Disc degeneration. Its frequency and relationship to symptoms

T1 mapping in patients with cervical spinal canal stenosis with and without decompressive surgery: A longitudinal study

BACKGROUND AND PURPOSE

Cervical spinal canal stenosis (cSCS) is a common cause of spinal impairment in the elderly. With conventional magnetic resonance imaging (MRI) suffering from various limitations, high-resolution single-shot T1 mapping has been proposed as a novel MRI technique in cSCS diagnosis. In this study, we investigated the effect of conservative and surgical treatment on spinal cord T1 relaxation times in cSCS.

METHODS

T1-mapping was performed in 54 patients with cSCS at 3 Tesla MRI at the maximum-, above and below the stenosis. Subsequently, intraindividual T1-differences (ΔT1) intrastenosis were calculated. Twenty-four patients received follow-up scans after 6 months.

RESULTS

Surgically treated patients showed higher ΔT1 at baseline (154.9 ± 81.6 vs. 95.3 ± 60.7), while absolute T1-values within the stenosis were comparable between groups (863.7 ± 89.3 milliseconds vs. 855.1 ± 62.2 milliseconds). In surgically treated patients, ΔT1 decreased inverse to stenosis severity. After 6 months, ΔT1 significantly decreased in the surgical group (154.9 ± 81.6 milliseconds to 85.7 ± 108.9 milliseconds, p = .021) and remained unchanged in conservatively treated patients. Both groups showed clinical improvement at the 6-month follow-up.

CONCLUSIONS

Baseline difference of T1 relaxation time (ΔT1) might serve as a supporting marker for treatment decision and change of T1 relaxation time might reflect relief of spinal cord narrowing indicating regenerative processes. Quantitative T1-mapping represents a promising additional imaging method to indicate a surgical treatment plan and to validate treatment success.

Cervical Vertebral Bone Quality Score Independently Predicts Distal Junctional Kyphosis After Posterior Cervical Fusion

BACKGROUND AND OBJECTIVE

Posterior cervical fusion is the surgery of choice when fusing long segments of the cervical spine. However, because of the limited presence of this pathology, there is a paucity of data in the literature about the postoperative complications of distal junctional kyphosis (DJK). We aimed to identify and report potential associations between the preoperative cervical vertebral bone quality (C-VBQ) score and the occurrence of DJK after posterior cervical fusion.

METHODS

The authors retrospectively reviewed records of patients who underwent posterior cervical fusion at a single hospital between June 1, 2010, and May 31, 2020. Patient data were screened to include patients who were >18 years old, had baseline MRI, had baseline standing cervical X-ray, had immediate postoperative standing cervical X-ray, and had clinical and radiographic follow-ups of >1 year, including a standing cervical X-ray at least 1 year postoperatively. Univariate analysis was completed between DJK and non-DJK groups, with multivariate regression completed for relevant clinical variables. Simple linear regression was completed to analyze correlation between the C-VBQ score and total degrees of kyphosis angle change.

RESULTS

Ninety-three patients were identified, of whom 19 (20.4%) had DJK and 74 (79.6%) did not. The DJK group had a significantly higher C-VBQ score than the non-DJK group (2.97 ± 0.40 vs 2.26 ± 0.46; P < .001). A significant, positive correlation was found between the C-VBQ score and the total degrees of kyphosis angle change (r 2 = 0.26; P < .001). On multivariate analysis, the C-VBQ score independently predicted DJK (odds ratio, 1.46; 95% CI, 1.27-1.67; P < .001).

CONCLUSION

We found that the C-VBQ score was an independent predictive factor of DJK after posterior cervical fusion.

The first experience with fully endoscopic posterior cervical foraminotomy and discectomy for radiculopathy performed in Viet Duc University Hospital

The aim of the article is to present the first experience of applying a full-endoscopic posterior cervical foraminotomy and discectomy performed at Viet Duc University Hospital in Hanoi and describe the outcomes of such surgical intervention. This surgical series includes 20 patients underwent surgery through full-endoscopic posterior cervical foraminotomy and discectomy. The definitive diagnosis of the patients and the evidence for surgical treatment was radiculopathy due to lateral or intraforaminal disk herniation, foraminal stenosis, and lateral recess stenosis. Patients with discogenic cervical radiculopathy but with a contraindication to endoscopic posterior cervical foraminotomy and discectomy were not subject to surgical intervention. All patients underwent a CT and MRT examination of the cervical spine before and after surgery as complementary diagnostic methods. Besides radiological diagnostic methods, electroneuromyography and spondylography were performed with functional samples, i.e., with head tilts in the front and back, to eliminate segmental instability. The timing and degree of the root pain syndrome regression were assessed using a VAS scale (visual and analog scale) with a subsequent comparison of preoperative and postoperative performance. Immediately after the operation, all patients noted a complete or nearly complete regression of the pain syndrome.

The Modic-endplate-complex phenotype in cervical spine patients: Association with symptoms and outcomes

This study describes a novel, combined Modic changes (MC) and structural endplate abnormality phenotype of the cervical spine, which we have termed the Modic-Endplate-Complex (MEC), and its association with preoperative symptoms and outcomes in anterior cervical discectomy and fusion (ACDF) patients. This was a retrospective study of prospectively collected data at a single institution. Preoperative cervical magnetic resonance imagings were used to assess the presence of MC and endplate abnormalities. Patients were divided into four groups: MC-only, endplate abnormality-only, the MEC and controls. The MEC was defined as the presence of both a MC and endplate abnormality in the cervical spine. Phenotypes were further stratified by location and compared to controls. Associations with patient-reported outcome measures were assessed using regression controlling for baseline characteristics. A total of 628 patients were included, with 84 MC-only, 166 endplate abnormality-only, and 187 MEC patients. Both MC (p < 0.001) and endplate abnormalities (p < 0.001) were independently associated with one another. MC at the adjacent level (p = 0.018), endplate abnormalities (regardless of location) (p = 0.001), and the MEC within the fusion segment (p = 0.027) were all associated with higher Neck Disability Index scores. Both MC within the fusion segment (p = 0.008) and endplate abnormalities within the fusion segment (p = 0.017) associated with lower Veteran's Rand 12-item scores. MC and structural endplate abnormalities commonly manifest concomitantly in patients indicated for ACDF for degenerative pathology. Patients with the endplate pathology, including the MEC phenotype, reported significantly higher levels of postoperative disability following ACDF. These findings add valuable data to the prognostic assessment of degenerative cervical spine patients.

Cervical disc degeneration: important considerations for the manual therapist

Cervical disc degeneration (CDD) is a progressive, age-related occurrence that is frequently associated with neck pain and radiculopathy. Consistent with the majority of published clinical practice guidelines (CPG) for neck pain, the 2017 American Physical Therapy Association Neck Pain CPG recommends cervical manipulation as an intervention to address acute, subacute, and chronic symptoms in the 'Neck Pain With Mobility Deficits' category as well for individuals with 'Chronic Neck Pain With Radiating Pain'. While CPGs are evidence-informed statements intended to help optimize care while considering the relative risks and benefits, these guidelines generally do not discuss the mechanical consequences of underlying cervical pathology nor do they recommend specific manipulation techniques, with selection left to the practitioner's discretion. From a biomechanical perspective, disc degeneration represents the loss of structural integrity/failure of the intervertebral disc. The sequelae of CDD include posterior neck pain, segmental hypermobility/instability, radicular symptoms, myelopathic disturbance, and potential vascular compromise. In this narrative review, we consider the mechanical, neurological, and vascular consequences of CDD, including information on the anatomy of the cervical disc and the mechanics of discogenic instability, the anatomic and mechanical basis of radiculitis, radiculopathy, changes to the intervertebral foramen, the importance of Modic changes, and the effect of spondylotic hypertrophy on the central spinal canal, spinal cord, and vertebral artery. The pathoanatomical and biomechanical consequences of CDD are discussed, along with suggestions which may enhance patient safety.

Reoperations after fusion surgeries for degenerative spinal diseases depending on cervical and lumbar regions: a national database study

BACKGROUND

Reoperation is one of the key factors affecting postoperative clinical outcomes. The reoperation rates of cervical surgeries might be different from those of lumbar surgeries due to the anatomical and biomechanical differences. However, there has been no study to compare the reoperation rate between them. The purpose is to compare reoperation rates after fusion surgeries for degenerative spinal diseases depending on the anatomic region of cervical and lumbar spines.

METHOD

We used the Korean Health Insurance Review & Assessment Service national database. Subjects were included if they had any of the primary procedures of fusion combined with the procedure of decompression procedures under the diagnosis of degenerative diseases (n = 42,060). We assigned the patients into two groups based on anatomical regions: cervical and lumbar fusion group (n = 11,784 vs 30,276). The primary endpoint of reoperation was the repeat of any aforementioned fusion procedures. Age, gender, presence of diabetes, associated comorbidities, and hospital types were considered potential confounding factors.

RESULTS

The reoperation rate was higher in the patients who underwent lumbar fusion surgery than in the patients who underwent cervical fusion surgery during the entire follow up period (p = 0.0275). A similar pattern was found during the late period (p = 0.0468). However, in the early period, there was no difference in reoperation rates between the two groups. Associated comorbidities and hospital type were noted to be risk factors for reoperation.

CONCLUSIONS

The incidence of reoperation was higher in the patients who underwent lumbar fusion surgery than those who underwent cervical fusion surgery for degenerative spinal diseases.

Longitudinal characterization of intervertebral disc remodeling following acute annular injury in a rat model of degenerative disc disease

Objective: Characterize 3D remodeling of the rat intervertebral disc (IVD) following acute annular injury via in vivo micro-computed tomography (µCT), ex vivo contrast-enhanced (CE)-µCT, and histology. Design: Female Lewis rats (N = 4/group) underwent either sham surgery or anterior annular puncture to L3-L4 and L5-L6 (n = 8 IVDs/group) to induce IVD degeneration. Rats were allowed ad libidum cage activity before and after surgery and underwent in vivo µCT scanning at baseline and every 2 weeks post-op for 12 weeks to characterize longitudinal changes in IVD height. At 12 weeks, lumbar spines were dissected and underwent CE-µCT scanning to characterize endpoint glycosaminoglycan distribution and nucleus pulposus (NP) volume ratio. Spines were processed for safranin-O-stained sagittal histology, and IVD degeneration was graded via the Rutges scale. Results: Puncture IVDs exhibited loss of IVD height at all time points from 4 weeks onward compared to Sham-the most severe height loss occurred posteriorly, with significant changes also occurring in the NP and laterally. Puncture IVDs exhibited higher CE-µCT attenuation, indicative of lower glycosaminoglycan content, and reduced NP volume ratio compared to Sham. Histologically, Puncture IVDs had higher Rutges damage scores and exhibited reduced NP cellularity and hydration, disorganized annulus fibrosus (AF) lamellae with evidence of the stab tract, and indistinct AF-NP border compared to Sham. Conclusions: Characterization of the complex, 3D alterations involved in the onset and early progression of IVD degeneration can foster greater understanding of the pathoetiology of IVD degeneration and may inform future studies assessing more sensitive diagnostic techniques or novel therapies.

Radiographic cervical spine degenerative findings: a study on a large population from age 18 to 97 years

Purpose

The aims of this study were (1) to determine the prevalence of radiographic cervical disc degeneration in a large population of patients aged from 18 to 97 years; (2) to investigate individually the prevalence and distribution of height loss, osteophyte formation, endplate sclerosis and spondylolisthesis; and (3) to describe the patterns of cervical disc degeneration.

Methods

A retrospective study was performed. Standard lateral cervical spine radiographs in standing, neutral position of 1581 consecutive patients (723 males, 858 females) with an average age of 41.2 ± 18.2 years were evaluated. Cervical disc degeneration was graded from C2/C3 to C6/C7 based on a validated quantitative grading system. The prevalence and distribution of radiographic findings were evaluated and associations with age were investigated.

Results

53.9% of individuals had radiographic disc degeneration and the most affected level was C5/C6. The presence and severity of disc degeneration were found to be significantly associated with age both in male and female subjects. The most frequent and severe occurrences of height loss, osteophyte formation, and endplate sclerosis were at C5/C6, whereas spondylolisthesis was most observed at C4/C5. Age was significantly correlated with radiographic degenerative findings. Contiguous levels degeneration pattern was more likely found than skipped level degeneration. The number of degenerated levels was also associated with age.

Conclusions

The presence and severity of radiographic disc degeneration increased with aging in the cervical spine. Older age was associated with greater number of degenerated disc levels. Furthermore, the correlations between age and the degree of degenerative findings were stronger at C5/C6 and C6/C7 than at other cervical spinal levels.

The outcomes of stand alone polyetheretherketone cages in anterior cervical discectomy and fusion

The procedure of anterior cervical discectomy and fusion is considered as the treatment of choice in degenerative disc disease, which material provides the best clinical and radiological fusion and other outcomes remains heavily debated. Materials that augment the process of fusion consist of bone grafting, titanium, polyetheretherketone (PEEK), or carbon cages. The application of PEEK cages has been recommended as it is radiolucent, and it has a modulus of elasticity that is similar to cortical bone. PEEK cages can be either filled with various materials or unfilled cages. Filled PEEK cages can include bone autografts, bone allografts, demineralized bone matrix, and other materials that facilitate fusion. This narrative review highlights that standalone filled PEEK cages were likely to have better radiological outcomes and satisfactory clinical outcomes for myelopathy when compared with standalone unfilled PEEK cages.

The role of estrogen in intervertebral disc degeneration

Intervertebral disc degeneration (IVDD) is a main contributor to low back and radicular pain, which imposes heavy economic burdens on society. However, the etiology and mechanism of IVDD are complex and still not completely clear. In particular, the role of estrogen in IVDD has not received much attention in recent research, although estrogen plays a crucial role in the metabolic dysfunction of others musculoskeletal structures, such as bone, muscle, and tendon. In this review, we attempt to describe the role of estrogen in IVDD and to summarize the proposed mechanisms in vivo and in vitro, as well as, to outline several interesting questions in this field.

Degenerative Cervical Myelopathy in Higher-Aged Patients: How Do They Benefit from Surgery?

Background: Degenerative cervical myelopathy (DCM) is the most common reason for spinal cord disease in elderly patients. This study analyzes the preoperative status and postoperative outcome of higher-aged patients in comparison to young and elderly patients in order to determine the benefit to those patients from DCM surgery. Methods: A retrospective analysis of the clinical data, radiological findings, and operative reports of 411 patients treated surgically between 2007 and 2016 suffering from DCM was performed. The preoperative and postoperative neurological functions were evaluated using the modified Japanese Orthopedic Association Score (mJOA Score), the postoperative mJOA Score improvement, the neurological recovery rate (NRR) of the mJOA Score, and the minimum clinically important difference (MCID). The Charlson Comorbidity Index (CCI) was used to evaluate the impact of comorbidities on the preoperative and postoperative mJOA Score. The comparisons were performed between the following age groups: G1: ≤50 years, G2: 51–70 years, and G3: >70 years. Results: The preoperative and postoperative mJOA Score was significantly lower in G3 than in G2 and G1 (p < 0.0001). However, the mean mJOA Score’s improvement did not differ significantly (p = 0.81) between those groups six months after surgery (G1: 1.99 ± 1.04, G2: 2.01 ± 1.04, G: 2.00 ± 0.91). Furthermore, the MCID showed a significant improvement in every age-group. The CCI was evaluated for each age-group, showing a statistically significant group effect (p < 0.0001). Analysis of variance revealed a significant group effect on the delay (weeks) between symptom onset and surgery (p = 0.003). The duration of the stay at the hospital did differ significantly between the age groups (p < 0.0001). Conclusion: Preoperative and postoperative mJOA Scores, but not the extent of postoperative improvement, are affected by the patients’ age. Therefore, patients should be considered for DCM surgery regardless of their age.

Evaluation of a Cost-Effective Novel Diagnostic Method for Lumbar Herniated Disc with Knee-Osteoarthritis: A Randomized Sample Study

The aim of this study was to determine a cost-effective diagnostic method for lumbar herniated disc with knee osteoarthritis (LHD-KOA) based on aberrant outcome measures, levels of biomarkers, and examination of the lower-extremity. Data were separately analyzed for each cohort suffering with LHD-KOA (n=108; 59.82±7.15years) and without LHD-KOA (n=108; 58.81±7.61years), and findings were confirmed with radiological images. The aberrant-leg-features (bilateral: knee gaps between the short head of biceps femoris and the surface of the bed, diameters of calves and thighs, angles of straight leg raising, knee-flexion and -extension in a supine position) and biochemical parameters (Interleukin-10, Tumor necrosis factor-alpha, C-reactive protein, creatine kinase-muscle, and Aldolase-A), and outcome measures, Western Ontario and McMaster Universities osteoarthritis index (WOMAC), knee-injury osteoarthritis outcomes scale (KOOS), Oswestry disability index (ODI), and body mass index (BMI)for participants with and without LHD-KOA were evaluated with appropriate techniques. All the subjects underwent standardized physical examination and completed a questionnaire. The risk ratios and mean± standard deviations of biomarkers, anatomical features, and outcome measures of the experimental subjects were highly significant compared to controls (p<0.0001). Results suggest that monitoring the studied aberrant outcome measures, biomarkers, and lower-anatomical features may be a cost-effective diagnostic tool for LHD-KOA. Further research is recommended for an alternative treatment protocol for LHD-KOA.

Quantification of spinal cord compression using T1 mapping in patients with cervical spinal canal stenosis - Preliminary experience

Background

Degenerative changes of the cervical spinal column are the most common cause of spinal cord lesions in the elderly. Conventional clinical, electrophysiological and radiological diagnostics of spinal cord compression are often inconsistent.

Materials and methods

The feasibility and diagnostic potential of a novel T1 mapping method at 0.5 mm resolution and 4 s acquisition time was evaluated in 14 patients with degenerative cervical spinal canal stenosis (SCS) and 6 healthy controls. T1 mapping was performed in axial sections of the stenosis as well as above and below. All subjects received standard T2-weighted MRI of the cervical spine (including SCS-grading 0-III), electrophysiological and clinical examinations.

Results

Patients revealed significantly decreased T1 relaxation times of the compressed spinal cord within the SCS (912 ± 53 ms, mean ± standard deviation) in comparison to unaffected segments above (1027 ± 39 ms, p < .001) and below (1056 ± 93 ms, p < .001). There was no difference in mean T1 in unaffected segments in patients (p = .712) or between segments in controls (p = .443). Moreover, T1 values were significantly lower in grade II (881 ± 46 ms, p = .005) than in grade I SCS (954 ± 29 ms). Patients with central conduction deficit tended to have lower T1 values within the SCS than patients without (909 ± 50 ms vs 968 ± 7 ms, p = .069).

Conclusion

Rapid high-resolution T1 mapping is a robust MRI method for quantifying spinal cord compression in patients with cervical SCS. It promises additional diagnostic insights and warrants more extended patient studies.

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Rapid T1 mapping at 0.5 mm resolution was tested in cervical spinal canal stenosis (SCS).

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T1 relaxation times significantly decreased within the SCS.

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T1 relaxation times were significantly lower in grade II vs grade I SCS.

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Central conduction deficits were inversely correlated with T1 relaxation time.

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Rapid T1 mapping robustly and accurately quantifies spinal cord compression.

A longitudinal study of disc height narrowing and facet joint osteoarthritis at the thoracic and lumbar spine, evaluated by computed tomography: the Framingham Study

BACKGROUND CONTEXT

Prevalence and progression of disc height narrowing (DHN) and facet joint osteoarthritis (FJOA) in the thoracic and lumbar regions in non-clinical populations are not well established.

PURPOSE

The present study aimed to use computed tomography (CT) images to determine the prevalence and progression of DHN and FJOA according to age, sex, and spinal region.

STUDY DESIGN

This is a 6-year longitudinal study.

SAMPLE

A total of 1,195 members of the Framingham Study (mean baseline age 61±9 years) were included in the study.

OUTCOME MEASURES

We compared the prevalence and progression (new or worsening) of moderate-to-severe DHN and FJOA by age, sex, and spinal region.

METHODS

A musculoskeletal radiologist evaluated DHN and FJOA from T4/T5 to L4/L5 on baseline and follow-up CT images using a semi-quantitative scale: 0=normal, 1=mild, 2=moderate, and 3=severe.

RESULTS

One-third or more of women and men ages 40-59 years at baseline had imaged-based evidence of prevalent DHN, more than half had prevalent FJOA, and DHN and FJOA prevalence increased approximately two- to fourfold in those age 60-69 and 70-89 years at baseline, respectively (p<.01). Progression of DHN and FJOA occurred more frequently at the lumbar than at the thoracic spine and more in women than in men (DHN: odds ratio [OR]=1.42, 95% confidence interval [CI]=1.07, 1.88; FJOA: OR=1.70, CI=1.33, 2.17).

CONCLUSIONS

Prevalence and progression of moderate-to-severe DHN and FJOA are common in non-clinical populations of older adults. The high frequency of spinal degeneration observed on CTs in this community-based study may contribute to challenges in interpreting the clinical significance of imaging evidence of DHN and FJOA. Future studies investigating the association of CT-based spinal degenerative features with pain and functional impairments in population-based samples are needed to help determine the clinical significance of imaged-based findings of DHN and FJOA.

CERVICAL ENDOSCOPIC DISC SURGERY: PRECISE APPROACH FOR MINIMALLY INVASIVE DECOMPRESSION

ABSTRACT Objective: Technological advances in recent decades have led to a complexity of choice of the most effective method for treating cervical disc herniations. The idea of removing disc herniations using endoscope techniques is not new, and is successfully used in the treatment of lumbar disc herniations. But in the case of the cervical spine, full endoscopic procedures only started to be performed at the beginning of 2014, by Yang JS and coauthors, and their effectiveness was and still is a matter of controversy. The proposed method of endoscopic portal disc herniation removal was used for the past two years, and its results were compared with the anterior microsurgical approach using a single-level cage implantation. Methods: Twenty-five patients were included in this study, with a comparator group of 25 patients operated by ordinary anterior cervical discectomy with a single-disc fusion. All patients were operated on by the same group of surgeons. Results: During the analysis of VAS data, it was confirmed that the degree of local and radicular pain in the two groups was not significantly different (p > 0.05). According to the Neck Disability Index (NDI) there was a significant difference between the two groups in relation to the endoscopic patient group. Data using the Odom criteria showed significantly better results for the endoscopic group. During the research it was observed that the patients in the endoscopically operated group were discharged from hospital more quickly, after 3 [2; 5] days compared to 5 [4; 6] days in the microsurgery group. Conclusion: The method performed is a safe and reliable alternative to convenient surgical techniques. Level of Evidenced II; Therapeutic study, investigating the results of treatment.

Managing the Complex Patient with Degenerative Cervical Myelopathy: How to Handle the Aging Spine, the Obese Patient, and Individuals with Medical Comorbidities

Degenerative cervical myelopathy (DCM) is the most common cause of nontraumatic spinal cord injury worldwide. Even relatively mild impairment in functional scores can significantly impact daily activities. Surgery is an effective treatment for DCM, but outcomes are dependent on more than technique and preoperative neurologic deficits.

EFFICACY OF CAGE PLACEMENT WITHOUT PLATE IN PATIENTS WITH CERVICAL MYELOPATHY WITH SINGLE-LEVEL AFFECTION

ABSTRACT Objective: To determine the efficacy of PEEK (Poly-ether-ether-ketone) cage without plate for the treatment of single-level cervical spondylosis. Methods: Ten patients with cervical myelopathy data, with a single-level root condition, seen at the outpatient clinic of the Neurosurgery Service, operated in 2016, mean age 53 years, 6 (60%) female, 4 (40%) obese, 3 (30%) smokers. The Cloward technique was used by anterior approach, discectomy, and PEEK cage placement. Results: At six months of surgery, 100% of the patients had increased intervertebral space, with a 100% reduction in osteophytes; only one patient had dysphagia, no patient had lesion of the adjacent segment and 10% had persistent root pathology. Cervical lordosis was observed in 90% of the patients and arthrodesis in 100% of the cases. Conclusions: Anterior approach arthrodesis using PEEK cage without cervical plate is effective as a treatment of cervical myelopathy in a single level.

Clinical features and surgical outcomes of cervical spondylotic myelopathy in patients of different ages: a retrospective study

STUDY DESIGN

Retrospective chart audit.

OBJECTIVES

This study aims to compare the clinical features and surgical outcomes in patients with cervical spondylotic myelopathy (CSM) among different age groups.

SETTING

The first Affiliated Hospital of Anhui Medical University, China.

METHODS

A total of 460 patients with CSM who were surgically treated over the period of 1995-2009 were investigated. Considering the peak age (40-60 years old) for the onset of symptoms, we divided the patients into three groups by age: young (<40), middle-aged (40-60), and old (>60). The differences in symptoms, symptom durations, involved levels, surgical approaches and outcomes were evaluated.

RESULTS

The number of symptoms and involved levels, symptom duration and posterior approach significantly increased with increasing age, whereas preoperative Japanese Orthopedic Association score decreased among the three groups. Spinal cord function improved after surgery in all groups. The highest degree of recovery occurred during the first 6 months after surgery, especially within the first week, and then reached a plateau. After 6 months, however, recovery continuously improved, stabilized and declined in the young, middle-aged, old groups, respectively. The recovery rate was not significantly different at an immediate period (1 week) after operation among the three groups, but was significantly different at later periods (3 or more months postoperatively). Three groups showed no difference in postoperative complication rates.

CONCLUSION

The severity of CSM increased with increasing age. Age was inversely correlated with recovery, and recovery decreased as age increased. Six months post operation was the prime time for the recovery of spinal cord function.

[The first experience with a new technique of portal endoscopic discectomy for herniated cervical discs]

Choosing the most appropriate tactics for surgical treatment of herniated cervical discs is a topical issue to be discussed. The idea of herniated disc removal using an endoscopic technique is not new. This is routine surgery for the lumbar spine. However, application of endoscopic techniques in surgery on the cervical spine was first reported only in 2014 (J. Yang, et al.).

OBJECTIVE

To master the methodology of a new technique, portal endoscopic discectomy, and define the indications for this surgery on herniated cervical discs; to compare outcomes of this surgery with outcomes of anterior microsurgical discectomy.

MATERIAL AND METHODS

The study included 25 patients who underwent portal endoscopic cervical discectomy. A comparison group consisted of 25 patients who underwent anterior microsurgical discectomy and placement of an interbody cage.

RESULTS

A comparison of the results of surgeries revealed no significant difference (p>0.05) in the degree of postoperative local and radicular pain syndrome. According to the Neck Disability Index (NDI), a significant improvement occurred in patients with endoscopic surgery. According to the Odom criterion, a significant advantage in the number of excellent and good outcomes occurred in patients of the study group. There were significant differences between groups in the duration of postoperative hospital stay. The duration was 3 days in the study group and 5 days in the control group, on average.

CONCLUSION

Portal endoscopic discectomy is highly efficient in treatment of herniated cervical discs and enables achieving clinical outcomes associated with much less surgical trauma. The study demonstrates not only the efficacy of the suggested technique but also its safety compared to that of traditional anterior microsurgical techniques that usually involve interbody fusion. This surgery surpasses other interventions in the rate of rehabilitation and social adaptation of patients as well as reduces postoperative hospital stay.

Sagittal spinopelvic alignment predicts hip function after total hip arthroplasty

The aim of this study was to investigate the association between preoperative sagittal spinopelvic alignment and postoperative clinical outcomes after total hip arthroplasty (THA). This retrospective study included 92 patients with hip osteoarthritis who underwent primary THA between May 2013 and October 2015. Patients' characteristics, radiographic sagittal spinopelvic parameters and modified Harris Hip Scores, including function scores (gait scores and functional activities scores), were investigated. Multivariate linear regression analysis was performed to determine the associations between each preoperative sagittal spinopelvic parameter and postoperative hip function The preoperative sagittal spinopelvic parameters that were associated with postoperative gait scores were sagittal vertical axis (adjusted β-coefficient=-0.28, P=0.02), lumbar lordosis angle (adjusted β-coefficient=0.29, P=0.0089), pelvic tilt (adjusted β-coefficient=-0.25, P=0.045), sacral slope (adjusted β-coefficient=0.27, P=0.017) and pelvic incidence minus lumbar lordosis angle (adjusted β-coefficient=-0.31, P=0.01). The preoperative sagittal spinopelvic parameters that were related to the postoperative functional activities scores were sagittal vertical axis (adjusted β-coefficient=-0.38, P=0.0051) and pelvic incidence minus lumbar lordosis angle (adjusted β-coefficient=-0.39, P=0.0033). Patients with preoperative imbalanced sagittal alignment such as larger sagittal vertical axis, larger pelvic incidence minus lumbar lordosis and retroversion of pelvis had poorer clinical outcomes than others after THA. While, those preoperative imbalanced patients with anteversion of pelvis may have a compensatory ability which could correct the abnormal sagittal alignment after THA. Preoperative sagittal spinopelvic alignment affected postoperative clinical outcomes after THA.

Classification of neck/shoulder pain in epidemiological research: a comparison of personal and occupational characteristics, disability, and prognosis among 12,195 workers from 18 countries

To inform case definition for neck/shoulder pain in epidemiological research, we compared levels of disability, patterns of association, and prognosis for pain that was limited to the neck or shoulders (LNSP) and more generalised musculoskeletal pain that involved the neck or shoulder(s) (GPNS). Baseline data on musculoskeletal pain, disability, and potential correlates were collected by questionnaire from 12,195 workers in 47 occupational groups (mostly office workers, nurses, and manual workers) in 18 countries (response rate = 70%). Continuing pain after a mean interval of 14 months was ascertained through a follow-up questionnaire in 9150 workers from 45 occupational groups. Associations with personal and occupational factors were assessed by Poisson regression and summarised by prevalence rate ratios (PRRs). The 1-month prevalence of GPNS at baseline was much greater than that of LNSP (35.1% vs 5.6%), and it tended to be more troublesome and disabling. Unlike LNSP, the prevalence of GPNS increased with age. Moreover, it showed significantly stronger associations with somatising tendency (PRR 1.6 vs 1.3) and poor mental health (PRR 1.3 vs 1.1); greater variation between the occupational groups studied (prevalence ranging from 0% to 67.6%) that correlated poorly with the variation in LNSP; and was more persistent at follow-up (72.1% vs 61.7%). Our findings highlight important epidemiological distinctions between subcategories of neck/shoulder pain. In future epidemiological research that bases case definitions on symptoms, it would be useful to distinguish pain that is localised to the neck or shoulder from more generalised pain that happens to involve the neck/shoulder region.

Menopause as a potential cause for higher prevalence of low back pain in women than in age-matched men

Female sex hormones play an important role in the aetiology and pathophysiology of a variety of musculoskeletal degenerative diseases. Postmenopausal women show accelerated disc degeneration due to relative oestrogen deficiency, resulting in narrower intervertebral disc space in women than age-matched men, increased prevalence of spondylolisthesis, and increased prevalence of facet joint osteoarthritis. Postmenopausal women also show higher osteoporosis related spine fracture rate, particularly at the thoracic-lumbar junction site. I propose the concept that low back pain (LBP) is more prevalent in postmenopausal women than age-matched men and is associated with the physiological changes caused by the relatively lower level of sex hormones after menopause in women. Considering hormone replacement treatment (HRT)'s consistent efficacy reported with menopause-associated osteoarthritis, an in-depth understanding of the role of the gonadal hormones in LBP modulation warrants further study. HRT initiated at early postmenopausal phase may be protective for recurring LBP. If this is the case, further cost-benefit analysis should be performed for optimal HRT regimen in cases of women with high risk of recurring severe LBP.

Prevalence of lumbar spondylosis and its association with low back pain among community-dwelling Japanese women

Background

Lumbar spondylosis is more prevalent among the middle-aged and elderly, but few population-based studies have been conducted, especially in Japan. The purpose of this study was to explore the prevalence of lumbar spondylosis and its associations with low back pain among community-dwelling Japanese women.

Methods

Lateral radiographs of the lumbar spine were obtained from 490 Japanese women ≥ 40 years old, and scored for lumbar spondylosis using the Kellgren-Lawrence (KL) grade at lumbar intervertebral level from L1/2 to L5/S1. Height and weight were measured, and body mass index (BMI) was calculated. Low back pain in subjects was assessed using a self-administered questionnaire. Stiffness index (bone mass) was measured at the calcaneal bone using quantitative ultrasound.

Results

Prevalence of radiographic lumbar spondylosis for KL ≥ 2, KL ≥ 3 and low back pain were 76.7%, 38.8% and 20.0%, respectively. Age was positively associated with radiographic lumbar spondylosis (KL = 2, KL ≥ 3) and low back pain. Greater BMI was associated with lumbar spondylosis with KL = 2, but not with KL ≥ 3. Stiffness index was associated with neither radiographic lumbar spondylosis nor low back pain. Multiple logistic regression analysis identified radiographic lumbar spondylosis (KL ≥ 3) at L3/4, L4/5 and L5/S1 was associated with low back pain, independent of age, BMI and stiffness index.

Conclusion

Severe lumbar spondylosis at the middle or lower level may contribute to low back pain.

Age-Related Incidence of Cervical Spondylosis in Residents of Jeju Island

Study Design

Cervical spine radiograms of 460 Jeju islanders.

Purpose

To investigate the age-matched incidences and severity of the cervical disc degeneration and associated pathologic findings.

Overview of Literature

Several related studies on the incidences of disc and Luschka's and facet joint degeneration have provided some basic data for clinicians.

Methods

Cervical radiographs of 460 (220 males and 240 females) patients in their fourth to ninth decade were analyzed. Ninety patients in their third decade were excluded because of absence of spondylotic findings.

Results

Overall incidence of cervical spondylosis was 47.8% (220 of 460 patients). The percentile incidences of spondylosis in the fourth, fifth, sixth, seventh, eighth and ninth decade was 13.2% (10 of 76 patients), 34.6% (37 of 107 patients), 58.9% (66 of 112 patients), 58.8% (50 of 85 patients), 70.3% (45 of 64 patients) and 75.0% (12 of 16 patients), respectively. The percentile incidences of one, two, three, four and five level spondylosis among 220 spondylosis patients was 45.5% (n=100), 34.1% (n=75), 15.0% (n=33), 4.5% (n=10), and 0.9% (n=2). Severity of disc degeneration ranged from ± to ++++, and was ± in 6.0% (24 segments), + in 49.6% (198 segments), ++ in 35.3% (141 segments), +++ in 9.0% (36 segments) and ++++ in 0.25% (one segment). Spurs and anterior ligament ossicle formed at the spondylotic segments, mostly at C4~6. The rate of posterior corporal spurs formation was very low. Olisthesis and ossification of the posterior longitudinal ligament were rarely combined with spondylosis. Cervical lordotic curve decreased gradually according to the progress of severity of spondylosis.

Conclusions

The incidence of cervical spondylosis and number of spondylotic segments increase, and degeneration gradually becomes more severe with age.

Influence of occupation on lumbar spine degeneration in men: the Korean National Health and Nutrition Examination Survey 2010-2013

PURPOSE

Certain lifetime occupations can influence lumbar spine degeneration (LSD). The authors investigated the association between various types of occupations and LSD using a nationwide survey.

METHODS

Data were obtained from the 2010 to 2013 Korea National Health and Nutrition Examination Survey (KNHANES). Types of lifetime occupation were categorized into four occupational groups: white-collar (WC) workers, pink-collar (PC) workers, blue-collar (BC) workers, and agribusiness and low-level (AL) workers. LSD was evaluated using a modified version of the Kellgren-Lawrence grade.

RESULTS

The results showed that the type of occupation was associated with increased risk of LSD. The risk of LSD increased in BC workers (adjusted OR 1.492; 95 % CI 1.13, 1.98) and AL workers (adjusted OR 2.539; 95 % CI 1.75, 3.68). The risk of severe LSD increased in BC workers (adjusted OR 1.734; 95 % CI 0.78, 1.98) and AL workers (adjusted OR 3.058; 95 % CI 1.96, 4.77). The risk of LBP tended to increase in AL workers (adjusted OR 1.380; 95 % CI 1.00, 1.90).

CONCLUSIONS

Our results suggest that LSD is influenced by the lifetime occupation: WC workers are least affected by LSD, and AL workers are at greatest risk of LSD.

Surgical outcomes of elderly patients with cervical spondylotic myelopathy: a meta-analysis of studies reporting on 2868 patients

OBJECTIVE

Cervical spondylotic myelopathy usually presents in the 5th decade of life or later but can also present earlier in patients with congenital spinal stenosis. As life expectancy continues to increase in the United States, the preconceived reluctance toward operating on the elderly population based on older publications must be rethought. It is a known fact that outcomes in the elderly cannot be as robust as those in the younger population. There are no publications with detailed meta-analyses to determine an acceptable level of outcome in this population. In this review, the authors compare elderly patients older than 75 years to a nonelderly population, and they discuss some of the relevant strategies to minimize complications.

METHODS

In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the authors performed a PubMed database search to identify English-language literature published between 1995 and 2015. Combinations of the following phrases that describe the age group (“elderly,” “non-elderly,” “old,” “age”) and the disease of interest as well as management (“surgical outcome,” “surgery,” “cervical spondylotic myelopathy,” “cervical degenerative myelopathy”) were constructed when searching for relevant articles. Two reviewers independently assessed the outcomes, and any disagreement was discussed with the first author until it was resolved. A random-effects model was applied to assess pooled data due to high heterogeneity between studies. The mean difference (MD) and odds ratio were calculated for continuous and dichromatic parameters, respectively.

RESULTS

Eighteen studies comprising elderly (n = 1169) and nonelderly (n = 1699) patients who received surgical treatment for cervical spondylotic myelopathy were included in this meta-analysis. Of these studies, 5 were prospective and 13 were retrospective. Intraoperatively, both groups required a similar amount of operation time (p = 0.35). The elderly group had lower Japanese Orthopaedic Association (JOA) scores (MD −1.36, 95% CI −1.62 to −1.09; p < 0.00001) to begin with compared with the nonelderly group. The nonelderly group also had a higher postoperative JOA score (MD −1.11, 95% CI −1.44 to −0.79; p < 0.00001), therefore demonstrating a higher recovery rate from surgeries (MD −11.98, 95% CI −16.16 to −7.79; p < 0.00001). The length of stay (MD 4.14, 95% CI 3.54–4.73; p < 0.00001) was slightly longer in the elderly group. In terms of radiological outcomes, the elderly group had a smaller postoperative Cobb angle but a greater increase in spinal canal diameter compared with the nonelderly group. The complication rates were not significant.

CONCLUSIONS

Cervical myelopathy is a disease of the elderly, and age is an independent factor for recovery from surgery. Postoperative and long-term outcomes have been remarkable in terms of improvement in mobility and independence requiring reduced nursing care. There is definitely a higher potential risk while operating on the elderly population, but no significant difference in the incidence of postoperative complications was noted. Withholding surgery from the elderly population can lead to increased morbidity due to rapid progression of symptoms in addition to deconditioning from lack of mobility and independence. Reduction in operative time under anesthesia, lower blood loss, and perioperative fluid management have been shown to minimize the complication rate. The authors request that neurosurgeons weigh the potential benefit against the risks for every patient before withholding surgery from elderly patients.

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.

Shoulder disorders and occupation

Shoulder pain is very common, and it causes substantial morbidity. Standardised classification systems based upon presumed patho-anatomical origins have proved poorly reproducible and hampered epidemiological research. Despite this, there is evidence that exposure to combinations of physical workplace strains such as overhead working, heavy lifting and forceful work as well as working in an awkward posture increases the risk of shoulder disorders. Psychosocial risk factors are also associated. There is currently little evidence to suggest that either primary prevention or treatment strategies in the workplace are very effective, and more research is required, particularly around the cost-effectiveness of different strategies.

WITHDRAWN: Medicinal and injection therapies for mechanical neck disorders

Withdrawn due to non‐compliance with The Cochrane Collaboration’s Commercial Sponsorship Policy

The editorial group responsible for this previously published document have withdrawn it from publication.

The design evolution of interbody cages in anterior cervical discectomy and fusion: a systematic review

BACKGROUND

Anterior cervical discectomy with fusion is a common surgical procedure for patients experiencing pain and/or neurological deficits due to cervical spondylosis. Although iliac crest bone graft remains the gold standard today, the associated morbidity has inspired the search for alternatives, including allograft, synthetic and factor/cell-based grafts; and has further led to a focus on cage fusion technology. Compared to their graft counterparts, cage interbody implants have enhanced biomechanical properties, with designs constantly improving to maximise biocompatibility and osseointegration. We present a systematic review examining the historical progress of implant designs and performance, as well as an update on the currently available designs, and the potential future of cervical interbody implants.

METHODS

We performed a systematic review using the keywords "cervical fusion implant design", with no limits on year of publication. Databases used were PubMed, Medline, Embase and Cochrane. In addition, the search was extended to the reference lists of selected articles.

RESULTS

180 articles were reviewed and 64 articles were eligible for inclusion. Exclusion criteria were based around study design, implant information and patient cohorts. The evolution of cage implant design has been shaped by improved understanding of ideal anatomy, progress in materials research and continuing experimentation of structural design. Originally, designs varied primarily in their choice of structure, however long-term studies have displayed the overall advantages of non-threaded, wedge shaped cages in complementing healthy anatomical profiles, and thus focus has shifted to refining material utilisation and streamlining anterior fixation.

CONCLUSIONS

Evolution of design has been dramatic over the past decades; however an ideal cage design has yet to be realised. Current research is focusing on the promotion of osseointegration through bioactiviation of surface materials, as well as streamlining anterior fixation with the introduction of integrated screws and zero profile designs. Future designs will benefit from a combination of these advances in order to achieve ideal disc heights, cervical alignments and fusions.

Effect of anterior cervical osteophyte in poststroke dysphagia: a case-control study

OBJECTIVE

To investigate whether the concomitant presence of anterior cervical osteophytes can influence the severity and outcome of patients with poststroke dysphagia.

DESIGN

Retrospective case-control study.

SETTING

Hospital.

PARTICIPANTS

A total of 40 participants were identified (N=40). Patients with poststroke dysphagia with anterior cervical osteophytes (n=20) were identified and matched by age, sex, location, and laterality of the stroke lesion to a poststroke dysphagia control group with no anterior cervical osteophytes (n=20).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Videofluoroscopic swallowing study, Functional Oral Intake Scale (FOIS), and Penetration-Aspiration Scale results assessed within the first month of stroke were analyzed. The FOIS at 6 months was recorded, and severity of dysphagia was compared between the 2 groups.

RESULTS

The case group had larger degrees of postswallow residues in the valleculae and pyriform sinuses (P=.020 and P<.001, respectively), with more patients showing postswallow aspiration (62.5%) than the control group (0%; P<.001), along with a higher risk of being on enteral nutrition feeding (odds ratio [OR]=13.933; 95% confidence interval [CI], 2.863-infinity) within the first month of stroke. At the 6-month follow-up, the case group had significantly lower mean FOIS scores (3.8±1.7) than the control group (6.1±1.3; P<.001), with an increased risk of having persistent dysphagia (OR=15.375; 95% CI, 3.195-infinity).

CONCLUSIONS

The presence of anterior cervical osteophytes, which may cause mechanical obstruction and interfere with residue clearance at the valleculae and pyriform sinuses and result in more postswallow aspiration, may influence initial severity and outcome of poststroke dysphagia. The presence of anterior cervical osteophytes may be considered an important clinical condition that may affect poststroke dysphagia rehabilitation.

Fractalkine receptor chemokine (CX3CR1) influences on cervical and lumbar disc herniation

BACKGROUND

Herniation of nuclear or disc material along with, inflammatory chemokines such as prostaglandin E2, interleukin-6, matrix metalloproteinase and nitric oxide has definite correlation, possibly they are over produced. CX3CL1 and its receptor (CX3CR1) are part of chemokine system involved in leukocyte recruitment and adhesion in chronic inflammatory disease, but its role in spinal herniated nucleus pulposus (HNP) is unknown. We evaluated the expression of CX3CL1 and CX3CR1 in patients with disc herniation to clarify the role of CX3CL1 and CX3CR1 in the disc degeneration and to compare between cervical and lumbar HNP.

MATERIALS AND METHODS

The mRNA concentrations of CX3CL1/CX3CR1 chemokine were analyzed in the surgically obtained disc specimens from C-HNP (n = 13) and L-HNP (n = 13) by real-time polymerase chain reaction (PCR). The localization of CX3CL1/CX3CR1 chemokine in the disc of C-HNP and L-HNP patients was determined using immunohistochemical study. Blood samples from patients with C-HNP and L-HNP patients were stained for CX3CR1 with flow cytometric analysis.

RESULTS

The CX3CL1 positive cell ratio in the discs was observed in both groups by immunohistochemical study. CX3CR1 was strongly expressed on endothelial cells in C-spine disc, but sparely expressed in L-spine disc. There was greater CX3CR1 mRNA expression in C-HNP patients than in L-HNP patients as quantified by reversal transcription-PCR (P = 0.010). CX3CR1 positive cell frequencies and CX3CR1 expression levels were increased in CD4 (+) T-cells and natural killer (NK) cells from patients with C-HNP (P = 0.210 and P = 0.040).

CONCLUSIONS

This study identified that increases in CX3CL1 and CX3CR1-expressing cells are significantly related to pathomechanism of HNP for the first time. Especially, CD4 (+) T-cells and NK cells expressing CX3CR1 may play an important role in developing C-HNP.

The association between lumbar spine radiographic features and low back pain: a systematic review and meta-analysis

BACKGROUND/PURPOSE

Low back pain (LBP) is a prevalent musculoskeletal condition and represents a substantial socioeconomic burden. Plain film radiography is a commonly used imaging technique. Radiographic features (RFs) such as disc space narrowing, osteophytes, spondylosis, endplate sclerosis, spondylolisthesis, and facet joint osteoarthritis have all been debated as potential pain generators in the lumbar spine. The aim of this study is to (1) determine the association between LBP and lumbar spine RFs in both community- and occupation-based groups and (2) to determine if there are differences in these associations between these two groups.

METHODS

A systematic electronic search of PubMed, EMBASE, CINAHL, and Cochrane was conducted with keywords related to LBP and lumbar spine RFs. The search was restricted from inception of each respective database to April 2014. Inclusion criteria consisted of observational studies of adults (≥18 years) with and without nonspecific LBP. Studies were excluded if they investigated LBP related to infection, malignancy, or rheumatologic nature or were conducted in cadavers. Quality assessment was conducted with the Item Bank for Assessment of Risk of Bias and Precision for Observational Studies of Interventions or Exposures. Random effect models were used for all pooled analyses with associations represented by odds ratios (OR) and 95% confidence intervals (95% CIs). Statistical heterogeneity was assessed with I(2), with significant heterogeneity represented as >50%.

RESULTS

Overall, 28 (22 community-based and six occupation-based) studies met the eligibility criteria consisting of 26,107 subjects. A significant, positive association was found between disc space narrowing and LBP, which did not differ (p = 0.22) in both community- and occupation-based studies [OR = 1.47 (95% CI: 1.36-1.58)] and [OR = 1.76 (95% CI: 1.34-2.33)], respectively. No significant statistical heterogeneity was present in either estimate (I(2) = 0.0%). A significant association was found between spondylolisthesis and LBP in occupation-based studies [OR = 2.21 (95% CI: 1.44-3.39)] that differed significantly (p < 0.01) from community-based studies [OR = 1.12 (95% CI: 1.03-1.23)]. These individual estimates were also homogeneous (I(2) = 0.0%). The association between other radiographic features was modest (i.e., spondylosis and osteophytes) or non-significant (i.e., endplate sclerosis and facet joint). Quality of included studies varied, with the majority demonstrating good quality.

CONCLUSION

A significant association was found between disc space narrowing in both community- and occupational-based populations without significant differences between the associations. A significant strong association was found between spondylolisthesis and LBP among the occupational group but was weakly associated in the community-based group, which supports that spondylolisthesis may contribute a specific cause for LBP.

Extracellular osmolarity regulates matrix homeostasis in the intervertebral disc and articular cartilage: evolving role of TonEBP

Degeneration of the intervertebral disc is characterized by changes in proteoglycan status, loss of bound water molecules, decreased tissue osmotic pressure and a resulting mechanical failure of the disc. A similar spectrum of changes is evident in osteoarthritic articular cartilage. When healthy, resident cells in these skeletal tissues respond to applied mechanical loads by regulating their own osmotic state and the hydration of the extracellular matrix. The transcription factor Tonicity-Responsive Enhancer Binding Protein (TonEBP or NFAT5) is known to mediate the osmoadaptive response in these and other tissues. While the molecular basis of how osmotic loading controls matrix homeostasis is not completely understood, TonEBP regulates the expression of aggrecan and β1,3-glucoronosyltransferase in nucleus pulposus cells, in addition to targets that allow for survival under hypertonic stress. Moreover, in chondrocytes, TonEBP controls expression of several collagen subtypes and Sox9, a master regulator of aggrecan and collagen II expression. Thus, TonEBP-mediated regulation of the matrix composition allows disc cells and chondrocytes to modify the extracellular osmotic state itself. On the other hand, TonEBP in immune cells induces expression of TNF-α, IL-6 and MCP-1, pro-inflammatory molecules closely linked to matrix catabolism and pathogenesis of both disc degeneration and osteoarthritis, warranting investigations of this aspect of TonEBP function in skeletal cells. In summary, the TonEBP system, through its effects on extracellular matrix and osmoregulatory genes can be viewed primarily as a protective or homeostatic response to physiological loading.

The life cycle of the intervertebral discs and vertebral bodies: a review

A review of the current concepts of growth, maturation and development of the vertebral bodies and intervertebral discs.

Quality of life and neck pain in nurses

OBJECTIVES

To investigate the association between neck pain and psychological stress in nurses.

MATERIAL AND METHODS

Nurses from the Avon Orthopaedic Centre completed 2 questionnaires: the Short Form-36 (SF-36) and 1 exploring neck pain and associated psychological stress.

RESULTS

Thirty four nurses entered the study (68% response). Twelve (35.3%) had current neck pain, 13 (38.2%) reported neck pain within the past year and 9 (26.5%) had no neck pain. Subjects with current neck pain had significantly lower mental health (47.1 vs. 70.4; p = 0.002), physical health (60.8 vs. 76.8; p = 0.010) and overall SF-36 scores (56.8 vs. 74.9; p = 0.003). Five (41.7%) subjects with current neck pain and 5 (38.5%) subjects with neck pain in the previous year attributed it to psychological stress.

CONCLUSIONS

Over 1/3 of nurses have symptomatic neck pain and significantly lower mental and physical health scores. Managing psychological stress may reduce neck pain, leading to improved quality of life for nurses, financial benefits for the NHS, and improved patient care.

Heritability estimation of osteoarthritis in the pig-tailed macaque (Macaca nemestrina) with a look toward future data collection

We examine heritability estimation of an ordinal trait for osteoarthritis, using a population of pig-tailed macaques from the Washington National Primate Research Center (WaNPRC). This estimation is non-trivial, as the data consist of ordinal measurements on 16 intervertebral spaces throughout each macaque's spinal cord, with many missing values. We examine the resulting heritability estimates from different model choices, and also perform a simulation study to compare the performance of heritability estimation with these different models under specific known parameter values. Under both the real data analysis and the simulation study, we find that heritability estimates from an assumption of normality of the trait differ greatly from those of ordered probit regression, which considers the ordinality of the trait. This finding indicates that some caution should be observed regarding model selection when estimating heritability of an ordinal quantity. Furthermore, we find evidence that our real data have little information for valid heritability estimation under ordered probit regression. We thus conclude with an exploration of sample size requirements for heritability estimation under this model. For an ordinal trait, an incorrect assumption of normality can lead to severely biased heritability estimation. Sample size requirements for heritability estimation of an ordinal trait under the threshold model depends on the pedigree structure, trait distribution and the degree of relatedness between each phenotyped individual. Our sample of 173 monkeys did not have enough information from which to estimate heritability, but estimable heritability can be obtained with as few as 180 related individuals under certain scenarios examined here.

The effect of age on sagittal plane profile of the lumbar spine according to standing, supine, and various sitting positions

Background

The sagittal alignment of the spine changes depending on body posture and degenerative changes. This study aimed to observe changes in sagittal alignment of the lumbar spine with different positions (standing, supine, and various sitting postures) and to verify the effect of aging on lumbar sagittal alignment.

Methods

Whole-spine lateral radiographs were obtained for young volunteers (25.4 ± 2.3 years) and elderly volunteers (66.7 ± 1.7 years). Radiographs were obtained in standing, supine, and sitting (30°, 60°, and 90°) positions respectively. We compared the radiological changes in the lordotic and segmental angles in different body positions and at different ages. Upper and lower lumbar lordosis were defined according to differences in anatomical sagittal mobility and kinematic behavior.

Results

Lumbar lordosis was greater in a standing position (52.79° and 53.90° in young and old groups, respectively) and tended to decrease as position changed from supine to sitting. Compared with the younger group, the older group showed significantly more lumbar lordosis in supine and 60° and 90° sitting positions (P = 0.043, 0.002, 0.011). Upper lumbar lordosis in the younger group changed dynamically in all changed positions compared with the old group (P = 0.019). Lower lumbar lordosis showed a decreasing pattern in both age groups, significantly changing as position changed from 30° to 60° (P = 0.007, 0.007).

Conclusions

Lumbar lordosis decreases as position changes from standing to 90°sitting. The upper lumbar spine is more flexible in individuals in their twenties compared to those in their sixties. Changes in lumbar lordosis were concentrated in the lower lumbar region in the older group in sitting positions.

Association of lumbar disc degeneration with osteoporotic fractures; the Rotterdam study and meta-analysis from systematic review

OBJECTIVE

To investigate the relation between lumbar disc degeneration (LDD) and all type of osteoporotic (OP) fractures including vertebral.

METHODS

This study is part of the Rotterdam study, a large prospective population-based cohort study among men and women aged 55years and over. In 2819 participants spine radiographs were scored for LDD (osteophytes and disc space narrowing (DSN)) from L1 till S1, using the Lane atlas. Osteoporotic (OP) fracture data were collected and verified by specialists during 12.8years. We considered two types of vertebral fractures (VFx): Clinical VFx (symptomatic fractures recorded by medical practitioners) and Radiographic VFx (using the McCloskey-Kanis method). Meta-analysis of published studies reporting an association of LDD features and VFx was performed. Differences in Bone Mineral Density (BMD) between participants with and without LDD features were analyzed using ANOVA. Risk of OP-fractures was analyzed using Cox regression.

RESULTS

In a total of 2385 participants, during 12.8years follow-up, 558 suffered an OP-fracture. Subjects with LDD had an increased OP fracture risk compared to subjects without LDD (HR: 1.29, CI: 1.04-1.60). LDD-cases have between 0.3 and 0.72 standard deviations more BMD than non-cases in all analyzed regions including total body BMD and skull BMD (P<0.001). Only males with LDD had increased risk for OP-fractures compared to males without LDD (adjusted-HR: 1.80, 95%CI: 1.20-2.70, P=0.005). The risk was also higher for VFx in males (HR: 1.64, CI: 1.03-2.60, P: 0.04). The association LDD-OP-fractures in females was lower and not significant (adjusted-HR: 1.08, 95%CI: 0.82-1.41). Meta-analyses showed that the risk of VFx in subjects with LDD has been studied only in women and there is not enough evidence to confidently analyze the relationship between LDD-features (DSN or/and OPH) and VFx due to low power and heterogeneity in phenotype definition in the collected studies.

CONCLUSIONS

Male subjects with LDD have a higher osteoporotic fracture risk, in spite of systemically higher BMD.

Lumbar Disc Degeneration in Osteoporotic Men: Prevalence and Assessment of the Relation with Presence of Vertebral Fracture

Objective.

The relationship between osteoarthritis (OA) and osteoporosis (OP) remains controversial. An inverse relationship between spine OA and the presence of prevalent vertebral fractures has been shown in osteoporotic women. Our objective was to assess this relationship in osteoporotic men.

Methods.

All the patients had OP based on densitometric data and were aged ≥ 65 years. Spine radiographs were performed according to a standardized procedure. Vertebral fractures were assessed from T4 to L4 by a semiquantitative method. Disc degenerative changes were assessed by the presence and severity of osteophytes and disc narrowing at levels T12–L1 to L5–S1. Logistic regression was used to study the relationship between the presence of vertebral fracture and lumbar disc degeneration.

Results.

The study included 261 osteoporotic men. The prevalence of vertebral fractures was 26.4% (69/261). At least 1 osteophyte was found in 91.6% (239/261) of patients, and at least 1 disc space narrowing in 63.5% (165/260). The prevalence of at least 1 osteophyte and/or at least 1 disc space narrowing was similar in patients with and those without vertebral fracture. No relationship was found between the presence and/or the severity of osteophytes and disc narrowings and the presence of prevalent vertebral radiographic fractures.

Conclusion.

In osteoporotic men, the prevalence of lumbar spine degeneration is high. There is no relationship between lumbar disc degeneration and the presence of vertebral fracture in osteoporotic men.

Socioeconomic and physical characteristics of individuals with degenerative lumbar spinal stenosis

STUDY DESIGN

A descriptive study of the association between demographic factors, and physical characteristics, and degenerative lumbar spinal stenosis (DLSS).

OBJECTIVE

To shed light on the association between socioeconomic parameters, physical characteristics, and DLSS.

SUMMARY OF BACKGROUND DATA

Lumbar spinal stenosis is a prevalent and disabling condition in the aging population. DLSS is considered to be the most common type and is essentially associated with disc disease, facet joint arthrosis, ligamentum flavum thickening, and osteophyte formation. Although there is ample information regarding the association between body mass index, cardiovascular disorders, smoking habits, and disc disease, very little is known about their association with DLSS. Data on the association of body physique (e.g., height and weight) and DLSS are limited.

METHODS

Two sample populations were studied. The first included 165 individuals with DLSS (mean age, 64 ± 9.9 yr) and the second 180 individuals without spinal stenosis related symptoms (mean age, 62.5 ± 12.6 yr). An evaluation of the cross-sectional area of the dural sac and degenerative listhesis for all participants was performed using computed tomographic lumbar spine images, obtained by Philips EBW station (Brilliance 64, Philips Medical System, Cleveland, OH). All participants were interviewed to obtain demographic, physical, and health data. Independent t test, Mann-Whitney and χ tests were used to determine the association between parametric and nonparametric variables and DLSS. Logistic regression analysis was carried out to reveal predicting variables for DLSS.

RESULTS

Females with stenosis were significantly heavier and shorter than their counterparts in the control group. We also noticed that they delivered babies more often than those in the control group. Prevalence of individuals experiencing diabetes mellitus was significantly higher in the males with stenosis than control group. In the stenosis group, the frequencies of individuals engaged in heavy manual labor (males) and housekeeping (females) were significantly higher than that of their counterparts in the control group.

CONCLUSION

Heavy manual labor and diabetes mellitus in males and housekeeping (females) play major roles in the genesis of DLSS.

Degenerative joint disease of the spine

Degenerative changes are the manifestations of metabolic disturbances in the matrix of intervertebral disks and zygapophysial joints. Genetic factors and physical loading contribute, but the strongest correlation is with age. Degenerative changes lack any significant correlation with spinal pain. Therefore, they do not constitute a diagnosis. Internal disk disruption is a distinctive condition that is independent of degeneration and age. Its biophysical and morphologic features correlate with back pain, as do its manifestations on magnetic resonance imaging.

Incidence and risk factors for radiographic lumbar spondylosis and lower back pain in Japanese men and women: the ROAD study

OBJECTIVE

To determine the incidence of radiographic lumbar spondylosis (LS)and lower back pain, and their risk factors in Japan using a large-scale population from the nationwide cohort Research on Osteoarthritis/osteoporosis Against Disability (ROAD) Study.

METHODS

Participants in the ROAD study who had been recruited between 2005 and 2007 were followed up with lumbar spine radiography for 3 years. A total of 2,282 paired radiographs (75% of the original sample) were scored using Kellgren and Lawrence (KL) grades, and the incidence and progression rate of radiographic LS was analyzed. The incidence of lower back pain was also examined. In addition, associations between risk factors and incident and progressive radiographic LS as well as incident lower back pain were tested.

RESULTS

Given a 3.3-year follow-up, the incidence of KL≥2 radiographic LS was 50.0% and 34.4% (15.3% and 10.5% per year), while that of KL≥3 LS was 15.3% and 23.7% (4.6% and 7.2% per year) in men and women, respectively. The progression rate of LS was 20.5% and 27.4% (6.2% and 8.3% per year) in men and in women, respectively. In addition, the incidence of lower back pain was 28.3% and 31.2% (8.6% and 9.5% per year) in men and women. Lower back pain was not significantly associated with incident radiographic LS, while a more severe KL grade at baseline was associated with incident lower back pain.

CONCLUSION

The present longitudinal study revealed a high incidence of radiographic LS in Japan.

Sex differences in spinal osteoarthritis in humans and rhesus monkeys (Macaca mulatta)

STUDY DESIGN

Retrospective study of male and female spinal osteoarthritis, characterized by lateral spine thoracolumbar radiographs, in humans and nonhuman primates.

OBJECTIVE

To characterize differences in prevalence and vertebral distribution of spinal osteoarthritis between men and women, between male and female macaques, and between the 2 phylogenetically related genera.

SUMMARY OF BACKGROUND DATA

Naturally occurring spinal osteoarthritis manifests similarly in humans and rhesus macaques. Other types of osteoarthritis particularly of the knee and hip have revealed sex differences in humans. In regard to spinal osteoarthritis, sex differences have been noted but without consistent results. Sex differences in macaques have not been examined.

METHODS

Radiographical evidence of disc space narrowing and osteophytosis was assessed using an atlas-scoring method. Prevalence was determined according to sex, age, body mass (for macaques only), and spinal location (human T4-L5; macaque T8-L7).

RESULTS

Average scores in macaques differed between the sexes, but they did not differ between men and women. The pattern of involvement along the spine was the same in male and female monkeys but differed between men and women: women had more thoracic involvement and men had more lumbar involvement. Overall, monkeys had a significantly higher prevalence of osteoarthritis than humans.

CONCLUSION

The appearance of sex differences in the prevalence of osteoarthritis is most likely a proxy measure for the effect of body mass. Sex differences were apparent in monkeys due to the fact that males are significantly heavier than females. No sex difference in prevalence was apparent in humans, and there is substantial overlap in body mass between men and women. Differences in the location of osteoarthritic involvement along the spine between men and women were obscured when only average scores were examined.

Locomotor dysfunction and risk of cardiovascular disease, quality of life, and medical costs: design of the Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS) and baseline characteristics of the study population

BACKGROUND

There is little evidence regarding long-term outcomes of locomotor dysfunction such as cardiovascular events, quality of life, and death. We are conducting a prospective cohort study to evaluate risk of cardiovascular disease, quality of life, medical costs, and mortality attributable to locomotor dysfunction. The present study determined baseline characteristics of participants in the Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS).

METHODS

Cohort participants were recruited from residents between 40 and 80 years old who received regular health check-ups conducted by local government each year between 2008 and 2010 in Minami-Aizu Town and Tadami Town in Fukushima Prefecture, Japan. Musculoskeletal examination included assessment of physical examination of the cervical and lumbar spine, and upper and lower extremities and of physical function, such as grasping power, one-leg standing time, and time for the 3-m timed up-and-go test. Cardiovascular risk factors, including blood pressure and biological parameters, were measured at annual health check-ups. We also conducted a self-administered questionnaire survey.

RESULTS

LOHAS participants comprised 1,289 men (mean age 65.7 years) and 1,954 women (mean age 66.2 years) at the first year. The proportion of obese individuals (body mass index 25.0 kg/m(2)) was 31.9% in men and 34.3% in women, and 41.0% of participants reported being followed up for hypertension, 7.0% for diabetes, and 43.6% for hypercholesterolemia. Prevalence of lumbar spinal stenosis was 10.7% in men and 12.9% in women, while prevalence of low back pain was 15.8% in men and 17.6% in women.

CONCLUSION

The LOHAS is a novel population-based prospective cohort study that will provide an opportunity to estimate the risk of cardiovascular disease, quality of life, medical costs, and mortality attributable to locomotor dysfunction, and to provide the epidemiological information required to develop policies for detection of locomotor dysfunction.

Cervical spine: degenerative conditions

Degenerative cervical spine disorders will affect up to two-thirds of the population in their lifetime. While often benign and episodic in nature, cervical disorders may become debilitating resulting in severe pain and possibly neurologic sequelae. Non-operative treatment continues to play an important role in treating these patients, with medications, therapy and interventional pain injections playing increasing roles in treatment. Surgical treatment including anterior and posterior decompression and fusion have been effective treatments of many cervical disorders, but may lead to significant problems including adjacent level disease. Laminotomy/foraminotomy and total disc arthroplasty may avoid some of these problems while providing similar clinical results. Ongoing clinical trials and studies are helping to define the role of these new technologies in treatment of patients with degenerative cervical disorders, although their greater benefit has yet to be proven.