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Complex posture and disc herniation – lifting properly important

Posture

Posture and Loading

In a signature paper by Broom et al. 1 these authors set out to investigate the effects of complex posture within the act of loading.

They used thirty seven motion segments of ovine lumbar spines and subjected them to compressive loading to simulate the event that a human may experience when they bend and twist while lifting a heavy object. What they found was the more complex (meaning more rotation) the angles were, the more likely they saw ruptures within the intervertebral disc.

These injuries were looked at with microstructural analysis with light microscopy and they saw pockets of nucleus pulposus between the annulus fibrous with evidence of delamination. They saw convoluted paths of injury which displaced the nucleus more so in the complex loading environment. They also saw how the nucleus tracked laterally and then in a circumferential pattern.

Conclusions

The authors concluded that postures do matter when it comes to loading the disc. And their bottom line is to keep the spine square if you want to avoid an injury that relates to a disc herniation.

MRI Study Finds LF Thickening Not Caused by Age-related Spinal Degeneration

Ligamentum Flavum thickening Option

An MRI study of 162 patients with lower back pain (LBP) and/or leg pain (LP) measured and analyzed the thickness of the ligamentum flavum (LF) at different levels of the lumbar spine and concluded that, though the LF thickness increased with the age of the patient, there was no apparent correlation between a decrease in disc-height and LF thickness. In fact, researchers found that LF thickness had already begun to increase in patients under 40, refuting the theory that LF thickness was caused by buckling of the LF into the spinal canal due to age-related degeneration.

 

The Study

The researchers involved in this study wanted to examine the theory that hypertrophy of the LF—which covers the postural-lateral spinal canal—is caused by age-related degeneration. Subjects included 87 female and 75 male LBP patients whose mean age was roughly 52-years-old. Patients with scoliosis, spinal fracture, or other deformities of the spine were excluded from the study. Radiographs were conducted, and the thickness of 648 LF was measured at various levels of the lumbar spine, and an analysis was performed by the researchers using Pearson’s coefficient test.

Results

Three important findings were achieved during analysis of the MRI results in this study: LF thickness increases with age; this thickness is not as pronounced at the L2-3 and L5-S levels as in other levels; the LF thickness was extremely pronounced at the L4-5 levels, particularly in younger subjects. Researchers concluded that LF thickening was already in progress in the back-pain study patients between the ages of 30-39.

Discussion

The results of this study indicate that practitioners should pay close attention to posterior, as well as anterior, elements of disc herniation patients prior to planning for surgical procedures. Thickening of the LF in LBP patients is more likely to occur prior to the age of 40 and is not caused by disc degeneration and LF buckling into the spinal canal, as has been previously suggested. Patients with obvious thickness of the LF at L2-3 should be examined for lumbar spinal canal stenosis, as the results of the study indicate a correlation between the two conditions.

Blurb: A study of lower back pain patients measured and analyzed ligamentum flavum (LF) at different levels of the lumbar spine and concluded that LF thickening occurs in younger (30-40) LBP patients and is not caused by buckling of the LF into the spinal canal due to age-related degeneration.

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MRI and McKenzie Prone Push-up

prone push-up, MRI

In an article in Musculoskeletal Science and Practice, researchers looked to quantify the hydration changes with the McKenzie prone push-up and MRI.

The intervertebral disc supports most of the weight in the upright posture. It is the largest avascular tissue in the human body and is a common source of pain in the case of discogenic problems. A popular therapeutic technique to reduce disc herniation is the McKenzie prone push-up. This is thought to centralize the nucleus pulposus of the disc to allow an improvement in healing.

prone push-up

Popular movement strategy for disc problems (source: https://www.spineuniverse.com/sites/default/files/legacy-images/pressup-BB.jpg)

MRI Methods

Using MRI, the authors attempted to measure the pixel density of T2 weighted images to estimate disc fluid content and displacement. As a base line, they had the 22 subjects lay down for 40 minutes before the study began. Then, they had the subjects conduct a series of prone push-ups to immediately follow-up with MRI imaging. They looked at the midsagittal slice of L4-5 and L5-S1.

Conclusions

In their conclusion they did not see any significant pixel re-orientation suggesting that the disc did not change with respect to hydration content. They did see significant anterior displacement at the L4-5 level, however.

Limitations to the Study

It is important to note that in the methods there were many limiting factors. For one, the researchers instructed the subjects to lay down for 40 minutes prior to the study. Previous work has shown that laying down for 10 minutes has an effect on disc height and respective hydraulics of the lumbar discs. Therefore, the subjects may have already had changes prior to the beginning of the prone push-ups. Another significant limitation to the study was that only the midsagittal section of the disc was measured and therefore changes outside of the field of view was not measured.

A congratulations to the authors for publishing this manuscript. However, much more research must be conducted to suggest that the prone push-up does not affect hydration and/or distribution of the intervertebral disc.

 

Review Recommends New Protocols in Diagnosing and Treating Non-Specific Low-Back Pain

non-specific low back pain

A review of studies involving the diagnosis and treatment of non-specific low back pain indicated that most patients do not require immediate diagnostic imaging or referrals to a back-pain specialist to properly treat their symptoms, which may be managed effectively through their primary care physician. The studies also suggest that non-pharmacologic treatments, including exercise, cognitive behavioral therapy, massage, stress reduction methods, operant therapy, spinal manipulation, acupuncture, or physical rehabilitation programs can provide some benefit to patients without an underlying spinal pathology who suffer from persistent lower back pain. Other types of intervention, though, including the use of opioids or NSAIDS, may offer temporary pain relief but few long-term palliative benefits and can be harmful over time. Careful risk-vs-benefit evaluation should be considered prior to prescribing these and other treatments (including spinal injections) for acute or persistent non-specific low-back pain patients. The researchers emphasized that providing information, reassurance, and counseling about low-back pain was beneficial to all patients and helped reduce pain-related anxiety.

Purpose of Study

Low-back pain is ubiquitous and a leading cause worldwide of missed work, early retirement, and poverty. The associated costs of medical treatment and diagnosis are astronomical (upwards of $87.6 billion in the U.S. alone), yet statistically-speaking patient outcomes have remained stagnant—patients are not responding better to the wide array of available diagnostic and treatment options.

Shift in Protocol & New Recommendations

New guidelines of low-back pain care recommend a shift in thought for primary care physicians in response to the diagnosis and treatment of neurogenic claudication, radicular pain, and non-specific LBP patient—focusing on patient education, less invasive evaluative methods, non-pharmaceutical treatments, exercise, behavioral cognitive and other therapies, and general good health lifestyle choices and practices. Patients should be offered information on the nature of low-back pain.

The authors of the review posit that tests designed to identify the source of LBP are generally not useful and have a low level of accuracy when it comes to making a firm diagnosis. Further, drug regimen used to treat neuropathic pain are frequently ineffective and can have harmful side-effects. The same is true of structure-based treatments, such as stem cells, corticosteroids, sclerosing agents, and anesthetic injections, all of which offer little in the way of long-term LBP relief.

Imaging is indicated only when a quick diagnosis is critical, such as when the physician suspects a bone fracture or cancer. Even when ‘red flags’ are present, the authors suggest, they may be indicative of a variety of physical conditions and are therefore too plentiful to be of use in determining whether or not imaging is called for in an acute LBP patient.

Patients suffering from non-specific LBP would benefit more from non-drug treatments that emphasize education, awareness, exercise, massage, superficial heat, acupuncture, behavioral and cognitive therapies or other non-pharmaceutical strategies. Though NSAIDs and muscle relaxants can relieve acute LBP for limited amounts of time, the potential harms of taking the drugs may outweigh the short-term benefits, so extreme caution and careful evaluation should be used in prescribing these medications to LBP patients. NSAIDS and muscle relaxants can relieve LBP, The use of opioids to treat acute LBP should be discouraged and, like spinal fusion, be reserved for only the most stubborn and debilitating cases of persistent LBP.

Blurb:

A review of protocols in diagnosing and treating non-specific lower back pain suggests that diagnostic imaging and specialized care is rarely necessary and that most patients would benefit from patient education about lower back pain, exercise, and other non-pharmaceutical interventions. Primary care physicians should treat non-specific LBP conservatively, by offering their patients information on the nature of lower back pain and encouraging exercise and healthy lifestyle habits. Massage, acupuncture, and other non-invasive treatments are preferable to surgery or epidural procedures, which provide little long-term pain relief and carry health risks. Opioid medications should be avoided in the treatment of acute and persistent non-specific lower back pain, due to their long-term inefficiency and abundant risks.

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.