Lumbar spine radiographic features and demographic, clinical, and radiographic knee, hip, and hand osteoarthritis

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DOI: 10.1002/acr.21720 · Source: PubMed
Abstract
To determine the prevalence of lumbar spine individual radiographic features (IRFs) of disc space narrowing (DSN), osteophytes (OST), and facet joint osteoarthritis (FOA); to describe the frequencies of demographic, clinical, and radiographic knee, hip, and hand osteoarthritis (OA) across lumbar spine IRFs; and to determine factors associated with lumbar spine IRFs. We conducted a cross-sectional study of 840 participants enrolled in the Johnston County Osteoarthritis Project (2003-2004). Sample-based prevalence estimates were generated for each lumbar spine IRF. The associations between lumbar spine IRFs and demographic, clinical, and peripheral joint OA were determined with logistic regression models. Sample-based prevalence estimates were similar for DSN (57.6%) and FOA (57.9%) but higher for OST (88.1%), with significant differences across race and sex. Hand and knee OA frequencies increased across IRFs, whereas the effect was absent for hip OA. African Americans had lower odds of FOA (adjusted odds ratio [OR(adj) ] 0.45 [95% confidence interval (95% CI) 0.32-0.62]), while there was no racial association with DSN and OST. Low back symptoms were associated with DSN (OR(adj) 1.37 [95% CI 1.04-1.80]) but not OST or FOA. Knee OA was associated with OST (OR(adj) 1.62 [95% CI 1.16-2.27]) and FOA (OR(adj) 1.69 [95% CI 1.15-2.49]) but not DSN. Hand OA was associated with FOA (OR(adj) 1.67 [95% CI 1.20-2.28]) but not with DSN or OST. No associations were found with hip OA. These findings underscore the importance of analyzing lumbar spine IRFs separately as the associations with demographic, clinical, and radiographic knee, hip, and hand OA differ widely.
Lumbar Spine Radiographic Features and
Demographic, Clinical, and Radiographic Knee,
Hip, and Hand Osteoarthritis
ADAM P. GOODE,
1
STEPHEN W. MARSHALL,
2
JORDAN B. RENNER,
2
TIMOTHY S. CAREY,
2
VIRGINIA B. KRAUS,
1
DEBRA E. IRWIN,
2
TIL STU
¨
RMER,
2
AND JOANNE M. JORDAN
2
Objective. To determine the prevalence of lumbar spine individual radiographic features (IRFs) of disc space narrowing
(DSN), osteophytes (OST), and facet joint osteoarthritis (FOA); to describe the frequencies of demographic, clinical, and
radiographic knee, hip, and hand osteoarthritis (OA) across lumbar spine IRFs; and to determine factors associated with
lumbar spine IRFs.
Methods. We conducted a cross-sectional study of 840 participants enrolled in the Johnston County Osteoarthritis Project
(2003–2004). Sample-based prevalence estimates were generated for each lumbar spine IRF. The associations between
lumbar spine IRFs and demographic, clinical, and peripheral joint OA were determined with logistic regression models.
Results. Sample-based prevalence estimates were similar for DSN (57.6%) and FOA (57.9%) but higher for OST (88.1%),
with significant differences across race and sex. Hand and knee OA frequencies increased across IRFs, whereas the effect
was absent for hip OA. African Americans had lower odds of FOA (adjusted odds ratio [OR
adj
] 0.45 [95% confidence
interval (95% CI) 0.32–0.62]), while there was no racial association with DSN and OST. Low back symptoms were
associated with DSN (OR
adj
1.37 [95% CI 1.04 –1.80]) but not OST or FOA. Knee OA was associated with OST (OR
adj
1.62
[95% CI 1.16 –2.27]) and FOA (OR
adj
1.69 [95% CI 1.15–2.49]) but not DSN. Hand OA was associated with FOA (OR
adj
1.67
[95% CI 1.20 –2.28]) but not with DSN or OST. No associations were found with hip OA.
Conclusion. These findings underscore the importance of analyzing lumbar spine IRFs separately as the associations
with demographic, clinical, and radiographic knee, hip, and hand OA differ widely.
INTRODUCTION
Lumbar spine degenerative changes are common and in-
crease in frequency with aging (1). Degenerative changes
in the spine are typically identified as individual radio-
graphic features (IRFs), such as disc space narrowing
(DSN), vertebral osteophytes (OST), and facet joint osteo-
arthritis (FOA). The prevalence of lumbar spine degener-
ative changes varies. Differences in study sample ages and
operational definitions in the severity of the condition are
the most likely reasons for these variations (2). The com-
munity-based (mean age 65 years) prevalence of DSN has
The findings and conclusions contained herein are those
of the authors and do not necessarily represent the official
position of the Centers for Disease Control and Prevention
and/or the Agency for Healthcare Research and Quality.
The Johnston County Osteoarthritis Project was supported
in part by the CDC/Association of Schools of Public Health
(cooperative agreements S043, S1734, and S3486); the Na-
tional Institute of Arthritis and Musculoskeletal and Skin
Diseases Multipurpose Arthritis and Musculoskeletal Dis-
ease Center (grant 5-P60-AR30701); and the National Insti-
tute of Arthritis and Musculoskeletal and Skin Diseases
Multidisciplinary Clinical Research Center (grant 5-P60-
AR49465-03). Dr. Goode’s work was supported by the Foun-
dation for Physical Therapy (educational tuition during his
PhD in epidemiology training at the University of North
Carolina Gillings School of Global Public Health), the NIH
Loan Repayment Program/National Institute of Arthritis
and Musculoskeletal and Skin Diseases (grant 1-L30-
AR057661-02), and the Agency for Healthcare Research and
Quality K-12 Comparative Effectiveness Career Develop-
ment Award (grant HS19479-01). Dr. Kraus’ work was sup-
ported by the NIH/National Institute on Aging Older Amer-
icans Independence Center (grant 5P30-AG-028716) and the
NIH/National Institute of Arthritis and Musculoskeletal and
Skin Diseases (grant 5P01-AR-050245).
1
Adam P. Goode, PT, DPT, PhD, Virginia B. Kraus, MD,
PhD: Duke University, Durham, North Carolina;
2
Stephen
W. Marshall, PhD, Jordan B. Renner, MD, Timothy S. Carey,
MD, MPH, Debra E. Irwin, PhD, MSPH, Til Stu¨ rmer, MD,
MPH, PhD, Joanne M. Jordan, MD, MPH: University of North
Carolina, Chapel Hill.
Dr. Carey is on the Blue Cross Blue Shield advisory panel
on criteria for “centers in excellence” spinal care.
Address correspondence to Adam P. Goode, PT, DPT,
PhD, Duke University Medical Center, 104002, Durham, NC
27708. E-mail: adam.goode@duke.edu.
Submitted for publication October 27, 2011; accepted in
revised form April 20, 2012.
Arthritis Care & Research
Vol. 64, No. 10, October 2012, pp 1536–1544
DOI 10.1002/acr.21720
© 2012, American College of Rheumatology
ORIGINAL ARTICLE
1536
been estimated to be between 5064%, whereas vertebral
OST have prevalence estimates between 75–94% (3–5).
FOA is a multifactorial process thought to be an indirect
result of DSN (1,6); however, to our knowledge, the com-
munity-based prevalence of radiographic FOA has not
been reported.
Community-based studies describing the differences in
sex and race within lumbar spine IRFs are limited. Previ-
ous studies have identified that men have more prevalent
OST than women (3–5,7). Pye et al (5) found no differences
in the prevalence of DSN between men and women, while
others have found the prevalence to be higher among
women (3,4). No studies have addressed sex differences
with plain film radiographic FOA. Racial differences have
been found to exist in spine-related health services utili-
zation (8) and diagnostic imaging procedures (9 –11). The
causes of these disparities are complex and poorly under-
stood (9). One way to improve this understanding is to
determine whether racial differences exist for lumbar
spine IRFs, but this has not been previously examined or
reported.
The association between plain film radiographs and low
back pain is complex (1). DSN has been associated with
low back pain (3–5), whereas the association between low
back pain and OST is debated (3–5,7). FOA continues to be
discussed as a source of low back pain, and the utilization
of interventions to treat facet joint pain continues to rise
(12). Recent work, however, has demonstrated no clear
relationship between computed tomography (CT)–identi-
fied FOA and low back pain (13). Clinical guidelines in-
dicate that plain film radiographs are a reasonable first
imaging technique for patients seeking care for low back
pain (14). In spite of this, the relationship between plain
film radiographic FOA and low back pain has yet to be
established in a community-based population.
The lumbar spine may not share the same etiologic
process of degeneration as the hand, hip, and knee (15),
suggesting that the disease process may differ both be-
tween and within subtypes of osteoarthritis (OA). Horvath
et al (16) found that Kellgren/Lawrence (K/L)–graded (17)
hip and knee OA was greater among participants with
spinal degeneration than those without. However, their
study consisted of a limited sample size of a younger
(mean age 46.1 years) Hungarian population in which
many were without lumbar spine, hip, and knee degener-
ative changes.
Previous studies have not examined the relationship
between plain film radiograph–identified DSN, OST, and
FOA and within demographic, clinical, and concomitant
knee, hip, and hand OA groups. Therefore, there are 3
primary objectives to these analyses: 1) to determine the
sample-based prevalence of lumbar spine IRFs in a biracial
community-based population; 2) to describe the frequency
of demographic, clinical, and radiographic concomitant
knee, hip, and hand OA factors across severity or presence
of the different lumbar spine IRFs; and 3) to determine
which factors are independently associated with lumbar
spine IRFs. We hypothesized that differences in frequen-
cies and associations within and between lumbar spine
IRFs would exist and might provide insight into the extent
to which the process of degenerative changes differs in the
lumbar spine.
MATERIALS AND METHODS
Participants. Data for these analyses came from partic-
ipants enrolled in the Johnston County Osteoarthritis Proj-
ect. Details of the sampling strategy and recruitment meth-
ods used for the Johnston County Osteoarthritis Project are
described elsewhere (18,19). Briefly, the Johnston County
Osteoarthritis Project is an ongoing population-based co-
hort study set in 6 rural townships of Johnston County,
North Carolina. The primary purpose of the Johnston
County Osteoarthritis Project is to determine the preva-
lence, incidence, and progression of knee, hip, hand, and
spine OA. Lumbar spine films were added at the time of
cohort enrichment (T1*; 2003–2004), following the first
followup (T1; 1999 –2003) of participants initially re-
cruited from 1991–1998. These particular analyses used
cross-sectional data from T1* from 1,015 participants who
completed 2 interviews and a clinical evaluation. The T1*
enrollment aimed to enrich the sample of African Ameri-
cans and younger participants. As such, participants at
T1* were younger (mean age 59.3 versus 65.8 years) and
had a higher proportion of African Americans (40% versus
28%) than those at T1; the 2 groups did not differ accord-
ing to sex (18).
Outcomes. Of the 1,015 participants entering new en-
rollment, 840 participants had radiographic data for the 3
outcomes of lumbar spine DSN, OST, or FOA. By protocol,
women of reproductive age (50 years) were excluded
from having lumbar spine radiographs (n 132). Few
participants refused lumbar spine radiographs (n 6), but
some exceeded the weight limit for the examination table
(n 23), and some films were missing or unreadable due
to congenital defect or surgery (n 16). Lateral lumbar
Significance & Innovations
The lumbar spine individual radiographic features
(IRFs) of disc space narrowing, vertebral osteo-
phytes, and facet joint osteoarthritis (OA) are com-
mon and differ significantly across race and sex.
The frequency of hand and knee OA consistently
increased across presence or severity of lumbar
spine IRFs, whereas this effect was weak or absent
for hip OA.
Adjusted associations between lumbar spine IRFs
and demographic, clinical, and concomitant knee,
hip, and hand OA varied widely with no associa-
tions found with hip OA.
These findings underscore the importance of ana-
lyzing lumbar spine IRFs as separate outcomes for
OA studies, as they likely reflect different pro-
cesses ongoing in the joint during the course of
this disease.
Determining Factors Associated With Lumbar Spine IRFs 1537
spine films were taken with the participant lying on his/
her left side. All lateral lumbar spine radiographs were
graded at each lumbar level by a single bone and joint
radiologist (JBR) without regard to participants’ clinical
status. DSN and OST were graded based upon the Burnett
Atlas (20) in a semiquantitative manner, where 0 none,
1 mild, 2 moderate, and 3 severe. The grading for
OST was done for each superior and inferior face of ante-
rior lumbar vertebrae. The outcomes were coded to deter-
mine differences across severity, individually for DSN and
OST, based upon each subject’s most severe feature. For
example, a participant was coded as 0 if there was no DSN
present, 1 if there was at least mild DSN but no moderate
or severe DSN at any level, 2 if there was at least moderate
severity at any level but no severe DSN present at any
level, or 3 if there was severe DSN at any level. Coding was
done in a similar fashion with the most severe anterior
superior or inferior vertebral OST. Both DSN and OST
were dichotomized into none versus mild or greater for
sample-based prevalence estimates. FOA was graded as
present or absent and coded in the same fashion for all
analyses.
Knee, hip, and hand radiographs. Posteroanterior knee
radiography of both knees in a weight-bearing posture
with a Synaflexer (CCBR-Synarc) positioning device was
available for 979 participants. The primary reason for
missing knee radiographs was knee arthroplasty. Antero-
posterior bilateral pelvis radiographs were available for
830 participants. The primary reasons for not having hip
radiographs were women of reproductive age (50 years;
n 132) and hip arthroplasty. Hand radiographs were
available for 1,012 participants. A single bone and joint
radiologist (JBR) read all hip, knee, and hand radiographs.
Interrater and intrarater reliability have been previously
reported with a weighted kappa of 0.86 and 0.89, respec-
tively, for both the hip and knee (21). Hip and knee OA, for
these analyses, was individually defined as a K/L score of
2–4 in at least 1 extremity. Hand OA was defined, similar
to a previous definition, as having at least 1 extremity with
a K/L grade of 2– 4 in 1 distal interphalangeal joint and 2
other interphalangeal joints or carpometacarpal joints (22).
Participant demographic and clinical factors. Demo-
graphic and clinical data were collected including age and
body mass index (BMI), measured at time of clinical ex-
amination (calculated from height measured without
shoes, and weight measured with a balance beam scale),
race (white or African American), and sex. Low back
symptoms were obtained at an interview by asking partic-
ipants to answer “yes” or “no” to the question, “On most
days, do you have pain, aching, or stiffness in your low
back?”
Statistical analysis. Descriptive statistics were gener-
ated in the form of means and SDs for continuous covari-
ates, and counts and percentages for categorical covariates.
Student’s t-tests (continuous covariates) and chi-square
tests (categorical covariates) were used for analysis of dif-
ferences.
Unconditional binary, proportional odds, and partial
proportional odds logistic regression models were used, as
appropriate, to determine independent associations be-
tween demographic and clinical factors and concomitant
radiographic knee, hip, and hand OA with each outcome.
Associations were adjusted for all demographic and clin-
ical covariates (i.e., age, race, sex, BMI, and low back
symptoms) and the other radiographic variables (i.e., knee,
hip, and hand OA). Collinearity was analyzed for all vari-
ables using variance inflation factors and tolerance values.
Odds ratios (ORs) and their 95% confidence intervals
(95% CIs) were the measures of association. However, it is
important to note that since the outcomes in these analyses
are common (10%), the ORs from these analyses will
likely overestimate the relative risk (23). The degree of
overestimation is dependent on the prevalence of disease
and strength of association (24).
Therefore, the associations reported should be viewed
relative to lumbar spine IRFs across demographic, clinical,
and concomitant knee, hip, and hand OA rather than in-
terpreted as the relative risk of the outcome of interest. All
analyses were conducted in Stata software, version 10. All
participants in the Johnston County Osteoarthritis Project
have provided informed consent for participation. The
Johnston County Osteoarthritis Project has been continu-
ously approved by the Institutional Review Boards of the
University of North Carolina and the Centers for Disease
Control and Prevention in Atlanta, Georgia.
RESULTS
A description of the demographic, clinical, and concomi-
tant radiographic knee, hip, and hand OA is provided in
Table 1. After exclusion of women age 50 years and
missing data, there were 840 lumbar spine radiographs
with complete data for DSN, OST, or FOA. The demo-
graphics of this sample were 37.6% African American and
62.3% female, a mean SD BMI of 30.4 6.3 kg/m
2
, and
a mean SD age of 60.1 10.3 years for men and 62.7
9.8 years for women.
Prevalence. Table 2 describes the sample-based preva-
lence of lumbar spine IRFs stratified by age, sex, and
race. The sample-based prevalence of DSN at a mild or
greater severity was 57.6% for all participants. Similarly,
the sample-based prevalence of FOA was 57.9% for all
participants, while the sample-based prevalence of OST
was higher (88.1% of all participants had at least mild
OST). FOA was significantly greater among women (P
0.004), whereas no significant difference with sex was
observed with DSN (P 0.068) or OST (P 0.912). White
participants had a significantly higher frequency of DSN
(P 0.014), OST (P 0.012), and FOA (P 0.001) than
African Americans. The frequency of lumbar spine IRFs
consistently increased across categories of increasing age.
The majority of participants had at least mild or greater
DSN and OST (54.5%) and OST and FOA (53.8%). In
addition, participants with concomitant DSN and FOA
(38.9%) and participants with all 3 lumbar spine IRFs
(37.3%) were also common.
1538 Goode et al
DSN. Table 3 provides the frequencies of demographic,
clinical, and radiographic knee, hip, and hand OA across
severity of DSN. Knee and hand OA increased substan-
tially as severity of DSN increased, whereas hip OA had a
weaker relationship to DSN severity. Increasing age, sex,
low back symptoms, knee and hand OA, and race were
associated with DSN in crude analyses. After adjustment,
increasing age, sex, and low back symptoms remained
independently associated with DSN (Table 4).
Vertebral OST. Table 5 provides the frequencies of de-
mographic, clinical, and radiographic knee, hip, and hand
OA across severity of vertebral OST. Women had higher
proportions of mild OST, whereas men demonstrated
higher proportions of moderate and severe OST. Knee, hip,
and hand OA increased in frequency with increasing se-
verity of OST. This effect was most pronounced with knee
OA. The proportional odds assumption was violated with
sex effects, demonstrating significant changes across levels
of OST severity. As such, after adjustment, men demon-
strated monotonically increasing ORs from 1.39 (95% CI
0.88–2.22), 3.18 (95% CI 2.25–4.50), and 5.74 (95% CI
3.20–10.28) with increasing severity, respectively. In-
creasing age, sex, low back symptoms, and knee, hip, and
hand OA were associated with OST in crude analyses.
After adjustment, increasing age, BMI, sex, and knee
OA demonstrated independent associations with OST
(Table 4).
FOA. Table 6 provides the frequencies of demographic,
clinical, and radiographic knee, hip, and hand OA with
presence or absence of FOA. Knee and hand OA frequen-
cies were greater among those with FOA, whereas low
back symptoms and hip OA were nearly equal in fre-
quency between those with and without FOA. Increasing
age, BMI, race, sex, and knee, hip, and hand OA were
associated with FOA in crude analyses. After adjustment,
increasing age, BMI, race, knee, and hand OA were inde-
pendently associated with FOA (Table 4).
DISCUSSION
Ours is the first study to describe the sample-based prev-
alence of plain film radiographic DSN, OST, and FOA
across sex and race subgroups from the same sample. The
differences in lumbar spine coding schemes and sample
ages have been reported to compromise comparisons
across studies (2). However, our sample-based prevalence
estimates fall in the middle range of previously reported
community-based studies for DSN and OST. Any differ-
ences are likely due to the younger mean age in our study
when compared to others. Our group has reported racial
differences in IRFs of the knee and hip (25,26). This was
also the case in the current study, as African Americans
had a lower sample-based prevalence of all 3 lumbar spine
IRFs. These findings may help improve our understanding
of racial differences observed in spine-related imaging uti-
lization. The similarities in sex-stratified sample-based
prevalence estimates for OST are not consistent with pre-
vious studies reporting that men have significantly more
prevalent OST (4,5). The inconsistency is most likely due
to differences in coding schemes, as some have combined
severity categories of OST prior to dichotomizing for prev-
alence analyses. However, differences in study mean ages
and locations between our study and others may also
contribute to this difference.
To our knowledge, this is the only study to have deter-
mined the sample-based prevalence of plain film radio-
graphic FOA in a community-based population. The sim-
ilarities in frequency estimates and overlap for DSN and
FOA support previous work suggesting that FOA is related
to DSN (1,6). Our sample-based prevalence estimates, for
all participants and stratified by sex, are similar to those
found by Kalichman et al (13) of CT-identified FOA. This
is interesting since lateral plain film radiographs are ad-
mittedly not optimal for identifying FOA due to the orien-
tation of the facet joint (27). This suggests that, on a pop-
ulation level, plain film radiography may be useful for the
study of FOA etiology, its association with low back symp-
toms, and its relationship to other lumbar spine IRFs and
the study of generalized OA.
Differences in associations were observed between de-
mographics of age, sex, and race, and lumbar spine IRFs.
Table 1. Distribution of selected demographic, clinical,
and radiographic variables for the 1,015 enrollment
participants in the Johnston County Osteoarthritis
Project (2003–2004)*
Value
Age, years 59.7 10.4
45–54 390 (38.4)
55–64 295 (29.1)
65–74 212 (20.9)
75 118 (11.6)
African American 408 (40.2)
White 607 (59.8)
Men 336 (33.1)
Women 679 (66.9)
BMI, kg/m
2
31.3 7.4
30 511 (50.3)
30 504 (49.7)
Low back symptoms
Present 524 (51.8)
Absent 488 (48.2)
Missing 3 (1)
K/L knee OA grade
2–4 285 (29.1)
0–1 694 (70.9)
Missing 36 (3.6)
K/L hip OA grade
2–4 196 (23.6)
0–1 634 (76.4)
Missing 185 (18.2)
K/L hand OA grade
2–4 225 (22.2)
0–1 787 (77.8)
Missing 3 (1)
* Values are the mean SD or the number (percentage). Low back
symptoms defined as pain, aching, or stiffness on most days. Knee
radiographs missing primarily for unilateral and bilateral arthro-
plasty; hip radiographs missing due to women age 50 years as a
result of study protocol and hip arthroplasty. BMI body mass
index; K/L Kellgren/Lawrence; OA osteoarthritis.
Determining Factors Associated With Lumbar Spine IRFs 1539
Consistent with previous work, increasing age demon-
strated similar associations across severity and presence of
lumbar spine IRFs (4,5,13). Also in agreement, we found a
moderate to strong adjusted association with BMI and both
OST and FOA and a nearly null association with DSN
(4,13). Pye et al reported that men have greater OST sever-
ity (5). Similarly, we found that the associations increase
in strength across severity of OST for men. This is the first
study to report on racial differences across lumbar spine
IRFs. The difference in associations across race indicates
the degenerative process for FOA differs when compared
to DSN and OST. Human cadaver studies have found no
statistical difference in the prevalence of FOA (28) or facet
joint orientation (29) between whites and African Ameri-
cans. Our findings indicate that there may be physical
activity or occupational exposures that lead to the de-
creased association of FOA among African Americans that
are beyond the scope of these analyses.
Differences in associations were also observed between
clinical factors of low back symptoms and lumbar spine
IRFs. Although the association between lumbar spine de-
generative changes and low back symptoms continues to
be debated in the literature (1), in general our results are
consistent with previous studies regarding a modest asso-
ciation between DSN and low back symptoms (4,5). Clin-
ical guidelines recommend plain film radiographs as a
reasonable first option in imaging for patients seeking care
for low back symptoms who either have “red flag” con-
cerns on initial presentation or who do not improve after
46 weeks of conservative care (30). Only modest associ-
ations have been consistently reported between DSN and
low back symptoms (3–5). Our findings do not change the
current clinical guidance regarding the use of plain film
radiographs and low back pain, but are useful in under-
standing whether the associations differ between lumbar
spine IRFs and low back symptoms. With OST, after ad-
justment, no association was observed with low back
symptoms; this is consistent with a previous study (5) but
is in contrast to others (3,4). The differences between our
study results and some others could likely be due to op-
Table 2. Sample-based prevalence of disc space narrowing (DSN), vertebral osteophytes (OST), and
facet joint osteoarthritis (FOA) stratified by sex, race, and age*
DSN P OST P FOA P
All participants, n 840 484 (57.6) 740 (88.1) 486 (57.9)
Age, years
45–54 86 (36.1) 188 (79.3) 92 (38.5)
55–64 153 (54.8) 247 (88.5) 146 (52.3)
65–74 151 (73.3) 193 (93.2) 149 (72.3)
75 94 (80.3) 112 (95.7) 99 (85.3)
Cross tabulation
DSN N/A 458 (54.5) 327 (38.9)
OST N/A N/A 452 (53.8)
DSN and OST N/A N/A 313 (37.3)
Women, n 523 314 (60.4) 0.068 462 (88.0) 0.912 323 (61.8) 0.004
Age, years
45–54‡ 48 (38.4) 104 (83.2) 59 (46.8)
55–64 101 (54.0) 163 (86.7) 101 (53.7)
65–74 97 (75.8) 117 (90.7) 92 (71.9)
75 68 (81.9) 78 (94.0) 71 (86.6)
Men, n 317 170 (53.6) 278 (87.7) 163 (51.4)
Age, years
45–54 38 (33.6) 84 (75.0) 33 (29.2)
55–64 52 (56.5) 84 (92.3) 45 (49.5)
65–74 54 (69.2) 76 (97.4) 57 (73.1)
75 26 (76.5) 34 (100.0) 28 (82.4)
African Americans, n 316 165 (52.2) 0.014 267 (84.5) 0.012 142 (44.9) 0.001
Age, years
45–54 33 (30.6) 80 (74.1) 26 (23.9)
55–64 61 (52.6) 102 (87.9) 51 (43.6)
65–74 44 (68.8) 59 (92.1) 44 (68.8)
75 27 (96.4) 26 (92.9) 21 (75.0)
White, n 524 319 (60.9) 473 (90.3) 344 (65.6)
Age, years
45–54 53 (40.8) 108 (83.7) 66 (50.8)
55–64 92 (56.4) 145 (89.0) 95 (58.6)
65–74 107 (75.4) 134 (93.7) 105 (73.9)
75 67 (75.3) 86 (96.6) 78 (88.6)
* Values are the number (percentage). DSN and vertebral OST coded as mild or greater, and FOA coded as absent or
present. N/A not applicable.
For difference in sex or race for each outcome.
Women age 50 years were excluded (n 132).
1540 Goode et al
erational definitions of low back symptom questions, grad-
ing scales, or coding schemes. The lack of association
between FOA and low back symptoms is consistent with
another US community-based study with CT-identified
FOA (13). This lack of association is concerning given that
utilization of interventions to treat facet joint pain have
increased dramatically from 1997 to 2006, with an annual
growth rate of 60% among Medicare beneficiaries (12).
The associations between lumbar spine IRFs and con-
comitant knee, hip, and hand OA differ. There was some
consistency observed in associations between lumbar
spine IRFs and knee and hand OA. After adjustment, both
knee and hand OA remained significantly associated with
lumbar spine OST and FOA. We have reported in previous
work that a high proportion of participants with hand or
knee OA also have spine OA from both a family study of
generalized OA in whites (22) and the Johnston County
Osteoarthritis Project cohort (31). Hand OA was indepen-
Table 3. DSN severity by demographic, clinical, and radiographic factors*
No DSN,
n 356
Mild DSN,
n 284
Moderate DSN,
n 161
Severe DSN,
n 39 P
Age, mean SD years 58.0 8.7 62.4 9.8 66.9 9.9 68.9 9.4 0.001
BMI, mean SD kg/m
2
30.4 6.3 30.4 6.4 30.5 6.4 29.7 5.5 0.921
Race, no. (%)
African American 151 (47.8) 106 (33.5) 45 (14.2) 14 (4.4) 0.019
White 205 (39.1) 178 (34.0) 116 (22.1) 25 (4.8)
Sex, no. (%)
Men 147 (46.4) 106 (33.4) 48 (15.1) 16 (5.1) 0.093
Women 209 (40.0) 178 (34.0) 113 (22.6) 23 (4.4)
Low back symptoms,
no. (%) (n 839)
163 (45.9) 141 (49.5) 97 (60.3) 22 (56.4) 0.020
OA, no. (%)
Knee (n 807) 78 (22.5) 79 (28.6) 63 (42.0) 15 (44.1) 0.001
Hip (n 818) 79 (22.6) 59 (21.0) 44 (28.8) 10 (27.8) 0.286
Hand (n 838) 62 (17.4) 71 (25.2) 66 (41.0) 21 (53.9) 0.001
* Disc space narrowing (DSN) coded based upon the subject’s most severe level. Proportions for symptoms, and knee,
hip, and hand osteoarthritis (OA), differ from column due to missing data. Low back symptoms defined as pain, aching,
or stiffness on most days. Knee and hip OA defined as Kellgren/Lawrence (K/L) score of grade 2–4. Hand OA defined as
the presence of K/L grade 2–4 in at least 1 distal interphalangeal joint and 2 other interphalangeal joints or carpometa-
carpal joints. BMI body mass index.
Table 4. Crude and adjusted associations between disc space narrowing, osteophytes, and facet joint osteoarthritis (OA) with
demographic, clinical, and radiographic factors*
Disc space narrowing Osteophytes Facet joint OA
Crude Adjusted† Crude Adjusted† Crude Adjusted†
Age, years
45–54 Ref. Ref. Ref. Ref. Ref. Ref.
55–64 2.14 (1.52–3.01) 1.60 (1.11–2.30) 1.89 (1.33–2.70) 1.64 (1.12–2.38) 1.75 (1.24–2.49) 1.23 (0.83–1.83)
65–74 4.96 (3.43–7.16) 2.84 (1.88–4.30) 4.53 (3.09–6.66) 2.82 (1.82–4.38) 4.18 (2.80–6.24) 2.25 (1.39–3.62)
75 7.55 (4.88–11.65) 3.07 (1.80–5.24) 5.14 (3.29–8.03) 3.14 (1.78–5.54) 9.30 (5.23–16.56) 2.98 (1.51–5.88)
BMI, kg/m
2
30 Ref. Ref. Ref. Ref. Ref. Ref.
30 1.00 (0.98–1.02) 0.86 (0.64–1.15) 1.46 (1.12–1.90) 1.55 (1.14–2.09) 1.33 (1.01–1.75) 1.56 (1.11–2.19)
Race
White Ref. Ref. Ref. Ref. Ref. Ref.
African American 0.68 (0.53–0.89) 1.00 (0.74–1.35) 0.83 (0.63–1.09) 0.98 (0.72–1.33) 0.42 (0.31–0.56) 0.45 (0.32–0.62)
Sex
Female Ref. Ref. Ref. Ref. Ref. Ref.
Male 0.76 (0.59–0.99) 0.68 (0.51–0.92) 1.94 (1.47–2.56) 2.68 (1.97–3.63) 0.66 (0.50–0.88) 0.75 (0.53–1.05)
Low back symptoms 1.44 (1.12–1.85) 1.37 (1.04–1.80) 1.28 (0.98–1.66) 1.11 (0.84–1.48) 1.05 (0.80–1.38) 0.84 (0.61–1.15)
Knee OA 1.94 (1.46–2.58) 1.16 (0.84–1.59) 2.45 (1.82–3.30) 1.62 (1.16–2.27) 2.69 (1.93–3.74) 1.69 (1.15–2.49)
Hip OA 1.20 (0.89–1.62) 0.99 (0.71–1.38) 1.31 (0.96–1.79) 1.01 (0.72–1.43) 1.23 (0.89–1.72) 0.89 (0.60–1.31)
Hand OA 2.63 (1.97–3.52) 1.14 (0.79–1.63) 2.00 (1.48–2.69) 0.81 (0.55–1.18) 4.55 (3.12–6.63) 1.67 (1.20–2.28)
* Values are the odds ratio (95% confidence interval). Disc space narrowing and osteophyte estimates from proportional odds model and facet joint
OA from binary logistic model. Low back symptoms defined as pain, aching, or stiffness on most days. Knee and hip OA defined as Kellgren/Lawrence
(K/L) grade 2– 4. Hand OA defined as the presence of K/L grade 2– 4 in at least 1 distal interphalangeal joint and 2 other interphalangeal joints or
carpometacarpal joints. Ref. referent group; BMI body mass index.
Adjusted for all demographic, clinical, and the other radiographic variables in this table.
Determining Factors Associated With Lumbar Spine IRFs 1541
dently associated with lumbar spine FOA, indicating that
the degenerative process may be different than that of DSN
or OST. Hip OA demonstrated no independent association
with DSN, OST, or FOA. Previous work in the Johnston
County Osteoarthritis Project and others has questioned
whether the process of hip OA is a separate entity and not
considered as part of generalized OA (32–34). Our findings
here indicate that hip degeneration may occur through a
different etiologic process when compared to that of the
lumbar spine. This is not surprising given the prevalence
of morphometric abnormalities cited as common etiologies
for hip OA (35–38).
These results underscore the importance of analyzing
lumbar spine IRFs separately since the degenerative pro-
cess may differ by demographic, clinical, and concomitant
radiographic knee, hip, and hand OA. Subsequently, these
findings may have important implications for future re-
search regarding generalized OA. The modest associations
between low back symptoms and lumbar spine radio-
graphic features observed in this study may not aid clini-
cians in the diagnosis or treatment referral for mechanical
low back pain related to degeneration in the lumbar spine.
Improvements in low back pain subgroup classification
and consistent use of standardized symptom ascertain-
ment across studies may improve the understanding of the
associations between plain film radiographs and low back
symptoms.
Our study has some limitations and several strengths.
The primary limitation is that these analyses are cross-
sectional and cannot determine causality, and longitudi-
nal analyses may differ. Not inherent to this study are the
differences in coding schemes that may limit comparisons
of the outcomes across studies. We coded the outcomes to
preserve the grading scale used for this study and provide
Table 5. Anterior vertebral OST by demographic, clinical, and radiographic factors*
No OST,
n 100
Mild OST,
n 484
Moderate OST,
n 185
Severe OST,
n 71 P
Age, mean SD years 56.9 8.6 60.5 9.6 65.6 9.9 66.7 9.9 0.001
BMI, mean SD kg/m
2
29.1 5.8 30.3 6.4 30.4 6.3 32.5 5.8 0.006
Race, no. (%)
African American 49 (15.5) 174 (55.1) 63 (19.9) 30 (9.5) 0.052
White 51 (9.7) 310 (59.2) 122 (23.3) 41 (7.8)
Sex, no. (%)
Men 37 (11.8) 148 (47.0) 83 (26.4) 47 (14.9) 0.001
Women 63 (12.0) 336 (64.0) 102 (19.4) 24 (4.6)
Low back symptoms,
no. (%) (n 839)
44 (44.0) 240 (49.5) 100 (54.1) 39 (54.9) 0.338
OA, no. (%)
Knee, n 807 13 (13.3) 121 (25.9) 68 (38.6) 33 (50.0) 0.001
Hip, n 818 14 (14.3) 117 (24.7) 41 (22.8) 21 (31.3) 0.068
Hand, n 838 17 (17.0) 110 (22.8) 65 (35.1) 28 (39.4) 0.001
* Anterior vertebral osteophytes (OST) coded based upon subject’s most severe superior or inferior lumbar level. Proportions for symptoms and knee,
hip, and hand OA differ from column due to missing data. Low back symptoms defined as pain, aching, or stiffness on most days. Knee and hip OA
defined as Kellgren/Lawrence (K/L) grade 2– 4. Hand OA defined as the presence of K/L grade 2– 4 in at least 1 distal interphalangeal joint and 2 other
interphalangeal joints or carpometacarpal joints. BMI body mass index; OA osteoarthritis.
Table 6. Facet joint OA by demographic, clinical, and radiographic factors*
Present, n 486 Absent, n 354 P
Age, mean SD years 64.7 10.2 57.5 8.2 0.001
BMI, mean SD kg/m
2
30.8 6.6 29.9 6.0 0.039
Race, no. (%)
African American 142 (44.7) 176 (55.4) 0.001
White 344 (65.9) 178 (34.1)
Sex, no. (%)
Men 163 (51.6) 153 (48.4) 0.004
Women 323 (61.6) 201 (38.4)
Low back symptoms, no. (%) (n 839) 247 (50.8) 175 (49.6) 0.721
OA, no. (%)
Knee, n 807 174 (37.8) 64 (18.4) 0.001
Hip, n 818 118 (25.1) 74 (21.3) 0.214
Hand, n 838 179 (36.8) 40 (11.3) 0.001
* Facet joint osteoarthritis (OA) coded as absent or present. Proportions for symptoms, knee, hip, and
hand OA differ from column due to missing data. Low back symptoms defined as pain, aching, or stiffness
on most days. Knee and hip OA defined as Kellgren/Lawrence (K/L) score of grade 2–4. Hand OA defined
as the presence of K/L grade 2– 4 in at least 1 distal interphalangeal joint and 2 other interphalangeal joints
or carpometacarpal joints. BMI body mass index.
1542 Goode et al
a descriptive analysis for future studies. Another limita-
tion is that our study was conducted among a community-
based sample of white and African American rural partic-
ipants over age 45 years in which African Americans were
deliberately targeted, which may limit the generalizability
of findings. However, this is a large well-balanced sample
of both men and women and is the only study to charac-
terize lumbar spine IRFs across race. Lastly, this is the first
community-based study to recognize that there are differ-
ences in associations between lumbar spine IRFs with
radiographic knee, hip, and hand OA.
AUTHOR CONTRIBUTIONS
All authors were involved in drafting the article or revising it
critically for important intellectual content, and all authors ap-
proved the final version to be submitted for publication. Dr.
Goode had full access to all of the data in the study and takes
responsibility for the integrity of the data and the accuracy of the
data analysis.
Study conception and design. Goode, Marshall, Renner, Carey,
Kraus, Irwin, Jordan.
Acquisition of data. Goode, Marshall, Renner, Carey, Jordan.
Analysis and interpretation of data. Goode, Marshall, Renner,
Carey, Kraus, Irwin, Stu¨rmer, Jordan.
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    • "OA progression is often of interest to the patient, especially if there will be a need for surgical intervention . Although the association of major joint OA has been linked to OA at other sites [10,12131418], this is the first study to associate the severity of hand OA with other major joint involvement and the risk of surgical intervention. In a longitudinal, multisite study, Hassett et al [32] found that knee OA progression is often associated with OA progression in the lumbar spine and hip; however, progression of hand OA showed inconsistent and insignificant results. "
    [Show abstract] [Hide abstract] ABSTRACT: Introduction The presence of hand OA increases the risk for developing OA in other major joints. Although genetic predisposition has been implicated in its causation, its exact role has yet to be established. The association of hand OA with symptomatic and asymptomatic major joint(s) has not been previously studied. Material and Methods 100 consecutive patients had a hand photo taken for visual documentation of the hand joints. Radiographs of hand and all major symptomatic joint(s) were analyzed and classified using the Kellgren-Lawrence (KL) scale by two independent observers including an orthopaedic radiologist. Results Severe hand OA was present in 91% of the patients. Radiographic analysis showed the hip was involved in 88% of the patients, of whom 85.2% (75) were symptomatic and 14.7% (13) were asymptomatic. 62.5% (55) of symptomatic hip patients required hip replacement. Knee involvement was present in 37% of the patients and all were symptomatic and 81.1% (30) of these required knee replacement. 33% (28) had bilateral and 6% (5) had ‘two joint (hip&knee)’ surgery. Spine involvement was present in 72% of the patients. There was a significant correlation between hand radiographic findings of OA and hip (r=0.68;p=0.03), knee (r=0.58;p=0.042), and spine (r=0.39;p=0.05) involvement. Conclusions There was a significant correlation between severe hand OA and hip, knee and spine involvement. Severity of Hand OA can have a predictive value on multiple joint involvement and risk of surgical intervention. This study emphasizes the need to investigate the genetic predisposition in causation of OA.
    Full-text · Article · Feb 2016
    • "and 1.44 (95% CI: 0.89–2.33) [36] [47]. Table 4 describes the counts, proportions, aORs and uORs, 95% CI, and categorization grade of radiographic features for each included occupation-based study. "
    [Show abstract] [Hide abstract] ABSTRACT: Background/purpose: Low back pain (LBP) is a prevalent musculoskeletal condition and represents a substantial socioeconomic burden. Plain film radiography is a commonly used imaging technique. Radiographic features (RFs) such as disc space narrowing, osteophytes, spondylosis, endplate sclerosis, spondylolisthesis, and facet joint osteoarthritis have all been debated as potential pain generators in the lumbar spine. The aim of this study is to (1) determine the association between LBP and lumbar spine RFs in both community- and occupation-based groups and (2) to determine if there are differences in these associations between these two groups. Methods: A systematic electronic search of PubMed, EMBASE, CINAHL, and Cochrane was conducted with keywords related to LBP and lumbar spine RFs. The search was restricted from inception of each respective database to April 2014. Inclusion criteria consisted of observational studies of adults (≥18 years) with and without nonspecific LBP. Studies were excluded if they investigated LBP related to infection, malignancy, or rheumatologic nature or were conducted in cadavers. Quality assessment was conducted with the Item Bank for Assessment of Risk of Bias and Precision for Observational Studies of Interventions or Exposures. Random effect models were used for all pooled analyses with associations represented by odds ratios (OR) and 95% confidence intervals (95% CIs). Statistical heterogeneity was assessed with I(2), with significant heterogeneity represented as >50%. Results: Overall, 28 (22 community-based and six occupation-based) studies met the eligibility criteria consisting of 26,107 subjects. A significant, positive association was found between disc space narrowing and LBP, which did not differ (p = 0.22) in both community- and occupation-based studies [OR = 1.47 (95% CI: 1.36-1.58)] and [OR = 1.76 (95% CI: 1.34-2.33)], respectively. No significant statistical heterogeneity was present in either estimate (I(2) = 0.0%). A significant association was found between spondylolisthesis and LBP in occupation-based studies [OR = 2.21 (95% CI: 1.44-3.39)] that differed significantly (p < 0.01) from community-based studies [OR = 1.12 (95% CI: 1.03-1.23)]. These individual estimates were also homogeneous (I(2) = 0.0%). The association between other radiographic features was modest (i.e., spondylosis and osteophytes) or non-significant (i.e., endplate sclerosis and facet joint). Quality of included studies varied, with the majority demonstrating good quality. Conclusion: A significant association was found between disc space narrowing in both community- and occupational-based populations without significant differences between the associations. A significant strong association was found between spondylolisthesis and LBP among the occupational group but was weakly associated in the community-based group, which supports that spondylolisthesis may contribute a specific cause for LBP.
    Full-text · Article · Dec 2014
    • "Mechanical, nutritional, traumatic, and genetic factors have all been implicated in the cascade of disc degeneration to variable degrees [2]. Increasing age, gender, higher body mass index (BMI) scores, demanding jobs/physical activities, lower bone mineral density, and genetic factors have been associated with lumbar degenerative disc disease [3,4,5,6,7,8]. In magnetic resonance imaging (MRI), which is a sensitive imaging method for the evaluation of degenerative disc disease, disc space narrowing, loss of T2-weighted signal within the nucleus pulposus, fissures, vacuum changes and calcification, endplate changes, ligamentous and/or marrow signal changes, presence of osteophytosis, and stenosis have been reported [2,9]. "
    [Show abstract] [Hide abstract] ABSTRACT: Study DesignCase-control.PurposeTo determine whether a disproportion between two neighboring vertebral end plates is associated with degenerative disc disease.Overview of LiteratureRecently, it has been suggested that disproportion of the end plates of two adjacent vertebrae may increase the risk of disc herniation.MethodsMagnetic resonance (MR) images (n=160) with evidence of grades I-II lumbar degenerative disc disease (modified Pfirrmann's classification) and normal MR images of the lumbar region (n=160) were reviewed. On midsagittal sections, the difference of anteroposterior diameter of upper and lower end plates neighboring a degenerated (in the case group) or normal (in the control group) intervertebral disc was calculated (difference of end plates [DEP]).ResultsMean DEP was significantly higher in the case group at the L5-S1 level (2.73±0.23 mm vs. 2.21±0.12 mm, p=0.03). Differences were not statistically significant at L1-L2 (1.31±0.13 mm in the cases vs. 1.28±0.08 mm in the controls, p=0.78), L2-L3 (1.45±0.12 mm in the cases vs. 1.37±0.08 mm in the controls, p=0.58), L3-L4 (1.52±0.13 mm in the cases vs. 1.49±0.10 mm in the controls, p=0.88), and L4-L5 (2.15±0.21 mm in the cases vs. 2.04±0.20 mm in the controls, p=0.31) levels. The difference at the L5-S1 level did not remain significant after adjusting for body mass index (BMI), which was significantly higher in the patients.ConclusionsEnd plate disproportion may be a significant, BMI-dependent risk factor for lumbar degenerative disc disease.
    Full-text · Article · Aug 2014
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