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Lumbar Lordosis and Disc Herniation in Young Participants – Spine Research

lordosis. degenrative joint disease

Flat Back (Lack of Lumbar Lordosis) and Disc Herniation

Lordosis, or the lack of it, has been thought to be a biomechanical precursor to disc herniation in the lumbar spine. To investigate this possible correlation, a group of researchers from Gothenburg University looked at sixteen young active young patients with a median age of 18yrs old who experienced a disc herniation and underwent discectomy surgery. 1

Lordosis is the curve in the lower back—which they measured before and after the surgery.

Lordosis

Researchers used the Roussouly 4-type classification system to measure the degree of lordosis in the lumbar spine.

The researchers found less lordosis in the subjects that had surgery for their disc herniation. In other words, disc herniation was twice as likely to be present in the group with a flatter back. All the disc herniations were found to be in the lowest two levels of the lumbar spine (L4-5 and L5-S1), consistent with other epidemiological studies. 2

Dynamic Disc Designs Models

At Dynamic Disc Designs Corp. we have worked to represent the anatomy accurately. Our Professional LxH  Dynamic Disc Model is created with 12mm of disc height anteriorly and 10mm posteriorly providing a slight lordotic curve. Further, the model has been created with a higher percentage of nucleus pulposus which is often found in younger lumbar spines. To demonstrate that disc herniation occurs more likely with less lordosis all one has to do is dynamically move the single-level model into a less lordosis position and manually create compression. With more lordosis, the nucleus has a more difficult time penetrating through the outer annulus fissure. This can be an important posture teaching point in the prevention of disc herniation.

If you want to take your patient education to a dynamic level, explore what Dynamic Disc Designs models can do for you, your practice and ultimately, your patients.

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Impact of Lumbar Disc Herniation (LDH) Treatment in Children & Adolescents – A Review

A review 1 in the European Spine Journal went over the treatments available for Lumbar Disc Herniation (LDH) in children and adolescents. The review shared which treatment showed the best results.

Why Conduct Such a Review?

Research has shared that LDH or lumbar disc herniation, while affecting adults, also impacted children as well as adolescents (pediatric LDH). It is important to note that pediatric LDH has a number of distinctive features due to the physiological natures of children and adolescents being unique.

Due to adult Lumbar Disc Herniation getting a lot of focus, there’s still a lot that needs to be understood about pediatric LDH. One of the areas involves the treatment available for such LDH and the possible effects of such treatments.

The current review study was conducted to help present an in-depth look at treatments for pediatric LDH and what they entail.

What Was the Methodology?

The searching strategy involved a literature search using electronic databases such as PUBMED and EMBASE. MeSH terminologies (adolescent, child, intervertebral disc displacement, and treatment outcome) and keywords (LDH, adolescent, and child) were used. There were no limitations applied.

The inclusion criteria involved articles featuring relevant information about LDH in adolescents and children. Related references were included, too. The clinical outcome in the articles was assessed, too. 

Take note; case series that didn’t feature a detailed description of the outcome were excluded. Also, case series involving patients over 21-years-of-age were excluded as well. The age-specific exclusion was because previous research demonstrated the human body had almost reached completion of growth during that time.

In the end, 44 series and a total of 8 case reports (with 1,664 cases) were included in the current review. All of the included articles fell in the 1945 to 2008 timeframe.

What Was Observed?

The review shared that LDH is quite a common disorder among adults. The frequency is believed to be much lower in children and adolescents. In all patients hospitalized for LDH, only 0.5-6.8% of the cases were reported as being pediatric patients.

Pediatric LDH is said to be caused by several potential factors. Self-reported or sport-related injury is considered to be the most common cause. This was because 30-60% of adolescents and children experiencing symptomatic LDH were reported to have a history of trauma before pain occurred. However, adult cases usually didn’t report a traumatic experience before the onset of symptoms.

Some recent studies have suggested trauma being an inciting factor that exacerbated pre-existing lesion in discs.

Another factor is considered to be genetics. It has been reported that 13-57% of adolescents with LDH have a first-degree relative with the same condition.

Looking at it from a clinical perspective, pediatric LDH clinically presents itself similarly to adult LDH. Take note; a distinctive feature is that up to 90% of the patients demonstrated a positive straight-leg raising test. 

This can be explained by the fact the nerve root tension is greater in children and adolescents. Also, adolescents and children had a lower chance of presenting neurological symptoms (including weakness and numbness).

What Were the Treatments?

Coming to the treatment part of the review, there’s Conservative treatment, Intradiscal therapy, and Surgical treatment.

Breaking it down, Conservative treatment for pediatric LDH included physical therapy, bed rest, analgesic and anti-inflammatory agents, and limiting physical activity.

As for Intradiscal therapy, chemonucleolysis was the only type being administered for adolescents and children.

Surgical treatment for pediatric LDH was recommended for pediatric LDH on a case-by-case basis. Percutaneous endoscopic discectomy or PED and Microsurgical discectomy or MD were involved.

What Was Concluded?

The review concluded that the diagnosis for adult and pediatric LDH remained similar. As for the treatment, Conservative methods have been reported to be less effective for pediatric LDH when compared to being used for adults. However, Conservative treatment remained the go-to for pediatric LDH cases.

If the said treatment failed, certain patients could be moved to Chemonucleolysis. Excellent short-term outcomes were reported when pediatric LDH was treated surgically (regardless of the modality). Take note; the outcome decreased during the mid-term follow-up, yet it’s considered effective for the long run.

Except for a few exceptions, Spinal fusion isn’t recommended for pediatric LDH.

The review also reported that pediatric LDH could occur in 10-year-olds and younger, with surgical treatments offering positive results.

From this review, one can realize the need to conduct more research involving pediatric LDH for improving treatments and being ready to address any post-treatment related issues.

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Disc Herniation Over-reported with Spondylolisthesis – Research

Disc Herniation Spondylolisthesis

Spondylolisthesis is the slippage of one vertebra on another—frequently found with disc herniation. However, in this recent paper titled: “Over-reporting of the disc herniation in lumbar spine MRI scans performed for patients with spondylolisthesis” 1 they sought to find if disc herniation is over-reported and in turn, possibly over-treated.

Spondylolisthesis is best diagnosed when the spine is under load. Many MRI scans, because done in the lie-down position, miss these small (or large) slippages. To accurately assess one for a spondylolisthesis, the spine is best visualized by x-ray in the forward bending and backward bending position. Upright MRI is also another great way to assess; however, the access to these expensive machines may not be available.

The authors of the above paper discuss how it is imperative to find an accurate diagnosis for both the conservative and surgical management of back pain.

Disc herniation is often found with spondylolisthesis. However, what they found was disc herniation reporting was often over-reported and believed that the disc herniation was more of a pseudo disc herniation rather than an actual disc herniation.

 

What do the authors mean by pseudo-herniation?

 

The authors point to a nomenclature issue. In Fardon’s 2014 paper 2 he helps clarify the language professionals use when discussing disc herniation, extrusion, protrusion and bulge. However, the authors of this paper explain that Fardon’s article does not address this nomenclature in light of spondylolisthesis.

 

They point out in this retrospective study of 258 patients that disc herniation was over-reported because the disc herniation was read with the superior vertebra in mind rather than referencing the lower vertebra. In other words, if the radiological reporting used the lower vertebra as a reference point, the reporting of a disc herniation would be much less because the outer disc border remained anterior to the posterior vertebral ring apophysis. Therefore, it is essential to deferentially diagnose whether symptoms are related to a real disc herniation or due to the mechanics of a spondylolisthesis. A spondylolisthesis can throw off the reporting in this case.

 

 

Dynamic Disc Designs creates 3d models to help reveal the dynamics of disc herniation, including the up-roofing of the disc material. This mechanism is shown in our Professional LxH Model, with the added features of spondylolisthesis.

 

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Is Shorter Lumbar Paraspinal Fascia Associated with Higher Intensity LBP and Disability?

LBP and Disability

A cross-section study 1, in Spine, was conducted to investigate the link low back pain (LBP) and disability had with the structural features of the thoracolumbar fascia. The results shared that a relationship existed between these factors.

The Context

While the Global Burden of Disease Study has researched LBP to be the leading cause of disability in humans, a lot of work needs to be done to fully understand the etiology associated with LBP. More research needs to be done to address all of the factors linked to LBP. Such understanding is crucial because it will help with creating targeted prevention strategies to help millions around the globe.

Previous research has analyzed LBP and disability to be associated with structural abnormalities of the lumbar spine. Furthermore, MRI has shown LBP to be linked to disc protrusion, disc degeneration, nerve root displacement or compression, and high-intensity zone. While more research is still needed, the present results do suggest that the issues of LBP and disability can be addressed by targeting structural factors. Take note, there’s evidence that suggests the thoracolumbar fascia may be linked to LBP. However, few MRI studies have examined such a link.

hypermobility-spine

The Study

The current study had an aim to examine the link present between the lumbar fascia’s length and LBP as well as disability. The study used MRI.

A total of 72 participants (49 females and 23 males) were recruited. They weren’t required to have any history of LBP or current LBP to participate. The MRI was performed, in this study, using a 3.0-T magnetic resonance unit (with the participants in supine position). The study administered the Chronic Pain Grade Questionnaire (CPG) at the time of the MRI.

The study used the Logistic regression analyses for examining any likely associations between fascial length and high pain intensity (or disability).

What did the Results Conclude?

The results of the study concluded that there was a significant association between a shorter length of fascia and high-intensity LBP and/or disability. Such association was after adjusting gender, age, and the body mass index. The association was strengthened after adjustment for the cross-section area (in the paraspinal compartment).

While more studies are required, the current results do suggest that fascia’s structural features likely play a role in disability and LBP.

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Do Concepts of Stability and Instability Matter for Back Pain?

Do Concepts of Stability and Instability Matter for Back Pain

A clinical commentary 1 in the Journal of Orthopaedic & Sports Physical Therapy was conducted to see if the concepts of stability and instability had any value when talking about Back Pain. The commentary’s argument was that the view of stability needed to be broadened and should also integrate interdisciplinary knowledge. Such a change was deemed necessary due to the complex nature of back pain.

What did it set out to do?

The current clinical commentary had the objective of providing a broad definition of stability. It showed how a unifying framework could be used to integrate different interpretations of spine stability. Furthermore, basic and clinical studies were examined to determine the link of spine stability to back pain. Recent scientific, as well as technological advancements, were also considered. The commentary also speculated on how to evolve the concept of stability (in a manner that also addresses non-mechanical issues lined to experiencing pain).

The main goal of the commentary was to display critical knowledge gathered from studying the concepts of stability and to share the potential present in understanding the etiology concerned with back pain.

Disc Herniation

 

Did it reach the intended goal?

While lumbar spine stability was the focus of this commentary, it was determined that similar concepts could still be used when covering different forms of back pain.

It shared that stability is linked to the central nervous system and how neural and mechanical coupling can help reduce the risk of instability connected to a healthy spine.

The commentary talked about how the messaging surrounding the human spine and its susceptibility should be made better for the general public’s understanding. A better understanding can also help reduce the likelihood of maladaptive strategies. A systems-based framework can also prove beneficial for interdisciplinary integration of knowledge; something this commentary stated needed improvement in the spine community.

The basic conclusion was that we still have a lot to learn about back pain. However, using a framework and using the potential that still exists, we can make the spine community efficient to help others.

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Kinematics Changes in Lumbar Disc Herniation Patients during Daily Living Activities

lumbar disc herniation

A study investigating kinematic changes in subjects with lumbar disc herniation (LDH) performing five activities of active daily living (ADL) found that LDH patients were more apt than healthy subjects to restrict the lower lumbar (LLx) and upper lumbar (ULx) spinal motions when performing ADLs. The LDH patients used pelvic rotation to compensate for their reduced lumbar flexibility and increased pelvic tilt and lower extremity flexion during problematic ADLs. 

What’s at Stake?

Lower back pain affects up to 85 percent of the worldwide population—especially those over 40—and can contribute to musculoskeletal problems when the lower spine and its surrounding structure is overloaded. Because LBP patients often restrict musculoskeletal motions during ADLs to avoid pain, understanding the kinematic idiosyncrasies of LBP patients during their ADLs is essential when treating spinal issues through physical therapy that involves gait and functional training. 

Past research has indicated LBP patients had less transverse plane movement than healthy subjects during level walking exercises. One study found that LBP subjects were more likely to exhibit spinal or pelvic rotation, while another study came to the opposite conclusion but found that LBP patients had less range of motion (ROM) in the lumbar spine than the control group. Conflicting studies have concluded that LBP patients had significant reductions in the range of hip flexion and spinal movement across all three planes during trunk flexion or better ROM in the lumbar spine, with more restriction in the pelvic or thorax ROM. The divergent conclusions are likely due to the trunk and whole lumbar being considered a single, rigid segment, rather than interconnected segments that operate independently. The prior studies may also have neglected to consider the kinematic differences among LBP patient subgroups. Analyzing the variability of joints and segments is vital when studying LBP patients and their unique kinematics. 

This study focused on how lumbar disc herniation (LDH) specifically contributes to LBP, including the lower trunk, thorax, hip, and pelvis. The goal of the study was to use a computing model to study LBP patients with LDH and understand their pain-related modulation of their lower extremities and multi-segmental trunk kinematics during level walking, stair climbing, trunk flexion, ipsilateral pickup, and contralateral pickup. 

The Study

Twenty-six healthy males with a mean age of approximately 24 years and seven LHD diagnosed male patients who were, on average, approximately 28 years old participated in the study. The disc herniations occurred at L4/5 in three of the LDH patients, L5/S1 in three cases, and at both locations in one patient. 

The motion of thorax, ULx, LLx, pelvis, hip, and knee were tracked via 3D active markers placed in various locations on the subjects’ spines, pelvises, thighs, and shanks. All the markers were placed by a single surgeon, who had previously demonstrated the five ADLs the subjects were to perform. After practicing the motions a few times, the subjects repeated them while data was collected through the active markers. 

The kinematics of the thoracic segment, ULx, LLx, pelvis, hip, and knee were calculated using a modified Gait-full-body computing model that would analyze the motion of each lumbar vertebra using at least three markers. The kinematic spine and hip angles were analyzed with the computing model using a Euler rotation sequence of spinal segments or thigh/pelvis movement, and the thoracic segment as it related to the L1 vertebra. The ROM for all segmental or joint angles during flexion-extension or gait cycles across all three planes in three planes was calculated, and data analysis was performed using a custom program. 

Results

The LDH subjects had much more pelvic rotation and LLx rotation than the healthy subjects during level walking. The LDH group had much less ROM for thoracic flexion, pelvic tilt, and hip abduction during stair climbing, but they showed more ROM for LLx rotation. No clinically significant variance was noted between the two groups for thoracic flexion, trunk flexion or ipsilateral and contralateral pickups. Lumbar flexion ROM was significantly decreased in the LDH group—especially for ULx with nearly no sagittal angular displacement.  

The findings suggest that people with LDH modulate their movement patterns and motor regulation in response to, or avoidance of pain. There were evident kinematic differences between the healthy subjects and LDH patients in this study. LDH patients had more pelvic rotation and increased LLx rotation during level walking, contradicting earlier studies where patients had less than or similar pelvic rotation when compared with healthy subjects. The use of different marker sets, study methods, computer models, and speed of motion might account for the varying test results, but it appears that pelvis and LLx motions in the transverse plane may have a more pronounced effect than that of the other two planes during LDH abnormal motion level walking analysis. 

Conclusion

In regard to the direction or range of motion, there were contrasting kinematic characteristics and different adaptations to LDH between the ULx and LLx in this study. The thoracic motion did not appear to be affected by the LDH when subjects were performing the ADLs, with the exception of stair climbing. During all five ADLs the LDH patients maintained limited lumbar flexion, and their pelvises, knees, and hips compensated for the lost lumbar motion capacity in the sagittal plane during contralateral pickups. In four of the five ADLs (the exception being stair climbing), the LDH patients increased their pelvic rotation significantly. They also had higher rates of antiphase movement between thorax and pelvis in the two pickups and in level walking and stair climbing in the transverse plane between ULx and LLx.

The findings of this study should help provide a more comprehensive understanding of how LDH influences kinematics and lead to more specific treatments and better therapeutic outcomes for LDH patients. 

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Most Patients in Study Believe LBP Flareups Have Biomedical, Rather than Psychosocial, Origins

biomedical cause, LBP

An Australian study 1 into what male and female lower back pain (LBP) patients believe about the cause of their LBP flair-ups found that the subjects were most likely to attribute the source of their recent pain to biomedical causes, including active movements and static postures, rather than psycho-social factors. Though current evidence points to a positive correlation between mental health issues, including stress, anxiety, and depression, and LBP, few of the patients in this study attributed the onset of LBP flair-ups to psycho-social causes.

What’s at Stake?

LBP is the most common global cause of disability, lost income, and productivity decreases in the marketplace. Post-acute LBP flair-ups contribute to chronic job absenteeism and economic disruption at the individual and collective societal levels. While many studies have investigated the various causes of acute LBP episodes, few have focused on the fluctuations and triggers of LBP flair-ups.

Initial episodes of LBP are considered by health professionals to be overwhelmingly biomedical/biomechanical in origin, and most patients when queried agree with that assumption.

This study was conducted to determine what LBP patients believe about the triggers of their LBP flair-ups, in the hope that better understanding patient views will lead to more effective management of intermittent, non-acute episodes of LBP.

 

Professional LxH Dynamic Disc Model

Professional LxH Dynamic Disc Model

The Study

One hundred and thirty male and female volunteer subjects with episodic LBP participated in the online study by answering questions about their beliefs about the triggers for their flair-ups. Their answers were analyzed for common factors and were then clustered into various themes and codes by similarities. These common codes were further categorized into two overarching themes—biomedical, and non-biomedical triggers.

Overarching Theme: Biomedical Triggers

More than eighty-four percent of the subjects identified their LBP flair-up triggers as biomedical. Active movement and static postures were the most commonly identified biomedical causes for this group’s LBP recurrences. Patients reporting active movement as a trigger for their recurring LBP were most likely to cite bending and twisting as the most frequent instigator of their pain. Many of these patients felt that the quality of these movements played a role in initiating their LBP. In these cases, it was not the movement itself, but the way they performed the movement that caused their pain.

Roughly 5 percent of the patients reporting active movement as the cause of their LBP flair-ups believed it was repetition of the movement that was responsible for their pain. They claimed that “overdoing” a task could lead to LBP episodes.

Some of the patients reporting biomedical triggers believed their LBP was caused by biomechanical dysfunction. Roughly two percent reported motor control issues, and another 2.3 percent blamed their pain on spinal damage of some kind. Other biomedical themes included knee pain, endometriosis, and constipation. Some patients felt their LBP flair-ups were caused by lack of exercise, and others blamed work for their pain. Two percent reported their flair-ups were caused by not taking maintenance pain medications as prescribed.

Other biomechanical causes included participation in sex, wearing the wrong shoes, and medical treatments.

Overarching Theme 2: Non-biomedical Triggers

Only 15.2 percent of the subjects questioned reported non-biomedical triggers as the source of their LBP. Two participants—one male, and one female—believed the cause of their flair-ups to be related to stress or the weather. A few reported psychological factors—including anxiety, the lack of creative outlets, family problems, and depression— as potential triggers of pain.

The patients who claimed the weather was a factor in their pain were most likely to blame a drop in barometric pressure or the cold. One patient believed the pain episodes were triggered by rain, temperature changes, or warm weather.

Two percent of patients who attributed their discomfort to non-biomedical conditions blamed irregular or bad sleep qualities for their pain. Roughly 1 percent felt their diet had something to do with their LBP flair-ups, and another 1 percent blamed fatigue.

Conclusion

More than half of the patients with intermittent LBP flair-ups believed their pain was caused by biomedical dysfunctions, and only a few believed the source of their pain was something other than biomedical problems. Active movements and static postures were the most cited triggers for LBP.

The findings in this study are consistent with previous literature about what patients believe to be the cause of their LBP. However, the lack of patient emphasis on psychosocial causes of LBP contrast with current evidence that indicates a positive correlation between psychological or mental states and persistent LBP.

The authors of this study emphasize the importance of further research into the validity of the triggers identified by the LBP patients in order to better understand LBP flair-ups and how those experiencing them conceptualize the event. Evidence indicates the efficacy of patient-centric treatment in LBP clinical outcomes, and better understanding what patients believe about their pain will help clinicians to identify more effective treatment plans to manage recurring LBP in their patients.

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