pathology
DESCRIPTION
PATHOLOGY. Degenerative changes in the lumbar spine disc degeneration vertebral compression deformities ligamentous laxity deterioration of facet joint cartilage May cause instability and subluxation of one vertebra on another (degenerative spondylolisthesis ). - PowerPoint PPT PresentationTRANSCRIPT
PATHOLOGYDegenerative changes in the lumbar spine
disc degenerationvertebral compression deformitiesligamentous laxitydeterioration of facet joint cartilage
May cause instability and subluxation of one vertebra on another (degenerative spondylolisthesis)
Anterolisthesis at L4-L5
PATHOLOGY
Backward slippage (retrolisthesis) is generally believed to be asymptomatic and of little clinical significance.
Forward slippage (anterolisthesis) may result in narrowing of vertebral canal and neural foramina (spinal stenosis) leading to development of chronic back pain (with or without leg pain). Compression of L5 spinal nerve may be involved.
PATHOLOGYWhen LS joint is particularly stable, L4 and L5 are more vulnerable to stress forces. If degenerative changes have occurred, anterolisthesis at L4 is more likely.Clinical symptoms associated with anterior subluxation
at L4-L5 80% at L3-L4 10-20%
PATHOLOGY
Spinal stenosis symptoms:
back pain progressing to leg painfunctional independence deterioratesreduced ability to walkreduced ability to carry out ADLs
Symptoms often episodic, no natural resolution over time
EPIDEMIOLOGYSeveral clinical and cadaveric studies suggest that anterolisthesis is 5 times more common in women vs men
2-4 times more common in blacks than whites
4 times more prevalent in diabetics
3 times more common in oophorectomized women compared to controls
Prevalence of lumbar listhesis (L3-S1) in elderly white women (SOF)
05
1015202530354045
65-69 70-74 75-79 80+
Age in years
% p
reva
lenc
e
anterolisthesisretrolisthesis
p for trend = 0.027
p for trend = 0.75
listhesis defined as subluxation > 3mm
CLINICAL RELATIONSHIPSRelationship between radiographic abnormalities and spinal symptoms is unclear.
People with no back pain show disc abnormalities (64%), stenosis (7%) andanterolisthesis (7%) (Boden, JBJS 1990, Jensen NEJM 1994 ).
Not known whether people with sub-clinical disease later develop symptoms.
Veteran’s Health Study
05
1015202530354045
LBP only LBP+LP to thigh LBP+LP below knee
% o
f coh
ort
n= 428 men
Selim, et al. Spine 1998
Veteran’s Health Study
Medic use
MRI
Surgery LBP alone
1.0
1.0
1.0
LP to thigh
1.5
(0.7,3.1)
3.2
(1.5,6.7)
0.9
(0.3,3.0)
LP below knee (-ve SLR)
1.8
(1.0,3.4)
3.5
(1.9,6.5)
3.7
(1.7,8.1)
LP below knee (+ve SLR)
5.1
(1.2,22.9)
6.8
(2.7,17.2)
3.9
(1.3,11.4)
Selim, et al. Spine 1998
0
10
20
30
40
50
60
70
PF RP BP GH VT MH SF RE
LBP onlyLBP/LP to thighLBP/LP below knee (-ve SLR)LBP/LP below knee (+ve SLR)
SF-36 scores for men with LBP enrolled in the Veteran’s Health Study
Scor
e
p for trend <0.05 for all domains
Selim, et al. Spine 1998
Distribution of lower back and leg pain symptoms w/in last month among white WHI women aged 50 years and older
0
10
20
30
40
50
60
No LBP LBP only LBP+LP LBP+LP imprby sitting
% o
f coh
ort
n=295 n=182n=47 n=49Vogt et al. J Gerontol 2002
30
40
50
60
70
80
90
100
PF RP BP GH VT MH SF RE
no LBPLBPLBP/LPLBP/LP improved by sitting
SF-36 scores for white women enrolled in WHI (adjusted for age and BMI)
Scor
e
Vogt et al. J Gerontol 2002
Relationship of race to prevalence and use of health care resources for LBP
Whites (%) AAmer (%)
Prev acute LBP last yr 8.3 (7.3, 9.3) 5.2 (3.8, 6.6)
Prev chronic LBP last yr 4.1 (3.4, 4.7) 3.0 (2.0, 4.0)
Prev seeking care 36 59
Random digit dialing + structured interview4,437 households in NC 8067 individuals
Carey, et al, Spine 1996
Relationship of race to prevalence and use of health care resources for LBP
Whites AAmer p
Pain score 5.25 5.92 <0.01
Disability score 11 12.1 0.01
X-rays (%) 49 40 0.05
Other imaging 10 6 0.05
Cohort study, random group of health care providers
Carey, et al, 2000
Elderly African American women (SOF) reporting back pain during previous four
weeks
50%
23%
20%
7%
no LBP
mild LBP
moderate LBP
severe LBPN=470
Back/leg symptoms in women aged 65 years and older during month prior to clinic visit (white women enrolled in
WHISTEN, black women enrolled in SLIP)
54.1 49.7
21.6
36.1 28.7
9.8
0102030405060708090
100
White women N=399
Black women N=470
% fr
eque
ncy Back pain, with leg
symptomsBack pain, no leg symptomsNo back pain
Prevalence of lumbar listhesis (L3-S1) in black elderly women by age
01020304050607080
65-69 70-74 75-79 80+
Age in years
% p
reva
lenc
e
AnterolisthesisRetrolisthesis
p for trend = 0.095
p for trend = 0.207
listhesis defined as subluxation > 3mm
% prevalence of listhesis among women 65 years and older
Antero Retro White Black White Black
L3-L4 4 13 6 1 L4-L5 20 36 4 2 L5-S1
9 30 7 3
L3-S1 29 58 14 4
Vogt, et al, The Spine J 2002
Effect of back pain & leg pain on daily life of black women during previous month
0
1
2
3
4
5
6
mood walk/move sleep work recreation enjoy
Odd
s r a
tio
expressed as age-adj odds ratio using back pain only as the reference - all p<0.001
Vogt, et al, The Spine J 2002
PREVENTION
Because most people experience LBPduring their lifetime, the distinction between primary and secondary prevention is blurred.
• which interventions can prevent occurrence of LBP?
• which interventions can prevent development of chronic LBP?
PREVENTION
Evidence-based medicine categories
Level A - strong consistent - multiple RCTs
Level B - moderate - one RCT + multiple CCTs
Level C - limited - one CCT
Level D - no evidence
PREVENTIONLumbar supports
•provide support• remind to lift properly intra-abdom pressure and intradiscal pressure
RCTs negativeCCTs positive – reduce incidence of LBP and back injury
Level A - ve
PREVENTION
Back Schools and Education
• provide knowledge about body mechanics, stress, exercise• aim to influence behavior
9 RCTs - most are negative5 CCTs - positive
Level A -ve
PREVENTION
Exercises
• strengthen back muscles• increase blood supply • improve mood and alter perception of pain
6 RCTs – reduced pain and sick leave
Level A + ve
PREVENTION
Ergonomics
• job related interventions
No RCTs or CCTs
Level D - ve
PREVENTION
Risk Factor Modification
• individual (weight, strength, smoking)
• biomechanical (lifting, posture)
• psychosocial (job control, job dissatisfaction, depression)
No RCTs or CCTs
Level D - ve
Review of 47 epidemiologic studies concluded that smoking may be a ‘weak risk indicator and not a cause of low back pain’ Le-Bouef-Yde Spine 1999
Smoking may have a systemic effect on the musculoskeletal system - associated with generalized pain.
Biological basis unknown - neuroendocrine effect?
Decrement in SF-36 scores (compared to age-sex specific norms) for patients with
spinal problems by smoking status
-80-70
-60-50-40
-30-20
-100
PF RP BP HP MH EF SF RE
Smokers (n = 4249) Non-smokers (n = 21206) General population in US
SF-3
6 sc
ore
Vogt, et al, Spine 2002
PREVENTION
Currently only exercise seems to be helpful in prevention of LBP.
Consistent evidence – Level A.
Linton, van Tulder, Spine 2001
PREVENTIONWhy the disappointing results?
• small studies, low power, short follow-up, variation in intervention, varying outcome
• natural course of back pain, hard to define and categorize, multi-factorial causation
• single modal programs studied mostly, maybe multi-dimensional approach needed
• timing, compliance