Low back pain in relation to lumbar disc degeneration
TL;DR: An increased risk of LBP (including all types) was found in relation to all signs of disc degeneration and sciatic pain with posterior disc bulges, and low back pain is strongly associated with occupation.
Abstract: STUDY DESIGN: Cross-sectional magnetic resonance imaging (MRI) study. OBJECTIVES: To study the relation of low back pain (LBP) to disc degeneration in the lumbar spine. BACKGROUND DATA: Controversy still prevails about the relationship between disc degeneration and LBP. Classification of disc degeneration and symptoms varies, hampering comparison of study results. METHODS: Subjects comprised 164 men aged 40-45 years-53 machine drivers, 51 construction carpenters, and 60 office workers. The data of different types of LBP, individual characteristics, and lifestyle factors were obtained from a questionnaire and a structured interview. Degeneration of discs L2/L3-L5/S1 (dark nucleus pulposus and posterior and anterior bulge) was assessed with MRI. RESULTS: An increased risk of LBP (including all types) was found in relation to all signs of disc degeneration. An increased risk of sciatic pain was found in relation to posterior bulges, but local LBP was not related to disc degeneration. The risks of LBP and sciatic pain were strongly affected by occupation. CONCLUSIONS: Low back pain is associated with signs of disc degeneration and sciatic pain with posterior disc bulges. Low back pain is strongly associated with occupation.
Citations
More filters
TL;DR: The intervertebral disc is a cartilaginous structure that resembles articular cartilage in its biochemistry, but morphologically it is clearly different, and shows degenerative and ageing changes earlier than does any other connective tissue in the body.
Abstract: The intervertebral disc is a cartilaginous structure that resembles articular cartilage in its biochemistry, but morphologically it is clearly different. It shows degenerative and ageing changes earlier than does any other connective tissue in the body. It is believed to be important clinically because there is an association of disc degeneration with back pain. Current treatments are predominantly conservative or, less commonly, surgical; in many cases there is no clear diagnosis and therapy is considered inadequate. New developments, such as genetic and biological approaches, may allow better diagnosis and treatments in the future.
1,124 citations
TL;DR: There was a positive correlation between the DDD score and low back pain and in a population setting, there is a significant association of LDD on MRI with back pain.
Abstract: Study design A cross-sectional population study of magnetic resonance imaging (MRI) changes. OBJECTIVE.: To examine the pattern and prevalence of lumbar spine MRI changes within a southern Chinese population and their relationship with back pain. Summary of background data Previous studies on MRI changes and back pain have used populations of asymptomatic individuals or patients presenting with back pain and sciatica. Thus, the prevalence and pattern of intervertebral disc degeneration within the population is not known. Methods Lumbar spine MRIs were obtained in 1043 volunteers between 18 to 55 years of age. MRI changes including disc degeneration, herniation, anular tears (HIZ), and Schmorl's nodes were noted by 2 independent observers. Differences were settled by consensus. Disc degeneration was graded using Schneiderman's classification, and a total score (DDD score) was calculated by the summation of the Schneiderman's score for each lumbar level. A K-mean clustering program was used to group individuals into different patterns of degeneration. Results Forty percent of individuals under 30 years of age had lumbar intervertebral disc degeneration (LDD), the prevalence of LDD increasing progressively to over 90% by 50 to 55 years of age. There was a positive correlation between the DDD score and low back pain. L5-S1 and L4-L5 were the most commonly affected levels. Apart from the usual patterns of degeneration, some uncommon patterns of degeneration were identified, comprising of subjects with skip level lesions (intervening normal levels) and isolated upper or mid lumbar degeneration. Conclusion LDD is common, and its incidence increases with age. In a population setting, there is a significant association of LDD on MRI with back pain.
714 citations
TL;DR: IL-1 is produced in the degenerate IVD, it is synthesized by native disc cells, and treatment of human disc cells with IL-1 induces an imbalance between catabolic and anabolic events, responses that represent the changes seen during disc degeneration.
Abstract: In this study, we investigated the hypotheses that in human intervertebral disc (IVD) degeneration there is local production of the cytokine IL-1, and that this locally produced cytokine can induce the cellular and matrix changes of IVD degeneration. Immunohistochemistry was used to localize five members of the IL-1 family (IL-1alpha, IL-1beta, IL-1Ra (IL-1 receptor antagonist), IL-1RI (IL-1 receptor, type I), and ICE (IL-1beta-converting enzyme)) in non-degenerate and degenerate human IVDs. In addition, cells derived from non-degenerate and degenerate human IVDs were challenged with IL-1 agonists and the response was investigated using real-time PCR for a number of matrix-degrading enzymes, matrix proteins, and members of the IL-1 family. This study has shown that native disc cells from non-degenerate and degenerate discs produced the IL-1 agonists, antagonist, the active receptor, and IL-1beta-converting enzyme. In addition, immunopositivity for these proteins, with the exception of IL-1Ra, increased with severity of degeneration. We have also shown that IL-1 treatment of human IVD cells resulted in increased gene expression for the matrix-degrading enzymes (MMP 3 (matrix metalloproteinase 3), MMP 13 (matrix metalloproteinase 13), and ADAMTS-4 (a disintegrin and metalloproteinase with thrombospondin motifs)) and a decrease in the gene expression for matrix genes (aggrecan, collagen II, collagen I, and SOX6). In conclusion we have shown that IL-1 is produced in the degenerate IVD. It is synthesized by native disc cells, and treatment of human disc cells with IL-1 induces an imbalance between catabolic and anabolic events, responses that represent the changes seen during disc degeneration. Therefore, inhibiting IL-1 could be an important therapeutic target for preventing and reversing disc degeneration.
702 citations
TL;DR: The degenerative disc, having lost its height, effects the structures close by, such as ligamentum flavum, facet joints, and the shape of the neural foramina, the main cause of spinal stenosis and radicular pain due to the disc degeneration in the aged populations.
Abstract: This review article describes anatomy, physiology, pathophysiology and treatment of intervertebral disc. The intervertebral discs lie between the vertebral bodies, linking them together. The components of the disc are nucleus pulposus, annulus fibrosus and cartilagenous end-plates. The blood supply to the disc is only to the cartilagenous end-plates. The nerve supply is basically through the sinovertebral nerve. Biochemically, the important constituents of the disc are collagen fibers, elastin fibers and aggrecan. As the disc ages, degeneration occurs, osmotic pressure is lost in the nucleus, dehydration occurs, and the disc loses its height. During these changes, nociceptive nuclear material tracks and leaks through the outer rim of the annulus. This is the main source of discogenic pain. While this is occurring, the degenerative disc, having lost its height, effects the structures close by, such as ligamentum flavum, facet joints, and the shape of the neural foramina. This is the main cause of spinal stenosis and radicular pain due to the disc degeneration in the aged populations. Diagnosis is done by a strict protocol and treatment options are described in this review. The rationale for new therapies are to substitute the biochemical constituents, or augment nucleus pulposus or regenerate cartilaginous end-plate or finally artificial disc implantation..
569 citations
Cites background from "Low back pain in relation to lumbar..."
...Back pain is strongly associated with degeneration of the intervertebral disc.(2) Disc degeneration, although in many cases asymptomatic,(3) is also associated with sciatica and disc herniation or prolapse....
[...]
TL;DR: It is argued that mechanics and biology are interconnected and amplify each other and the proposed disease model explains the comparable efficacy of very different animal models of disc degeneration, but also helps to consider the consequences of therapeutic interventions, either at the cellular, material or mechanical level.
528 citations
References
More filters
TL;DR: In this paper, the authors performed magnetic resonance imaging on sixty-seven individuals who had never had low-back pain, sciatica, or neurogenic claudication, and found that about one-third of the subjects were found to have a substantial abnormality.
Abstract: We performed magnetic resonance imaging on sixty-seven individuals who had never had low-back pain, sciatica, or neurogenic claudication. The scans were interpreted independently by three neuro-radiologists who had no knowledge about the presence or absence of clinical symptoms in the subjects. About one-third of the subjects were found to have a substantial abnormality. Of those who were less than sixty years old, 20 per cent had a herniated nucleus pulposus and one had spinal stenosis. In the group that was sixty years old or older, the findings were abnormal on about 57 per cent of the scans: 36 per cent of the subjects had a herniated nucleus pulposus and 21 per cent had spinal stenosis. There was degeneration or bulging of a disc at at least one lumbar level in 35 per cent of the subjects between twenty and thirty-nine years old and in all but one of the sixty to eighty-year-old subjects. In view of these findings in asymptomatic subjects, we concluded that abnormalities on magnetic resonance images must be strictly correlated with age and any clinical signs and symptoms before operative treatment is contemplated.
2,645 citations
TL;DR: On MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions but not extrusions, and the discovery by MRI of bulging disks in people with low back pain may frequently be coincidental.
Abstract: Background The relation between abnormalities in the lumbar spine and low back pain is controversial. We examined the prevalence of abnormal findings on magnetic resonance imaging (MRI) scans of the lumbar spine in people without back pain. Methods We performed MRI examinations on 98 asymptomatic people. The scans were read independently by two neuroradiologists who did not know the clinical status of the subjects. To reduce the possibility of bias in interpreting the studies, abnormal MRI scans from 27 people with back pain were mixed randomly with the scans from the asymptomatic people. We used the following standardized terms to classify the five intervertebral disks in the lumbosacral spine: normal, bulge (circumferential symmetric extension of the disk beyond the interspace), protrusion (focal or asymmetric extension of the disk beyond the interspace), and extrusion (more extreme extension of the disk beyond the interspace). Nonintervertebral disk abnormalities, such as facet arthropathy, were also d...
2,153 citations
TL;DR: The prevalence, validity and reliability of high-intensity zones in the annulus fibrosus seen on T2-weighted magnetic resonance images of patients with intractable low-back pain were determined and this sign is diagnostic of painful internal disc disruption.
Abstract: The prevalence, validity and reliability of high-intensity zones in the annulus fibrosus seen on T2-weighted magnetic resonance images of patients with intractable low-back pain were determined. This sign was readily recognized by two independent observers. It occurred in 28% of 500 patients undergoing magnetic resonance imaging for back pain. The presence of a highintensity zone correlated significantly with the presence of Grade 4 annular disruption and with reproduction of the patient's pain. Its sensitivity as a sign of either annular disruption or pain was modest but its specificity was high, and its positive predictive value for a severely disrupted, symptomatic disc was 86%. This sign is diagnostic of painful internal disc disruption.
575 citations
TL;DR: There was evidence of an inflammatory response to the nuclear material injected, but no inflammatory response occurred in the control group, and the dogs were killed at times identical to the experimental group.
Abstract: Homogenized autogenous nucleus pulposus was injected into the lumbar epidural space of four dogs through an indwelling catheter. After daily injections of the material over 5 to 7 days, the dogs were killed at 5, 7, 14, or 21 days after the first injection. In four dogs that served as controls, normal saline was injected on an identical schedule and the dogs were killed at times identical to the experimental group. Evaluation of the dural sac, the spinal cord and its roots was performed by gross inspection and microscopic analysis. There was evidence of an inflammatory response to the nuclear material injected, but no inflammatory response occurred in the control group.
530 citations
TL;DR: Findings indicate a more extensive disc innervation in the severely degenerated human lumbar disc compared with normal discs, which provides further evidence for the existence of a morphologic substrate of discogenic pain.
Abstract: Study Design The authors investigated the innervation of discographically confirmed degenerated and ''painful'' human intervertebral discs Objective To determine the type and distribution patterns of nerve fibers present in degenerated human intervertebral discs Summary of Background Data The innervation of intervertebral discs has previously been extensively described in fetal and adult animals as well as humans However, little is yet known about the innervation of severely degenerated human lumbar discs The question may be posed whether a disc that has been removed for low back pain possesses an increased innervation compared with normal discs Methods The presence of nerve fibers was investigated using acetylcholinesterase enzyme histochemistry, as well as neurofilament and substance P immunocytochemistry From 10 degenerated and 2 control discs, the anterior segments were excised and their nerve distribution studied by examining sequential sections Results In all specimens, nerve fibers of different diameters were found in the anterior longitudinal ligament and in the outer region of the disc In 8 of 10 degenerated discs, fibers were also found in the inner parts of the disc Substance P-immunoreactive nerve fibers were sporadically observed in the anterior longitudinal ligament and the outer zone of the anulus fibrosus Conclusions Findings indicate a more extensive disc innervation in the severely degenerated human lumbar disc compared with normal discs The nociceptive properties of at least some of these nerves are highly suggested by their substance P immunoreactivity, which provides further evidence for the existence of a morphologic substrate of discogenic pain
475 citations