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Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects. A Prospective Investigation

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Abstract

Background: In the 1980s and 1990s Magnetic Resonance Imaging (MRI) was gaining popularity as the diagnostic imaging technique of choice for the investigation of disorders affecting the lumbar spine. The sensitivity of MRI to detect previously undetectable pathologies (e.g. tears in the annulus fi brosus) was well recognised but led the authors of this paper to question if MRI was suffi ciently specifi c. Method: Sixty-seven individuals who had never had lowback pain, sciatica, or neurogenic claudication underwent MRI scans of their lumbar spine. The scans were reviewed by three neuro-radiologists who were blinded to the reports of the other radiologists and to the presence or absence of clinical symptoms in the subjects. Results: Approximately one-third of the subjects were found to have an abnormality on their MRI scan. In the group under the age of 60, 20 % were found to have herniated discs and one had spinal stenosis. In subjects >60 years old, 57 % had 'abnormal' scans. The abnormalities that were detected included herniated discs in 36 % of subjects, and 21 % had spinal stenosis. Minor abnormalities such as degeneration or bulging of a disc were found in 35 % of the subjects aged between 20 and 39 years, and in all but one of the over 60 age group. Conclusion: The authors conclude that the high incidence of bulging and degenerate discs seen on MRI scans in asymptomatic subjects indicates that they should be viewed as normal or as part of the aging process. They recommend that before operative treatment is contemplated abnormalities on magnetic resonance images must be strictly correlated with age and any clinical signs and symptoms.

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... DLSS is a chronic disease prevalent among aged adults [5]. A recent study shows that DLSS presented in up to 8.0 % of adults aged 50 years or older, and the incidence increases with advancing age [6], while another recent study involving sixty-seven individuals shows that DLSS is found on magnetic resonance imaging in more than 20 % of individuals aged more than 60 [7]. Typical symptoms of DLSS include pain in the groin, hips, and buttocks [1,7]. ...
... A recent study shows that DLSS presented in up to 8.0 % of adults aged 50 years or older, and the incidence increases with advancing age [6], while another recent study involving sixty-seven individuals shows that DLSS is found on magnetic resonance imaging in more than 20 % of individuals aged more than 60 [7]. Typical symptoms of DLSS include pain in the groin, hips, and buttocks [1,7]. The destructive impacts of DLSS on the ability to walk and move independently significantly diminishes the life quality of aged adults. ...
Article
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Background: Degenerative lumbar spinal stenosis (DLSS) is a common degenerative condition in older adults. Muscle atrophy (MA) is a leading cause of muscle weakness and disability commonly reported in individuals with spinal stenosis. The purpose of this study was to investigate if the MA correlates with the grade of spinal stenosis in patients with DLSS. Methods: A retrospective analysis on 48 male and 184 female DLSS patients aged around 54.04 years (54.04 ± 8.93) were involved and divided into 6 groups according to claudication-distance-based grading of spinal stenosis, which confirmed by two independent orthopedic surgeons using T2- weighted images. Using 1.5T MRI scanner, the severity of MA is assessed based on its negative correlation with the ratio of total fat-free multifidus muscle cross-sectional area (TFCSA) to total multifidus muscle cross-sectional area (TCSA). Adobe Photoshop CS6 was used for qualitative image analysis and calculate the TFCSA/TCSA ratio to assess the severity of MA, compare the grade of MA with the spinal stenosis segment, stenosis grade and symptom side. Results: In DLSS group, The TFCSA/TCSA ratio are 74.33 ± 2.18 in L3/4 stenosis, 75.51 ± 2.79 in L4/5 stenosis, and 75.49 ± 2.69 in L5/S1 stenosis. there were significant decreases in the TFCSA/TCSA ratio of stenotic segments compared with non-stenotic segments of the spinal canal (P < 0.05) while no significant difference between the non-stenotic segments (P > 0.05). TFCSA/TCSA ratios is significant differences in the TFCSA/TCSA ratios of the 6 DLSS groups (F = 67.832; P < 0.05). From Group 1 to Group 6, the TFCSA/TCSA ratio of stenotic segments positively correlated with the absolute claudication distance (ACD). (P < 0.001, r = 0.852). Besides, the TFCSA/TCSA ratios are smaller in the symptomatic sides of the spine than the contralateral sides (t = 4.128, P = 0.001). Conclusions: The stenotic segments of the spinal canal are more atrophied than the non-stenotic segment in DLSS patients. It is shows that a strong positive correlation between the severity of multifidus atrophy and the severity of spinal stenosis.
... We have tried to highlight this by clarifying the effect of axial load in supine position in Figure legend (Fig 1) and by clarifications/alterations in 2:nd paragraph of the discussion, including references strengthening the effect of applied load in MRI. 4. The results would be more powerful if there was correlation with clinical results ...
... However, it is well recognized that clinical findings in LSS not always correlate with radiological findings. Mildly affected patients can have signs of severe stenosis on MRI and vice versa [4,5]. ...
Article
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Unfortunately, the ninth reference was incorrectly published in the original publication. The complete correct reference is given below.
... Despite the association between IVD degeneration and LBP, the correspondence between the clinical presentation of LBP and IVD imaging findings is quite poor (Rea et al., 2012). One possibility for this lack of specificity may be that most diagnostic imaging of the spine is performed in supine, a minimally loaded position (Baker, 2014;Wilke et al., 2006). An individual in standing generates lumbar intradiscal pressures approximately five times greater than in supine (Nachemson, 1981) and complex multiaxial forces (Naserkhaki et al., 2016) that result in different tensile and shear deformations across the IVD (Aiyangar et al., 2013;Wang et al., 2009). ...
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Traditional diagnostic imaging of the spine is performed in supine, a relatively unloaded position. However, the spine is subjected to complex loading environments in daily activities such as standing. Therefore, we seek to quantify the changes from supine to standing in the spines of young, healthy individuals in standing using a positional MRI system. This is an observational study that examined the changes in the spine and individual intervertebral discs (IVDs) during supine and standing of forty healthy participants (19 males / 21 females) without a history of low back pain. The regional lumbar spinal alignment was measured by the sagittal Cobb angle. Segmental IVD measurements included the segmental Cobb angle, anterior to posterior height (A/P) ratio, and IVD width measured at each L1/L2 - L5/S1 levels. The intra-observer intra-class correlation (ICC) consistency model showed values for measurements ranged from 0.76-0.98. The inter-observer ICC values ranged from 0.68-0.99. The Cobb angle decreased in standing. The L5/S1 segmental Cobb angle decreased in standing. The L2/L3 and L3/L4 A/P ratios increased and the L5/S1 A/P ratio decreased in standing. No differences in IVD width were observed from supine to standing. This study examined the regional lumbar spinal alignment and segmental IVD changes from supine to standing in young, healthy individuals without LBP using pMRI. In developing and validating these measurements, we have also established the normative data for healthy, asymptomatic population that could be useful for other investigations examining how individuals with spinal or IVD pathologies may adapt between supine and standing.
... Assessment of the individuals underlying structure and degree of joint pathology may be important to objectify in some presentations of PFP. However, consistent with emerging evidence in other common musculoskeletal conditions such as low back pain (Baker, 2014;Jensen et al., 1994), the correlation between structure and symptoms has been shown to be tenuous in those with PFP . Imaging findings should have limited impact on treatment decisions in most cases, and clinicians who are working with patients seeking interventions aiming to address structure or structural pathology should ensure adequate time is spent discussing the available evidence (Barton & Crossley, 2016) as they either lack evidence to support their use (e.g. ...
Article
Patellofemoral pain (PFP) is one of the most prevalent conditions within sports medicine, orthopaedic and general practice settings. Long-term treatment outcomes are poor, with estimates that more than 50% of people with the condition will report symptoms beyond 5 years following diagnosis. Additionally, emerging evidence indicates that PFP may be on a continuum with patellofemoral osteoarthritis. Consensus of world leading clinicians and academics highlights the potential benefit of delivering tailored interventions, specific to an individual's needs, to improve patient outcome. This clinical masterclass aims to develop the reader's understanding of PFP aetiology, inform clinical assessment and increase knowledge regarding individually tailored treatment approaches. It offers practical application guidance, and additional resources, that can positively impact clinical practice.
... Spinal canal stenosis often occurs in middle ages and due to degenerative changes. One of the most important causes of spinal canal stenosis is disc herniation which is one of the most common and important causes of low back pain in various societies and has a relatively high prevalence [3,4]. The most common type of canal stenosis is the intervertebral disc bulging toward the spinal canal, leading to reduced spinal canal space and narrowing of the canal (discogenic canal stenosis). ...
Article
Background: The Percutaneous laser disc decompression (PLDD) method was first described by Daniel Choy in Australia in 1987. Therefore, in this study, we examined the clinical signs and symptoms of patients with spinal canal stenosis due to disc protrusion after PLDD surgery. Methods: In this clinical trial study, 43 patients with spinal canal stenosis due to lumbar disks who referred to Kashani and Zahra Marzieh educational hospitals from 2006 to 2016 were entered the study. The patients were divided into two groups as discogenic canal stenosis (3 females and 9 males) and complex degenerative disorder (canal stenosis due to discogenic and ligamentos) (16 females and 15 males). Patients underwent PLDD surgery and the clinical manifestations such as back and radicular pain, claudication, and complications of the surgery (hematoma, reoperation, and neurological symptoms) in patients were evaluated until one year after the operation. Results: After one year of surgery, the mean of back and radicular pains significantly decreased in both groups (P<0.05). All patients with claudication in the discogenic group improved and 35.5% of patients with complex degenerative disorder were not claudication after one year of surgery. The outcomes of treatment in patients with discogenic canal stenosis were 91.7% excellent, and 8.3% fair and in the complex degenerative disorder group were 64.5% excellent, 19.4% good and 16.1% fair (P=0.16). None of the patients had new neurological symptoms, and 12.9% of the complex degenerative disorder group patients needed reoperation. Conclusion: The PLDD method is a better procedure for discogenic canal stenosis than complex degenerative disorder. Therefore, more studies are required in this field for long time.
... Magnetic resonance imaging (MRI) technologies are currently one of the most effective tools in the diagnosis of a wide variety of socially significant pathologies including cancer, arteriosclerosis, episodes. Ischemic and neurodegenerative diseases [1,2,3,4].This paper gives detailed idea of pre-processing, and segmentation(FCM, soft and hard) of MRI brain tumor images. This paper also insights the machine learning(SOM, NN and SVM) approach for automatic classification(PTPSA, fBM) of brain tissues. ...
Article
Magnetic resonance imaging (MRI) technologies are currently one of the most effective tools in the diagnosis of a wide variety of socially significant pathologies including cancer, arteriosclerosis, episodes. Ischemic and neurodegenerative diseases [1, 2, 3, 4]. This paper gives detailed idea of pre-processing, and segmentation(FCM, soft and hard) of MRI brain tumor images. This paper also insights the machine learning(SOM, NN and SVM) approach for automatic classification(PTPSA, fBM) of brain tissues. Different performance evaluation parameter and similarity metrics are discuss to define the efficiency of computer-aided diagnostic (CAD) system.
... Assessment of the individuals underlying structure and degree of joint pathology may be important to objectify in some presentations of PFP. However, consistent with emerging evidence in other common musculoskeletal conditions such as low back pain (Baker, 2014;Jensen et al., 1994), the correlation between structure and symptoms has been shown to be tenuous in those with PFP . Imaging findings should have limited impact on treatment decisions in most cases, and clinicians who are working with patients seeking interventions aiming to address structure or structural pathology should ensure adequate time is spent discussing the available evidence (Barton & Crossley, 2016) as they either lack evidence to support their use (e.g. ...
Article
Objectives: (i) To assess the reliability of knee crepitus measures, (ii) to investigate the association between knee crepitus and PFP; (iii) to investigate the relationship between knee crepitus with self-reported function, physical activity and pain. Design: Cross-sectional. Setting: Laboratory-based study. Participants: 165 women with PFP and 158 pain-free women. Main outcome measures: Knee crepitus test, anterior knee pain scale (AKPS) and self-reported worst knee pain in the last month, knee pain after 10 squats and knee pain after 10 stairs climbing. Results: Knee crepitus clinical test presented high reliability Kappa value for PFP group was 0.860 and for pain-free group was 0.906. There is a significantly greater proportion of those with crepitus in the PFP group than in the pain-free group (OR = 4.19). Knee crepitus had no relationship with function (rpb = 0.03; p = 0.727), physical activity level (rpb = 0.010; p = 0.193), worst pain (rpb = 0.11; p = 0.141), pain climbing stairs (rpb = 0.10; p = 0.194) and pain squatting (rpb = 0.02; p = 0.802). Conclusion: Women who presents knee crepitus have 4 times greater odds to be in a group with PFP compared to those who do not. However, knee crepitus has no relationship with self-reported clinical outcomes of women with PFP.
... Kombinacija zmanjšanega naklona križni- ce in zmanjšane ledvene lordoze lahko tudi povzroča BVK (Chaleat-Valayer, 2011). Na drugi strani pa številne študije kažejo pojavnost strukturne spremembe v led- venem delu hrbtenice pri asimptomatskih pacientih (Boden, 1990;Evcik, 2003in Baker, 2014). V zadnjih desetletjih je nastalo nemalo število raziskav, ki nakazujejo, da je zmanjšana gibljivost v kolku povezana z BVK (Sward 1990;Sjolie 2004;Van Dillen 2008). ...
Article
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Low back pain presents a global health burden with increasing prevalence in sedentary as well as sport population. The aim of this study was to assess the prevalence of low back pain and its associations with altered lumbar spine posture, flexibility and mobility in lumbar spine and hips. A total of 96 sport active participants from four different sports disciplines were randomly included into the prospective study, aged 26,9± 6,9 years. We assessed alterations, flexibility and mobility of lumbar spine and hips with the wall test, goniometry, Schoeber`s test and functional measurement system, respectively. The pain was assessed with low back pain questionnaire for athletes. There were no significant correlation between low back pain and anatomic alterations of lumbar spine or the flexibility, neither did higher degree of pain affect the functional performance in selected FMS tests. However, a low but significant correlation was obtained between higher degree of low back pain and decreased external hip rotation (p = 0,031). In our study the selected clinical tests failed to objectively assess the relations with low back pain, therefore we suggest more systemic approach both in science and practice in order to lower the prevalence of this global health problem.
... In both cases, hip fractures and AVN were diagnosed on MRI scans. [1,4,5,6,9] In the first case, following bilateral hip fusions, the patient underwent an L5-S1 decompression. In the second case, the lumbar MRI was negative, the hip X-rays were negative, but the MRI documented bilateral AVN of the femoral neck (e.g., in the initial stages) appropriately treated by orthopedics' surgeon. ...
Article
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Background Occasionally, hip pathologies may present alone or combined with lumbar spine pathology, especially lumbar stenosis. Although the history and clinical examination may help differentiate between the two, hip X-rays alone without accompanying magnetic resonance imaging (MRI) studies may prove unreliable. Case Descriptions Case 1 – A 72-year-old male presented with the sudden onset of severe back and left posterior thigh pain. Straight leg raising test was positive at 70° (right) and 60° (left), and he had left lower extremity numbness and weakness. The lumbar MRI showed L5-S1 spinal stenosis. Although X-rays of both hips were negative, the MRI showed bilateral femoral neck fractures. He underwent screw fixation of the hip fractures and later underwent endoscopic decompression of the spinal stenosis. Case 2 – A 35-year-old male presented with low backache and right hip pain of 1 month’s duration. The neurological examination was normal, except for positive straight leg raising bilaterally at 60°. The spine MRI was normal. However, despite negative X-ray of both hips, the hip MRI revealed avascular necrosis (AVN) of both femoral heads requiring subsequent orthopedic management. Conclusion Hip pathology may mimic lumbar spinal stenosis. In the two cases presented, plain X-rays failed to document hip fractures (case 1) and AVN (case 2), respectively, both of which were later diagnosed on MRI studies.
... Despite the association between IVD degeneration and LBP, the correspondence between the clinical presentation of LBP and IVD imaging findings is quite poor (Rea et al., 2012). One possibility for this lack of specificity may be that most diagnostic imaging of the spine is performed in supine, a minimally loaded position (Baker, 2014;Wilke et al., 2006). An individual in standing generates lumbar intradiscal pressures approximately five times greater than in supine (Nachemson, 1981) and complex multiaxial forces (Naserkhaki et al., 2016) that result in different tensile and shear deformations across the IVD (Aiyangar et al., 2013;Wang et al., 2009). ...
Article
Background: Most diagnostic imaging of the spine is performed in supine, a relatively unloaded position. Although the spine is subjected to functional loading that changes the spinal alignment and intervertebral disc geometry, little data exists on how healthy spines adapt to standing. This study seeks to quantify the changes of the lumbar spine from supine to standing in young, back-healthy individuals using a positional magnetic resonance imaging system. Methods: This is an observational study that examined the changes in the lumbar spine alignment and intervertebral disc geometry between supine and standing of forty participants (19 males/21 females) without a history of low back pain. The regional lumbar spinal alignment was measured by the sagittal Cobb angle. Segmental intervertebral disc measurements included the segmental Cobb angle, anterior-to-posterior height ratio, and intervertebral disc width measured at L1/L2 - L5/S1 levels. Intra-class correlation was performed for intra- and inter-observer measurements. Findings: The intra-observer intra-class correlation consistency model ranged from 0.76 to 0.98 with the inter-observer correlation ranging from 0.68 to 0.99. The Cobb angle decreased in standing. The L5/S1 segmental Cobb angle decreased in standing. The L2/L3 and L3/L4 anterior-to-posterior height ratios increased and the L5/S1 anterior-to-posterior height ratio decreased in standing. No difference in intervertebral disc widths was observed from supine to standing. Interpretations: We established normative data for a back-healthy population, using a positional magnetic resonance imaging system, that could inform future investigations that examine the standing-induced adaptations of the lumbar spine in individuals with spinal or intervertebral disc pathologies.
Article
Bioinformatics analysis of published microarray data. This study aimed to reveal the possible genes and pathways related to the pathogenesis of DD by analyzing the microarray data. Disc degeneration (DD) is one of the main causes of low back pain, which has become an enormous economic burden for society. Gene expression data of annulus cells and nucleus pulposus cells from DD patients and controls subjects were downloaded from Gene Expression Omnibus. T-test and enrichment analysis were used to identify differentially expressed genes (DEGs) and DEGs-associated functions and pathways in DD respectively. Protein-protein interaction network and module were constructed to analyze the key nodes associated with this disease. Totally 326 DEGs and 35 DEGs were obtained from the annulus cells and nucleus pulposus cells, respectively. The DEGs of DD in annulus cells were mainly involved in translation, cell adhesion, cell death regulation and skeletal system development whilst the DEGs in nucleus pulposus cells were mainly related to the biological processes of vascular system development, skeletal system development and enzyme-linked receptor protein signaling pathway. COL3A1 was the common DEGs in both annulus cells and nucleus pulposus cells. The ribosomal proteins (RPL8, RPS16 and RPS23) in module were enriched in biological processes of translation, translation elongation and RNA processing. The results revealed the involvement of COL3A1 in skeletal system process and RPL8, RPS16 and RPS23 in the protein synthesis processes in the progression of DD, suggesting their potential use in the diagnosis and therapy of DD.
Article
Background: Lumbar herniated nucleus pulposus (HNP) is a common spinal pathology often treated by microscopic lumbar discectomy (MLD), though prior reports have not demonstrated which preoperative MRI factors may contribute to significant clinical improvement after MLD. Purpose: To analyze the MRI characteristics in patients with HNP that predict meaningful clinical improvement in Health Related Quality of Life scores (HRQoL) after MLD. Study design/setting: Retrospective clinical and radiological study of patients undergoing MLD for HNP at a single institution over a two-year period. Patient sample: 88 patients receiving MLD treatment for HNP. Outcome measures: Cephalocaudal Canal Migration; Canal & HNP Anterior-Posterior (AP) Lengths and Ratio; Canal & HNP Axial Areas and Ratio; Hemi-Canal & Hemi-HNP Axial Areas and Ratio; Disc appearance (black, grey or mixed), Baseline (BL) and 3-Month (3M) postoperative Health Related Quality of Life Scores. Methods: Patients > 18 years old who received MLD for HNP with BL and 3M HRQoL scores of PROMIS (Physical Function, Pain Interference, and Pain Intensity), ODI, VAS Back, and VAS Leg scores were included. HNP and spinal canal measurements of cephalocaudal migration, AP length, area, hemi-area, and disc appearance were performed using T2 axial and sagittal MRI. HNP measurements were divided by corresponding canal measurements to calculate AP, Area, and Hemi-Area ratios. Using known minimal clinically important differences (MCID) for each ΔHRQoL score, patients were separated into two groups based on whether they reached MCID (MCID+) or did not reach MCID (MCID-). The MCID for PROMIS Pain Intensity was calculated using a decision tree. A linear regression illustrated correlations between PROMIS vs ODI and VAS Back/Leg scores. Independent t-tests and chi [2] tests were utilized to investigate significant differences in HNP measurements between the MCID+ and MCID- groups. Results: There were 88 MLD patients included in the study (Age=44.6±14.9, 38.6% Female). PROMIS Pain Interference and Pain Intensity were strongly correlated with ODI and VAS Back/Leg (R≥.505), and Physical Function correlated with ODI and VAS Back/Leg (R=-.349) (all p<.01). The strongest MRI predictors of meeting HRQoL MCID were grey disc appearance, HNP area (>116.6 mm2), and Hemi-Area Ratio (>51.8%). MCID+ patients were 2.7 times more likely to have a grey HNP MRI signal than a mixed or black HNP MRI signal in 5 out of 6 HRQoL score comparisons (p<.025). MCID+ patients had larger HNP areas than MCID- patients had in 5 out of 6 HRQoL score comparisons (116.6mm2 ± 46.4 vs 90.0mm2 ± 43.2, p<.04). MCID+ patients had a greater Hemi-Area Ratio than MCID- patients had in 4 out of 6 HRQoL score comparisons (51.8% ± 14.7 vs 43.9% ± 14.9, p<.05). Conclusions: Patients who met MCID after MLD had larger HNP areas and larger Hemi-HNP Areas than those who did not meet MCID. These patients were also 2.7x more likely to have a grey MRI signal than a mixed or black MRI signal. When accounting for HNP area relative to canal area, patients who met MCID had greater Hemi-HNP canal occupation than patients who did not meet MCID. The results of this study suggest that preoperative MRI parameters can be useful in predicting patient reported improvement after MLD.
Article
Introduction Magnetic reasoning imaging (MRI) is the imaging modality of choice for detecting spinal pathologies. The study of the appropriateness of MRI utilization in Saudi Arabia is lacking. As a result, this research aims to assess the use and misuse of lumbar MRI in lower back pain (LBP) at the National Guard Hospital (NGH) in Jeddah city. Methods This is a retrospective cohort study that included all adult patients who had lumbar MRI for LBP at NGH in 2019. A total of 1,225 patients were included. Patients with extreme ages, trauma, recent lumbar spine surgery, spine or spinal canal tumors, and infection were excluded, leaving a number of 805 patients. Specific MRI findings were obtained and assessed in association with history and physical examination. Results LBP with radiculopathy was the most common complaint (82.9%) followed by LBP without radiculopathy (12.8%), with the lowest being limb pain alone (2.6%). Overall, 72% of patients had negative MRI findings, which did not explain their symptoms, and 28% had positive MRI findings that were not associated with their symptoms (p < 0.001). A complete physical examination was performed on 27.5% of patients, of which only 12% had positive findings. MRI was ordered for 72.5% of patients without a complete physical examination. Finally, 88.2% of patients who had MRI were managed conservatively, while only 6.7% were managed with surgery (p < 0.04). Conclusion The number of patients who had proper assessment prior to the ordering of MRI was significantly low. The decision to request MRI was not based on any scientific basis. This study has demonstrated that without proper and strict guidelines, MRIs will continue to be overutilized, which, in turn, will have negative consequences on the waiting time for an MRI and the cost of all the unnecessary MRIs. Furthermore, a good number of patients nowadays who do not have any indications for an MRI keep asking their physicians for it, and if the physician refuses, they transfer to another physician who will order the MRI.
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Purpose To evaluate the effect on the spinal canal at the treated and adjacent level(s), in patients treated for lumbar spinal stenosis (LSS) with percutaneous interspinous process device (IPD) Aperius™ or open decompressive surgery (ODS), using axial loading of the spine during MRI (alMRI). Materials Nineteen LSS patients (mean age 67 years, range 49–78) treated with IPDs in 29 spine levels and 13 LSS patients (mean age 63 years, range 46–76) operated with ODS in 22 spine levels were examined with alMRI pre- and 3 months postoperatively. Radiological effects were evaluated by measuring the dural sac cross-sectional area (DSCSA) and by morphological grading of nerve root affection. Results For the IPD group, no DSCSA increase was observed at the operated level (p = 0.42); however, a decrease was observed in adjacent levels (p = 0.05). No effect was seen regarding morphological grading (operated level: p = 0.71/adjacent level: p = 0.94). For the ODS group, beneficial effects were seen for the operated level, both regarding DSCSA (p < 0.001) and for morphological grading (p < 0.0001). No changes were seen for adjacent levels (DSCSA; p = 0.47/morphological grading: p = 0.95). Postoperatively, a significant difference between the groups existed at the operated level regarding both evaluated parameters (p < 0.003). Conclusions With the spine imaged in an axial loaded position, no significant radiological effects of an IPD could be detected postoperatively at the treated level, while increased DSCSA was displayed for the ODS group. In addition, reduced DSCSA in adjacent levels was detected for the IPD group. Thus, the beneficial effects of IPD implants on the spinal canal must be questioned. Graphic abstract These slides can be retrieved under Electronic Supplementary Material. Open image in new window
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Objectives Hamstring injuries in athletes can lead to significant time away from competition as a result of persistent posterior thigh pain. These cases are often difficult to treat as the state of the tissues alone cannot explain symptoms. In non-athletic populations with persistent pain, disruptions to tactile, proprioceptive, and spatial cortical representations exist, which has led to promising brain-based treatments. Here, we explored whether athletes with persistent posterior thigh pain also display impairments in these cortical representations. Design Cross-sectional study. Methods Fourteen male professional athletes with persistent posterior thigh pain (‘Patients’) and 14 pain-free age, sport, body mass index and level-matched controls (‘Controls’) participated. The tactile cortical representation was assessed using two-point discrimination (TPD) threshold and accuracy of tactile localisation; the proprioceptive cortical representation was assessed using a left/right judgement task; spatial processing was assessed using an auditory detection task. Results TPD thresholds were similar for Patients and Controls (p = 0.70). Patients were less accurate at localising tactile stimuli delivered to their affected leg, slower to make left/right judgements when the lower limb image corresponded to the side of their affected leg, and less accurate at detecting auditory stimuli delivered near their affected leg, when compared to their healthy leg or to the leg of Controls (p < 0.01 for all). Conclusions Leg-specific tactile, proprioceptive, and spatial processing deficits exist in athletes with persistent posterior thigh pain. That these processing deficits exist despite rehabilitation and normal tissue healing time suggests they may play a role in the persistence of posterior thigh pain.
Article
Background: Painful lumbar radiculopathy is a neuropathic pain condition, commonly attributed to nerve root inflammation/compression by disc herniation. The present exploratory study searched for associations between pain intensity and inflammatory markers, herniated disc size, infection, psychological factors and pain modulation in patients with confirmed painful lumbar radiculopathy scheduled for spine surgery. Methods: Prior to surgery, 53 patients underwent the following evaluation: pain intensity measured on a 0-10 numeric rating scale (NRS) and the Short-Form McGill Pain Questionnaire; sensory testing (modified DFNS protocol); pain processing including temporal summation and conditioned pain modulation (CPM); neurological examination; psychological assessment including Spielberger's Anxiety Inventory, Pain Sensitivity Questionnaire and the Pain Catastrophizing Scale. Pro-inflammatory cytokine levels (IL-1b, IL-6, IL-8, IL-17, TNFα, IFNg) and microbial infection (ELISA and rt-PCR) in blood and disc samples obtained during surgery. MRI scans assessments for disc herniation size/volume (MSU classification/ three-dimensional volumetric analysis). Results: Complete data was available from 40 (75%) patients (15 female) aged 44.8±16.3 years. Pain intensity (NRS) positively correlated with pain catastrophizing and CPM (r=0.437, P=0.006; r=0.421, P=0.007; respectively), but not with disc/blood cytokine levels, bacterial infection or MRI measures. CPM (P=0.001) and gender (P=0.029) were associated with average pain intensity (adjusted R2=0.443). Conclusions: This exploratory study suggests that pain catastrophizing, CPM and gender, seem to contribute to pain intensity in patients with painful lumbar radiculopathy. The role of mechanical compression and inflammation in determining the intensity of painful radiculopathy remains obscure.
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Background The type, timing, and extent of provision of rehabilitation for lumbar discectomy patients in the UK are currently unknown. The aim of this study was to determine the provision and type of rehabilitation for patients undergoing lumbar discectomy in UK neurosurgical centers. Method Physical therapists involved in treating lumbar discectomy patients in UK neurosurgery centers were invited to complete an online survey that asked about the type, timing (preop, postop), and rehabilitation content for patients undergoing lumbar discectomy. Results Seventeen UK neurosurgery centers completed the survey. Twelve (36%) responded from the 33 centers targeted as well as an additional five private centers. All participating centers provided a rehabilitation service for lumbar discectomy patients. Rehabilitation was provided preoperatively in n = 6 (35%) centers, postoperatively as an inpatient in all centers, and postoperatively as an outpatient in n = 14 (82%) centers. Factors that influenced the decision to provide rehabilitation included both external and internal or patient-related factors. Preoperative rehabilitation focused mainly on education, whilst postoperative outpatient rehabilitation focused more on exercises. Rehabilitation consistently included mobility, functional task training, and exercise prescription. Conclusions Whilst all neurosurgical centers in this survey provided some form of rehabilitation for patients undergoing LD surgery, the approach remains inconsistent. Rehabilitation was delivered most frequently postoperatively, with one in three centers providing it preoperatively. Rehabilitation content also varied depending on when it was provided. Further research is needed to determine the optimum timing, contents, and target of rehabilitation for patients undergoing LD surgery.
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As life expectancy increases, degenerative lumbar spinal stenosis (DLSS) becomes a common health problem among the elderly. DLSS is usually caused by degenerative changes in bony and/or soft tissue elements. The poor correlation between radiological manifestations and the clinical picture emphasizes the fact that more studies are required to determine the natural course of this syndrome. Our aim was to reveal the association between lower lumbar spine configuration and DLSS. Two groups were studied: the first included 67 individuals with DLSS (mean age 66 ± 10) and the second 100 individuals (mean age 63.4 ± 13) without DLSS-related symptoms. Both groups underwent CT images (Philips Brilliance 64) and the following measurements were performed: a cross-section area of the dural sac, vertebral body dimensions (height, length and width), AP diameter of the bony spinal canal, lumbar lordosis and sacral slope angles. All measurements were taken at L3 to S1. Vertebral body lengths were significantly greater in the DLSS group at all levels compared to the control, whereas anterior vertebral body heights (L3, L4, L5) and middle vertebral heights (L3, L5) were significantly smaller in the LSS group. Lumbar lordosis, sacral slope and bony spinal canal were significantly smaller in the DLSS compared to the control. We conclude that the size and shape of vertebral bodies and canals significantly differed between the study groups. A tentative model is suggested to explain the association between these characteristics and the development of degenerative spinal stenosis.
Article
To investigate the prevalence of osteoarthritis (OA) of the knee in elderly subjects, we studied the Framingham Heart Study cohort, a population-based group. During the eighteenth biennial examination, we evaluated the cohort members for OA of the knee by use of medical history, physical examination, and anteroposterior (standing) radiograph of the knees. Radiographs were obtained on 1,424 of the 1,805 subjects (79%). Their ages ranged from 63–94 years (mean 73). Radiographs were read by a radiologist who specializes in bone and joint radiology, and were graded 0–4 according to the scale described by Kellgren and Lawrence. OA was defined as grade 2 changes (definite osteophytes), or higher, in either knee. Radiographic evidence of OA increased with age, from 27% in subjects younger than age 70, to 44% in subjects age 80 or older. There was a slightly higher prevalence of radiographic changes of OA in women than in men (34% versus 31%); however, there was a significantly higher proportion of women with symptomatic disease (11% of all women versus 7% of all men; P = 0.003). The age-associated increase in OA was almost entirely the result of the marked age-associated increase in the incidence of OA in the women studied. This study extends current knowledge about OA of the knee to include elderly subjects, and shows that the prevalence of knee OA increases with age throughout the elderly years.
Article
The relation between abnormalities in the lumbar spine and low back pain is controversial. We examined the prevalence of abnormal findings on magnetic resonance imaging (MRI) scans of the lumbar spine in people without back pain. We performed MRI examinations on 98 asymptomatic people. The scans were read independently by two neuroradiologists who did not know the clinical status of the subjects. To reduce the possibility of bias in interpreting the studies, abnormal MRI scans from 27 people with back pain were mixed randomly with the scans from the asymptomatic people. We used the following standardized terms to classify the five intervertebral disks in the lumbosacral spine: normal, bulge (circumferential symmetric extension of the disk beyond the interspace), protrusion (focal or asymmetric extension of the disk beyond the interspace), and extrusion (more extreme extension of the disk beyond the interspace). Nonintervertebral disk abnormalities, such as facet arthropathy, were also documented. Thirty-six percent of the 98 asymptomatic subjects had normal disks at all levels. With the results of the two readings averaged, 52 percent of the subjects had a bulge at at least one level, 27 percent had a protrusion, and 1 percent had an extrusion. Thirty-eight percent had an abnormality of more than one intervertebral disk. The prevalence of bulges, but not of protrusions, increased with age. The most common nonintervertebral disk abnormalities were Schmorl's nodes (herniation of the disk into the vertebral-body end plate), found in 19 percent of the subjects; annular defects (disruption of the outer fibrous ring of the disk), in 14 percent; and facet arthropathy (degenerative disease of the posterior articular processes of the vertebrae), in 8 percent. The findings were similar in men and women. On MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions but not extrusions. Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.
Article
Two hundred and eleven patients with lumbar disc herniation at 242 levels were divided into 5 groups by their appearances on magnetic resonance imaging (MRI), and the findings at operation were compared to assess the accuracy of the MRI classification. There were no negative explorations. There was 92% sensitivity, 91% specificity and 92% accuracy for MRI in distinguishing protruded discs from other forms of lumbar disc herniation. For sequestrated discs there was 92% sensitivity, 99% specificity and 97% accuracy. In the extruded subligamentous type there was 71% sensitivity, 82% specificity and 79% accuracy, and 52% sensitivity, 92% specificity and 81% accuracy in the extruded transligamentous type. The overall accuracy of MRI predicting the types of herniated lumbar intervertebral disc was 85%. High resolution MRI is sensitive in detecting disc disease and specific in characterizing various subgroups of disc herniation, especially those which are sequestrated.
Article
This was a prospective 3-year follow-up study of randomized matched subgroups of 15-year-old school children with or without low back pain initially. In addition to low back pain and leisure time physical activity, spinal mobility, trunk muscle strength, and early degenerative findings of the lumbar spine were evaluated. Reliable epidemiologic studies on the prevalence of low back pain and development of early degenerative changes of the lumbar spine in young persons have been sparse. Along with several other characteristics, the relationship of these changes to frequent low back pain in young persons is not known. After a questionnaire-based survey was administered, subjects with or without low back pain were examined initially and at follow-up with special reference to leisure time physical activity, anthropometry, spinal mobility, trunk muscle strength, and magnetic resonance imaging findings of the lumbar spine. At baseline and at follow-up, those subjects with initial low back pain were characterized by a low frequency of physical activity and decreased spinal function. During follow-up, the occurrence of disc degeneration increased significantly more in the original group with low back pain than among asymptomatic subjects. Furthermore, disc degeneration at baseline significantly predicted future frequent low back pain. Initial disc protrusion also predicted future frequent low back pain. After the rapid physical growth period, there seemed to be a causal relationship between the early evolution of the degenerative processes of the lower lumbar discs and frequent low back pain in several subjects.
Article
To identify the magnetic resonance (MR) abnormalities of the lumbar spine that have a low prevalence in asymptomatic patients and thus determine the findings that are predictive of low back pain in symptomatic patients. Sagittal T1-weighted and sagittal and axial T2-weighted MR images were obtained in 60 asymptomatic volunteers aged 20-50 years. The MR images were evaluated with regard to intervertebral disk abnormalities, end plate abnormalities, and osteoarthritis of the facet joints by two musculoskeletal radiologists independently. Disk bulging or disk protrusion was found in 42 (14%) and 48 (16%) of the intervertebral spaces in 37 (62%) and 40 (67%) subjects, respectively. High-signal-intensity zones were found commonly (in 23 [7.7%] and 25 [8.3%] of the intervertebral spaces in 19 (32%) and 20 (33%) subjects, respectively). Disk extrusions were less common (in 11 [3.7%] and 11 [3.7%] of the intervertebral spaces in 11 (18%) and 11 (18%) subjects, respectively). There were no disk sequestrations. A nerve root compression in a single intervertebral space was diagnosed by one reader. End plate abnormalities were found in two (0.7%) and six (1.9%) of the intervertebral spaces in two (3%) and six (10%) subjects, respectively. No severe osteoarthritis was diagnosed by either reader. In patients younger than 50 years, disk extrusion and sequestration, nerve root compression, end plate abnormalities, and osteoarthritis of the facet joints are rare and, therefore, may be predictive of low back pain in symptomatic patients.
Article
In 1989, a group of sixty-seven asymptomatic individuals with no history of back pain underwent magnetic resonance imaging of the lumbar spine. Twenty-one subjects (31%) had an identifiable abnormality of a disc or of the spinal canal. In the current study, we investigated whether the findings on the scans of the lumbar spine that had been made in 1989 predicted the development of low-back pain in these asymptomatic subjects. A questionnaire concerning the development and duration of low-back pain over a seven-year period was sent to the sixty-seven asymptomatic individuals from the 1989 study. A total of fifty subjects completed and returned the questionnaire. A repeat magnetic resonance scan was made for thirty-one of these subjects. Two neuroradiologists and one orthopaedic spine surgeon interpreted the original and repeat scans in a blinded fashion, independent of clinical information. At each disc level, any radiographic abnormality, including bulging or degeneration of the disc, was identified. Radiographic progression was defined as increasing severity of an abnormality at a specific disc level or the involvement of additional levels. Of the fifty subjects who returned the questionnaire, twenty-nine (58%) had no back pain. Low-back pain developed in twenty-one subjects during the seven-year study period. The 1989 scans of these subjects demonstrated normal findings in twelve, a herniated disc in five, stenosis in three, and moderate disc degeneration in one. Eight individuals had radiating leg pain; four of them had had normal findings on the original scans, two had had spinal stenosis, one had had a disc protrusion, and one had had a disc extrusion. In general, repeat magnetic resonance imaging scans revealed a greater frequency of disc herniation, bulging, degeneration, and spinal stenosis than did the original scans. The findings on magnetic resonance scans were not predictive of the development or duration of low-back pain. Individuals with the longest duration of low-back pain did not have the greatest degree of anatomical abnormality on the original, 1989 scans. Clinical correlation is essential to determine the importance of abnormalities on magnetic resonance images.
Article
For this study, 43 asymptomatic individuals underwent magnetic resonance imaging of the lumbar spine in both supine psoas-relaxed position and supine axial compression in extension. The change in dural cross-sectional area between positions at each disc level was calculated. To evaluate the effect of axial loading on asymptomatic individuals, as compared with the effect on patients who have clinical signs of lumbar spinal canal stenosis, and to assess the effect that different magnitude and duration of the applied load have on the dural cross-sectional area. Degenerative changes in the spine are found in both symptomatic and asymptomatic individuals. A study of patients with suspected clinical lumbar spine encroachment examined in both psoas-relaxed position and axial compression in extension with computed tomographic myelography or magnetic resonance imaging of the lumbar spine is reported. A significant decrease in dural cross-sectional area was found, respectively, in 80% and 76% of the patients. The study subjects underwent magnetic resonance imaging examinations in both psoas-relaxed position and axial compression in extension. The examination of the subject under axial compression in extension was performed with the lumbar spine in a supine position using a compression device. Degenerative changes in and adjacent to the spinal canal were registered. The dural cross-sectional areas were determined for psoas-relaxed position and axial compression in extension, then compared. In seven reexamined individuals, the dural cross-sectional area was calculated after an axial load corresponding to 25% and 50% of their body weight and a loading time of 5 to 60 minutes. A significant decrease in dural cross-sectional area from psoas-relaxed position to axial compression in extension was found in 24 individuals (56%), most frequently at L4-L5, and increasingly with age. In four individuals (5 disc levels), a decrease in dural cross-sectional area to less than 100 mm2 from psoas-relaxed position to axial compression in extension was found. In seven reexamined individuals, a significant decrease in dural cross-sectional area was found: in five after 5 minutes load of 25% of their body weight, and in two with 50% of their body weight. Using magnetic resonance imaging, a significant decrease in dural cross-sectional area after axial loading was found less frequently in asymptomatic than in symptomatic subjects. The decrease was more frequent at L4-L5, and increasingly with age. The load should be 50% of the subject's body weight applied for at least 5 minutes.