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.

The authors are the first to report in one paper, multiple lumbar disc degeneration definitions and their associations with low back pain, for the separate genders and discreet age groups. In this study, disc space narrowing appeared to be more strongly associated with low back pain than osteophytes, especially in men. Disc space narrowing at 2 or more levels appeared more strongly associated with low back pain than disc space narrowing at only 1 level. The strength of the associations increased with chronic low back pain. The majority of the associations were strengthened by excluding level L5–S1.

The most frequently observed radiographic feature of lumbar disc degeneration was osteophytes, with greater frequency in men than in women. Narrowing, however, was more common in women than in men and was also shown to be more frequent at the lower disc levels. Both individual radiographic features increased in frequency with age.

Data from many studies suggest an association with lumbar disc degeneration and low back pain. The authors are not aware of data from population-based samples that have investigated the association of different definitions of lumbar disc degeneration with self-reported low back pain. MacGregor et al performed a study, using MRI scans to assess risk factors associated with severe back pain. They investigated a number of features including; disc height, signal change, disc bulge and anterior osteophytes, and made a sum score for all features together. This sum was associated with severe back pain. However, they did not state which features had the highest predictive capability. Some studies suggest an association between osteophytes and low back pain and some studies suggest an association between disc space narrowing and low back pain. The data from this study confirms the association between low back pain and disc space narrowing. In addition, the data suggest an association with osteophytes, only when a more specific definition (osteophytes) is used. However, when osteophytes and disc space narrowing were both included in the model, there was no association with osteophytes anymore. Therefore osteophytes do not have an independent association with low back pain and seem therefore an inferior derivate from disc space narrowing.

Some studies suggest that the strength of the association between low back pain and disc space narrowing grows with increasing severity of disc space narrowing. Data from this study confirm this, but only when L5–S1 is excluded. Further, the data indicate that the association between low back pain and disc space narrowing increases when a greater number of levels are affected.

The explanation for the stronger association between low back pain and disc space narrowing compared with the presence of osteophytes is unknown. It is possible that the reduction of space between the vertebrae as a consequence of the degenerative disc is more likely to lead to increased pressure on facet joints and spinal ligaments.

The explanation for the stronger association between back pain and disc space in men compared with the association in women is also unknown. It is possible that even though women reported low back pain more often, only a small proportion of the complaints are due to lumbar disc degeneration, whereas other factors determine the feeling of pain. Men and women could also report pain differently therefore effecting the association between back pain, disc space narrowing and gender. Cecchi et al showed that women presented with significantly more severe pain than men.

A possible explanation for the stronger association between low back pain and disc space narrowing, excluding level L5–S1, is the possible overrating of the narrowing grade of the lumbosacral disc. The height of the lumbosacral disc is difficult to score due to its narrowed height relative to disc L4–L5. The lumbosacral disc is also different in appearances among different individuals, independently of disease. Therefore, by using the lumbar disc definition “narrowing 1 to 4,” the inconsistency of the grading scores at this level is ruled out. Furthermore, some differences in the reported associations in the prior studies can be explained by the stratified results. Possible explanations for relatively low odds ratios previously reported could be due to the use of a young age group, the use of women only and scoring of the lumbosacral level.

Data from this study confirms the findings from recent population based radiographic surveys showing a greater frequency and severity of osteophytes in men than in women. A possible explanation for the greater frequency in men is the higher BMD in men. However, after including BMD in the model, although less explicit, men still show a greater frequency and severity of osteophytes.

Data from this study suggest a greater frequency and severity of narrowing in women than in men and confirms that the prevalence of osteophytes and disc space narrowing increases with age in both men and women.

The authors defined chronic low back pain to be present when the duration of the low back pain was more than 1 year. In this way the definition chronic low back pain included long lasting chronic complaints with long lasting impact on ones life. When they defined chronic low back pain to be present when the duration of the low back pain was more than 6 months, the OR of the associations diminished.

From this data, a useful case definition for lumbar disc degeneration can be deduced; specifically disc space narrowing at 2 or more levels from L1/2 to L4–L5. This definition shows the strongest relationship with low back pain and represents a more generalized form of lumbar disc degeneration. As a result it might be a promising clinically relevant phenotype in genetic and epidemiologic lumbar disc degeneration research.

The data provides evidence for a moderate association between disc space narrowing and low back pain. This association is only slightly less than the association of pain and radiologic knee osteoarthritis and even slightly more than the association of pain and radiologic hand osteoarthritis in the same population sample.

The most important aspect of the data are that disc space narrowing at 2 or more levels is even more related to chronic low back pain. The ability of lumbar disc degeneration in predicting low back pain at the follow-up period was unfortunately not possible to investigate, as no questions about low back pain specifically were asked at the follow-up visit.

The data provides evidence for an association between disc space narrowing and low back pain especially in men, with the association increasing, with increasing numbers of affected intervertebral disc spaces. The data highlights the frequent occurrence of individual radiographic features, as well as the increased frequency in age, of the individual radiographic features of lumbar disc degeneration in population samples of men and women.

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.

The Journal of Bone and Joint Surgery (American) 84:2022-2028 (2002)
“This study revealed that the Tt allele of the vitamin-D receptor gene was more frequently associated with multilevel and severe disc degeneration and disc herniation than was the TT allele, pointing to an increased risk of disc disease at an early age in subjects with the Tt allele in the vitamin-D receptor gene.”

Spine: 1 December 1999 – Volume 24 – Issue 23 – p 2456
“The current study showed that multilevel and severe disc degeneration was present in the participants with shorter variable numbers of tandem repeat length of the aggrecan gene. This suggests that subjects with shorter variable numbers of tandem repeat length of the aggrecan gene have a risk of having multilevel disc degeneration develop at an early age.”

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.

The criteria for determining facet tropism have varied greatly, although the actual definition of facet tropism is asymmetry between the right and left facet joints. In the lumbar spine, the majority of facet joints vary by less than 7° in orientation between the two sides. Noren et al. defined facet asymmetry as a bilateral angle difference greater than 5°. In other biomechanical studies, facet asymmetry was defined as a difference in facet angles greater than 1-10° or one SD. Grogan, et al. divided facet joint tropism into three distinct classifications. When the orientation differed from one side to another by more than 7°, the facet joints at that level were defined as having tropism. Moderate tropism was defined as a difference of 7° to 15° between the orientation of the joints (one SD from the mean difference) and severe tropism was defined as a difference of more than 15° (two SDs from the mean) between the two sides. For the current study, the authors defined facet tropism to be bilateral angular asymmetry greater than 7°.

The angular difference inherent to facet joint tropism causes biomechanical issues. By definition, facet joint degeneration exists when one joint has more coronal orientation than the other. Farfan and Sullivan emphasized the importance of coronally facing facet joints upon the development of lumbar disc herniations. Coronally facing facet joints offer little resistance to shear intervertebral force, so that the joints tend to rotate toward the side of the more coronary facing facet joint, possibly leading to additional rotational stress on the annulus fibrosus. Loback, et al. showed that facet joint asymmetry is found more likely on the side of the coronally facing facet joint. When tropism was present, the motion segment was found to have a tendency to rotate towards the more oblique joint when axial loads were applied. This asymmetric axial rotation caused by tropism can place additional torsional loads on the intervertebral discs which can lead to intervertebral disc injury and degeneration. This biomechanical mechanism was used to describe the development of lumbar disc herniation, disc degeneration, and degenerative spondylolisthesis associated with facet tropism. Some studies have claimed that lumbar facet joint tropism does not accelerate degeneration of the facet joints. For the current study, the authors chose to investigate facet tropism and some of the findings associated with lumbar degenerative disc disease, including disc degeneration, facet joint degeneration, and spondylolisthesis (translational segmental motion).

The role of facet tropism in the pathogenesis of disc degeneration is a contested issue. Boden, et al. and Vanharanta, et al. reported no significant correlation between facet tropism and disc degeneration. However, Noren, et al. concluded that the existence of facet tropism can increase the risk of disc degeneration. Additionally, Dai reported that a significant correlation existed between facet joint tropism and the degree of disc degeneration in patients with degenerative spondylolisthesis. In the present study, no significant correlation was observed between facet joint tropism and disc degeneration at L3-L4, L4-L5, or L5-S1. However, a higher (but not statistically significant) incidence of highly degenerated discs at L4-L5 was observed within the facet tropism group.

Grogan, et al. concluded that lumbar facet joint tropism does not accelerate facet joint degeneration. They reported no significant differences in facet joint degeneration between facet joints with and without tropism. However, there are many limitations associated with this study. It was based on a small number of specimens (21 cadavers) and an even smaller number of lumbar facet joints exhibiting facet tropism (10 out of 104 lumbar facet joints). Additionally, this study did not take the level, where the tropism occurred, into consideration. Our current study included L3-L4, L4-L5, and L5-S1 facet joints belonging to 300 living participants and our findings were found to be similar to Grogan et al.’s at L3-L4 and L5-S1. However, at L4-L5, a significant correlation between facet joint tropism and facet joint degeneration was observed. Based on the fact that L4-L5 experiences the most segmental flexion and extension within the lower lumbar spine, this result suggests that the existence of facet tropism within highly mobile lumbar segments could affect the development of facet joint degeneration.

Berlemann, et al. reported that facet joint asymmetry does not seem to play a major role in the development of degenerative spondylolisthesis. However, Dai found that facet joint tropism was a predisposing factor for the development of degenerative spondylolisthesis. The present study found no association between facet tropism and translational segmental motion (such as vertebral slippage) within the lumbar spine. Our results indicate that facet tropism has no major association with the development of degenerative spondylolisthesis.

Previous reports have shown that facet orientation has a significant association with degenerative spondylolisthesis. Additionally, some of these studies reported that, in patients with degenerative spondylolisthesis, the transverse plane of facet joints was more sagittally oriented. All of these studies found that individuals with larger facetjoint angles, relative to the coronal plane (more sagittal orientation of facet joint), exhibited a higher incidence of degenerative spondylolisthesis. Although facet orientation was not taken into consideration for this study, the authors believe that it is an important element for understanding all of the factors that lead to the development of spondylolisthesis, and that this topic should be investigated further.

Another interesting factor to take into consideration is the existence of facet joint tropism within normal spines. This raises questions as to the root causality of facet joint tropism. Facet joint tropism could be caused by an inborn characteristic of the human spine, as a result of mechanical stresses on the spine (i.e., asymmetric loading of the human spine) or as a consequence of existing spinal deformities (i.e., scoliosis). Noren, et al. documented that subjects with lumbar degenerative disc disease had a higher incidence of facet joint tropism than the normal population. The nature of the relationship between facet joint tropism and degenerative changes within the lumbar spine remains a controversial topic. Essentially, there are two sides to this debate, one advocating that facet tropism leads to degeneration and the other claiming that certain degenerative statuses (i.e., degenerative spondylolisthesis) lead to facet tropism. Our results show that, at active functional spine units, facet tropism partially influences the development of facet joint degeneration. This seems to give legitimacy to the theory that facet tropism can lead to facet joint degeneration, although further investigation into the relationship between facet tropism and facet joint degeneration is necessary.

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.

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.

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.

Matrix metalloproteinases (MMPs) are known to be involved in the degradation of the nucleus pulposus during intervertebral disc degeneration. This study investigated MMP-10 (stromelysin-2) expression in the nucleus pulposus during intervertebral disc degeneration and correlated its expression with proinflammatory cytokines and molecules involved in innervation and nociception during degeneration which results in low back pain.

Human nucleus pulposus tissue was obtained at post-mortem from patients without a history of back pain and graded as histologically normal or degenerate. Symptomatic degenerate nucleus pulposus samples were also obtained at surgery for low back pain. Expression of MMP-10 mRNA and protein was analysed using real time PCR and immunohistochemistry. Gene expression for proinflammatory cytokines IL-1 and TNF-alpha, nerve growth factor and the pain associated neuropeptide Substance P were also analysed. Correlations between MMP-10 and IL-1, TNF-alpha and nerve growth factor were assessed along with nerve growth factor with Substance P.

MMP-10 mRNA was significantly increased in surgical degenerate nucleus pulposus when compared to post-mortem normal and post-mortem degenerate samples. MMP-10 protein was also significantly higher in degenerate surgical nucleus pulposus samples compared to post-mortem normal. IL-1 and MMP-10 mRNA demonstrated a significant correlation in surgical degenerate samples, while TNF-alpha was not correlated with MMP-10 mRNA. Nerve growth factor was significantly correlated with both MMP-10 and Substance P mRNA in surgical degenerate nucleus pulposus samples.

MMP-10 expression is increased in the symptomatic degenerate intervertebral disc, where it may contribute to matrix degradation and initiation of nociception. Importantly, this study suggests differences in the pathways involved in matrix degradation between painful and pain free intervertebral disc degeneration.

This study has demonstrated, for the first time, increased MMP-10 expression in the symptomatic degenerate intervertebral disc when compared to non-degenerate or asymptomatic degenerate intervertebral disc . The correlation of MMP-10 with IL-1 and nerve growth factor, combined with the correlation between nerve growth factor and Substance P in symptomatic degenerate intervertebral disc’s suggests differences in the catabolic pathways between painful and pain free intervertebral disc degeneration. While this study focused on gene and protein expression profiling, it emphasizes the importance of MMP-10 in symptomatic intervertebral disc degeneration and highlights that a more detailed investigation into these pathways, including analysis of enzyme activities is required to better understand the underlying pathogenesis.

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.

Posterior Cervical Sympathetic Syndrome is a condition that is characterized by a host of cranial symptoms, such as headaches, abnormal functions of the eyes and the ears, and psychological and mental disorders. This syndrome usually appears after neck injuries, inflammation, or neoplasm.”

Sympathetic symptoms related to the neck may include; vertigo, disequilibrium, tinnitus, scotomata, decreased vision, dysphagia, dysphonia, cough, anxiety and asthenia.

History: In 1925, Jean Alexandre Barre, M.D., a French neurologist, and in 1928, Yong-Choen Lieou, a Chinese physician, each independently described a syndrome with a variety of symptoms thought to be due to a dysfunction in the posterior cervical sympathetic nervous system (a group of nerves located near the vertebrae in the neck). The posterior cervical sympathetic syndrome became known as Barre-Lieou Syndrome.

In a case documented in Vertebrogenic autonomic dysfunction-subjective symptoms published in The Journal of the CCA. 1981 Jun;25(2): 51-7,

Mrs. F. presented with neck pain and headaches. She had sustained a whiplash injury 2 years previously and her symptoms had cleared with chiropractic therapy. Her present symptoms had recurred 2 months prior to her consultation here. She complained of a constant, moderate to severe upper cervical ache which radiated into the occipital-frontal regions. The cephalalgia occurred daily and intensified in the midafternoon. She reported associated dizziness and difficulty in focusing her eyes. She could not clearly focus on close objects and stated that while driving, the windshield seemed to move back and forth in relation to her eyes. She was constantly squinting in an effort to see clearly. She had been seen by an optometrist 3 weeks previously with negative findings.

On examination, cervical extension, right side-bending and left rotation were painful and limited. There was palpable paravertebral muscle spasm and restriction of motion in the upper cervical articulations. Trigger points were found here which reproduced the cephalalgia.

Cervicogenic autonomic dysfunction was objectivated with the following manoeuvres:

1. Triggers: Firm pressure over the right lamina of C2 precipitated an immediate bout of blurred vision and diplopia.
2. Resisted Motion: Resisted cervical extension (with the head fixed so as to exclude vestibular motion) resulted in an episode of “swooning” and vertigo.
3. Cervical Torsion: The patient’s head was fixed by an assistant (so as to exclude vestibular motion) and the torso was rotated, flexed, extended, side-bent and circumducted under the immobilized cranium. These manoeuvres precipitated vertigo.

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.

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.

Previous cross-sectional studies have demonstrated that age-related changes of the cervical spine are widely present even in asymptomatic healthy subjects. Boden et al, who conducted MRI of the cervical spine in asymptomatic healthy subjects, reported that degenerative MRI findings were recognized frequently in subjects 40 years and older despite the absence of symptoms. Lehto et al conducted MRI of the cervical spine, using a 0.1-T MRI imager in 89 healthy subjects. Some sorts of abnormal findings were recognized in 62% of the subjects 40 years and older, whereas abnormal findings were rare in those younger than 40 years.

Although these several cross-sectional studies have been reported, the longitudinal studies on the aging processes of the spine are very scarce. However, this kind of study is necessary as a control when assessing the outcomes of various surgical and nonsurgical interventions against various cervical spinal diseases. Once surgical intervention for serious cervical intervertebral disc herniation and cervical spondylotic myelopathy, secondary to disc degeneration, is warranted, anterior cervical discectomy with fusion is the usual procedure and the gold standard. It is widely and anecdotally believed that degeneration of the intervertebral discs adjacent to the fusion level are accelerated by fusion, thereby causing later problems, Yue et al investigated 71 patients who underwent anterior cervical fusion, and found progression of disc degeneration at the adjacent intervertebral levels in 73% of the patients after a long-time follow-up. They reported that reoperation was required in 17% of the 71 patients. To solve adjacent segment deterioration, attempts to develop and clinically apply artificial intervertebral discs and homologous intervertebral disc transplantation that preserves physiologic motions of the cervical spine have been carried out. However, at present, it is unknown whether anterior fusion truly accelerates degeneration of the adjacent segment or whether motion preservation technique can really prevent degeneration, because there has been few longitudinal study on the normal aging processes of the disc that can serve as an appropriate control. Borenstein et al followed 31 of 67 asymptomatic healthy subjects (follow-up rate, 46%) longitudinally for 7 years and repeated MR studies of the lumbar spine, and found that low back pain appeared in 42.0% and progression of degenerative findings on MRI was recognized in 74.2% of the subjects.

The report by Gore et al is the only longitudinal study of the cervical spine in healthy subjects. They performed a 10-year longitudinal follow-up study of healthy subjects without cervical spine-related symptoms, using plain x-ray, and found that, at follow-up, neck pain was recognized in 15% of their subjects, who had no symptoms at the time of initial imaging, and that changes in x-ray findings were recognized in 63% of the subjects.

The present longitudinal 10-year follow-up study revealed that degeneration of the cervical intervertebral discs progressed in 81.1% of the initially asymptomatic subjects. According to the evaluation in the different age groups, progression of disc space narrowing and foraminal stenosis was observed more frequently in subjects 50 years and older than those under 50 years of age, while the proportions the subjects with progression of decrease in the signal intensities of the intervertebral disc, anterior compression of the dura and the spinal cord, and PDP were higher in subjects 20 to 49 years old than in those older than 50 years. The differences in the degree of progression in the different MR findings among the different age groups may reflect the presence of different stages in the degeneration processes of the intervertebral discs. Our results suggested that biochemical changes in the intervertebral disc represented by the decrease in the signal intensity on MRI and early structural changes of the disc represented by anterior dural compression and posterior disc protrusion occur in the younger age groups (20-50 years) and more advanced structural changes in the intervertebral disc represented by disc space narrowing and foraminal stenosis occur in the older age groups (older than 50 years).

Smoking habit, labor, history of lumbar surgery, etc. were suggested as factors accelerating the aging process of the cervical intervertebral discs in several previous studies. The subjects of most of these studies were patients with serious cervical spinal disorders requiring surgery and few such studies dealt with healthy subjects, as this present study. The proportion of the subjects with progression of degeneration of the intervertebral disc during 10-year study period was higher in the elderly than in the young age groups. However, there was no significant correlation between progression of disc degeneration and the parameters, including gender, smoking, alcohol, sport and BMI, which have been reported to be related to disc degeneration in the previous studies.

Most cross-sectional studies on asymptomatic volunteers conducted to date have shown that degenerative changes in the intervertebral discs are frequently observed on MRI, suggesting that such degenerative changes on MRI are often not associated with clinical symptoms. However, in the present longitudinal study, patients who developed clinical symptoms during 10 years, including neck pain and stiff shoulder demonstrated significantly more frequent progression of structural disc degeneration on MRI including anterior compression of dura and spinal cord, posterior disc protrusion, disc space narrowing, and foraminal stenosis than those without development of clinical symptoms. Thus, unlike the results of the previous cross-sectional studies, progression of structural changes of intervertebral discs on MRI during a long-time period is likely to correlate significantly with clinical symptoms.

The present study is the first large-scale longitudinal study, in which the degree of degeneration of the cervical spine was investigated using MRI, demonstrating progression of disc degeneration in initially asymptomatic healthy volunteers. The result of the present study can serve as a useful control for the evaluation of the postinterventional course in patients with various cervical spinal disorders.

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.

The etiology of anterior lumbar vertebral osteophytes is considered as follows. An increased flexibility between the vertebral bodies due to disc degeneration leads to the production of inhomogeneous mechanical stress on the ossification of bone under the cartilage of the vertebral body; consequently, sclerotic or hyperplastic changes occur on the edge of the vertebral body, leading to the formation of osteophytes. However, the level of degradation of the intervertebral disc is not always consistent with the degree of formation of osteophytes, and, like the syndesmophytes described by Schumacher et al., osteophytes may be caused by the ossification of the anterior longitudinal ligament and the annulus fibrosus of the intervertebral disc.

The study of anterior lumbar vertebral osteophytes by O’Neill et al. demonstrated that X-ray examination of the lumbar spine of subjects screened for osteoporosis exhibited an increased frequency of anterior lumbar vertebral osteophytes with aging. Furthermore, Watanabe et al. reported that there was a positive correlation between the size of osteophytes and the age of patients in whom the size of lumbar vertebral osteophytes was measured at the autopsy. These studies indicated that osteophytes were caused by aging changes. On the other hand, anterior lumbar vertebral osteophytes have been reported to occur most frequently at L3–L4, and more frequently in men and obese patients or those with heavy physical activity than in women or other patients. Other studies have revealed that spur formation is showing a tendency to intensify annually in approximately 4% of people, and that people with osteophytes are less likely to develop osteoporosis.

We reviewed the literature with respect to the direction of spur formation, and found a study by Pate et al. who used 200 cadavers to identify the occurrence rates of claw and traction osteophytes at 2,000 locations in the intervertebral spaces of Th12-L1, L1–L2, L2–L3, L3–L4, and L4–L5. They observed that 182 (91%) of the 200 cadavers had osteophytes in at least one intervertebral space. These spurs were distributed in approximately 48% of the 2,000 locations, with claw osteophytes accounting for about 39% and traction osteophytes accounting for some 9%. The former were dominant in Th12 to L2, while the latter were more evident in L3 to L5. The authors results show a similar tendency. Although there is a previous report on the direction of spur formation, they considered that this study was worth the effort because it closely examined a considerable number of cases in terms of the direction of spur formation. The authors believe the discussion on the direction of spur formation in our study will help researchers in this field explore the causes and meaning of spur formation, and investigate the pathology and progress of lumbar spine degeneration.

The results of this study showed that pairs of osteophytes frequently formed in the direction of the adjacent disc in upper lumbar vertebrae (L1–L2 and L2–L3) and in a direction away from the adjacent disc in middle or lower lumbar vertebrae (L3–L4, L4–L5, and L5-S1). Shao et al. reported that the ventral disc height and lordosis angle were greater in L3–L4, L4–L5, and L5-S1 than in L1–L2 and L2–L3. It was also reported that the degree of disc degeneration tended to be higher in L3–L4, L4–L5, and L5-S1 than in L1–L2 and L2–L3, with intervertebral instability being more frequently observed in the lower lumbar vertebrae. The authors postulate that anatomical and biomechanical differences as well as differences in the degenerative process of the upper and lower lumbar vertebrae are among the essential factors that determine the direction of spur formation in intervertebral spaces.

As a limitation of this study, they mention that the subjects were outpatients of the spine unit of their department. Thus, they are planning to conduct a similar study targeting the general population. In a future study, they will investigate the deformation of multiple intervertebral disc spaces, with regard to biomechanical differences between upper lumbar vertebrae and middle or lower lumbar vertebrae in human lumbar vertebrae of cadavers. They are also planning to investigate the direction of spur formation in a cross-sectional and in a longitudinal study.