Cervical Spine Study Suggests Pathogenesis of Osteoarthritis More Prevalent in Aging Men

Pathogenesis Osteoarthritis

A cross-sectional autopsy study of the articular facet joints of 72 male and female cadavers found degenerative changes, including splitting, fissures, thickening and thinning of calcified cartilage and subchondral bone plates were associated with aging. Male subjects were more likely to demonstrate cartilage degeneration than females, though age-related changes were observed in both sexes. The degenerative changes noted appeared at all spinal levels where osseous structures of the cervical spinal facet joints or articular cartilage were involved. The study’s findings may be significant in understanding the progression of osteoarthritis.

Seeking to Better Understand Age-related Neck Pain

There are many possible causes for debilitating neck pain—a leading cause of disability worldwide. One possible cause of musculoskeletal neck pain is osteoarthritis—particularly, that of the cervical spine facet joints. A better understanding of the mechanisms involved in neck pain and how gender may influence the development and progression of cervical neck pain is necessary.

The Study

Researchers obtained C4-C7 spinal segments from 29 female, and 43 male cadavers to evaluate morphological and histomorphometric variables of 1132 articular facets. The mean age of the female cervical samples was 53 years, and the male samples were roughly 38 years old. A linear regression model was used to analyze the microscopic examination and random sampling data retrieved during the study.

Age-related Bone and Cartilage Changes More Prominent in Men, but Evident in All

The male samples involved in this study demonstrated more extensive cartilage degeneration than the female cervical samples. Statistically-significant increases in fissures, splitting, osteophytes, calcified cartilage and subchondral bone plate thickness were associated with aging in the data analysis. This was true at all levels of the cervical spine that involved osseous structures of the facet joints and articular cartilage. Overall, there were few differences between the male and female subject samples when it came to histomorphometric variables, including a gradual increase of subchondral bone and cartilage thickness and a decrease of hyaline articular cartilage thickness with age. This could indicate that age-related degeneration of these structures follows a similar path in both genders. The results indicate that there is an increase of 2 percent per decade in cartilage thickness, which suggests that endochondral ossification is involved in the pathology of osteoarthritis. The findings also indicated that increasing age was related to an increase in subchondral sclerosis and the development of osteophytes in the articular skeleton. The maximum cartilage length also increased by .56 mm per decade, or roughly 4 percent per person and was more pronounced in male samples than in female ones. The presence of synovial folds was similar in all male and female samples aged 20-79 years.

Multifactorial Approach to Neck Pain in the Elderly Recommended

Although it seems probably that OA changes in the cervical spine may be linked to neck pain in the aging population, the exact mechanisms involved in the development of neck pain remain unclear. Women over the age of 45 are more likely than their male counterparts to report neck pain, but this study found that aging males are more prone to cervical degenerative changes than females, indicating that there may be other causes besides OA of the facet joints when it comes to neck pain in the elderly population. The authors of the study recommend practitioners take a multifactorial approach when it comes to diagnosing and treating neck pain in the elderly.

Blurb:

A study of lower cervical spine facet joints in cadavers suggests the causes of neck pain in the aging –one of the leading debilitating musculoskeletal conditions— are multifactorial and should be treated as such. Researchers found strong evidence that a progressive thickening of cervical joint cartilage in the aging population could play a role in the development of cervical osteoarthritis, particularly in men, whose spinal sample degeneration was more severe than that of the female subject samples. However, since women are more likely than men to complain of neck pain after the age of 45, the findings highlight the need for practitioners to osteoarthritis only one of many possible causes when diagnosing and treating neck pain in the elderly.

Three Month Study Compares Lumbar MR Image Changes of LBP Subjects to Control Group

An exploratory study comparing lumbar spine magnetic resonance (MR) images of 20 lower back pain (LBP) sufferers with those of 10 control subjects over a 12-week period found that both groups had a similar number of participants whose spinal imaging demonstrated changes over time, but the LBP subjects were twice as likely as the control subjects to have a change in disc herniation, nerve root compromise, or annular fissure on their scans.

Lumbar MR Image Study

Researchers sought to explore the clinical significance of lumbar MR image findings in diagnosing and treating patients with LBP—the leading cause of disability worldwide. Because it is often difficult to identify the underlying cause of LBP in patients, the researchers involved in the study were seeking to clarify the role of imaging in helping to diagnose and treat LBP.

The study included two groups—one group of 20 subjects who suffered from LBP, and a control group of 10 individuals who had experienced no LBP within the past 12 months. The two groups were given baseline MRI scans and then more scans at 1, 2, 6, and 12 weeks. The scans were compared by a clinical radiologist at the end of the 12-week period to determine the proportion of control and LBP subjects whose scans had demonstrated spinal changes during the study. The radiologist was unaware of which group each image belonged to prior to studying the scans.

Lumbar MRI Results

Eighty-five percent of the LBP subjects had at least one change in their MR imaging during the 12-weeks, and roughly 80 percent of the control subjects demonstrated at least a single change in their study scans. Significantly, the LBP subjects were twice as likely to exhibit changes in disc herniation, annular fissures, or root compromise as the control group subjects. Aside from these changes, the two groups were similar in their MR change proportions, and neither group demonstrated changes in facet joint arthropathy, canal stenosis, and spondylolisthesis or retrolisthesis.

Back Pain Subjects Had Twice as Many Degenerative Changes in Lumbar MRIs

The study’s researchers were surprised at the significant (double) proportion of LBP sufferers’ changes in disc herniation, root compromise, and annular fissures, as compared to the control group. They theorized that the reason for the similarity of change proportions in the control and LBP group’s MR imaging is that the control group changes represented “true” changes that occur naturally over time. It is also possible that differing imaging postures or techniques across the various scans could account for some of the similarities in image changes. They suggest future studies compare images of acute LBP subjects to a control group for a better perspective on the significance of these findings.

LBP During Upright Standing May Be Related to Lumbar Intervertebral Angle Distribution, Study Finds

A study of how intervertebral angles were distributed in two asymptomatic control groups—those who would develop lower back pain (LBP) after prolonged standing, and those who did not develop pain—found that there was a correlation between the distribution of intervertebral angles in pain developers (PD) throughout lumbar spines during upright standing poses, while there was little difference in the amount of lumbar lordosis, range of motion, lumbar spine recurve, or lumbar vertebral wedging between the two groups.

The Study

Eight subjects from a previous study were recruited for the purposes of characterizing lumbar postures in PDs and non-pain-developers (NPD). Researchers wished to find out how the distribution of intervertebral angles differed in both groups during standing x-rays. The study also looked at the range of motion (ROM) and various lumbar vertebral characteristics in members of each group. Eight male and female PDs were compared with eight male and female NPDs. PDs had reported developing LBP after two hours of standing in the previous study. An x-ray technician used a diagnostic high voltage x-ray generator to create radiographs of each participant during three static poses: upright standing, full extension, and full flexion. Measurements were made to determine each subject’s intervertebral angles as they related to each other and to the superior endplate and inferior vertebrae. The person responsible for analyzing the measurements was blinded to the pain groups until all the variables had been computed, and statistical models were created using SAS, with dependent variables grouped by Pose. The data was later analyzed, where statistically significant.

Results

Overall, those in the NPD study group had L5/S1 angles that were significantly more extended than their L1/L2, L2/L3, or L3/L4 angles. In addition, their L4/L5 angles were more extended than their L1/L2 angles. Those in the PD group were less varied and only showed differences between L1/L2 and L5/S1 with extension. For the most part, the two pain groups showed little variation in ROM, lumbar lordosis, vertebral wedging, or recurve, though subjects in the PD group did have a more equitable distribution of intervertebral angles throughout their lumbar spines in standing and full extension poses. PDs did not exhibit more lumbar lordosis while standing, but they were more likely to be recognized by their rate of extension during upright standing poses. This indicates that the overall lumbar spine characteristics of PDs and NPDs are similar, though they vary regionally when in extended poses. Therefore, it may be useful to use fully extended postures when identifying PDs versus NPDs in radiographic studies.

How Microgravity Affects the Biomechanical Properties of Caudal and Lumbar Mouse Discs

A lumbopelvis spine model with elastomeric sacroiliac joints (simulated hyaline and fibrocartilage thickness) adhered to a matching ilium and sacral bony specimen

A study of how microgravity affects the biomechanical properties of caudal and lumbar mouse discs showed that caudal discs that had been exposed to microgravity for 15 days experienced biomechanical diminishment, while their lumbar discs were relatively unaffected. The caudal discs lost height, were more likely to creep, and demonstrated less nuclear swelling strain dependence than the discs used in the control group.

The Study

The mice involved in the study were part of NASA’s Biospeciman Sharing Program and were exposed to 15 days of flight on the space shuttle prior to being sacrificed for analysis. Each mouse was radiographed prior to being dissected and having the soft tissues removed. The mice were mounted onto custom mechanical instruments that measured the rate of compressive creep and tissue deformation under a constant load. After five cycles of compressive creep loading and measuring, a displacement controlled stress relaxation test was used to measure the amount of nuclear swelling pressure, then the researchers calculated the change displacement and load response to determine the swelling pressure. All results were then analyzed using the Levonberg-Marquardt algorithm, and creep parameters were analyzed with a non-parametric test. The results of the control (non-flight) and space-flight group were compared for all parameters to determine any statistical differences or similarities.

Results

There was a statistically-significant difference in the caudal discs of the control and spaceflight specimen groups, but there was little difference in the lumbar discs of the two groups. The caudal discs of the spaceflight group were 32 percent shorter and crept 2.5 times more than those in the non-flight subjects. Strain-dependence of the spaceflight group’s swelling pressure was 70 percent lower than that of the non-flight group. This could help to explain the back-pain complaints of astronauts returning to Earth after long spaceflights.

Conclusion

The results of this study indicate that the effects of microgravity on the biomechanical properties of intervertebral caudal discs is significant in murine samples. Specifically, there is a diminishing effect in that microgravity appears to lessen disc height, increase the rate of creep, and lower strain-dependence swelling pressure in caudal discs. Though there were no statistically-significant differences between the spaceflight and non-flight study groups at the lumbar disc levels, it is possible that this is because mice are quadrupedal and thus may not have the excess swelling capacity that humans require to counter the daily loading of an upright posture. It is also possible that mice counter loading demands by transferring loads to their tails or adapting their movements during usual and zero-gravity conditions. In any event, the study findings indicate that constraining spinal movements to reduce nucleus swelling during the return to normal gravity conditions could help to lessen the negative effects of microgravity on astronauts on their return to Earth after a lengthy space flight.

 

Lower Back Pain a Possible Indicator of Future Osteoarthritis of the Knee or Hip, Study Finds

Future Osteoarthritis of the Knee or Hip

A study examining the purported link between lower back pain (LBP) and lumbar disc degeneration (LDD) determined evidence of an association between LBP and hip or knee osteoarthritis. A review of several published observational studies was unable to establish an association between LBP and osteophytes, though a moderate association between LBP (particularly neuropathic pain) and disc space narrowing was noted.

The Study

Researchers used logistic regression models to analyze associations between radiographic features of LDD and neuropathic pain in a total of 699 study participants who completed a questionnaire and lumbar radiograph. The radiographs were analyzed by two independent observers, who found that the presence of osteophytes in 98 percent of the population was not associated in any significant way with LBP.

Disc space narrowing, however, which occurred in 67 percent of the study participants, was significantly associated with neuropathic and LBP.  

The results of the 8-year follow-up, cross-sectional study in the Cohort Hip and Knee (CHECK) cohort in the Netherlands found that radiographs of the lumbar spine in patients with hip and knee osteoarthritis demonstrated a strong association between LDD and disc space narrowing, with LBP (particularly neuropathic) but little association between osteophytes and LBP. However, LBP was frequently reported in patients with osteoarthritis of the hip and knee.

Discussion

Though there appears to be no overt association between the presence of osteophytes in radiographs and LBP, a link is evident between disc narrowing/ degeneration and LBP. Furthermore, the presence of LBP in a great percentage of hip and knee osteoarthritis patients in cross-sectional study indicates a possible link between the conditions. The results of this study indicate the need for further research into the possible link between osteoarthritis of the hip and knee and LBP/LDD.

, , ,

Few Studies Examine the Effect of Health Literacy on LBP Treatment Outcomes

Spine Patient Education, Patient Centered, Education

A review of published research on the implications of patient Healthcare Literacy (HL) in patients with lower back pain (LBP) found that evidence-based studies were minimal and that further research could be beneficial in determining future treatment costs and outcomes. The ability of chronic pain sufferers to access, understand, and apply health information defines HL and can be helpful to practitioners treating LBP patients. The reviewers sought to understand how HL affects LBP patient treatment outcomes.

The Review

Researchers performed a data search using lower back pain terms in PubMed, Web of Science, PsychInfo, and CINAHL but found only three studies that directly addressed the issue of HL in patients with LBP. The search parameters were limited to studies conducted between the years of 2000-2017, published in English, and formatted as an article or review. Of the initial 1037 articles that met the initial criteria, only three were empirical research studies related to HL in patients with LBP.

Due to the lack of adequate data, a full, systematic review of the subject in question was not possible. Still, the authors of the review noted that, based on the limited data, patients with chronic LBP may have a more negative attitude towards their health and a more difficult time managing their health than patients without chronic back pain. Since self-health management is a central tenet of HL, this finding could indicate that better HL could assist in determining a better, more satisfying attitude and outcome for LBP patients.

One reviewed study looked at the effect of HL on patient empowerment and found that patients who had lower levels of HL were the most dependent on practitioners and least self-empowered when it came to managing their LBP. This was true of patients who used medication for chronic conditions and those who were treated without medication. This suggests that better HL in LBP patients can empower patients and lead to a more satisfying treatment outcome.

Conclusion

Though there are limited published studies about how HL affects LBP patient treatment outcomes, the available data suggests that patients who are better informed about their health are more likely to feel empowered and have a more satisfying treatment outcome. Patients who were being treated with or without medication were more likely to report better self-sufficiency and a sense of empowerment when they were more familiar with their condition and understood the health treatment options available to them. Further evidence-based research should be conducted to fully understand the relationship between improved HL and patient treatment experience and outcomes.

KEYWORDS: the effect of health literacy on LBP treatment outcomes. the implications of patient healthcare literacy (HL) in patients with lower back pain (LBP), how HL affects LBP patient treatment outcomes, self-health management, satisfying treatment outcome.

 

Follow-Up Study Finds Lumbar Transforaminal Epidural Steroid Injections Offer Only Temporary Pain Relief

Lumbar Transforaminal Epidural Steroid Injections

A post-five-year physician follow-up of a predetermined study group of patients who had received lumbar transforaminal epidural steroid injections (TFESI’s) to treat acute unilateral lumbar pain from their single level herniated nucleus found that, although the procedure offered temporary relief, most patients reported needed some type of additional pain intervention (medicinal, another TFESI, or back surgery) when interviewed 5 to 9 years after their procedure.

The Study

The 39 patients interviewed in this study were part of an original 78 subjects who had enrolled in a randomized controlled trial, in which the remaining patients were unreachable after multiple attempts five years after their TFESI’s.

Results

During a phone follow-up, 30 of the 39 patients reported having experienced recurring pain since their initial procedure, though only nine reported experiencing pain at the time of the phone call. Three patients were taking opioid medication to relieve their pain. Nine patients reported having had subsequent TFESI procedures since the first, and 19 of the subjects reported having had back surgery since their TFESI. Three patients reported unemployment due to their recurring back pain.

A comparison of the subjects who reported having had surgery to those who had not showed no difference in the rate of recurring or current pain, additional injections, unemployment, or opioid use.

Conclusion

While TFESI ‘s can be an effective means of short-term pain relief for patients with lumbar intervertebral disc herniation radicular pain, most patients interviewed in this study reported the recurrence of symptoms and need subsequent relief treatments—surgical, opioid, or another TFESI—five to nine years after their initial injection. Because there was little difference in the percentage of patients who chose surgery and those who had at least one subsequent TRESI in relation to the rate of pain recurrence, the authors of the study suggest that physicians should discuss and decide upon appropriate pain treatment measures with their patients based upon the frequency and severity of their acute pain, as well as their response history of previous treatments. Radicular pain caused by a herniated disc is a condition that should be treated effectively in its acute stage, though it is likely to remain a recurring health issue that may require multiple treatments over long periods of time. This fact should be considered by the practitioner and patient when deciding on appropriate treatment measures.