Association of atherosclerosis with low back pain and the degree of disc degeneration

Does vertebral osteoporosis delay or accelerate lumbar disc degeneration? A systematic review

The effect of vertebral osteoporosis on disc degeneration is still debated. The purpose of this study was to provide a systematic review of studies in this area to further reveal the relationship between the two. Relevant studies were searched in electronic databases, and studies were screened according to inclusion and exclusion criteria, and finally, basic information of the included studies was extracted and summarized. This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A total of 34 publications spanning 24 years were included in our study. There were 19 clinical studies, including 12 prospective studies and 7 retrospective studies. Of these, 7 considered vertebral osteoporosis to be positively correlated with disc degeneration, 8 considered them to be negatively correlated, and 4 considered them to be uncorrelated. Two cadaveric studies were included, one considered the two to be negatively correlated and one considered them not to be correlated. Seven animal studies were included, of which five considered a positive correlation between vertebral osteoporosis and disc degeneration and two considered a negative correlation between the two. There were also 6 studies that used anti-osteoporosis drugs for intervention, all of them were animal studies. Five of them concluded that vertebral osteoporosis was positively associated with disc degeneration, and the remaining one concluded that there was no correlation between the two. Our systematic review shows that the majority of studies currently consider an association between vertebral osteoporosis and disc degeneration, but there is still a huge disagreement whether this association is positive or negative. Differences in observation time and follow-up time may be one of the reasons for the disagreement. A large number of clinical and basic studies are still needed in the future to further explore the relationship between the two.

Lipid metabolism disorder promotes the development of intervertebral disc degeneration

Lipid metabolism is a complex process that maintains the normal physiological function of the human body. The disorder of lipid metabolism has been implicated in various human diseases, such as cardiovascular diseases and bone diseases. Intervertebral disc degeneration (IDD), an age-related degenerative disease in the musculoskeletal system, is characterized by high morbidity, high treatment cost, and chronic recurrence. Lipid metabolism disorder may promote the pathogenesis of IDD, and the potential mechanisms are complex. Leptin, resistin, nicotinamide phosphoribosyltransferase (NAMPT), fatty acids, and cholesterol may promote the pathogenesis of IDD, while lipocalin, adiponectin, and progranulin (PGRN) exhibit protective activity against IDD development. Lipid metabolism disorder contributes to extracellular matrix (ECM) degradation, cell apoptosis, and cartilage calcification in the intervertebral discs (IVDs) by activating inflammatory responses, endoplasmic reticulum (ER) stress, and oxidative stress and inhibiting autophagy. Several lines of agents have been developed to target lipid metabolism disorder. Inhibition of lipid metabolism disorder may be an effective strategy for the therapeutic management of IDD. However, an in-depth understanding of the molecular mechanism of lipid metabolism disorder in promoting IDD development is still needed.

Intervertebral disc degeneration-Current therapeutic options and challenges

Degeneration of the intervertebral disc (IVD) is a normal part of aging. Due to the spine's declining function and the development of pain, it may affect one's physical health, mental health, and socioeconomic status. Most of the intervertebral disc degeneration (IVDD) therapies today focus on the symptoms of low back pain rather than the underlying etiology or mechanical function of the disc. The deteriorated disc is typically not restored by conservative or surgical therapies that largely focus on correcting symptoms and structural abnormalities. To enhance the clinical outcome and the quality of life of a patient, several therapeutic modalities have been created. In this review, we discuss genetic and environmental causes of IVDD and describe promising modern endogenous and exogenous therapeutic approaches including their applicability and relevance to the degeneration process.

Association between anemia and lumbar disc degeneration in patients with low back pain: an observational retrospective study

OBJECTIVE

The goal of this study was to evaluate the possible associations between anemia and morphologic features of lumbar disc degeneration (LDD) in subjects with low back pain.

MATERIALS AND METHODS

A total of 131 patients with normocytic or microcytic anemia (mean age 41.0 ± 6.4 yrs, BMI: 24.8 ± 3.3 kg/m², 12.2% men) and a matched control group of 131 patients without anemia (mean age 41.0 ± 6.4 yrs, BMI: 24.9 ± 3.1 kg/m², 12.2% men) were evaluated for LDD according to the Pfirrmann scoring system. The primary outcome was the difference of radiological features of LDD between two groups. The second outcome was the correlation between the hemoglobin (Hb) value and disc degeneration (DD). Statistical associations were assessed by Student's t-test, Chi-square test, and Spearman correlation.

RESULTS

Anemic patients had a significantly higher number of degenerated discs than non-anemic patients in the level of L2/3 and L3/4 (p < 0.05). We also found that the severe DD occurred more frequently in the level of L2/3, L3/4 and L5/S1 among anemic patients (p < 0.05). In addition, we noticed that the incidence of multilevel LDD happened much more frequently in patients with anemia (p < 0.05). The Hb value showed a borderline negative correlation with the total score of DD (p = 0.056).

CONCLUSION

The results suggested that patients with anemia, and those without are radiologically different with varying patterns of DD. Patients with back pain and anemia were more likely to have extensive and severe DD. Although relevant mechanisms are not yet well understood, this study improved our understandings of the pathophysiology for LDD.

Knee osteoarthritis and adverse health outcomes: an umbrella review of meta-analyses of observational studies

BACKGROUND

Knee osteoarthritis (OA) is a common condition, associated with a high rate of disability and poor quality of life. Despite the importance of such evidence in public health, no umbrella review (i.e., a review of other systematic reviews and meta-analyses) has systematically assessed evidence on association between knee OA and adverse health outcomes.

AIMS

To map and grade all health outcomes associated with knee OA using an umbrella review approach.

METHODS

The search was made across several databases up to 22 April 2022. We used an umbrella review of systematic reviews with meta-analyses of observational studies assessing the effect sizes, based on random effect summary, 95% prediction intervals, heterogeneity, small study effects, and excess significance bias. The evidence was then graded from convincing (class I) to weak (class IV).

RESULTS

Among 3,847 studies initially considered, five meta-analyses were included for a total of five different outcomes. Three adverse outcomes were significantly associated with knee OA (i.e., cardiovascular mortality, falls, and subclinical atherosclerosis). The presence of knee OA was associated with a significantly higher risk of cardiovascular mortality (odds ratio, OR = 1.17; 95%CI, confidence intervals: 1.02-1.34), falls (RR = 1.34; 95%CI: 1.10-1.64), and conditions associated with subclinical atherosclerosis (OR = 1.43; 95%CI: 1.003-2.05). The certainty of each of this evidence was weak.

CONCLUSIONS

Our umbrella review suggests that knee OA can be considered as putative risk factor for some medical conditions, including cardiovascular diseases and falls, however, it is important to note that the evidence is affected by potential biases.

Smoking, alcohol and coffee consumption and risk of low back pain: a Mendelian randomization study

PURPOSE

Low back pain (LBP) is a common health problem in the global population. This study aims to assess whether smoking initiation, alcohol consumption, and coffee consumption are causally with an increased risk of LBP.

METHODS

A two-sample Mendelian Randomization (MR) study was designed, based on summary-level data from the largest published genome-wide association studies. Single nucleotide polymorphisms with genome-wide significance level (P < 5.0 × 10-8) were selected as instrumental variables for each exposure. Standard inverse-variance weighted (IVW) method was used as the primary statistical method. The weighted median, MR-Egger regression, and MR-PRESSO methods, which relax some IV assumptions, were used for sensitivity analysis.

RESULTS

Genetically predicted smoking initiation was causally associated with higher odds of LBP. The pooled OR of LBP using IVW method was 1.36 (95%CI 1.22 1.52; P = 6.0 × 10-8) for one SD increase in the prevalence of smoking initiation, which was supported by the weighted median method (OR: 1.41, 95%CI 1.22, 1.64; P = 5.7 × 10-6). Sensitivity analysis confirmed the robustness of pooled OR of LBP. There was no evidence to suggest a causal effect of alcohol and coffee consumption on LBP. The pooled ORs of LBP were 1.36 (95%CI 0.94, 1.97; P = 0.10) for alcohol consumption and 1.00 (95%CI 0.99, 1.00; P = 0.17) for coffee consumption, respectively.

CONCLUSION

Smoking is casually associated with an increased risk of LBP. Smoking control should be recommended in LBP patients to avoid worsening the disease. The safety of LBP with moderate alcohol and coffee consumption merits more study.

Systemic Risk Factors for Adult Spinal Deformity (ASD): A Retrospective Analysis of 48 Patients

Introduction: Adult spinal deformity (ASD) results in significant patient morbidity and burden to quality of life. The degree to which systemic risk factors and comorbidities that contribute to ASD affect specific spinopelvic parameters is not well-documented. We determine the extent to which preoperative risk factors may contribute to spinopelvic parameters associated with ASD.

Methods: Retrospective single-center study of 48 patients with ASD. Analysis of variance (ANOVA) linear regression analysis was performed to evaluate correlation between systemic comorbidities (obesity, arterial hypertension (HTN), hyperlipidemia (HLD), cardiomyopathy, diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), and asthma) and the following radiographic parameters: pelvic incidence (PI), lumbar lordosis (LL), C7 sagittal vertical axis (C7SVA), and the T10-L2 sagittal cobb angle.

Results: A total of 48 patients were included with mean C7SVA of 79.6 mm (SD: 63, range: 43-254), mean LL of 32.9° (SD: 15.9, range: -14 to 78), T10-L2 sagittal cobb angle of 3° (SD: 12.7, range: -24 to 30), and PI was 49° (SD: 10.7, range: 21 to 77). Only DM correlated with sagittal imbalance with high C7SVA and PI-LL mismatch. The beta coefficient for DM and preoperative C7SVA was 0.49, t=3.16, p=0.003, preoperative PI-LL mismatch standardized beta coefficient was -0.4, t=-2.38, p=0.022, and preoperative T10-L2 sagittal cobb standard beta coefficient was -0.07, t=-0.46, p=0.645. No significant correlations were found for asthma, COPD, HTN, HLD, or cardiomyopathy.

Conclusions: Diagnosis of DM was found to correlate with pathologic C7SVA and significant PI-LL mismatch associated with ASD. HTN, HLD, cardiomyopathy, obesity, and pulmonary disease did not correlate with radiographic findings of sagittal imbalance.

Impact of dyslipidemia on the severity of symptomatic lumbar spine degeneration: A retrospective clinical study

BACKGROUND

Lumbar intervertebral disc degeneration (IVDD) is an important cause of low back pain or sciatica, and metabolic factors play an important role. However, little is known about the relationship of dyslipidemia to the risk of intervertebral disc degeneration (IVDD). This study aimed to assess the impact of serum lipid levels on the severity of lumbar disc degeneration and to investigate its association with endplate inflammation.

METHODS

We conducted a case retrospective study in which a total of 302 hospitalized Chinese patients were recruited, of whom 188 (112 males and 76 females; mean age: 51.66 years) were without underlying disease, while the remaining 114 patients (51 males and 63 females; mean age: 62.75 years) had underlying diseases. We examined fasting serum lipid levels for total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C). Magnetic resonance imaging (MRI) was used to determine endplate inflammation. Pfirrmann grading and Weishaupt grading were used to evaluate the severity of intervertebral disc degeneration and facet joint degeneration, respectively.

RESULTS

There was no difference in age, gender, and general BMI between the two groups (P > 0.05), but there were significantly high levels in TC, LDL-C, and LDL-C/HDL-C (P = 0.04, P = 0.013, P = 0.01, respectively). TG and HDL-C showed no significant difference (P = 0.064, P = 0.336, respectively). The multivariate logistic regression model showed that age was a risk factor for the occurrence of endplate inflammation. In the group without underlying diseases, age, but not other indicators, was a risk factor for the occurrence of endplate inflammation (P < 0.01), In the group with underlying diseases, none of the patient indicators was directly related to the occurrence of endplate inflammation (P > 0.05). A nonlinear machine learning model was used to measure the contribution of each factor to the disease outcome and to analyze the effect between the top three contributing factors and the outcome variables. In patients without underlying diseases, the top three factors contributing to the severity grading of intervertebral disc degeneration were age (32.9%), high-density lipoproteins (20.7%), and triglycerides (11.8%). For the severity grading of facet joint degeneration, the top three contributing factors were age (27.7%), high-density lipoproteins (19.4%), and triglycerides (14.6%). For patients with underlying diseases, the top three factors contributing to intervertebral disc degeneration were age (25.4%), BMI (15.3%), and low-density lipoprotein/high-density lipoprotein ratio (13.9%). In terms of degree classification for facet joint degeneration, the top three contributing factors were age (17.5%), BMI (17.2%), and total cholesterol (16.7%).

CONCLUSION

This study shows that age, high-density lipoprotein, and triglycerides affect the degree of degeneration in patients with symptomatic lumbar degeneration without underlying diseases. Age and BMI are two major factors affecting the severity of degeneration in patients with underlying diseases, and dyslipidemia is a secondary factor. However, there is no clear association between dyslipidemia and the occurrence of endplate inflammation in either group.

Autophagy as a potential therapeutic target in intervertebral disc degeneration

Autophagy is an evolutionarily conserved intracellular recirculation system that delivers cytoplasmic content to lysosomes for degradation, thereby maintaining metabolism and homeostasis. Recent studies have found that autophagy plays a dual role in intervertebral disc degeneration (IDD). Most studies have shown that inducing autophagy can slow down the process of IDD. A few studies have shown that extensive autophagy activation-mediated apoptosis accelerates IDD. In this review, we describe the pathophysiological characteristics of intervertebral disc (IVD), the mechanism of autophagy and the application of regulating autophagy in the treatment of IDD, hoping to provide a certain theoretical basis for the biotherapy of IDD.

The Application of Mesenchymal Stromal Cells and Their Homing Capabilities to Regenerate the Intervertebral Disc

Chronic low back pain (LBP) remains a challenging condition to treat, and especially to cure. If conservative treatment approaches fail, the current “gold standard” for intervertebral disc degeneration (IDD)-provoked back pain is spinal fusion. However, due to its invasive and destructive nature, the focus of orthopedic research related to the intervertebral disc (IVD) has shifted more towards cell-based therapeutic approaches. They aim to reduce or even reverse the degenerative cascade by mimicking the human body’s physiological healing system. The implementation of progenitor and/or stem cells and, in particular, the delivery of mesenchymal stromal cells (MSCs) has revealed significant potential to cure the degenerated/injured IVD. Over the past decade, many research groups have invested efforts to find ways to utilize these cells as efficiently and sustainably as possible. This narrative literature review presents a summary of achievements made with the application of MSCs for the regeneration of the IVD in recent years, including their preclinical and clinical applications. Moreover, this review presents state-of-the-art strategies on how the homing capabilities of MSCs can be utilized to repair damaged or degenerated IVDs, as well as their current limitations and future perspectives.

Factors associated with seeking medical care for low back pain in a twin adult sample

BACKGROUND

Previous studies have only investigated how symptom presentation and socio-demographic factors influence care-seeking for low back pain (LBP). However, the influence of health and lifestyle factors remains unclear, and the potential confounding effects of aggregated familial factors (including genetics and the early shared environment) has not been considered extensively.

METHODS

A cross-sectional analysis was performed on 1605 twins enrolled in the Murcia Twin Registry (Spain). The outcome was seeking medical care for LBP and various self-reported demographic, health and lifestyle factors were considered predictors. All variables except sleep quality and diabetes were collected in 2013, which were cross-referenced from 2009 to 2010. A multivariate logistic regression model was performed on the total sample, followed by a co-twin case-control analysis.

RESULTS

The only significant factor found to increase the odds of seeking medical care for LBP without being affected by familial factors was poor sleep quality (total sample OR = 1.58, 95%CI 1.24-2.01; case-control OR = 1.75, 95%CI 1.14-2.69). The factors that were associated with reduced odds of seeking medical care for LBP and not confounded by familial factors were male sex (case-control OR = 0.55, 95%CI 0.33-0.93), alcohol intake (case-control OR = 0.90, 95%CI 0.82-0.99) and a history of diabetes (case-control OR = 0.50, 95%CI 0.25-0.97). No other factors significantly influenced medical care-seeking for LBP.

CONCLUSIONS

People reporting poor sleep quality are more likely to seek medical care for LBP in the long term, with this relationship being independent from aggregated familial factors. Conversely, males, people reporting higher alcohol intake, and people with a history of diabetes are less likely to seek medical care for LBP.

SIGNIFICANCE

This is the first study investigating the factors that influence seeking medical care for LBP, while adjusting for the influence of familial factors using a co-twin control design. Poor sleep quality is associated with seeking medical care for LBP in the long term and does not appear to be confounded by familial factors. Early screening for indicators of poor sleep quality and appropriate referral to interventions for improving sleep quality or reducing pain in sleep may improve LBP management.

A Simple Scale for Screening Lower-Extremity Arterial Disease as a Possible Cause of Low Back Pain: a Cross-sectional Study Among 542 Subjects

BACKGROUND

Epidemiological, imaging, and anatomical studies suggest an association between proximal arterial atherosclerosis and development of low back pain (LBP).

OBJECTIVES

We aimed to define (1) the frequency and (2) factors associated with exercise-induced proximal ischemia (EIPI) in individuals with LBP and (3) develop a clinical screening scale.

DESIGN

Monocentric cross-sectional study.

PARTICIPANTS

All patients with history of ongoing LBP referred to our exercise investigation laboratory for exercise transcutaneous oximetry (ex-tcPO₂) between January 2011 and December 2017 (n = 542; mean age, 65.4 ± 10.9; 83.9% men).

MAIN MEASURES

EIPI was defined as a decrease from rest of oxygen pressure (DROP) below - 15 mmHg on the lumbar and/or buttock probes. Ex-tcPO₂ is a reliable validated tool for diagnosing EIPI in comparison with arteriography and computed tomography angiography. Ex-tcPO₂ was performed on a treadmill until symptom manifestation or exhaustion. Clinical data were collected using interview questionnaires, medical file review, and clinical examination.

KEY RESULTS

EIPI was diagnosed in 282 patients (52%). Age ≤ 70 years (OR, 2.22; 95% CI, 1.35-3.57; p = 0.002), a history of proximal revascularization (OR, 2.64; 95% CI, 1.50-4.65; p = 0.001), use of antiplatelet medication (OR, 1.71; 95% CI, 0.96-3.06; p = 0.069), a relationship between exercise and LBP (OR, 2.61; 95% CI, 1.49-4.57; p = 0.001), and an abnormal ankle to brachial index (OR, 2.87; 95% CI, 1.77-4.66; p < 0.0001) were identified as EIPI predictors. Using these items, we developed a screening scale that showed an area under the receiver operating characteristics curve of .756. At a score of ≥ 3, the sensitivity, specificity, and accuracy for EIPI were 84%, 55%, and 71%, respectively.

CONCLUSIONS

EIPI was common among our patients with LBP undergoing ex-TcPO₂. Our screening scale could help better select the patients who require angiography.

Direct and Intervertebral Disc-Mediated Sensitization of Dorsal Root Ganglion Neurons by Hypoxia and Low pH

Objective

Ischemia-related risk factors are consistently correlated with discogenic pain, but it remains unclear how the ischemia-associated hypoxia and acidosis influence the peripheral sensory nervous system, namely the dorsal root ganglion (DRG), either directly or indirectly via intervertebral disc (IVD) mediation.

Methods

Bovine tail IVD organ cultures were preconditioned in different hypoxic and/or acidic conditions for 3 days to collect the conditioned medium (CM). The DRG-derived ND7/23 cells were either treated by the IVD CM or directly stimulated by hypoxic and/or acidic conditions. Neuronal sensitization was evaluated using calcium imaging (Fluo-4) after 3 days.

Results

We found that direct exposure of DRG cell line to hypoxia and acidosis increased both spontaneous and bradykinin-stimulated calcium response compared to normoxia-neutral pH cultures. Hypoxia and low pH in combination showed stronger effect than either parameter on its own. Indirect exposure of DRG to hypoxia-acidosis-stressed IVD CM also increased spontaneous and bradykinin-stimulated response, but to a lower extent than direct exposure. The impact of direct hypoxia and acidosis on DRG was validated in a primary sheep DRG cell culture, showing the same trend.

Conclusion

Our data suggest that targeting hypoxia and acidosis stresses both in IVD and DRG could be a relevant objective in discogenic pain treatment.

Long-term mortality in older adults with chronic pain: a nationwide population-based study in Taiwan

PURPOSE

This study was conducted to clarify the long-term mortality in the older population with chronic pain (CP), which is still unclear.

METHODS

We identified 17,568 older participants (aged ≥ 65 years) with CP and an identical number of comparison cohort without CP matched 1:1 by age and sex between 1996 and 2000 from the Taiwan National Health Insurance Research Database. Causes of CP, underlying comorbidities, living areas, and mortality were collected for analyses. The long-term mortality and the causes of mortality were compared between the two cohorts through follow-up since 2000 until 2015.

RESULTS

The mean age (± standard deviation) was 73.5 ± 5.7 years, and female participants comprised 55.1% in both cohorts. The most common causes of CP were osteoarthritis (24.2%), spinal disorders (22.4%), peripheral vascular diseases (14.0%), and osteoporosis (9.5%). Older participants with CP had an increased rate of long-term mortality compared to that among their counterparts without CP after adjusting for the underlying comorbidities and the causes of CP (adjusted hazard ratio [AHR]: 1.18; 95% confidence interval [CI] 1.14-1.21). The increased mortality rate was observed even after the follow-up of 6 years (AHR 1.15; 95% CI 1.10-1.20). No significant difference was observed in the causes of mortality between the two cohorts. The most common cause of mortality was malignancy, followed by cardiovascular and cerebrovascular diseases.

CONCLUSIONS

Chronic pain was associated with an increased rate of long-term mortality in the older population. Early detection and intervention for treating CP are suggested for this population.

Effect of diminished flow in rabbit lumbar arteries on intervertebral disc matrix changes using MRI T2-mapping and histology

Background

Impaired lumbar artery flow has been reported in clinical and epidemiological studies to be associated with low back pain and lumbar disc degeneration. However, it has not been experimentally demonstrated that impaired lumbar artery flow directly induces intervertebral disc (IVD) degeneration by affecting IVD matrix metabolism. The purpose of this study was to evaluate whether ligation of the lumbar artery can affect degenerative changes in the rabbit IVD.

Methods

New Zealand White rabbits (n = 20) were used in this study. Under general anesthesia, the third and fourth lumbar arteries were double-ligated using vascular clips. The blood flow to the L3/L4 disc (cranial disc) was reduced by ligation of the third lumbar artery and that of the L5/L6 disc (caudal disc) by ligation of the fourth lumbar artery. The blood flow to the L4/L5 disc (bilateral disc) was decreased by ligation of both the third and fourth lumbar arteries. The L2/L3 disc was used as the control. Disc height was radiographically monitored biweekly until 12 weeks after surgery. The rabbits were sacrificed at 4, 8, and 12 weeks after surgery and magnetic resonance imaging (MRI) T2-mapping, histology and immunohistochemistry were assessed.

Results

Lumbar artery ligation did not induce significant changes in disc height between control and ischemic discs (cranial, bilateral and caudal discs) during the 12-week experimental period. T2-values of ischemic discs had no significant trend to be lower than those of the control L2/L3 discs. Histologically, Safranin-O staining changed following ligation of corresponding IVD lumbar arteries. Histological grading scores for disc degeneration, which correlated significantly with MRI T2-values, had significant changes after the surgery. Immunohistochemical analysis showed that the ligation of lumbar arteries significantly affected a change in the percentage of HIF-1α immunoreactive cells of ischemia discs compared to that of control discs four weeks after the surgery (p < 0.05).

Conclusions

The MRI and histology results suggest that diminished flow in lumbar arteries induce mild changes in the extracellular matrix metabolism of rabbit IVDs. These matrix changes, however, were not progressive and differed from the degenerative disc changes seen in the process of human IVD degeneration.

Association between serum lipids and low back pain among a middle-aged Japanese population: a large-scale cross-sectional study

Background

Abnormal lipid levels have been suggested as a mechanism leading to atherosclerosis of the lumbar vessels, resulting in low back pain (LBP). This study examined whether abnormal lipid levels were associated with LBP among middle-aged adults in Japan.

Methods

The present study included adults between 40 and 64 years old who underwent an annual health checkup. A total of 258,367 eligible participants were analyzed to investigate associations of LBP with low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and LDL-C/HDL-C ratio. Participants were categorized into two groups according to each of LDL-C, HDL-C, and LDL-C/HDL-C ratio (LDL-C: ≥ 140 vs. < 140 mg/dL; HDL-C: ≥ 40 vs. < 40 mg/dL; LDL-C/HDL-C ratio: ≥ 2.5 vs. < 2.5). Information on LBP was obtained using a self-administered questionnaire. Logistic regression modeling was used to calculate the odds ratio (OR) and 95% confidence interval (CI) for LBP.

Results

The prevalence of LBP was 2.2% in men and 2.1% in women. Multivariable analysis adjusting for age, body mass index, and lifestyle factors found significant associations for HDL-C <  40 mg/dL (OR, 1.34; 95%CI, 1.20–1.48 in men; OR, 1.32; 95%CI, 1.02–1.72 in women) and LDL-C/HDL-C ratio ≥ 2.5 (OR, 1.17; 95%CI, 1.09–1.26 in men; OR, 1.15; 95%CI, 1.03–1.29 in women) with LBP.

Conclusions

Low HDL-C and high LDL-C/HDL-C ratio were significantly associated with LBP in a middle-aged Japanese population. These findings might support the atherosclerosis-LBP hypothesis.

Lumbar Schmorl's Nodes and Their Correlation with Spine Configuration and Degeneration

The aim of this study was to reveal whether demographic aspect, vertebral morphometry, and spine degeneration are associated with lumbar Schmorl's nodes (SNs). A retrospective cross-sectional study was performed using data from the Department of Radiology (Carmel, Medical Center, Israel) for 180 individuals: age range between 40 and 99 years; 90 males and 90 females. All participants had undergone high-resolution CT scans for abdominal diagnostic purposes in the same supine position prior to our study, which enabled the processing of the scans in all planes and allowed a 3D reconstruction of the lower lumbar region. Eighty individuals (44.4%) had at least one SN along the lumbar spine, particularly at L3-4 level (30%). Vertebral body length (L1 to L3) and width (L1 and L4) were significantly greater in the SNs group compared to non-SNs group. On contrast, disc height (L3-4 and L4-5) was significantly lesser in SNs group than non-SNs group. SNs was significantly associated with smoking (X²= 4.436, P=0.02) and degenerative lumbar spinal stenosis (X²= 5.197, P=0.038). Moreover, the prevalence of SN was significantly greater in individuals with vacuum phenomenon and osteophytes formation (L1-2 to L4-5 levels). This study indicates that vacuum phenomenon on L3-4 (OR: 4.7, P=0.034), smoking habit (OR: 3.2, P=0.003), disc height loss of L4-5 (OR: 0.798, P=0.008), vertebral body length of L1 (OR: 1.37, P<0.001), and age (OR: 1.05, P=0.002) increase the probability of developing lumbar SNs.

Combined Aorto-Iliac and Anterior Lumbar Spine Reconstruction: A Case Series

BACKGROUND

Treatment options for aortic-iliac pathology may include endovascular repair and open surgical repair. Treatment options for degenerative disc disease (DDD) are varied but commonly include anterior reconstruction. When both the aortic-iliac and spinal pathologies are significant and surgical intervention is indicated for each pathology, the opportunity exists for concurrent treatment of both the aortic-iliac pathology and DDD in the same operation. The purpose of this case series was to document the safety and feasibility of a surgical strategy whereby a combined elective reconstructive procedure was performed for aortic and anterior lumbar spinal pathologies.

METHODS

The case histories of 5 patients who were treated for both spinal and vascular pathology are presented. Surgical outcome measures included operative time, blood loss, length of stay, and complications. Spine-specific outcome measures included Oswestry Disability Index, Roland Morris Disability Questionnaire, and visual analogue scores (back and leg).

RESULTS

The spinal reconstructions performed included 1 L4-5 total disc replacement (TDR), 1 L4-5, L5-S1 anterior lumbar interbody fusion (ALIF), 1 L5-S1 ALIF, and 2 hybrid procedures (L4-5 TDR with L5-S1 ALIF). Vascular reconstructions included 4 aorto-bi-iliac bypass grafts and 1 aortic tube graft. The average operative time was 365 minutes (ranging between 330 and 510 minutes), the average blood loss was 1699 mL (range between 1160 and 2960 mL), and the average length of hospital stay was 14 days (range from 8 to 22 days). There were no in-hospital complications, and all patients experienced significant improvement in both back and leg pain. One patient developed kinking of the iliac limbs of the vascular graft 1 year postoperatively, which was managed with endovascular stenting of the graft.

CONCLUSIONS

Aortic-iliac pathology and DDD are significant pathologies often treated in isolation. This study illustrates that, despite its complexity, highly trained individuals in a specialized setting can perform combined surgery to achieve a satisfactory outcome for the patient.

LEVEL OF EVIDENCE

Level IV evidence.

Short-term increase in discs' apparent diffusion is associated with pain and mobility improvements after spinal mobilization for low back pain

Pain perception, trunk mobility and apparent diffusion coefficient (ADC) within all lumbar intervertebral discs (IVDs) were collected before and shortly after posterior-to-anterior (PA) mobilizations in 16 adults with acute low back pain. Using a pragmatic approach, a trained orthopaedic manual physical therapist applied PA mobilizations to the participants' spine, in accordance with his examination findings. ADC _all was computed from diffusion maps as the mean of anterior (ADC _ant ), middle (ADC _mid ), and posterior (ADC _post ) portions of the IVD. After mobilization, pain ratings and trunk mobility were significantly improved and a significant increase in ADC _all values was observed. The greatest ADC _all changes were observed at the L₃-L₄ and L₄-L₅ levels and were mainly explained by changes in ADC _ant and ADC _post , respectively. No significant changes in ADC were observed at L₅-S₁ level. The reduction in pain and largest changes in ADC observed at the periphery of the hyperintense IVD region suggest that increased peripheral random motion of water molecules is implicated in the IVD nociceptive response modulation. Additionally, ADC changes were observed at remote IVD anatomical levels that did not coincide with the PA spinal mobilization application level.

The Effect of Smoking on Spinal Fusion

BACKGROUND

Spinal fusion surgery is performed about half a million times per year in the United States and millions more worldwide. It is an effective method for reducing pain, increasing stability, and correcting deformity in patients with various spinal conditions. In addition to being a well-established risk factor for a variety of medical conditions, smoking has deleterious effects on the bone healing of spinal fusions. This review aims to specifically analyze the ways in which smoking affects the outcomes of spinal fusion and to explore ways in which these negative consequences can be avoided.

PURPOSE

This article provides a complete understanding of the ways smoking affects spinal fusion from a biochemical and clinical perspective. Recommendations are also provided for ways in which surgeons can limit patient exposure to the most serious negative outcomes associated with cigarette smoking.

STUDY DESIGN/SETTING

This study was a retrospective literature review done using the NCBI database. The research was compiled at NYU Hospital for Joint Diseases and the NYU Center for Musculoskeletal Care.

METHODS

A comprehensive literature review was done spanning research on a variety of subjects related to smoking and spinal fusion surgery. The biochemistry of smoking and fusion healing were examined in great detail. In addition, both in vivo animal studies and human clinical studies were evaluated to explore fusion success related to the effects of smoking and its biochemical factors on spinal fusion surgery.

RESULTS

Smoking significantly increases the risk of pseudoarthrosis for patients undergoing both lumbar and cervical fusions. In addition to nonunion, smoking also increases the risk of other perioperative complications such as infection, adjacent-segment pathology, and dysphagia. Treatment options are available that can be explored to reduce the risk of smoking-related morbidity, such as nicotine replacement therapy and use of bone morphogenetic proteins (BMPs).

CONCLUSIONS

It has been clearly demonstrated from both a biochemical and clinical perspective that smoking increases the rate of perioperative complications for patients undergoing spinal fusion surgery, particularly pseudoarthosis. It has also been shown that there are certain approaches that can reduce the risk of morbidity. The most important recommendation is smoking cessation for four weeks after surgery. In addition, patients may be treated with certain surgical techniques, including the use of BMPs, to reduce the risk of pseudoarthrosis. Lastly, nicotine replacement therapy is an area of continued interest in relation to spinal fusion outcomes and more research needs to be done to determine its efficacy moving forward.

Atherosclerotic Disease and its Relationship to Lumbar Degenerative Disk Disease, Facet Arthritis, and Stenosis With Computed Tomography Angiography

BACKGROUND

The intervertebral disk is the largest avascular structure in the body. It relies on passive diffusion from arteries at the periphery of the disk for nutrition. Previous studies have suggested a correlation between vascular disease and lumbar degenerative disk disease (DDD), but the association with facet arthritis and stenosis has not been evaluated.

OBJECTIVE

To evaluate the degree of lumbar artery stenosis, aortic atherosclerosis on computed tomography angiography, and its relationship to lumbar DDD, facet arthritis, and spinal canal stenosis.

DESIGN

Retrospective case review.

SETTING

Academic tertiary care hospital.

PARTICIPANTS

Not applicable.

METHODS

A total of 300 lumbar arteries (150 lumbar artery pairs of the first to fifth lumbar arteries) were evaluated on consecutive computed tomography angiography scans. Severity of vascular disease of lumbar arteries was documented as normal, mild, moderate, severe, or occluded. Aortic vascular disease was documented along the posterior wall where the lumbar arteries originate.

MAIN OUTCOME MEASUREMENTS

The relationship between vascular disease with DDD, facet arthritis, and spinal canal stenosis was examined and further evaluated controlling for age.

RESULTS

Lumbar artery and aortic atherosclerosis had a positive relationship with DDD, facet arthritis, and spinal stenosis that was statistically significant (P < .05) even after controlling for age. The correlation coefficient was greatest in the younger age group when looking at lumbar artery vascular disease with DDD (0.73, confidence interval 0.50-0.96, P < .0001) and aortic vascular disease with DDD (0.72, confidence interval 0.49-0.94, P < .0001). The correlation of vascular disease with facet arthritis and stenosis was not strong in the older age group.

CONCLUSION

Atherosclerotic disease of the lumbar arteries and aorta correlated with lumbar DDD, facet arthritis, and spinal canal stenosis after we adjusted for age, although the correlation with facet arthritis and spinal canal stenosis was not as strong in the older age group.

LEVEL OF EVIDENCE

IV.

Possible involvement of the oxLDL/LOX-1 system in the pathogenesis and progression of human intervertebral disc degeneration or herniation

Epidemiological studies have concluded that hyperlipidemia and atherosclerosis were related to intervertebral disc degeneration (IVDD). The presence of oxidized low density lipoprotein (ox-LDL) and the expression of lectin-like oxidized low density lipoprotein receptor 1 (LOX-1) have not been explored in this tissue. In this study, we investigated the presence of ox-LDL and the expression of its receptor LOX-1 in non-degenerated, degenerated or herniated human intervertebral discs (IVDs). The expression of LOX-1 and matrix metalloproteinase 3 (MMP3) were studied after incubating nucleus pulposus cells (NPCs) with ox-LDL. The presence of ox-LDL and LOX-1 was positively related with the extent of IVDD in nucleus pulposus (NP), end-plate cartilage and outer annulus fibrous, but not with the extent of degeneration of inter annulus fibrous. Ox-LDL significantly reduced the viability of human NPCs in a dose and time-dependent manner, and increased the expression of MMP3 induced by LOX-1. Pretreatment with anti-human LOX-1 monoclonal antibody reversed these effects. Ox-LDL, principally mediated by LOX-1, enhanced MMP3 production in NPCs through the NF-κB signaling pathway. In conclusion, increased accumulation of ox-LDL and LOX-1 in IVDs indicates a specific role of the receptor-ligand interaction in degeneration or herniation of IVDs.

Fibroblast Transplantation Results to the Degenerated Rabbit Lumbar Intervertebral Discs

Background:

Our study is an analysis of the histological and radiological changes in degenerated lumbar intervertebral discs, after transplantation of fibroblasts in rabbits. With that study we aimed to show the viability of the fibroblasts injected to the degenerated discs, and observe their potential for further studies.

Method:

The apoptosis of the cell is one of the factors at the disc degeneration process. Fibroblasts may act as mesenchymal stem cells at the tissue to which they are injected and they may replace the apoptotic cells. The nucleus pulposus of the discs from eight rabbits were aspirated under scopic guidance to induce disc degeneration.

Results:

One month later, cultured fibroblasts, which had been taken from the skin, were injected into the disc. The viability and the potential of the injected cells for reproduction were studied histologically and radiologically. Cellular formations and organizations indicating to the histological recovery were observed at the discs to which fibroblasts were transplanted. The histological findings of the discs to which no fibroblasts were transplanted, did not show any histological recovery. Radiologically, no finding of the improvement was found in both groups. The fibroblasts injected to the degenerated discs are viable.

Conclusion:

The findings of improvement, observed in this study, suggest that fibroblast transplantation could be an effective method of therapy for the prevention or for the retardation of the degenerative disease of the discs.

The Association Between Atherosclerosis and Low Back Pain: A Systematic Review

OBJECTIVE

To assess the evidence of association between atherosclerosis and low back pain (LBP). TYPE: Focused systematic review.

LITERATURE SURVEY

PubMed, Web of Science, CINAHL, and EMBASE were searched for original research articles, not limited by language, from January 1, 1990, to October 31, 2016.

METHODOLOGY

Titles and then abstracts were identified using predefined search terms and excluded based on lack of relevancy. This was followed by full-text reviews. Two authors independently assessed methodological quality based on Cochrane Handbook for Systematic Reviews of Interventions.

SYNTHESIS

A total of 26 studies met the inclusion criteria. The quality of the studies was low to moderate. There was significant heterogeneity across articles with respect to methodology. There was insufficient evidence to support an association between ischemia and low back pain.

CONCLUSIONS

The cause of LBP remains poorly understood. Better insight into how intervertebral disk changes relate to LBP is needed to guide future research. High-quality prospective studies are needed to answer the question of whether atherosclerosis is a risk factor for LBP.

LEVEL OF EVIDENCE

II.

Association between Knee Osteoarthritis, Cardiovascular Risk Factors, and the Framingham Risk Score in South Koreans: A Cross-Sectional Study

Background

Osteoarthritis is a significant burden on personal health and for social cost, and its prevalence is rising. Recent research has revealed an association between osteoarthritis and cardiovascular disease, and this study uses the Framingham risk score (FRS), which is widely used as a composite index of cardiovascular risk factors, to investigate the association between osteoarthritis and various cardiovascular risk factors.

Methods

A total 9,514 participants aged 50 years or older who received knee X-ray diagnosis of the 5th Korean National Health and Nutrition Examination Survey (total surveyees = 24,173) released by the Korean Centers for Disease Control and Prevention was included for analysis. Knee osteoarthritis patients were defined as participants with K-L grade ≥2 on knee X-ray regardless of knee pain. The association between major cardiovascular risk factors (blood pressure, diabetes, cholesterol, and smoking habits), FRS, and knee osteoarthritis was analyzed, adjusting for various covariates.

Results

Prevalence of knee osteoarthritis in Koreans aged ≥50 years was 36.6%, and higher in women (men: 24.9%, women: 45.4%). Prevalence of knee osteoarthritis in participants with hypertension was significantly higher than those without hypertension (fully adjusted odds ratio (OR) 1.26; 95% confidence interval (CI) 1.08–1.48). Knee osteoarthritis prevalence was also higher in participants with impaired fasting glucose or diabetes than those without (age, sex adjusted OR 1.19; 95% CI 1.00–1.41). Also, OR values increased statistically significantly with FRS as a continuous variable (fully adjusted OR 1.007; 95% CI 1.00–1.01).

Conclusions

Prevalence of knee osteoarthritis was associated with hypertension and diabetes, which are major cardiovascular risk factors, and the FRS. Further studies on FRS pertaining to its relationship with osteoarthritis are warranted.

Increased low back pain prevalence in females than in males after menopause age: evidences based on synthetic literature review

Female sex hormones play an important role in the etiology and pathophysiology of a variety of musculoskeletal degenerative diseases. Postmenopausal women show accelerated disc degeneration due to relative estrogen deficiency. This literature review aims to validate or falsify this hypothesis, i.e., while overall females have higher prevalence of low back pain (LBP) across all age groups, this male vs. female difference in LBP prevalence further increases after female menopause age. The literature search was performed on PubMed on January 2, 2016. The search word combination was (low back pain) AND prevalence AND [(males OR men) AND (females OR women)]. The following criteria were taken to include the papers for synthetic analysis: (I) only English primary literatures on nonspecific pain; (II) only prospective studies on general population, but not population with occupational LBP causes, of both males and female subjects studied using the same LBP criterion, ages-specific information available, and males and female subjects were age-matched; (III) studies without major quality flaws. In total 98 studies with 772,927 subjects were analyzed. According to the information in the literature, participant subjects were divided into four age groups: (I) school age children group: 6-19 years; (II) young and middle aged group: 20-50 years; (III) mixed age group: data from studies did not differentiate age groups; (IV) elderly group: ≥50 years old. When individual studies were not weighted by participant number and each individual study is represented as one entry regardless of their sample size, the median LBP prevalence ratio of female vs. males was 1.310, 1.140, 1.220, and 1.270 respectively for the four age groups. When individual studies were weighted by participant number, the LBP prevalence ratio of female vs. males was 1.360, 1.127, 1.185, and 1.280 respectively for the four groups. The higher LBP prevalence in school age girls than in school age boys is likely due to psychological factors, female hormone fluctuation, and menstruation. Compared with young and middle aged subjects, a further increased LBP prevalence in females than in males was noted after menopause age.

Is Chronic Low Back Pain Associated with the Prevalence of Coronary Heart Disease when Genetic Susceptibility Is Considered? A Co-Twin Control Study of Spanish Twins

Objective

To investigate the chronic low back pain and coronary heart disease relationship, after adjusting for relevant confounders, including genetics.

Methods

In a cross-sectional design, 2148 twins were recruited from the Murcia Twin Registry, Spain. The exposure was chronic LBP and the outcomes were myocardial infarction and other coronary heart diseases—lifetime and in the last 2 years–based on standardized health-related questionnaires. First, logistic regression analysis investigated associations of the total sample followed by a matched co-twin control analyses, with all complete twin pairs discordant for chronic LBP utilised, separated for zygosity—dizygotic (DZ) and monozygotic (MZ) pairs, which adjusted for shared familial factors, including genetics.

Results

Chronic LBP pain is associated with lifetime myocardial infarction [odds ratio (OR) = 2.69, 95% confidence interval (CI) = 1.35–5.36], other coronary heart diseases over a lifetime (OR = 2.58, 95% CI: 1.69–3.93) and in the last two years (OR = 2.19, 95% CI: 1.33–3.60), while there was a borderline association with myocardial infarction in the last 2 years (OR = 2.64, 95% CI: 0.98–7.12). Although the magnitude of the association remained or increased in the co-twin control analyses, none reached statistical significance.

Conclusion

Chronic LBP is associated with a higher prevalence of myocardial infarction and coronary heart disease. It is possible that this association remains even when controlling for genetics and early shared environment, although this should be investigated with larger samples of twins discordant for LBP.

Serum lipid levels are positively correlated with lumbar disc herniation--a retrospective study of 790 Chinese patients

Background

Abnormal serum lipid levels have been shown to be associated with the occurrence of atherosclerosis, but little is known about the relationships of them with the risk of developing intervertebral disc degeneration (IVDD) in Chinese population.

Methods

We performed a case–control study to assess the relationship between serum lipid levels and lumbar disc degeneration. A total of 790 Chinese patients were recruited for this study at the time of hospitalization. We examined fasting serum lipid levels of total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C). 396 patients (235 men and 161 women; mean age: 41.07 years) underwent surgery for single-level lumbar disc herniation. A control group of 394 patients (225 men and 169 women; mean age: 42.1 years) underwent surgery for wounded lower limbs during the same period. Patients in the control group were collected randomly from among patients who were age- and sex-matched patients with the case group.

Results

Patients with lumbar disc herniation had significantly higher TC and LDL-C serum concentrations (P < 0.001 for both) than controls. Percentage of High-TC, High-TG, High-LDL-C, borderline High-TC and borderline High-LDL-C were significantly higher in the disc herniation group (P = 0.017, P = 0.002, P = 0.039, P =0.002 and P < 0.001, respectively). Ratios of TC/HDL-C and LDL-C/HDL-C were significantly associated with disc herniation (P < 0.001 for both). Logistic regression revealed that patients with higher serum LDL-C levels had a higher risk of disc herniation, in which odds ratio (OR) was 1.462 and confidence interval (CI) was 1.179 ~ 1.813. Moreover, patients with High-TG and borderline High-LDL-C had a higher probability of disc herniation (OR: 2.974, CI: 1.488 ~ 5.945, statistical power: 100 %; OR: 1.626, CI: 1.012 ~ 2.612, statistical power: 61.4 %, respectively). However, hyperlipidaemia did not seem to be associated with the herniated segment of the lumbar intervertebral disc (p = 0.374).

Conclusions

The present study suggests that dyslipidaemia may be associated with a higher risk of developing lumbar disc herniation. Serum lipid levels could be a useful predictor for intervertebral disc degeneration in Chinese population.

Association of severe disc degeneration with all-cause mortality and abdominal aortic calcification assessed prospectively in older men: findings of a single-center prospective study of osteoporosis in men

OBJECTIVE

To assess the association of disc degeneration with all-cause mortality and with the severity and rate of progression of abdominal aortic calcification (AAC) in older men.

METHODS

Men >50 years of age (n = 766) underwent lateral spine radiography and blood collection and were monitored prospectively. We assessed the association of disc degeneration with all-cause mortality (at 10 years), AAC severity (at baseline), and AAC progression (at 7.5 years).

RESULTS

After adjustment for confounders, including AAC, the total overall grade score for AAC predicted all-cause mortality (hazard ratio [HR] 1.20 per SD increase [95% confidence interval (95% CI) 1.01-1.43]). The highest tertile of the total overall grade score was associated with higher mortality rates (39.3/1,000 person-years for a score of >8 versus 20.9/1,000 person-years for a score of 0-8; adjusted HR 1.47 [95% CI 1.05-2.06]). The odds of severe AAC (score of >5) increased with the total disc space narrowing score (adjusted HR 1.44 per SD [95% CI 1.11-1.87]). The highest tertile of the total disc space narrowing score was associated with higher odds of severe AAC (adjusted HR 2.42 versus the lowest tertile [95% CI 1.24-4.73]). The probability of long-term AAC stability decreased with an increasing total osteophyte score (adjusted HR 0.66 per SD [95% CI 0.49-0.88]). The highest tertile of the total osteophyte score was associated with a lower probability of AAC stability (adjusted HR 0.35 versus the lowest tertile [95% CI 0.18-0.71]).

CONCLUSION

Older men with severe disc degeneration have greater AAC severity, faster AAC progression, and higher all-cause mortality rates.

The spinal stenosis pedometer and nutrition lifestyle intervention (SSPANLI): development and pilot

BACKGROUND CONTEXT

Owing to mobility limitations, people with lumbar spinal stenosis (LSS) are at risk for diseases of inactivity, including obesity. Therefore, weight management in LSS is critical. Body mass index is the strongest predictor of function in LSS, suggesting that weight loss may promote physical activity and provide a unique treatment option. We propose a lifestyle modification approach of physical activity and nutrition education, delivered through an e-health platform.

PURPOSE

The purpose of this study was to develop and pilot an e-health intervention aimed at increasing physical activity and decreasing fat mass in people with LSS.

STUDY DESIGN

The study design was based on intervention development and pilot.

PATIENT SAMPLE

Ten overweight or obese individuals with LSS were confirmed clinically and on imaging.

OUTCOME MEASURES

Self-reported measures were food record, Short-Form 36 (SF-36), pain scales, Swiss Spinal Stenosis Symptom and Physical Function Scales, Oswestry Disability Index (ODI), Pain Catastrophizing Questionnaire, Tampa Scale for Kinesiophobia, Center for Epidemiologic Studies(Depression) Scale, Behavioral Regular in Exercise Questionnaire, and Regulation for Eating Behavior Scale and physiologic measures were dual-energy X-ray absorptiometry (DXA), blood draw, 7-day accelerometry, self-paced walking test, and balance test.

METHODS

The e-health platform was developed.

INTERVENTION

during Week 1, participants received a pedometer and a personalized consultation with a dietitian and an exercise physiologist. For 12 weeks, participants logged on to the e-health Web site to access personal step goals, nutrition education videos, and a discussion board. Follow-up occurred at Week 13.

RESULTS

Nine participants had a mean age of 67.5±6.7 years (60% women). Significant improvements were observed for fat mass (DXA), trunk fat mass, symptom severity (Swiss Symptom Scale), energy intake, maximum continuous activity (accelerometry), and mental health (SF-36) (p<.05). Nonsignificant improvements were observed for waist circumference, pain, ODI, and obesity biomarkers. Seventy percent lost weight, 50% increased walking capacity, and 60% increased quality of life. The mean increase in steps was 15%.

CONCLUSIONS

The spinal stenosis pedometer and nutrition lifestyle intervention was shown to be feasible, attractive to participants, and effective in this small sample. This intervention provides people with LSS the opportunity to participate in their own health management, potentially improving access to care. Efficacy is currently being assessed in a randomized trial.

Metabolic syndrome increases the prevalence of spine osteoarthritis

OBJECTIVE

To determine whether the prevalence of severe spinal osteoarthritis (OA) increases with the number of metabolic syndrome (MetS) risk factors.

METHODS

Data from a single surgeon's high volume, spine surgery practice were reviewed. Severe OA was defined as degenerative spondylolisthesis or cervical or lumbar stenosis causing neurologically based symptoms and early OA as lumbar and cervical spondylosis causing axial pain only. Logistic regression modeling was used to determine the odds (adjusted for age and sex) of having severe spine OA with more numerous MetS risk factors.

RESULTS

Severe spinal OA was identified in 839/1502 patients (55.9%) and early OA in the remaining 663 individuals (44.1%). The overall prevalence of MetS was 30/1502 (2.0%): 26/839 (3.1%) in the severe OA group and 4/663 (0.6%) in the early OA group (P = 0.001). Presence of all four MetS risk factors was associated with almost quadruple the odds of having severe OA as compared with absence of risk factors (OR 3.9 [1.4-11.6], P < 0.01).

CONCLUSION

The components of MetS are more prevalent in subjects with severe spinal OA than in those with spondylosis causing axial pain. Future study of the association between MetS and the incidence of OA is required.

Do abnormal serum lipid levels increase the risk of chronic low back pain? The Nord-Trøndelag Health Study

Background

Cross-sectional studies suggest associations between abnormal lipid levels and prevalence of low back pain (LBP), but it is not known if there is any causal relationship.

Objective

The objective was to determine, in a population-based prospective cohort study, whether there is any relation between levels of total cholesterol, high density lipoprotein (HDL) cholesterol and triglycerides and the probability of experiencing subsequent chronic (LBP), both among individuals with and without LBP at baseline.

Methods

Information was collected in the community-based HUNT 2 (1995–1997) and HUNT 3 (2006–2008) surveys of an entire Norwegian county. Participants were 10,151 women and 8731 men aged 30–69 years, not affected by chronic LBP at baseline, and 3902 women and 2666 men with LBP at baseline. Eleven years later the participants indicated whether they currently suffered from chronic LBP.

Results

Among women without LBP at baseline, HDL cholesterol levels were inversely associated and triglyceride levels positively associated with the risk of chronic LBP at end of follow-up in analyses adjusted for age only. Adjustment for the baseline factors education, work status, physical activity, smoking, blood pressure and in particular BMI largely removed these associations (RR: 0.96, 95% CI: 0.85–1.07 per mmol/l of HDL cholesterol; RR: 1.16, 95% CI: 0.94–1.42 per unit of lg(triglycerides)). Total cholesterol levels showed no associations. In women with LBP at baseline and men without LBP at baseline weaker relationships were observed. In men with LBP at baseline, an inverse association with HDL cholesterol remained after complete adjustment (RR: 0.83, 95% CI: 0.72–0.95 per mmol/l).

Conclusion

Crude associations between lipid levels and risk of subsequent LBP in individuals without current LBP are mainly caused by confounding with body mass. However, an association with low HDL levels may still remain in men who are already affected and possibly experience a higher pain intensity.

Patterns of lumbar disc degeneration are different in degenerative disc disease and disc prolapse magnetic resonance imaging analysis of 224 patients

BACKGROUND CONTEXT

Existing research on lumbar disc degeneration has remained inconclusive regarding its etiology, pathogenesis, symptomatology, prevention, and management. Degenerative disc disease (DDD) and disc prolapse (DP) are common diseases affecting the lumbar discs. Although they manifest clinically differently, existing studies on disc degeneration have included patients with both these features, leading to wide variations in observations. The possible relationship or disaffect between DDD and DP is not fully evaluated.

PURPOSE

To analyze the patterns of lumbar disc degeneration in patients with chronic back pain and DDD and those with acute DP.

STUDY DESIGN

Prospective, magnetic resonance imaging-based radiological study.

METHODS

Two groups of patients (aged 20-50 years) were prospectively studied. Group 1 included patients requiring a single level microdiscectomy for acute DP. Group 2 included patients with chronic low back pain and DDD. Discs were assessed by magnetic resonance imaging through Pfirmann grading, Schmorl nodes, Modic changes, and the total end-plate damage score for all the five lumbar discs.

RESULTS

Group 1 (DP) had 91 patients and group 2 (DDD) had 133 patients. DP and DDD patients differed significantly in the number, extent, and severity of degeneration. DDD patients had a significantly higher number of degenerated discs than DP patients (p<.000). The incidence of multilevel and pan-lumbar degeneration was also significantly higher in DDD group. The pattern of degeneration also differed in both the groups. DDD patients had predominant upper lumbar involvement, whereas DP patients had mainly lower lumbar degeneration. Modic changes were more common in DP patients, especially at the prolapsed level. Modic changes were present in 37% of prolapsed levels compared with 9.9% of normal discs (p<.00). The total end-plate damage score had a positive correlation with disc degeneration in both the groups. Further the mean total end-plate damage score at prolapsed level was also significantly higher.

CONCLUSION

The results suggest that patients with disc prolapse, and those with back pain with DDD are clinically and radiologically different groups of patients with varying patterns, severity, and extent of disc degeneration. This is the first study in literature to compare and identify significant differences in these two commonly encountered patient groups. In patients with single-level DP, the majority of the other discs are nondegenerate, the lower lumbar spine is predominantly involved and the end-plate damage is higher. Patients with back pain and DDD have larger number of degenerate discs, early multilevel degeneration, and predominant upper lumbar degeneration. The knowledge that these two groups of patients are different clinically and radiologically is critical for our improved understanding of the disease and for future studies on disc degeneration and disc prolapse.

Assessment of lower extremity arterial blood flow in females with knee osteoarthritis

To investigate whether blood flow in the lower extremity arteries changes in patients with osteoarthritis (OA) using color Doppler ultrasonography. The study comprised 39 female patients with osteoarthritis and 30 healthy female controls. The patients were evaluated using visual analogue scale (VAS) at rest and the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Color Doppler imaging was used to measure mid-diastolic velocity (MD), pulsatility index (PI), peak systolic velocity (PS), end-diastolic velocity (ED), vascular diameter, and flow volume in the external iliac (EIA), common femoral (CFA), superficial femoral (SFA), deep femoral (DFA), popliteal (PA), anterior tibial (ATA), posterior tibial (PTA), and distal superficial femoral arteries (DSFA). The femoral artery intima-media thickness (FIMT) was also measured. OA patients' PS and flow volume in the EIA and SFA were greater than those of controls, as were PI and ED in the EIA, ED in the PA, MD in the DFA, and the diameter of the PA, ATA, and PTA (p < 0.05). There were no statistically significant differences in FIMT between patients with knee OA and controls (p > 0.05). The flow volume of the main arteries feeding the knee joint is significantly greater than normal in patients with symptomatic knee OA. No evidence was identified relating this difference to ischemic processes.

High prevalence of abdominal aortic aneurysm in patients with chronic low back pain

Low back pain (LBP) is one of the most common symptoms in outpatient clinics, and abdominal aortic aneurysm (AAA) is one of the causes of LBP. In the present study, we examined the prevalence of chronic LBP in patients with aortic aneurysm. The study included 23 patients with AAA and 23 patients with thoracic aortic aneurysm (TAA); all of them visited a regional center hospital in Akita, Japan. A total of 207 hypertension patients were also enrolled as a control. Chronic LBP was defined in patients who visited the orthopedic outpatient clinic for the LBP treatment for more than three months. The prevalence of chronic LBP in the AAA group (52.2%) was significantly higher than that in the TAA (17.4%, P < 0.05) or hypertension patients (11.6%, P < 0.01). The rate of a trigger point (TP) injection was significantly higher in the AAA group or the TAA group than that in hypertension patients (P < 0.01, P < 0.05), but there was no significant difference between the AAA and TAA groups. The TP injection represents an injection of local anesthesia to the low back muscles. We also evaluated the involvement of various factors in LBP caused by AAA, such as age, gender, blood pressure, the existence of dissection, and the maximum diameter of AAA, but none of them showed significant relationship to LBP. The prevalence of LBP is high in AAA patients, and doctors who treat chronic LBP should be aware of AAA as a potential cause of LBP.

Body mass index and musculoskeletal pain: is there a connection?

Background

Back pain is one of the most common complaints that patients report to physicians and two-thirds of the population has an elevated body mass index (BMI), indicating they are either overweight or obese. It was once assumed that extra body weight would stress the low back and lead to pain, however, researchers have reported inconsistencies association between body weight and back pain. In contrast, more recent studies do indicate that an elevated BMI is associated with back pain and other musculoskeletal pain syndromes due to the presence of a chronic systemic inflammatory state, suggesting that the relationship between BMI and musculoskeletal pains be considered in more detail.

Objective

To describe how an elevated BMI can be associated with chronic systemic inflammation and pain expression. To outline measurable risk factors for chronic inflammation that can be used in clinical practice and discuss basic treatment considerations.

Discussion

Adiposopathy, or “sick fat” syndrome, is a term that refers to an elevated BMI that is associated with a chronic systemic inflammatory state most commonly referred to as the metabolic syndrome. The best available evidence suggests that the presence of adiposopathy determines if an elevated BMI will contribute to musculoskeletal pain expression. It is not uncommon for physicians to fail to identify the presence of adiposopathy/metabolic syndrome.

Conclusion

Patients with an elevated BMI should be further examined to identify inflammatory factors associated with adiposopathy, such as the metabolic syndrome, which may be promoting back pain and other musculoskeletal pain syndromes.

Relationship between lumbar spinal stenosis and lifestyle-related disorders: a cross-sectional multicenter observational study

STUDY DESIGN

A cross-sectional multicenter observational study.

OBJECTIVE

To identify associations between lumbar spinal stenosis (LSS) and lifestyle-related diseases.

SUMMARY OF BACKGROUND DATA

Impaired blood flow as a result of arteriosclerosis facilitates degenerative changes in the spine. However, associations between LSS and lifestyle-related diseases (hypertension, diabetes, and dyslipidemia) remain unclear.

METHODS

Participants comprised 526 patients diagnosed with LSS using the clinical diagnostic support tool and magnetic resonance imaging at 64 facilities. Data on 1218 males and 1636 females in the general population were selected from the 2006 National Health and Nutrition Survey as control data. We investigated the prevalence of lifestyle-related diseases (hypertension, diabetes, and dyslipidemia) and levels of hemoglobin A1c, total cholesterol, and high-density lipoprotein cholesterol. LSS and control groups were divided into 4 subgroups by age (nonelderly, <70 yr old; elderly, ≥ 70 yr) and sex. Statistical analyses were performed to compare patients with LSS and the control group using the χ test or Fisher exact text. Values of P < 0.05 were considered statistically significant.

RESULTS

Among nonelderly patients, proportions of patients with hypertension and diabetes mellitus were higher in patients with LSS than in controls (P < 0.01 each). The proportion of patients with hemoglobin A1c was 6.1% or greater and higher for female patients with LSS than for female controls (P < 0.05). No significant difference in the proportion of patients with dyslipidemia was apparent between the LSS and control groups.

CONCLUSION

After adjusting for age and sex, this study revealed a close association between diabetes and hypertension in 50- to 69-year-old patients with LSS. Physicians should consider the possibility of concomitant hypertension or diabetes mellitus when examining 50- to 69-year-old patients with LSS.

The molecular basis of intervertebral disc degeneration

BACKGROUND

Intervertebral disc (IVD) degeneration remains a clinically important condition for which treatment is costly and relatively ineffective. The molecular basis of degenerative disc disease has been an intense focus of research recently, which has greatly increased our understanding of the biology underlying this process.

PURPOSE

To review the current understanding of the molecular basis of disc degeneration.

STUDY DESIGN

Review article.

METHODS

A literature review was performed to identify recent investigations and current knowledge regarding the molecular basis of IVD degeneration.

RESULTS

The unique structural requirements and biochemical properties of the disc contribute to its propensity toward degeneration. Mounting evidence suggests that genetic factors account for up to 75% of individual susceptibility to IVD degeneration, far more than the environmental factors such as occupational exposure or smoking that were previously suspected to figure prominently in this process. Decreased extracellular matrix production, increased production of degradative enzymes, and increased expression of inflammatory cytokines contribute to the loss of structural integrity and accelerate IVD degeneration. Neurovascular ingrowth occurs, in part, because of the changing degenerative phenotype.

CONCLUSIONS

A detailed understanding of the biology of IVD degeneration is essential to the design of therapeutic solutions to treat degenerative discs. Although significant advances have been made in explaining the biologic mediators of disc degeneration, the inhospitable biochemical environment of the IVD remains a challenging environment for biological therapies.

Prognostic factors of prolonged disability in patients with chronic low back pain and lumbar degeneration in primary care: a cohort study

STUDY DESIGN

A cohort study with 1-year follow-up.

OBJECTIVE

To identify prognostic factors in patients with chronic nonspecific low back pain (LBP).

SUMMARY OF BACKGROUND DATA

The factors (e.g., sociodemographical, low back-related, radiological, and biological) associated with persistent pain and disability for patients with chronic nonspecific LBP are uncertain. Furthermore, sparse information exists about the relationship between biological factors like impaired fasting glucose tolerance and chronic nonspecific LBP.

METHODS

The participants consisted of 250 patients with nonspecific LBP of more than 6 months duration and degenerative lumbar osteoarthritis. The patients were originally recruited for a randomized controlled trial from the clinics of general practitioners, physiotherapists, and chiropractors. Potential predictors were evaluated at baseline. The outcome was absolute level of pain-related disability (Roland-Morris Disability Questionnaire [RMDQ]) at 1 year. The association between potential prognostic factors and the outcome was analyzed with multivariate linear backward regression.

RESULTS

At baseline and 1 year, the RMDQ scores were 9.5 and 5.1 points, respectively. Mean (SD) baseline values for body mass index (BMI), EuroQol (EQ)-index, EQ-visual analogue scale were 25.4 (4.3), 0.60 (0.3), and 61.2 (20.8), respectively. Higher pain-related disability levels (1-year RMDQ score) were associated with 6.1 mmol/L or more fasting glucose level at baseline (β, 3.7; 95% confidence interval [CI], 1.2-6.1; P = 0.00), baseline pain-related disability (β 0.2; 95% CI, 0.1-0.4; P = 0.00), BMI (β, 0.2; 95% CI, 0.1-0.3; P < 0.03), EQ-index (β, -4.5; 95% CI, 6.9 to 2.1; P = 0.00), and EQ-visual analogue scale (β, 0.3; 95% CI, -0.6 to -0.0; P = 0.03). However, a limited number of patients had 6.1 mmol/L or more of fasting glucose level at baseline (13/250 patients). The imaging findings, modic changes, and high intensity zones had no predictive ability.

CONCLUSION

Increased pain-related disability at 1 year was seen in patients with impaired fasting glucose tolerance, greater pain-related disability, higher BMI, and lower quality of life at baseline.

Lumbar degenerative disc disease: current and future concepts of diagnosis and management

Low back pain as a result of degenerative disc disease imparts a large socioeconomic impact on the health care system. Traditional concepts for treatment of lumbar disc degeneration have aimed at symptomatic relief by limiting motion in the lumbar spine, but novel treatment strategies involving stem cells, growth factors, and gene therapy have the theoretical potential to prevent, slow, or even reverse disc degeneration. Understanding the pathophysiological basis of disc degeneration is essential for the development of treatment strategies that target the underlying mechanisms of disc degeneration rather than the downstream symptom of pain. Such strategies ideally aim to induce disc regeneration or to replace the degenerated disc. However, at present, treatment options for degenerative disc disease remain suboptimal, and development and outcomes of novel treatment options currently have to be considered unpredictable.

The association between peripheral artery and lumbar spine disease: a single-center study

BACKGROUND

While intermittent claudication is the hallmark of symptomatic peripheral artery disease, most patients with peripheral artery disease have atypical symptoms. The presence of lumbosacral spine disease, a common cause of nonvascular lower extremity pain, may confound the diagnosis of peripheral artery disease. The goal of this study was to quantify the prevalence of severe lumbar spine degenerative disease in patients referred for lower extremity arterial studies.

METHODS

All patients over age 18 years referred for segmental limb pressures and pulse volume recordings at rest and following treadmill exercise testing at a tertiary medical center accredited vascular diagnostic laboratory, who also underwent magnetic resonance imaging or computed tomography of the lumbar spine within 6 months of the arterial studies, were included in the analysis. Frequencies of peripheral artery disease and lumbar spine degenerative disease were determined, and medical records were reviewed for cardiovascular risk factors and prior vascular and spinal interventions.

RESULTS

One hundred seven subjects (63 men) with a mean age of 70 years (range 35-88 years) were included in the analysis. Lumbar spine disease was present in 81 (75.7%) of the patients referred for vascular testing. The percentage of lumbar spine disease was equivalent in both patients with exercise-induced deterioration in arterial pressure and in those with a physiologic response to exercise. Compared with patients with a normal response to exercise, patients with exercise-induced peripheral artery disease had a lower resting ankle-brachial index (mean 0.79 vs 1.09, P <.001), abnormal pulse volume recordings, and were less likely to use opiate analgesics and more likely to have undergone lower extremity revascularization.

CONCLUSIONS

Severe lumbar spine degenerative disease is widely prevalent in patients referred for lower extremity arterial studies. Our findings may help explain the high prevalence of atypical limb symptoms among peripheral artery disease patients.

Quantitative assessment of abdominal aortic calcification and associations with lumbar intervertebral disc height loss: the Framingham Study

BACKGROUND CONTEXT

Vascular disease has been proposed as a risk factor for disc height loss (DHL).

PURPOSE

To examine the relationship between quantitative measures of abdominal aortic calcifications (AACs) as a marker of vascular disease, and DHL, on computed tomography (CT).

STUDY DESIGN

Cross-sectional study in a community-based population.

PATIENT SAMPLE

Four hundred thirty-five participants from the Framingham Heart Study.

OUTCOME MEASURES

Quantitative AAC scores assessed by CT were grouped as tertiles of "no" (reference), "low," and "high" calcification. Disc height loss was evaluated on CT reformations using a four-grade scale. For analytic purposes, DHL was dichotomized as moderate DHL of at least one level at L2-S1 versus less than moderate or no DHL.

METHODS

We examined the association of AAC and DHL using logistic regression before and after adjusting for cardiovascular risk factors and before and after adjusting for age, sex, and body mass index (BMI).

RESULTS

In crude analyses, low AAC (odds ratio [OR], 2.05 [1.27-3.30]; p=.003) and high AAC (OR, 2.24 [1.38-3.62]; p=.001) were strongly associated with DHL, when compared with the reference group of no AAC. Diabetes, hypercholesterolemia, hypertension, and smoking were not associated with DHL and did not attenuate the observed relationship between AAC and DHL. Adjustment for age, sex, and BMI markedly attenuated the associations between DHL and low AAC (OR, 1.20 [0.69-2.09]; p=.51) and high AAC (OR, 0.74 [0.36-1.53]; p=.42).

CONCLUSIONS

Abdominal aortic calcification was associated with DHL in this community-based population. This relationship was independent of cardiovascular risk factors. However, the association of AAC with DHL was explained by the effects of age, sex, and BMI.

Structure and biology of the intervertebral disk in health and disease

The intervertebral disks along the spine provide motion and protection against mechanical loading. The 3 structural components, nucleus pulposus, annulus fibrosus, and cartilage endplate, function as a synergistic unit, though each has its own role. The cells within each of these components have distinct origins in development and morphology, producing specific extracellular matrix proteins that are organized into unique architectures fit for intervertebral disk function. This article focuses on various aspects of intervertebral disk biology and disruptions that could lead to diseases such as intervertebral disk degeneration.

Intervertebral disk nutrition: a review of factors influencing concentrations of nutrients and metabolites

The biomechanical behavior of the intervertebral disk ultimately depends on the viability and activity of a small population of resident cells that make and maintain the disk's extracellular matrix. Nutrients that support these cells are supplied by the blood vessels at the disks' margins and diffuse through the matrix of the avascular disk to the cells. This article reviews pathways of nutrient supply to these cells; examines factors that may interrupt these pathways, and discusses consequences for disk cell survival, disk degeneration, and disk repair.