiliation(s)
- Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Jørn Aaen
- Department of Orthopaedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Anne Negård
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway.,Department of Registration, Cancer Registry Norway, Oslo, Norway
| | - Margreth Grotle
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway.,Department of Physiotherapy, Faculty of Health Science, Oslo Metropolitan University, P.O. box 4, St. Olafs plass, Oslo, Norway
| | - Christian Hellum
- Division of Orthopaedic Surgery, Oslo University Hospital Ulleval, Oslo, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Kari Indrekvam
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Kysthospitalet in Hagevik. Orthopaedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway.,Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Helena Brisby
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Orthopaedics, Institute for clinical sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erland Hermansen
- Department of Orthopaedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.,Hofseth BioCare, Ålesund, Norway
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Hodges PW, Bailey JF, Fortin M, Battié MC. Paraspinal muscle imaging measurements for common spinal disorders: review and consensus-based recommendations from the ISSLS degenerative spinal phenotypes group. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3428-3441. [PMID: 34542672 DOI: 10.1007/s00586-021-06990-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/12/2021] [Accepted: 09/05/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Paraspinal muscle imaging is of growing interest related to improved phenotyping, prognosis, and treatment of common spinal disorders. We reviewed issues related to paraspinal muscle imaging measurement that contribute to inconsistent findings between studies and impede understanding. METHODS Three key contributors to inconsistencies among studies of paraspinal muscle imaging measurements were reviewed: failure to consider possible mechanisms underlying changes in paraspinal muscles, lack of control of confounding factors, and variations in spinal muscle imaging modalities and measurement protocols. Recommendations are provided to address these issues to improve the quality and coherence of future research. RESULTS Possible pathophysiological responses of paraspinal muscle to various common spinal disorders in acute or chronic phases are often overlooked, yet have important implications for the timing, distribution, and nature of changes in paraspinal muscle. These considerations, as well as adjustment for possible confounding factors, such as sex, age, and physical activity must be considered when planning and interpreting paraspinal muscle measurements in studies of spinal conditions. Adoption of standardised imaging measurement protocols for paraspinal muscle morphology and composition, considering the strengths and limitations of various imaging modalities, is critically important to interpretation and synthesis of research. CONCLUSION Study designs that consider physiological and pathophysiological responses of muscle, adjust for possible confounding factors, and use common, standardised measures are needed to advance knowledge of the determinants of variations or changes in paraspinal muscle and their influence on spinal health.
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Affiliation(s)
- Paul W Hodges
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, 4072, Australia.
| | - Jeannie F Bailey
- Department of Orthopedic Surgery, University of California, San Francisco, CA, USA
| | - Maryse Fortin
- Department of Health, Kinesiology & Applied Physiology, Concordia University, Montreal, QC, Canada
| | - Michele C Battié
- Faculty of Health Sciences and Western's Bone and Joint Institute, Western University, London, ON, Canada
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5
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Yamamoto S, Malakoutian M, Theret M, Street J, Rossi F, Brown SHM, Saito M, Oxland TR. The Effect of Posterior Lumbar Spinal Surgery on Biomechanical Properties of Rat Paraspinal Muscles 13 Weeks After Surgery. Spine (Phila Pa 1976) 2021; 46:E1125-E1135. [PMID: 34156788 DOI: 10.1097/brs.0000000000004036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Preclinical study in rodents. OBJECTIVE To investigate changes in biomechanical properties of paraspinal muscles following a posterior spinal surgery in an animal model. SUMMARY OF BACKGROUND DATA Posterior spine surgery damages paraspinal musculature per histological and imaging studies. The biomechanical effects of these changes are unknown. METHODS 12 Sprague-Dawley rats were divided equally into sham and surgical injury (SI) groups. For sham, the skin and lumbodorsal fascia were incised at midline. For SI, the paraspinal muscles were detached from the vertebrae, per normal procedure. Thirteen weeks postsurgery, multifidus and longissimus biopsies at L1, L3, and L5 levels were harvested on the right. From each biopsy, three fibers and three to six bundles of fibers (∼10-20 fibers ensheathed in their extracellular matrix) were tested mechanically to measure their passive elastic modulus. The collagen content and fatty infiltration of each biopsy were also examined histologically by immunofluorescence staining. Nonparametric statistical methods were used with a 1.25% level of significance. RESULTS A total of 220 fibers and 279 bundles of fibers were tested. The elastic moduli of the multifidus and longissimus fibers and longissimus fiber bundles were not significantly different between the SI and sham groups. However, the elastic modulus of multifidus fiber bundles was significantly greater in the SI group compared to sham (SI median 82 kPa, range 23-284; sham median 38 kPa, range 23-50, P = 0.0004). The elastic modulus of multifidus fiber bundles in the SI group was not statistically different between spinal levels (P = 0.023). For histology, only collagen I deposition in multifidus was significantly greater in the SI group (median 20.8% vs. 5.8% for sham, P < 0.0001). CONCLUSION The surgical injury increased the passive stiffness of the multifidus fiber bundles. Increased collagen content in the extracellular matrix is the likely reason and these changes may be important in the postoperative compensation of the spine.Level of Evidence: N/A.
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Affiliation(s)
- Shun Yamamoto
- Department of Orthopaedics, The University of British Columbia, Vancouver, Canada
- International Collaboration on Repair Discoveries (ICORD), The University of British Columbia, Vancouver, Canada
- Department of Orthopaedic Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Masoud Malakoutian
- International Collaboration on Repair Discoveries (ICORD), The University of British Columbia, Vancouver, Canada
- Department of Mechanical Engineering, The University of British Columbia, Vancouver, Canada
| | - Marine Theret
- School of Biomedical Engineering, The University of British Columbia, Vancouver, Canada
- Department of Medical Genetics, The University of British Columbia, Vancouver, Canada
| | - John Street
- Department of Orthopaedics, The University of British Columbia, Vancouver, Canada
- International Collaboration on Repair Discoveries (ICORD), The University of British Columbia, Vancouver, Canada
| | - Fabio Rossi
- School of Biomedical Engineering, The University of British Columbia, Vancouver, Canada
- Department of Medical Genetics, The University of British Columbia, Vancouver, Canada
| | - Stephen H M Brown
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Canada
| | - Mitsuru Saito
- Department of Orthopaedic Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Thomas R Oxland
- Department of Orthopaedics, The University of British Columbia, Vancouver, Canada
- International Collaboration on Repair Discoveries (ICORD), The University of British Columbia, Vancouver, Canada
- Department of Mechanical Engineering, The University of British Columbia, Vancouver, Canada
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van Eerd M, Patijn J, Loeffen D, van Kleef M, Wildberger J. The Diagnostic Value of an X-ray-based Scoring System for Degeneration of the Cervical Spine: A Reproducibility and Validation Study. Pain Pract 2021; 21:766-777. [PMID: 33837629 PMCID: PMC8518644 DOI: 10.1111/papr.13013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 03/11/2021] [Accepted: 03/29/2021] [Indexed: 11/28/2022]
Abstract
Background In interventional pain medicine, cervical facet joint (CFJ) pain is commonly treated with CFJ denervation techniques, almost automatically assuming degeneration of the CFJs as an important cause of CFJ pain. A standard cervical X‐ray is still commonly used in the clinical evaluation of patients suspected for CFJ degeneration. Although degenerative features can be visualized by different radiological imaging techniques, the relation between radiological degenerative features of the cervical spine and pain remains controversial. Paramount in order to estimate the clinical usefulness of a radiological imaging is to establish the reproducibility of the radiological scoring system. A reproducible and clinically feasible diagnostic scoring system was developed to estimate cervical degeneration on standard cervical X‐rays. Materials and Methods A reproducibility study for the interpretation of degenerative abnormalities on standard cervical X‐rays was performed, using a dichotomous outcome (degenerative abnormalities present Yes/No). The estimation of intervertebral disc height loss on standard cervical X‐rays was validated with computed tomography (CT) scan measurements. Results Five radiological degenerative features on standard cervical X‐rays (disc height loss, anterior vertebral osteophytes, posterior vertebral osteophytes, vertebral end plate sclerosis, and uncovertebral osteoarthritis) showed a substantial to excellent reproducibility (kappa value ≥ 0.60). The qualitative definition of disc height loss used in the reproducibility study showed a substantial agreement with the actual measurements of disc height loss on CT scan (kappa value = 0.69). Conclusion Subjective judgment of a cervical standard X‐ray is a reproducible method to demonstrate degenerative abnormalities of the cervical spine.
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Affiliation(s)
- Maarten van Eerd
- Department of Anesthesiology and Pain Management, Amphia Ziekenhuis, Breda, The Netherlands.,Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jacob Patijn
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Daan Loeffen
- Division of Medical Imaging and Clinical Laboratories, Department of Radiology and Nuclear Medicine, University Medical Centre Maastricht, Maastricht, The Netherlands
| | - Maarten van Kleef
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Joachim Wildberger
- Division of Medical Imaging and Clinical Laboratories, Department of Radiology and Nuclear Medicine, University Medical Centre Maastricht, Maastricht, The Netherlands
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The structural, functional and electrophysiological assessment of paraspinal musculature of patients with ankylosing spondylitis and non-radiographic axial spondyloarthropathy. Rheumatol Int 2021; 41:595-603. [PMID: 33502552 DOI: 10.1007/s00296-020-04781-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 12/29/2020] [Indexed: 12/20/2022]
Abstract
Paravertebral muscles are affected in spondyloarthritis. Decreased mobility of spine may lead to atrophy and fatty degeneration of these muscles. The objective of this study was to compare the sonographic, electrophysiological and magnetic resonance imaging (MRI) features of paraspinal muscles between patients with ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA). The patients who were diagnosed as AS with modified New York criteria and those as nr-axSpA with ASAS 2009 criteria were enrolled. Clinical evaluation, electrophysiological examination including nerve conduction studies and needle electromyography (EMG) for lower extremities and paraspinal mapping (PSM) were performed by the first examiner. The second examiner measured lumbar multifidus areas, graded the fatty degeneration of the muscle at different levels in T2 weighted axial MRI and also performed the ultrasonographic evaluation. A total of 19 patients with AS and 14 patients with nr-axSpA were evaluated. MRI of 2 patients with AS could not be obtained. Right lumbar multifidus area/vertebra area (MV ratio) was smaller in AS patients at L3 level (p 0,029); there were no significant differences in other levels. Fatty degeneration was also higher in AS patients in left multifidus at L5-S1 disc level (p 0,015). PSM scores that demonstrate the extent of denervation in paraspinal muscles were significantly higher in AS patients than in nr-axSpA patients (p < 0,001). Patients with AS have more fatty degeneration and denervation in paraspinal muscles. These processes may also contribute the severity of pain and disability. The relationship between paraspinal muscle denervation and progression of fatty degeneration should further be revealed.
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Dillingham TR, Annaswamy TM, Plastaras CT. Evaluation of persons with suspected lumbosacral and cervical radiculopathy: Electrodiagnostic assessment and implications for treatment and outcomes (Part II). Muscle Nerve 2020; 62:474-484. [PMID: 32564381 DOI: 10.1002/mus.27008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/18/2020] [Indexed: 11/06/2022]
Abstract
The electrodiagnostic (EDX) examination with needle electromyography (EMG) is the most important means of testing for radiculopathy. This test has modest sensitivity but high specificity and complements imaging of the spine. In this second of a two-part review, the implications of electrodiagnostic findings for diagnosis and clinical management of persons with radiculopathy are reviewed. An EMG confirmed lumbosacral radiculopathy is associated with better clinical outcomes for persons undergoing aggressive conservative management. A positive EMG test portends a better clinical response to epidural corticosteroid injections. If a person undergoes spine surgery, a positive pre-operative EMG for radiculopathy is also associated with better outcomes.
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Affiliation(s)
- Timothy R Dillingham
- Department of Physical Medicine and Rehabilitation, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thiru M Annaswamy
- Electrodiagnostic and Spine Sections, VA North Texas Health Care System, Dallas VA Medical Center, Department of Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Christopher T Plastaras
- Musculoskeletal Spine & Sports Rehabilitation Medicine, MossRehab, Einstein Spine Institute, Co-Chair, Albert Einstein Healthcare Network, Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Ferrero E, Skalli W, Lafage V, Maillot C, Carlier R, Feydy A, Felter A, Khalifé M, Guigui P. Relationships between radiographic parameters and spinopelvic muscles in adult spinal deformity patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 29:1328-1339. [DOI: 10.1007/s00586-019-06243-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 10/27/2019] [Accepted: 11/28/2019] [Indexed: 02/07/2023]
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10
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Geography of Lumbar Paravertebral Muscle Fatty Infiltration: The Influence of Demographics, Low Back Pain, and Disability. Spine (Phila Pa 1976) 2019; 44:1294-1302. [PMID: 30946297 DOI: 10.1097/brs.0000000000003060] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cross-sectional. OBJECTIVE We quantified fatty infiltration (FI) geography of the lumbar spine to identify whether demographics, temporal low back pain (LBP), and disability influence FI patterns. SUMMARY OF BACKGROUND DATA Lumbar paravertebral muscle FI has been associated with age, sex, LBP, and disability; yet, FI accumulation patterns are inadequately described to optimize interventions. METHODS This cross-sectional study employed lumbar axial T1-weighted magnetic resonance imaging in 107 Southern-Chinese adults (54 females, 53 males). Single-slices at the vertebral inferior end-plate per lumbar level were measured for quartiled-FI, and analyzed against demographics, LBP, and disability (Oswestry Disability Index). RESULTS Mean FI% was higher in females, on the right, increased per level caudally, and from medial to lateral in men (P < 0.05). FI linearly increased with age for both sexes (P < 0.01) and was notably higher at L 4&5 than L1, 2&3 for cases aged 40 to 65 years. BMI and FI were unrelated in females and inversely in males (P < 0.001). Females with LBPweek and males with LBPyear had 1.7% (each) less average FI (P < 0.05) than those without pain at that time-point. Men locating their LBP in the back had less FI than those without pain (P < 0.001). Disability was unrelated to FI for both sexes (P > 0.05). CONCLUSION Lumbar paravertebral muscle FI predominates in the lower lumbar spine, notably for those aged 40 to 65, and depends more on sagittal than transverse distribution. Higher FI in females and differences of mean FI between sexes for BMI, LBP, and disabling Oswestry Disability Index suggest sex-differential accumulation patterns. Our study contradicts pain models rationalizing lumbar muscle FI and may reflect a normative sex-dependent feature of the natural history of lumbar paravertebral muscles. LEVEL OF EVIDENCE 2.
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11
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Changes in Structure and Function of the Back Muscles in Low Back Pain: Different Time Points, Observations, and Mechanisms. J Orthop Sports Phys Ther 2019; 49:464-476. [PMID: 31151377 DOI: 10.2519/jospt.2019.8827] [Citation(s) in RCA: 113] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Spinal health depends on optimal back muscle performance, and this is determined by muscle structure and function. There has been substantial research evaluating the differences in structure and function of many back muscles, including the multifidus and erector spinae, but with considerable variation in results. Many studies have shown atrophy, fat infiltration, and connective tissue accumulation in back muscles, particularly deep fibers of the multifidus, but the results are not uniform. In terms of function, results are also somewhat inconsistent, often reporting lower multifidus activation and augmented recruitment of more superficial components of the multifidus and erector spinae, but, again, with variation between studies. A major recent observation has been the identification of time-dependent differences in features of back muscle adaptation, from acute to subacute/recurrent to chronic states of the condition. Further, these adaptations have been shown to be explained by different time-dependent mechanisms. This has substantial impact on the rationale for rehabilitation approaches. The aim of this commentary was to review and consolidate the breadth of research investigating adaptation in back muscle structure and function, to consider explanations for some of the variation between studies, and to propose how this model can be used to guide rehabilitation in a manner that is tailored to individual patients and to underlying mechanisms. J Orthop Sports Phys Ther 2019;49(6):464-476. doi:10.2519/jospt.2019.8827.
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Crawford R, Gizzi L, Dieterich A, Ni Mhuiris Á, Falla D. Age-related changes in trunk muscle activity and spinal and lower limb kinematics during gait. PLoS One 2018; 13:e0206514. [PMID: 30408111 PMCID: PMC6224053 DOI: 10.1371/journal.pone.0206514] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 10/15/2018] [Indexed: 11/19/2022] Open
Abstract
The influence of age on spinal muscle activation patterns and its relation to kinematics is poorly understood. We aimed at understanding age-related changes to spine and trunk muscle activity in addition to spinal and lower limb kinematics during treadmill walking under various conditions. An observational study was conducted evaluating asymptomatic young (n = 10; 3F, 7M; 26.3±2.5yrs) and older (n = 9; 3F, 6M; 67.1±4.2yrs) adults’ treadmill walking at 2km/h and 4km/h, each at 0, 1, 5, and 10% inclination. Unilateral (right side) electromyography (EMG) was recorded from deep and superficial multifidus (intramuscular) and erector spinae and abdominal obliques (surface); trunk and leg kinematics were also measured. Muscle activity was characterised by peak amplitude and duration of activity, and the time-point of peak amplitude in the gait cycle (0–100%). Peak activation in older adults was lower for the superficial multifidus (p<0.0001) and higher for the thoracolumbar (p<0.001) and lumbar erector spinae (p<0.01). The duration of activation was longer in older adults for all muscles (p<0.05) except the superficial multifidus, and longer during faster walking for all participants. The time-point of peak amplitude in the gait cycle was earlier in older participants for the external obliques (p<0.05). Walking speed appeared to influence muscle activity more than inclination. Older adults used less spine, trunk and lower limb motion, except at the ankle. Age-related differences within multifidus and between paravertebral and trunk muscles were inconsistent. Walking at 4km/h at 5–10% inclination may specifically target the lumbar paravertebral muscles.
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Affiliation(s)
- Rebecca Crawford
- Institute for Health Sciences, Zürich University of Applied Sciences, Winterthur, Switzerland
| | - Leonardo Gizzi
- University Medical Center Göttingen, Göttingen, Niedersachsen, Germany
| | - Angela Dieterich
- University Medical Center Göttingen, Göttingen, Niedersachsen, Germany
| | - Áine Ni Mhuiris
- Institute for Health Sciences, Zürich University of Applied Sciences, Winterthur, Switzerland
| | - Deborah Falla
- University Medical Center Göttingen, Göttingen, Niedersachsen, Germany
- * E-mail:
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Elliott JM, Hancock MJ, Crawford RJ, Smith AC, Walton DM. Advancing imaging technologies for patients with spinal pain: with a focus on whiplash injury. Spine J 2018; 18:1489-1497. [PMID: 28774580 PMCID: PMC6874915 DOI: 10.1016/j.spinee.2017.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/11/2017] [Accepted: 06/16/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Radiological observations of soft-tissue changes that may relate to clinical symptoms in patients with traumatic and non-traumatic spinal disorders are highly controversial. Studies are often of poor quality and findings are inconsistent. A plethora of evidence suggests some pathoanatomical findings from traditional imaging applications are common in asymptomatic participants across the life span, which further questions the diagnostic, prognostic, and theranostic value of traditional imaging. Although we do not dispute the limited evidence for the clinical importance of most imaging findings, we contend that the disparate findings across studies may in part be due to limitations in the approaches used in assessment and analysis of imaging findings. PURPOSE This clinical commentary aimed to (1) briefly detail available imaging guidelines, (2) detail research-based evidence around the clinical use of findings from advanced, but available, imaging applications (eg, fat and water magnetic resonance imaging and magnetization transfer imaging), and (3) introduce how evolving imaging technologies may improve our mechanistic understanding of pain and disability, leading to improved treatments and outcomes. STUDY DESIGN/SETTING A non-systematic review of the literature is carried out. METHODS A narrative summary (including studies from the authors' own work in whiplash injuries) of the available literature is provided. RESULTS An emerging body of evidence suggests that the combination of existing imaging sequences or the use of developing imaging technologies in tandem with a good clinical assessment of modifiable risk factors may provide important diagnostic information toward the exploration and development of more informed and effective treatment options for some patients with traumatic neck pain. CONCLUSIONS Advancing imaging technologies may help to explain the seemingly disconnected spectrum of biopsychosocial signs and symptoms of traumatic neck pain.
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Affiliation(s)
- James M. Elliott
- Department of Physical Therapy and Human Movement Sciences,
Feinberg School of Medicine, Northwestern University, 645 N. Michigan Ave, Suite
1100, Chicago, IL, USA,School of Health and Rehabilitation Sciences, The
University of Queensland, Australia,The University of Sydney, Faculty of Health Sciences & the Northern Sydney Local Health District; The Kolling Institute, St. Leonards, NSW, Australia,Corresponding author. Department of Physical
Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern
University, 645 N. Michigan Ave, Suite 1100, Chicago, IL 60611, USA. Tel.:
(0011) 1-312-503-2304. (J.M.
Elliott)
| | - Mark J. Hancock
- Faculty of Medicine and Health Sciences, Macquarie
University, 2 Technology Pl, Macquarie Park, Sydney, NSW 2113, Australia
| | - Rebecca J. Crawford
- Zürich University of Applied Sciences,
Gertrudstrasse 15, 8401 Winterthur, Switzerland
| | - Andrew C. Smith
- Regis University School of Physical Therapy, 3333 Regis
Boulevard, Denver, CO 80221, USA
| | - David M. Walton
- School of Physical Therapy, Western University, Room 1588,
London, Ontario N6G 1H1, Canada
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Crawford RJ, Elliott JM, Volken T. Change in fatty infiltration of lumbar multifidus, erector spinae, and psoas muscles in asymptomatic adults of Asian or Caucasian ethnicities. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:3059-3067. [PMID: 28698963 DOI: 10.1007/s00586-017-5212-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 07/03/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE Fatty infiltration (FI) is a feature of degenerating muscle that predominates in the low lumbar spine, associates with pain, and is confounded by age, spinal degeneration, and curvature. We determined rates for decline of lumbar muscle quality according to ethnicity, muscle, and spinal level in asymptomatic subjects. METHODS Cross-sectional simulation study assessing aggregated data; 650 Asians aged 20-89 years versus 80 Caucasians aged 20-62 years. Change in lumbar multifidus, erector spinae (ES), and psoas fat content were computed using synthetic data and Monte Carlo simulations. General linear regression models and multivariate adaptive regression splines enabled estimation of yearly decline rates [with 95% confidence intervals (CI)]. RESULTS ES at L1-5 (total) shows steeply reduced density (rate; CI) for Asians in older (>53.3 years) adulthood (-0.32; -0.27 to -0.36/year). For Asians, multifidus (-0.18; -0.15 to -0.20/year) and psoas (-0.04; -0.03 to -0.06/year) also decline, while ES in younger ≤53.3 years) adults does not (0.06; 0.01-0.12/year). Caucasian multifidus declines (increasing FI % rate; CI) insignificantly faster (L1-5; 0.23; 0.10-0.36%/year) than ES (0.13; 0.04-0.22%/year). Multifidus decline does not differ between ethnicities. ES in older Asians generally declines fastest across ethnicities and muscles, and particularly in the low lumbar levels. Low lumbar levels show higher rates of decline in Asians, with mixed level-dependencies apparent in Caucasians. CONCLUSIONS Decline in lumbar muscle composition may differ between ethnicities and muscles. ES and low lumbar levels appear increasingly susceptible in Asians. Longitudinal studies examining rate of change to muscle composition may provide distinction between spinal conditions.
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Affiliation(s)
- Rebecca J Crawford
- Institute for Health Sciences, School of Health Professions, Zurich University of Applied Sciences, Technikumstrasse 81, 8401, Winterthur, Switzerland. .,Faculty of Health Sciences, Curtin University, Perth, Australia.
| | - James M Elliott
- Institute for Health Sciences, School of Health Professions, Zurich University of Applied Sciences, Technikumstrasse 81, 8401, Winterthur, Switzerland.,Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia
| | - Thomas Volken
- Institute for Health Sciences, School of Health Professions, Zurich University of Applied Sciences, Technikumstrasse 81, 8401, Winterthur, Switzerland
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Abbas J, Slon V, May H, Peled N, Hershkovitz I, Hamoud K. Paraspinal muscles density: a marker for degenerative lumbar spinal stenosis? BMC Musculoskelet Disord 2016; 17:422. [PMID: 27724897 PMCID: PMC5057209 DOI: 10.1186/s12891-016-1282-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 10/01/2016] [Indexed: 11/10/2022] Open
Abstract
Background The condition of paraspinal muscles is known to be associated with some variables such as age, gender, and low back pain. It is generally agreed that these muscles play an important role in the stability and functional movements of the lumbar vertebral column. Although spinal instability has been shown to play an essential role in degenerative lumbar spinal stenosis (DLSS), the role of paraspinal muscles remains elusive. The main purpose of this study was to shed light on the relationship between the condition of paraspinal muscles and symptomatic DLSS. Methods Two sample populations were studied. The first included 165 individuals with DLSS (age range: 40–88, sex ratio: 80 M/85 F) and the second 180 individuals without spinal stenosis related symptoms and low back pain (age range: 40–99, sex ratio: 90 M/90 F). Measurements were taken at the middle part of L3 vertebral body, using CT axial images (Philips Brilliance 64). Muscles density was measured in Hounsfield units (HU) using a 50 mm2 circle of the muscle mass at three different locations and the mean density was then calculated. The cross-sectional area (CSA) was also measured using the quantitative CT angiography method. Analysis of Covariance (adjusted for body mass index and age) was performed in order to determine the relationship between the condition of paraspinal muscles and symptomatic DLSS. Results Individuals in the stenosis group had higher muscle density as compared to the control group. The CSA values for the erector spinae (both sexes) and psoas (males) muscles were significantly greater in the stenosis group as compared to their counterparts in the control group. Additionally, density of multifidus (both sexes) and erector spinae (males) muscles was significantly associated with symptomatic DLSS. Conclusions Our results show that individuals with symptomatic DLSS manifest greater paraspinal muscles density and CSA (erector spinae), compared to the control group. Density of multifidus increases the likelihood of symptomatic DLSS.
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Affiliation(s)
- Janan Abbas
- Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. .,Department of Physical Therapy, Zefat Academic College, Zefat, Israel.
| | - Viviane Slon
- Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hila May
- Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nathan Peled
- Department of Radiology, Carmel Medical Center, Haifa, Israel
| | - Israel Hershkovitz
- Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kamal Hamoud
- Department of Physical Therapy, Zefat Academic College, Zefat, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel.,Department of Orthopaedic Surgery, The Baruch Padeh Poriya Medical Center, Tiberias, Israel
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16
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Crawford RJ, Volken T, Valentin S, Melloh M, Elliott JM. Rate of lumbar paravertebral muscle fat infiltration versus spinal degeneration in asymptomatic populations: an age-aggregated cross-sectional simulation study. SCOLIOSIS AND SPINAL DISORDERS 2016; 11:21. [PMID: 27536737 PMCID: PMC4975884 DOI: 10.1186/s13013-016-0080-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 07/19/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND The spinal column including its vertebrae and disks has been well examined and extensively reported in relation to age-aggregated degeneration. In contrast, paravertebral muscles are poorly represented in describing normative degeneration. Increasing evidence points to the importance of paravertebral muscle quality in low back health, and their potential as a modifiable factor in low back pain (LBP). Studies examining normative decline of paravertebral muscles are needed to advance the field's etiological understanding. With a novel approach and based on published data, we establish and compare decline rates of imaging features for degeneration of lumbar vertebrae and disks, versus fatty infiltration in paravertebral muscles in asymptomatic adults. METHODS Our cross-sectional simulation study examined age-aggregated data from three published studies who reported on asymptomatic adults spanning 18-60 years. Prevalence rates of imaging degenerative features of the spinal column were examined via logistic regression and compared with percentage fatty infiltration in erector spinae, multifidus and psoas using synthetic data and Monte Carlo simulation with 10,000 endpoint-specific regression iterations. General linear regression models were employed to estimate marginal effects of age reported as a one-year change rate (with 95 % confidence intervals) for comparisons between all reported spinal features. RESULTS Declines in multifidus (0.24 & 0.11 %/year), erector spinae (0.13 & 0.07 %/year), and psoas (0.04 %/year) occur at similarly slow rates to disk protrusion (0.25 %/year), annular fissure (0.15 %/year), and spondylolisthesis (0.29 %/year). Multifidus showed a trend for faster decline than erector spinae, particularly in men. Of the features examined, disk signal loss declined fastest, and psoas muscle the slowest. CONCLUSIONS Degeneration of lumbar paravertebral muscles occurs slowly in asymptomatic adults, with a tendency to be most pronounced in multifidus. Rate of decline of spinal structures represents a novel variable that warrants inclusion as a known feature of the expected degenerative cascade, and to provide a basis for comparison to diseases of the spine in research and clinical practice. Concurrent examination of spinal features using advanced imaging to improve muscle analysis would be a strong addition to the field.
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Affiliation(s)
- Rebecca J Crawford
- Institute for Health Sciences, School of Health Professions, ZHAW, Zurich University of Applied Sciences, Technikumstrasse 81, CH-8401 Winterthur, Switzerland ; Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Thomas Volken
- Institute for Health Sciences, School of Health Professions, ZHAW, Zurich University of Applied Sciences, Technikumstrasse 81, CH-8401 Winterthur, Switzerland
| | - Stephanie Valentin
- Equine Clinic, University of Veterinary Medicine, Vienna, Austria ; Institute for Sport, Physical Education & Health Sciences, The University of Edinburgh, Edinburgh, UK
| | - Markus Melloh
- Institute for Health Sciences, School of Health Professions, ZHAW, Zurich University of Applied Sciences, Technikumstrasse 81, CH-8401 Winterthur, Switzerland ; Faculty of Health Sciences, Curtin University, Perth, Australia ; Centre for Medical Research, University of Western Australia, Perth, Australia
| | - James M Elliott
- Institute for Health Sciences, School of Health Professions, ZHAW, Zurich University of Applied Sciences, Technikumstrasse 81, CH-8401 Winterthur, Switzerland ; Feinberg School of Medicine, Northwestern University, Chicago, USA ; School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia
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17
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Crawford RJ, Gizzi L, Mhuiris ÁN, Falla D. Are regions of the lumbar multifidus differentially activated during walking at varied speed and inclination? J Electromyogr Kinesiol 2016; 30:177-83. [PMID: 27471779 DOI: 10.1016/j.jelekin.2016.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/17/2016] [Accepted: 07/11/2016] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Lumbar multifidus is a complex muscle with multi-fascicular morphology shown to be differentially controlled in healthy individuals during sagittal-plane motion. The normal behaviour of multifidus muscle regions during walking has only received modest attention in the literature. This study aimed to determine activation patterns for deep and superficial multifidus in young adults during walking at different speeds and inclination. METHODS This observational cohort study evaluated ten healthy volunteers in their twenties (three women, seven men) as they walked on a treadmill in eight conditions; at 2km/h and 4km/h, each at 0, 1, 5, and 10% inclination. Intramuscular EMG was recorded from the deep and superficial multifidus unilaterally at L5. Activity was characterized by: amplitude of the peak of activation, position of peak within the gait cycle (0-100%), and duration relative to the full gait cycle. RESULTS Across all conditions superficial multifidus showed higher normalised EMG amplitude (p<0.01); superficial multifidus peak amplitude was 232±115% higher when walking at 4km/h/10%, versus only 172±77% higher for deeper region (p<0.01). The percentage of the gait cycle where peak EMG amplitude was detected did not differ between regions (49±13%). Deep multifidus duration of activation was longer when walking at the faster vs slower speed at all inclinations (p<0.01), which was not evident for superficial multifidus (p<0.05). Thus, a significantly longer activation of deep multifidus was observed compared to superficial multifidus when walking at 4km/h (p<0.05). CONCLUSIONS Differential activation within lumbar multifidus was shown in young adults during walking. The prolonged, more tonic activation of deep relative to superficial regions of multifidus during gait supports a postural function of deeper fibres.
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Affiliation(s)
- Rebecca J Crawford
- Institute for Health Sciences, Zürich University of Applied Sciences, Technikumstrasse 71, Winterthur 8401, Switzerland; Faculty of Health Professions, Curtin University, Kent Street, Perth 6102, Australia.
| | - Leonardo Gizzi
- Institute of Neurorehabilitation Systems, Bernstein Focus Neurotechnology Göttingen, Bernstein Center for Computational Neuroscience, University Medical Center Göttingen, Georg-August University, Göttingen, Germany.
| | - Áine Ni Mhuiris
- Institute for Health Sciences, Zürich University of Applied Sciences, Technikumstrasse 71, Winterthur 8401, Switzerland.
| | - Deborah Falla
- School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK.
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18
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Multifidus Muscle Changes After Back Injury Are Characterized by Structural Remodeling of Muscle, Adipose and Connective Tissue, but Not Muscle Atrophy: Molecular and Morphological Evidence. Spine (Phila Pa 1976) 2015; 40:1057-71. [PMID: 25943090 DOI: 10.1097/brs.0000000000000972] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Longitudinal case-controlled animal study. OBJECTIVE To investigate putative cellular mechanisms to explain structural changes in muscle and adipose and connective tissues of the back muscles after intervertebral disc (IVD) injury. SUMMARY OF BACKGROUND DATA Structural back muscle changes are ubiquitous with back pain/injury and considered relevant for outcome, but their exact nature, time course, and cellular mechanisms remain elusive. We used an animal model that produces phenotypic back muscle changes after IVD injury to study these issues at the cellular/molecular level. METHODS Multifidus muscle was harvested from both sides of the spine at L1-L2 and L3-L4 IVDs in 27 castrated male sheep at 3 (n = 10) or 6 (n = 17) months after a surgical anterolateral IVD injury at both levels. Ten control sheep underwent no surgery (3 mo, n = 4; 6 mo, n = 6). Tissue was harvested at L4 for histological analysis of cross-sectional area of muscle and adipose and connective tissue (whole muscle), plus immunohistochemistry to identify proportion and cross-sectional area of individual muscle fiber types in the deepest fascicle. Quantitative polymerase chain reaction measured gene expression of typical cytokines/signaling molecules at L2. RESULTS Contrary to predictions, there was no multifidus muscle atrophy (whole muscle or individual fiber). There was increased adipose and connective tissue (fibrotic proliferation) cross-sectional area and slow-to-fast muscle fiber transition at 6 but not 3 months. Within the multifidus muscle, increases in the expression of several cytokines (tumor necrosis factor α and interleukin-1β) and molecules that signal trophic/atrophic processes for the 3 tissue types (e.g., growth factor pathway [IGF-1, PI3k, Akt1, mTOR], potent tissue modifiers [calcineurin, PCG-1α, and myostatin]) were present. CONCLUSION This study provides cellular evidence that refutes the presence of multifidus muscle atrophy accompanying IVD degeneration at this intermediate time point. Instead, adipose/connective tissue increased in parallel with the expression of the genes that provide putative mechanisms for multifidus structural remodeling. This provides novel targets for pharmacological and physical interventions. LEVEL OF EVIDENCE N/A.
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19
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Cheng I, Ho S, Kennedy DJ. Electrodiagnostic testing before surgery for spinal stenosis. PM R 2014; 6:945-50. [PMID: 25441719 DOI: 10.1016/j.pmrj.2014.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 09/18/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Ivan Cheng
- Department of Orthopaedics, Stanford University, Redwood City, CA(∗)(‡)
| | - Suehun Ho
- Department of Physical Medicine and Rehabilitation, SUNY Upstate Medical University, Syracuse, NY(†)
| | - David J Kennedy
- Department of Orthopaedics, Stanford University, Redwood City, CA(∗)(‡).
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20
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A conceptual model of compensation/decompensation in lumbar segmental instability. Med Hypotheses 2014; 83:312-6. [DOI: 10.1016/j.mehy.2014.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 05/25/2014] [Accepted: 06/04/2014] [Indexed: 11/18/2022]
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21
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Haig AJ, London Z, Sandella DE. Symmetry of paraspinal muscle denervation in clinical lumbar spinal stenosis: support for a hypothesis of posterior primary ramus stretching? Muscle Nerve 2013; 48:198-203. [PMID: 23813584 DOI: 10.1002/mus.23750] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 09/30/2012] [Accepted: 12/04/2012] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Denervation of the paraspinal muscles in spinal disorders is frequently attributed to radiculopathy. Therefore, patients with lumbar spinal stenosis causing asymmetrical symptoms should have asymmetrical paraspinal denervation. METHODS Seventy-three patients with clinical lumbar spinal stenosis, aged 55-85 years, completed a pain drawing and underwent masked electrodiagnostic testing, including bilateral paraspinal mapping and testing of 6 muscles on the most symptomatic (or randomly chosen) limb. RESULTS With the exception of 10 subjects with unilateral thigh pain (P = 0.043), there was no relationship between side of pain and paraspinal mapping score for any subgroups (symmetrical pain, pain into 1 calf only). Among those with positive limb EMG (tested on 1 side), no relationship between side of pain and paraspinal EMG score was found. CONCLUSION Evidence suggests that paraspinal denervation in spinal stenosis may not be due to radiculopathy, but rather due to stretch or damage to the posterior primary ramus.
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Affiliation(s)
- Andrew J Haig
- Department of Physical Medicine and Rehabilitation, University of Michigan, 325 East Eisenhower, Ann Arbor, Michigan 48108, USA.
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22
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Smuck M, Crisostomo RA, Trivedi K, Agrawal D. Success of initial and repeated medial branch neurotomy for zygapophysial joint pain: a systematic review. PM R 2013; 4:686-92. [PMID: 22980421 DOI: 10.1016/j.pmrj.2012.06.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 04/13/2012] [Accepted: 06/20/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To review the duration of pain relief after initial and repeated radiofrequency neurotomy (RFN) for cervical and lumbar zygapophysial joint pain. METHODS We searched PubMed to identify all articles that met review criteria for in-depth analysis, synthesis, and review. RESULTS Data from 16 articles are reported in this review, including 8 cervical studies, 7 lumbar studies, and 1 study of both cervical and lumbar treatment. Overall, methodology and design quality of cervical studies exceeded that of lumbar studies. For initial cervical RFN, average range duration of >50% pain relief was 7.3-8.6 months. Repeated cervical RFN was successful 67%-95% of the time when the first RFN procedure was successful. When the first RFN procedure was unsuccessful, repeated RFN was successful 0%-67% of the time. The average range duration of pain relief after successful repeated RFN was 6.0-12.7 months. For initial lumbar RFN, the average duration of >50% pain relief was 9.0 months. Repeated lumbar RFN was successful 33%-85% of the time when the first RFN procedure was successful. The average duration of pain relief after successful repeated lumbar RFN was 11.6 months. CONCLUSIONS The results of this review indicate that pain relief after initial RFN generally ends after 7-9 months and that repeating RFN is likely to provide additional pain relief if initial RFN was successful. Results are similar between cervical and lumbar spine studies.
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Affiliation(s)
- Matthew Smuck
- PM&R Section, Department of Orthopaedic Surgery, Stanford University Spine Center, Redwood City, CA 94063, USA.
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Beneck GJ, Kulig K. Multifidus atrophy is localized and bilateral in active persons with chronic unilateral low back pain. Arch Phys Med Rehabil 2012; 93:300-6. [PMID: 22289241 DOI: 10.1016/j.apmr.2011.09.017] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 09/06/2011] [Accepted: 09/06/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the lumbar multifidi muscle volume devoid of fat local to the site of pain in persons with and without chronic unilateral lower lumbar pain. DESIGN Prospective cross-sectional design. SETTING University biokinesiology laboratory. PARTICIPANTS Active individuals (n=14) with chronic unilateral lower lumbar pain (>1 y) were matched for age, height, weight, and activity level with healthy individuals (n=14). Individuals with back pain had minimal disability (Oswestry Disability Index [mean ± SD], 14.9%±6.3%) at the time of testing. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Multifidus and erector spinae muscle volumes at the L5-S1 levels, multifidus muscle volumes at the L4 and S2-3 levels. RESULTS Average multifidus volume was diminished by 18.1% between groups (P=.026) only at the L5-S1 levels. There was no difference between painful and pain-free sides. There were no volume differences between groups above L5, below S1, or in erector spinae at the L5-S1 levels. CONCLUSIONS The results of this study indicate that despite a low level of disability and an activity level similar to that of matched control subjects, considerable localized, bilateral multifidus atrophy is present. Such impaired size of the multifidus will likely reduce its capacity to control intersegmental motion, thus increasing the susceptibility to further injury. Unlike acute unilateral low back pain (LBP), muscle size is reduced bilaterally in persons with chronic unilateral LBP.
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Affiliation(s)
- George J Beneck
- Department of Physical Therapy, California State University Long Beach, Long Beach, CA 90840, USA.
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Koo YS, Cho CS, Kim BJ. Pitfalls in using electrophysiological studies to diagnose neuromuscular disorders. J Clin Neurol 2012; 8:1-14. [PMID: 22523508 PMCID: PMC3325427 DOI: 10.3988/jcn.2012.8.1.1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 06/01/2011] [Accepted: 06/01/2011] [Indexed: 12/02/2022] Open
Abstract
Electrodiagnostic testing is used widely for the full characterization of neuromuscular disorders and for providing unique information on the processes underlying the pathology of peripheral nerves and muscles. However, such testing should be considered as an extension of anamnesis and physical examination, not as pathognomonic of a specific disease entity. There are many pitfalls that could lead to erroneous interpretation of electrophysiological study results when the studies are not performed properly or if they are performed in the presence of anatomical aberrations. The diagnostic reliability of electrodiagnostic studies can be improved and the associated pitfalls overcome if the physician is familiar with all of those possible pitfalls. In this article we discuss the most common and important pitfalls associated with electrodiagnostic medicine.
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Affiliation(s)
- Yong Seo Koo
- Department of Neurology, Korea University College of Medicine, Seoul, Korea
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25
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Abstract
STUDY DESIGN Cross-sectional design. OBJECTIVE To investigate whether recurrent low back pain (LBP) is associated with changes in motor cortical representation of different paraspinal muscle fascicles. SUMMARY OF BACKGROUND DATA Fascicles of the lumbar paraspinal muscles are differentially activated during function. Human studies indicate this may be associated with a spatially separate array of neuronal networks at the motor cortex. Loss of discrete control of paraspinal muscle fascicles in LBP may be because of changes in cortical organization. METHODS Data were collected from 9 individuals with recurrent unilateral LBP and compared with 11 healthy participants from an earlier study. Fine-wire electrodes selectively recorded myoelectric activity from short/deep fascicles of deep multifidus (DM) and long/superficial fascicles of longissimus erector spinae (LES), bilaterally. Motor cortical organization was investigated using transcranial magnetic stimulation at different scalp sites to evoke responses in paraspinal muscles. Location of cortical representation (center of gravity; CoG) and motor excitability (map volume) were compared between healthy and LBP groups. RESULTS Individuals with LBP had a more posterior location of LES center of gravity, which overlapped with that for DM on both hemispheres. In healthy individuals, LES center of gravity was located separately at a more anterior location to that for DM. Map volume was reduced in LBP compared to healthy individual across muscles. CONCLUSION The findings highlight that LBP is associated with a loss of discrete cortical organization of inputs to back muscles. Increased overlap in motor cortical representation of DM and LES may underpin loss of differential activation in this group. The results further unravel the neurophysiological mechanisms of motor changes in recurrent LBP and suggest motor rehabilitation that includes training of differential activation of the paraspinal muscles may be required to restore optimal control in LBP.
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Suri P, Miyakoshi A, Hunter DJ, Jarvik JG, Rainville J, Guermazi A, Li L, Katz JN. Does lumbar spinal degeneration begin with the anterior structures? A study of the observed epidemiology in a community-based population. BMC Musculoskelet Disord 2011; 12:202. [PMID: 21914197 PMCID: PMC3182965 DOI: 10.1186/1471-2474-12-202] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Accepted: 09/13/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prior studies that have concluded that disk degeneration uniformly precedes facet degeneration have been based on convenience samples of individuals with low back pain. We conducted a study to examine whether the view that spinal degeneration begins with the anterior spinal structures is supported by epidemiologic observations of degeneration in a community-based population. METHODS 361 participants from the Framingham Heart Study were included in this study. The prevalences of anterior vertebral structure degeneration (disk height loss) and posterior vertebral structure degeneration (facet joint osteoarthritis) were characterized by CT imaging. The cohort was divided into the structural subgroups of participants with 1) no degeneration, 2) isolated anterior degeneration (without posterior degeneration), 3) combined anterior and posterior degeneration, and 4) isolated posterior degeneration (without anterior structure degeneration). We determined the prevalence of each degeneration pattern by age group < 45, 45-54, 55-64, ≥65. In multivariate analyses we examined the association between disk height loss and the response variable of facet joint osteoarthritis, while adjusting for age, sex, BMI, and smoking. RESULTS As the prevalence of the no degeneration and isolated anterior degeneration patterns decreased with increasing age group, the prevalence of the combined anterior/posterior degeneration pattern increased. 22% of individuals demonstrated isolated posterior degeneration, without an increase in prevalence by age group. Isolated posterior degeneration was most common at the L5-S1 and L4-L5 spinal levels. In multivariate analyses, disk height loss was independently associated with facet joint osteoarthritis, as were increased age (years), female sex, and increased BMI (kg/m(2)), but not smoking. CONCLUSIONS The observed epidemiology of lumbar spinal degeneration in the community-based population is consistent with an ordered progression beginning in the anterior structures, for the majority of individuals. However, some individuals demonstrate atypical patterns of degeneration, beginning in the posterior joints. Increased age and BMI, and female sex may be related to the occurrence of isolated posterior degeneration in these individuals.
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Affiliation(s)
- Pradeep Suri
- Division of PM&R, VA Boston Healthcare System, Boston, USA.
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Suri P, Rainville J, Kalichman L, Katz JN. Does this older adult with lower extremity pain have the clinical syndrome of lumbar spinal stenosis? JAMA 2010; 304:2628-36. [PMID: 21156951 PMCID: PMC3260477 DOI: 10.1001/jama.2010.1833] [Citation(s) in RCA: 143] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
CONTEXT The clinical syndrome of lumbar spinal stenosis (LSS) is a common diagnosis in older adults presenting with lower extremity pain. OBJECTIVE To systematically review the accuracy of the clinical examination for the diagnosis of the clinical syndrome of LSS. DATA SOURCES MEDLINE, EMBASE, and CINAHL searches of articles published from January 1966 to September 2010. STUDY SELECTION Studies were included if they contained adequate data on the accuracy of the history and physical examination for diagnosing the clinical syndrome of LSS, using a reference standard of expert opinion with radiographic or anatomic confirmation. DATA EXTRACTION Two authors independently reviewed each study to determine eligibility, extract data, and appraise levels of evidence. DATA SYNTHESIS Four studies evaluating 741 patients were identified. Among patients with lower extremity pain, the likelihood of the clinical syndrome of LSS was increased for individuals older than 70 years (likelihood ratio [LR], 2.0; 95% confidence interval [CI], 1.6-2.5), and was decreased for those younger than 60 years (LR, 0.40; 95% CI, 0.29-0.57). The most useful symptoms for increasing the likelihood of the clinical syndrome of LSS were having no pain when seated (LR, 7.4; 95% CI, 1.9-30), improvement of symptoms when bending forward (LR, 6.4; 95% CI, 4.1-9.9), the presence of bilateral buttock or leg pain (LR, 6.3; 95% CI, 3.1-13), and neurogenic claudication (LR, 3.7; 95% CI, 2.9-4.8). Absence of neurogenic claudication (LR, 0.23; 95% CI, 0.17-0.31) decreased the likelihood of the diagnosis. A wide-based gait (LR, 13; 95% CI, 1.9-95) and abnormal Romberg test result (LR, 4.2; 95% CI, 1.4-13) increased the likelihood of the clinical syndrome of LSS. A score of 7 or higher on a diagnostic support tool including history and examination findings increased the likelihood of the clinical syndrome of LSS (LR, 3.3; 95% CI, 2.7-4.0), while a score lower than 7 made the diagnosis much less likely (LR, 0.10; 95% CI, 0.06-0.16). CONCLUSIONS The diagnosis of the clinical syndrome of LSS requires the appropriate clinical picture and radiographic findings. Absence of pain when seated and improvement of symptoms when bending forward are the most useful individual findings. Combinations of findings are most useful for identifying patients who are unlikely to have the diagnosis.
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Affiliation(s)
- Pradeep Suri
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, and Spaulding Rehabilitation Hospital and VA Boston Healthcare System, Boston, Massachusetts 02114, USA.
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Schwarzenbach O, Rohrbach N, Berlemann U. Segment-by-segment stabilization for degenerative disc disease: a hybrid technique. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 19:1010-20. [PMID: 20130934 DOI: 10.1007/s00586-010-1282-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Revised: 09/30/2009] [Accepted: 01/14/2010] [Indexed: 11/28/2022]
Abstract
Patients with multisegmental degenerative disc disease (DDD) resistant to conservative therapy are typically treated with either fusion or non-fusion surgical techniques. The two techniques can be applied at adjacent levels using Dynesys (Zimmer GmbH, Winterthur, Switzerland) implants in a segment-by-segment treatment of multiple level DDD. The objective of this study was to evaluate the clinical and radiological outcome of patients treated using this segment-by-segment application of Dynesys in some levels as a non-fusion device and in other segments in combination with a PLIF as a fusion device. A consecutive case series is reported. The sample included 16 females and 15 males with a mean age of 53.6 years (range 26.3-76.4 years). Mean follow-up time was 39 months (range 24-90 months). Preoperative Oswestry disability index (ODI), back- and leg-pain scores (VAS) were compared to postoperative status. Fusion success and system failure were assessed by an independent reviewer who analyzed AP and lateral X-rays. Back pain improved from 7.3 +/- 1.7 to 3.4 +/- 2.7 (p < 0.000002), leg pain from 6.0 +/- 2.9 to 2.3 +/- 2.9 (p < 0.00006), and ODI from 51.6 +/- 13.2% to 28.7 +/- 18.0% (p < 0.00001). Screw loosening occurred in one of a total of 222 implanted screws (0.45%). The results indicate that segment-by-segment treatment with Dynesys in combination with interbody fusion is technically feasible, safe, and effective for the surgical treatment of multilevel DDD.
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Thoracic disc herniation in a patient with tethered cord and lumbar syringomyelia and diastematomyelia: magnetic resonance imaging and neurophysiological findings. Spine (Phila Pa 1976) 2009; 34:E484-7. [PMID: 19525827 DOI: 10.1097/brs.0b013e31819211c9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case report. OBJECTIVE To describe the diagnostic challenges in a patient suffering from thoracic disc herniation (TDH) and spina bifida complicated by multiple lumbar spinal cord abnormalities, i.e., tethered cord, lumbar syringomyelia, and diastematomyelia. SUMMARY OF BACKGROUND DATA Advances in neuroimaging, i.e., magnetic resonance imaging, increase the sensitivity to disclose both clinically relevant but also other spine and spinal cord abnormalities. TDH accounts for less than 1% of all surgically treated disc herniations. Syringomyelia and diastematomyelia are comparably rare and present with varying degrees of spinal cord dysfunction. METHODS A 54-year-old women presented with progressive pain and sensorimotor symptoms in the lower back and limbs. Neurologic examination revealed lower limb spastic motor deficits and spinal ataxia. Magnetic resonance imaging revealed a T6-T7 disc herniation, with spinal cord signal change in addition to a spina bifida with sacral tethered cord, lumbar syringomyelia, and diastematomyelia. Combined neurophysiological testing identified a neurologic lesion in the mid thoracic cord, with normal lower limb nerve conduction and reflex recordings, but pathologic somatosensory-evoked potential and T6 paravertebral electromyography. RESULTS The patient was diagnosed with a clinically relevant T6-T7 disc herniation and underwent successful surgical decompression resulting in electrophysiological improvements. CONCLUSION This unique case highlights the value of electrophysiology in the evaluation of a complex spinal disorder in a patient suffering from acquired TDH in the presence of extensive congenital spine and spinal cord abnormalities. Clinical symptoms and signs can be complemented by neurophysiological techniques to improve diagnostic accuracy and improve the basis for treatment recommendations. In cases involving multiple spinal abnormalities, a comprehensive neurophysiological assessment beyond paravertebral electromyography studies, including nerve conduction and somatosensory-evoked potential recordings, is recommended to assist in confirming the diagnosis.
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Haig AJ, Yamakawa KSJ, Parres C, Chiodo A, Tong H. A prospective, masked 18-month minimum follow-up on neurophysiologic changes in persons with spinal stenosis, low back pain, and no symptoms. PM R 2009; 1:127-36. [PMID: 19627886 PMCID: PMC2735230 DOI: 10.1016/j.pmrj.2008.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 10/15/2008] [Accepted: 10/16/2008] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe neurophysiologic changes over time in persons with and without spinal complaints and to assess whether paraspinal denervation predicts change in stenosis on magnetic resonance imaging (MRI) and clinical course. DESIGN Prospective, controlled, masked trial. SETTING University spine program. PARTICIPANTS Persons aged 55 to 80 years, screened for polyneuropathy and determined on clinical examination to have spinal stenosis, mechanical low back pain, or no spinal symptoms. INTERVENTIONS A comprehensive codified history was obtained and subjects underwent physical examination, ambulation testing, masked electrodiagnostic testing including paraspinal mapping, and MRI, repeated at greater than 18 months. This study presents detailed technical information and additional analyses not reported previously. MAIN OUTCOME MEASUREMENTS Change in electrodiagnostic findings. Among persons with clinical stenosis, relationship of change in paraspinal mapping scores to MRI findings and clinical changes. RESULTS Of 149 initial subjects, 83 (79.3% of eligible subjects) repeated testing at 20 (+/-2 SDs) months. No significant change in limb muscle spontaneous activity or motor unit pathology was noted in any group. In 23 persons with initial diagnosis of stenosis, paraspinal mapping electromyography related to change in diagnosis over time (analysis of variance F = 3.77, P = .037), but not to most initial magnetic resonance imaging measurements or to change in spinal canal diameter. CONCLUSIONS Clinical spinal stenosis is neurophysiologically stable in most persons. Paraspinal electromyographic changes reflect large changes in clinical course, but neither neurophysiologic nor clinical changes relate to change in spinal geometry over 20 months.
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Affiliation(s)
- Andrew J Haig
- Department of Physical Medicine and Rehabilitation, The University of Michigan, Ann Arbor, MI 48108, USA.
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Neurological complications of ankylosing spondylitis: neurophysiological assessment. Rheumatol Int 2009; 29:1031-40. [PMID: 19153738 DOI: 10.1007/s00296-009-0841-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2008] [Accepted: 01/05/2009] [Indexed: 11/08/2022]
Abstract
Studies examined the neurological involvement of ankylosing spondylitis (AS) are limited. This study aimed to assess the frequency of myelopathy, radiculopathy and myopathy in AS correlating them to the clinical, radiological and laboratory parameters. Included were 24 patients with AS. Axial status was assessed using bath ankylosing spondylitis metrology index (BASMI). Patients underwent (a) standard cervical and lumbar spine and sacroiliac joint radiography, (b) somatosensory (SSEP) and magnetic motor (MEP) evoked potentials of upper and lower limbs, (c) electromyography (EMG) of trapezius and supraspinatus muscles. Patients' mean age and duration of illness were 36 and 5.99 years. Bath ankylosing spondylitis metrology index mean score was 4.6. Twenty-five percent (n = 6) of patients had neurological manifestations, 8.3% of them had myelopathy and 16.7% had radiculopathy. Ossification of the posterior (OPLL) and anterior (OALL) longitudinal ligaments were found in 8.3% (n = 2) and 4.2% (n = 1). About 70.8% (n = 17) had >or=1 neurophysiological test abnormalities. Twelve patients (50%) had SSEP abnormalities, seven had prolonged central conduction time (CCT) of median and/or ulnar nerves suggesting cervical myelopathy. Six had delayed peripheral or root latencies at Erb's or interpeak latency (Erb's-C5) suggesting radiculopathy. Motor evoked potentials was abnormal in 54% (n = 13). Twelve (50%) and five (20.8%) patients had abnormal MEP of upper limbs and lower limbs, respectively. About 50% (n = 12) had myopathic features of trapezius and supraspinatus muscles. Only 8.3% (n = 2) had neuropathic features. We concluded that subclinical neurological complications are frequent in AS compared to clinically manifest complications. Somatosensory evoked potential and MEP are useful to identify AS patients prone to develop neurological complications.
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Haig AJ, Geisser ME, Tong HC, Yamakawa KSJ, Quint DJ, Hoff JT, Chiodo A, Miner JA, Phalke VV. Electromyographic and magnetic resonance imaging to predict lumbar stenosis, low-back pain, and no back symptoms. J Bone Joint Surg Am 2007; 89:358-66. [PMID: 17272451 DOI: 10.2106/jbjs.e.00704] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Magnetic resonance imaging is commonly used to diagnose lumbar spinal stenosis. Some persons without symptoms have a small lumbar spinal canal. Electrodiagnosis has been used to diagnose spinal stenosis for over sixty years, but we are aware of no masked, controlled trials of the use of electrodiagnosis for that purpose. This study was performed to evaluate the relationships of magnetic resonance imaging measures and electrodiagnostic data with the clinical syndrome of spinal stenosis. METHODS One hundred and fifty persons between the ages of fifty-five and eighty years old, including asymptomatic volunteers and persons referred for lumbar magnetic resonance imaging, underwent clinical examination, electrodiagnosis, and magnetic resonance imaging. Subjects were excluded if they had neuromuscular disease, sacral cancer, or inadequate test results, which left 126 subjects for the final analysis. The final cohort was divided into three groups--no back pain, mechanical back pain, and clinical spinal stenosis--on the basis of the impression of the examining physician, for whom the results of the magnetic resonance imaging and electrodiagnostic testing were masked. A spine surgeon also reviewed both the imaging and clinical examination data. RESULTS The examining physician's diagnosis of clinical spinal stenosis was significantly related to the neurological findings on examination (p < 0.05) and to the spine surgeon's diagnosis (p < 0.001). The diagnosis of clinical spinal stenosis was also significantly related to the presence of fibrillations on electrodiagnostic testing (p < or = 0.003), the minimum anteroposterior diameter of the spinal canal on the magnetic resonance images (p = 0.016), and the average of the two smallest spinal canal diameters (p = 0.008) on the images. Measurements on magnetic resonance imaging did not differentiate subjects with clinical spinal stenosis from controls better than chance, whereas paraspinal mapping electrodiagnosis scores did. CONCLUSIONS This prospective, controlled, masked study of electrodiagnosis and magnetic resonance imaging for older subjects showed that imaging does not differentiate symptomatic from asymptomatic persons, whereas electrodiagnosis does. We believe that radiographic findings alone are insufficient to justify treatment for spinal stenosis.
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Affiliation(s)
- Andrew J Haig
- University of Michigan Spine Program, Department of Physical Medicine and Rehabilitation, University of Michigan, 325 East Eisenhower Parkway, Ann Arbor, MI 48108, USA.
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