The association between lumbar disc degeneration and low back pain: the influence of age, gender, and individual radiographic features.
From: Spine (Phila Pa 1976). 2010 Mar 1;35(5):531-6.
Back pain is one of the most common musculoskeletal complaints of the elderly, with a point prevalence of 26.9% in the Netherlands. Van Tulder et al performed a systematic review and reported that lumbar disc degeneration could be a possible risk factor for back pain in adults. However, the review reported that the methodologic quality of most of these studies was low and the studies were difficult to compare due to difference in gender frequencies, age groups, settings, radiographic grading systems, and definitions for lumbar disc degeneration.
Lumbar disc degeneration is characterized radiologic by the presence of osteophytes, endplate sclerosis, and disc space narrowing. In 1993, Lane et al presented a reliable grading system for these individual radiographic features. In a recent review, this grading system was recommended for use in epidemiologic studies. There have been a number of recent studies that have used the classification of the individual radiographic features of disc degeneration defined by Lane et al. One of these studies described the occurrence of these separate features and their relationship with back pain in the open population, but only in a limited sample.
However, it is still unknown how to combine the individual radiographic features and how to define a clinically relevant definition for lumbar disc degeneration. Currently there is no consensus about whether the lumbosacral disc should be scored. Some studies have included the lumbosacral level in their definition of lumbar disc degeneration, while others have not. Currently within the literature, there have been no studies that have explored different definitions of lumbar disc degeneration and their association with low back pain within one study sample.
The purpose of this study was to explore the association of the different individual radiographic features, including osteophytes and disc space narrowing, with self-reported low back pain. Different definitions of lumbar disc degeneration with self-reported low back pain and disability were considered in a large open population sample. Furthermore, in order to disentangle the discrepancies in reported strength of the associations, the authors characterized the frequency of the different individual radiographic features of lumbar disc degeneration and definitions of lumbar disc degeneration, as well as their association with low back pain status, by age, gender, and vertebral level.
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Association of the Polymorphisms of Vitamin D Receptor and Aggrecan Genes with Degenerative Disc Disease.
From: Genet Test Mol Biomarkers. 2010 Mar 31. [Epub ahead of print]
The aim of this study was to investigate the association between the polymorphisms of vitamin D receptor and aggrecan genes and degenerative disc disease in young Turkish patients. Aggrecan and vitamin D receptor proteins are the main components of bone and cartilage. In our study, the polymorphisms of vitamin D receptor and aggrecan genes were investigated in a total of 300 individuals regarding disc degeneration and herniation.
An association was found in the patients having vitamin D receptor gene TT, Tt, FF, and Ff genotypes with the protrusion type of disc herniation, whereas the patients having tt and ff genotypes were associated with extrusion/sequestration types of the disease. Also, an association was observed between TT and FF genotypes of vitamin D receptor gene and mild forms of disc degeneration; and tt, ff, and Ff genotypes and severe forms of the disease. There was also an association between shorter, normal, and longer alleles of the aggrecan gene and a protrusion type of disc herniation. An association was found between short alleles and multilevel and severe disc degeneration, as well as normal and long alleles and mild disc degeneration. This study revealed that the polymorphisms of vitamin D receptor and aggrecan genes are associated with disc degeneration and herniation.
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Relationship of facet tropism with degeneration and stability of functional spinal unit
From: Yonsei Med J. 2009 Oct 31;50(5):624-9
Facet tropism is defined as asymmetry in both the facet joint angles of the lumbar and lumbosacral regions. For many years, the effect of facet tropism on the development of intervertebral disc degeneration has been debated. However, the specific details regarding the effects of facet tropism on the development of degenerative disc disease remains as the subject of debate. Most of the previous facet tropism studies have focused on the relationship between facet tropism and lumbar disc herniation.
The role of facet tropism in the pathogenesis of lumbar degenerative disc disease is not fully understood Currently, controversy exists surrounding the question of whether or not any significant relationship exists between facet tropism and the development of disc or facet joint degeneration. Additionally, the relationship between facet tropism and degenerative spondylolisthesis and translational segmental motion is highly controversial.
In the current study, the authors attempted to evaluate the effect of facet tropism on disc and facet joint degeneration. Additionally, the relationship between facet tropism and changes in translational segmental motion was investigated.
Facet tropism is defined as asymmetry between the left and right facet joint angles of the lumbar spine. Asymmetry in the orientation of the zygapophyseal joint surfaces is not uncommon, with estimates of its occurrence at 10-70.5% of the population. Our study revealed an incidence of facet tropism in 35% of the spinal units which were taken into consideration. Facet tropism is most common at L5-S1, followed by L4-L5.
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Muscone Protects Vertebral End plate Degeneration by Antiinflammatory Property
From: Clin Orthop Relat Res. 2009 Sep 18
Neck pain is one of the most common chronic conditions affecting quality of life and sometimes causing disability in adults. Most chronic neck pain is the result of degeneration of the intervertebral discs in the cervical spine. An intact end plate cartilage is critical for normal disc functions, as the major nutrient supply of the discs is diffused through the end plates. Pathological changes in end plate cartilage are closely related to disc degeneration and thus to cervical spondylopathy. Prevention and reduction of lesions to the vertebral end plate are high research priorities.
IL-1beta may play an important role in intervertebral disc degeneration. This being the case, inhibiting IL-1beta could provide a therapeutic approach for reducing or preventing disc degeneration. Muscone reportedly relieves pain and suppresses inflammation. Therefore, the authors asked whether muscone, a potent antiinflammatory agent, could reduce proinflammatory cytokines in vitro (end-plate cartilage cultures) and end-plate degeneration in vivo (a rat model that induces intervertebral disc degeneration). In vitro, muscone reversed IL-1beta-induced upregulation of IL-1beta, tumor necrosis factor alpha, cyclooxygenase 2, inducible nitric oxide synthase, matrix metalloproteinase 13, aggrecanase 2, and nitric oxide and downregulation of Col2alpha1 and aggrecan. Pretreatment with muscone (6.25, 12.5, 25 mumol/L) inhibited the IL-1beta-induced phosphorylation of extracellular signal-regulated kinases 1/2 and c-Jun N-terminal kinase in a dose-dependent manner. In vivo, muscone inhibited the expression of prostaglandin E2, 6-keto-prostaglandin F1alpha, IL-1beta, and tumor necrosis factor alpha and recovered the structural distortion of the degenerative disc. The findings suggest muscone is a promising agent for treating intervertebral disc degeneration through its antiinflammatory effects.
Prevalence and correlates of musculoskeletal pain in Chinese elderly and the impact on 4-year physical function and quality of life
From: Public Health. 2009 Aug 24
Examination of the prevalence, correlates and prospective impact of musculoskeletal pain on physical and psychological function in a population health survey of elderly Chinese men and women. Four thousand men and women, aged 65 years and over, living in the community in Hong Kong took part in this study. A questionnaire to determine demographics, socio-economic status, medical history, smoking, alcohol intake and level of physical activity was administered by an interviewer. Participants were asked about the presence of pain in the back, neck, hip and knee in the past 12 months. They were re-interviewed after 4 years of follow-up to document physical performance measures, psychological function and occurrence of falls, fractures and mortality.
Overall, back pain was most prevalent (48%), followed by knee (31%), neck (22.5%) and hip (8.9%) pain; the values was nearly twice as high in women compared with men for all sites. The presence of pain was not correlated with age, but was associated with various measures of socio-economic status as well as comorbidities. Baseline prevalence of pain was related to physical performance and quality-of-life measures, and fracture incidence after 4 years of follow-up.
Musculoskeletal pain is prevalent among elderly men and women, being much higher in the latter, giving rise to considerable functional and psychological impairments. Osteoporosis and osteoarthritis are likely to be the main underlying causes. The condition may be considered part of the frailty syndrome, and in this context, prevention and management represent major public health challenges.
Increased expression of matrix metalloproteinase-10, nerve growth factor and substance P in the painful degenerate intervertebral disc
From: Arthritis Res Ther. 2009 Aug 20;11(4):R126. [Epub ahead of print]
The human intervertebral disc is an avascular and aneural tissue comprising a central gelatinous region (the nucleus pulposus), surrounded by a fibrous ring of highly organised collagen fibres (the annulus fibrosus). The extracellular matrix of the nucleus pulposus is rich in type II collagen and proteoglycans, predominantly aggrecan, which produces a highly hydrated matrix capable of withstanding the loads experienced within the spine. This extracellular matrix is constantly being remodelled in a process driven by the constituent nucleus pulposus cells.
During intervertebral disc degeneration there is an imbalance in the normal homeostatic mechanisms, which favours matrix catabolism and leads to a loss of disc height,
coupled with ingrowth of both nerves and blood vessels into both the annulus fibrosus and nucleus pulposus. The authors have previously demonstrated that this ingrowth of nerves into the degenerate intervertebral disc is associated with low back pain. While low back pain is multifactorial, studies have shown that this debilitating condition affecting around 80% of adults at some stage of life is associated with intervertebral disc degeneration in approximately 40% of cases. Indeed in a recent study by Cheung et al (2009) it has been shown that there is a significant association of lumber disc degeneration imaged by MRI with low back pain.
The nucleus pulposus of the normal human intervertebral disc is an avascular and aneural environment, comprising of chondrocyte like cells embedded within an extracellular matrix rich in proteoglycans and collagens. This matrix is continuously remodelled in a process controlled by the nucleus pulposus cells and closely regulated by anabolic growth factors and catabolic cytokines. In intervertebral disc degeneration there is disregulation in this finely balanced homeostatic matrix turnover mechanism, leading to an increase in catabolic processes over anabolic matrix formation. Over time this results in breakdown of matrix, until the disc loses both height and function and in a large proportion of cases there is innervation and initiation of the pain response which leads to low back pain.
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Association between cervical curvature and cervical sympathetic symptoms
From: Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2009 Jun;31(3):381-2
To investigate the association between cervical curvature and cervical sympathetic symptoms, the clinical data of 318 patients with cervical spondylosis who underwent surgical treatment in our department between July 2003 and December 2007 were retrospectively analyzed. All patients were divided into group without sympathetic symptoms (n = 284) and group with sympathetic symptoms (n = 34). The curvatures of both groups on cervical lateral radiographs were measured using Borden method and statistical analysis was performed.
The incidence of abnormal cervical curvature in group with cervical sympathetic symptoms were 67.6% (23/34), which was significantly higher than that in group without cervical sympathetic symptoms (50.7%, 144/284). Cervical curvature abnormality may be an independent factor that affects the cervical sympathetic symptoms.
In Zhonghua Wai Ke Za Zhi. 2008 Sep 15;46(18):1424-7, Treatment and mechanism of cervical spondylosis with sympathetic symptoms concluded: The sympathetic nerve fibers distributed in the cervical posterior longitudinal ligament maybe another one significant factor causing sympathetic symptom of cervical spondylosis.
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The prevalence cervical facet arthrosis: an osseous study in a cadveric population
From: Spine J. 2009 May 26. [Epub ahead of print]
Cervical facet arthrosis has been implicated as a cause for neck pain, radiculopathy, occipital headache, and ear pain. The objective of this study was to examine the occurrence of facet arthrosis in the cervical spine. This study examined cadaveric specimens from the Hamann Todd Collection. Four hundred sixty-five skeletally mature human cervical spines from the Hamann Todd Collection in the Cleveland Museum of Natural History were obtained for analysis. The authors analyzed the facets for arthrosis. We graded no arthrosis as Grade 0. Facets with peripheral osteophytic reaction, but with no lateral mass distortion were graded as Grade 1. Facets with peripheral osteophytic reaction and lateral mass distortion were graded as Grade 2. Facets that were ankylosed were graded as Grade 3. Each specimen was examined bilaterally at levels from C2-C3 through C6-C7, yielding 4,650 specimen assessments. The data were analyzed to compare cervical levels, gender, facet side, age groups, and race.
In the entire population of 465 specimens, the upper cervical specimens appeared to be affected by facet arthrosis more frequently than the lower levels; 12.37% of the specimens had bony evidence of arthrosis at the C2-C3 level; 13.33% of the specimens had arthrosis occur at the C3-C4 level; 14.62% at the C4-C5 level; 7.85% at the C5-C6 level, and 4.84% at the C6-C7 level. The large majority of all cervical facet arthrosis was found to be Grade 1 at all levels.
In the older population, the prevalence of facet arthrosis is as high as 29.87% for the C4-C5 level. C4-C5 level appears to be affected the most frequently, followed by the C3-C4 level, then C2-C3, C5-C6, and C6-C7.
The prevalence of cervical facet arthrosis increases with age, and occurs more commonly in the upper cervical spine.
Aging of the cervical spine in healthy volunteers: a 10-year longitudinal magnetic resonance imaging study
From: Spine. 2009 Apr 1;34(7):706-12
Prevalence of back and neck problems is high among general populations, and it has been estimated that neck pain is recognized in 9,000,000 and both neck and low back pain in 19,000,000 people in the United States. The total cost for the treatment of neck pain in Netherlands in 1996 was estimated to be US $686 million.
Aging of the cervical spine can inevitably occur in anyone. Recent advances in basic researches on disc degeneration have revealed its possible mechanisms including a decrease in proteoglycan contents and water concentration, involvement of inflammatory cytokines such as interleukin-15 and iTNF-α, and some genetic factors. Since the intervertebral disc is one of the tissues subject to early aging processes starting as early as 20 years of age, and is often the source of cervical spinal disorders causing neck pain and related symptoms, it is important to ascertain the processes of aging when considering treatments for age-related cervical spinal diseases. There have been a few studies on aging of the cervical spine in healthy subjects using plain x-ray, computed tomography, or magnetic resonance imaging (MRI). In particular, MRI has excellent tissue resolution and can sharply visualize degeneration of the intervertebral discs. However, the majority of these studies were cross-sectional, and have only been able to determine the prevalence of age-related degenerative changes in the cervical spine, but failed to clarify the sequential processes of aging. Thus, long-term longitudinal studies following the same individuals are necessary to elucidate the accurate aging processes of the cervical spine.
We conducted a cross-sectional study of MRI findings of the cervical spine in 497 asymptomatic healthy subjects between 1993 and 1996,11 and showed that the incidence of degenerative changes in the cervical spine increased with age; the incidence of degenerative findings on MRI was 17% and 12% in male and female teenagers, respectively, and was 86% and 89% in male and female subjects in their 60s, respectively.
In the present study, which was conducted approximately 10 years after the previous study, a part of the same cohort was recruited and underwent follow-up MRI. The objectives of this longitudinal study were to investigate the processes of the progression of intervertebral disc degeneration and to clarify correlations between the progression of intervertebral disc degeneration and the development of clinical symptoms.
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Direction of the formation of anterior lumbar vertebral osteophytes
From: BMC Musculoskelet Disord. 2009 Jan 13;10:4
X-ray images of lumbar degenerative diseases often show not only claw osteophytes, but also pairs of osteophytes that form in a direction away from the adjacent disc. We have investigated the direction of the formation of anterior lumbar vertebral osteophytes across the lumbar vertebrae using a sufficient number of lumbar radiographs, because osteophytes images can provide essential information that will contribute to the understanding of the pathology and progress of lumbar spine degeneration.
Kirkardy-Willis et al. reported that lumbar degenerative diseases began with disc degeneration, and, during a period characterized by the development of different pathologies including disc herniation, spinal instability and spinal canal stenosis, ended with the formation of anterior lumbar vertebral osteophytes that would stabilize the spinal column. According to the radiographic Nathan’s classification of anterior lumbar vertebral osteophytes, in a claw osteophyte, a bone bridge forms across the intervertebral disc space as a result of the curve and extension of a cranial osteophyte and a caudal osteophyte across the adjacent disc.
Actually, X-ray images of lumbar degenerative diseases often show not only claw osteophytes, but also pairs of osteophytes that form in a direction away from the adjacent disc. The latter type is called traction osteophytes or traction spurs, and have been described as indicators of intervertebral instability on a plain radiographic image by Macnub et al. Besides, Pate et al. reported from their studies in 200 cadavers that both claw and traction osteophytes had the same histology, and that traction osteophytes could turn into claw osteophytes during the lumbar degenerative process. In 1998, Heggeness demonstrated that both claw and traction osteophytes formed as a result of the same degenerative process. For a decade after these reports, researchers have no longer paid attention to the types of osteophytes and the direction of their formation. We have investigated the direction of the formation of anterior lumbar vertebral osteophytes across the lumbar vertebrae using a sufficient number of lumbar radiographs, because osteophytes images can provide essential information that will contribute to the understanding of the pathology and progress of lumbar spine degeneration.
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