Before opting for spinal stenosis surgery, it is important to discuss the potential risks and other treatment options with the surgeon. Lumbar Decompression Back Surgery. Cervical Stenosis with Myelopathy. Living with Lumbar Spinal Stenosis. You are here Conditions Spinal Stenosis. What Is Spinal Stenosis? By Benjamin Bjerke, MD.
Associations of x-ray features of LDD with severity of disability and intensity of pain are inconclusive. Female gender and pain radiating into legs are significant confounders. Disability due to chronic low back pain is one of the leading health care problems in most regions of the world including South Asia [ 1 ]. It affects all aspects of life including physical, mental, and social well-being [ 2 ].
Disabling chronic low back pain is reported to be a major issue in occupational health in Sri Lanka [ 3 , 4 ]. Most chronic low back pains are related to mechanical causes including injuries of the musculoskeletal structures of the spine and pathologies associated with lumbar disc degeneration LDD [ 5 , 6 ]. LDD is a common finding in the aging spine and symptoms of chronic mechanical low back pain are not always correlated with the radiological features of LDD.
Patients with chronic low back pain receive routine spinal imaging lumbar x-ray, computed tomography, or magnetic resonance imaging [MRI] and MRI of lumbar spine has become the popular choice for routine imaging as it gives a direct visualisation of the disc without exposure to the radiation. However MRI is not a cost effective method in routine spinal imaging in developing countries and clinicians in developing countries like Sri Lanka regularly use x-ray lumbar spine as a feasible option for assessing features related to LDD [ 7 ].
There are mixed evidence for the association of LDD with chronic mechanical low back pain and disability. Although, routine x-ray of lumbar spine does not affect the outcome of the treatment of uncomplicated acute and subacute low back pain [ 8 ], x-ray features related to LDD may benefit the clinical diagnosis and management of chronic low back pain and disability when combined with other factors such as proper history taking, severity of symptoms, surgical risks and costs [ 8 ].
Disc space narrowing and anterior osteophytes are the main x-ray features of LDD [ 9 ] and are proven to be highly correlated with the morphological stages of LDD [ 10 ]. Disc space narrowing is associated with lumbar spinal stenosis, disc herniation and spondylolisthesis which are also related to the pain and disability [ 11 ].
Disc space narrowing is associated with the presence of chronic low back pain [ 9 , 12 ] and intensity of pain [ 13 ]. This association becomes stronger with increasing severity of disc space narrowing [ 12 , 13 ]. Mostly these associations are reported in population based studies and their study samples were limited to middle aged and elderly individuals [ 9 , 12 , 13 ]. There are a limited number of studies which have investigated the association of disc space narrowing with disability [ 9 ].
Although anterior osteophyte is the most frequently observed degenerative feature of the aging lumbar spine, it has variably correlated results on its association with intensity of pain [ 9 , 13 ]. With regard to disability, we could not find enough evidence to prove its association with anterior osteophytes [ 9 , 14 ]. Advancing age increases the susceptibility for severe disability [ 18 ]. In most studies females have reported increased intensity of pain and severe disability [ 19 , 20 ].
In addition obese patients have a higher risk for recurrent disabling low back pain [ 21 ]. Furthermore pain radiating into legs is associated with symptomatic disc herniation contributing to severe pain and disability [ 22 ].
Age, gender, BMI and the presence of pain radiating into legs may be helpful in predicting the severity of x-ray features of LDD. Advancing age increases the susceptibility for severe degeneration [ 23 , 24 ]. In addition, there is evidence that males have more degenerative changes compared to females [ 9 ], but there are other studies that have given contradicting results [ 25 ]. However the evidence for associations of gender, BMI and the presence of pain radiating into legs with grade of x-ray features of LDD are inconsistent and need further investigation.
Routine x-ray of lumbar spine is carried out during the management of chronic low back pain in developing countries. Details about age, gender, BMI and the presence of pain radiating into legs are helpful in deciding to prescribe x-ray of lumbar spine as these variables might be useful in predicting the grade of x-ray features of the spine, clinical outcomes and deciding treatment options. Disc space narrowing has significant association with chronic low back pain while anterior osteophytes and LDD have variably correlated results.
Most of these studies were population based studies and conducted in middle aged and elderly individuals. There is lack of studies which have assessed the associations of x-ray features of LDD with severity of disability and intensity of pain in patients with chronic mechanical low back pain in clinical settings. There is a wide variation in intensity of pain and disability among patients with chronic mechanical low back pain and patients with severe symptoms require comprehensive care.
If there is an association between the grade of x-ray features of LDD, spondylolisthesis and severity of disability and intensity of pain, it would greatly benefit the clinical management with regard to both resource allocation and type of treatment to administer.
The objective of our study was to assess the associations of the x-ray features of lumbar disc degeneration and lumbar spondylolisthesis with severity of disability and intensity of pain in patients with chronic mechanical low back pain adjusting for age, gender, BMI and pain radiating into legs. A descriptive cross-sectional study was conducted on consecutive patients with chronic mechanical low back pain who attended the rheumatology clinic, National Hospital of Sri Lanka, Colombo, from May to May Both male and female patients of Sri Lankan origin with chronic mechanical low back pain aged 20 to 69 years were recruited to the study.
Both patients with and without x-ray evidence of LDD and spondylolisthesis were included. Low back pain was defined as pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without pain radiating into the leg [ 19 ]. Back pain during day time worsening in the latter part of the day due to movements was considered to be due to a mechanical cause [ 28 ].
Chronicity was defined as pain on most days of the week for at least three months [ 2 ]. Patients with back pain due to inflammatory causes seronegative spondyloarthropathies, diffuse idiopathic skeletal hyperostosis, rheumatoid arthritis , visceral origin urinary tract infections, inflammatory pelvic disease , systemic infections affecting spine spinal tuberculosis , metabolic bone diseases osteoporosis and osteomalacia , fractures in the vertebral column, past surgeries in the spine, and spinal tumours were excluded.
Pregnant females and patients who refuse to participate in the study were also excluded. The study was carried out in accordance with the Declaration of Helsinki and with the approval of the Ethics Review Committee of the Faculty of Medicine, University of Colombo.
Patients who fulfilled the inclusion and exclusion criteria were recruited to the study after obtaining written informed consent. Demographic age and gender and clinical data intensity of pain, severity of disability, presence of pain radiating into legs, and BMI were recorded using a pretested interviewer administered questionnaire and clinical examination.
The intensity of pain was measured using a 0 to point numeric rating scale. Patients were asked to score the average intensity of pain experienced during the past 7 days out of [ 29 — 31 ]. MODI is a low back pain specific disability questionnaire with ten items which assess pain and its impact on the activities of daily living including personal care, lifting, walking, sitting, standing, sleeping, travelling, social work, home and work duties.
Each item has six responses where higher values represent greater disability. Sum of responses was calculated and presented as a percentage [ 32 , 33 ].
Pain radiating into legs was positive if the pain radiated below the knee of either one or both legs. Height cm and weight kg of the patients were recorded with light clothing and without shoes to the nearest 0. International cut off values were used for categorisation of BMI [ 35 ].
Static lateral lumbar x-rays were obtained from all patients. Patients were in lateral recumbent position on the table flexing the knees and hips just enough to achieve comfortable position and a small sandbag was kept between the knees. Midaxillary plane was aligned to the middle of the table and the central x-ray beam was directed perpendicular to the body of the L3 vertebra [ 36 ].
Collected lateral lumbar x-rays were evaluated by a consultant radiologist blinded to the clinical details of the patients. Reduction of the height of the disc space compared to the adjacent normal disc space was defined as the disc space narrowing and presence of bony outgrowths of the vertebral body arising from the borders of superior and inferior surfaces extending anteriorly was defined as anterior osteophyte.
End plate sclerosis was not taken into account due to its low interobserver reliability [ 9 , 15 ]. Lumbar spondylolisthesis was defined as presence of displacement of one vertebral body relative to the next most inferior vertebral body and assessed in lateral recumbent lumbar x-ray [ 11 ]. However the ability to assess the spondylolisthesis in lateral recumbent lumbar x-ray is limited.
Interobserver reproducibility was assessed using a second medical officer who was trained on radiographic evaluation according to the Lane atlas. Assesment of the x-ray features of lumbar disc degeneration - lateral x-ray of lumbar spine.
Descriptive statistics were calculated to summarise the sample characteristics. Both univariable and multivariable analyses were carried out. Multivariable generalised linear model with linear response was used when the severity of disability and intensity of pain were used as the continuous outcome variables.
Separate linear regression models were created for each feature. Multivariable ordinal logistic regression was used when the severity of x-ray features of LDD disc space narrowing, anterior osteophytes and overall LDD were used as the ordinal outcome variables 0, 1 and 2. Age, gender, BMI and presence of pain radiating into legs were defined as confounder variables in all regression models.
Statistical analysis was carried out using SPSS version Accessed March 7, Goldman L, et al. Mechanical and other lesions of the spine, nerve roots and spinal cord. In: Goldman-Cecil Medicine. Philadelphia, Pa. Frontera WR. Lumbar spinal stenosis. Cervical stenosis, myelopathy and radiculopathy. North American Spine Society. Levin K. Lumbar spinal stenosis: Treatment and prognosis. Kim K, et al. Nonsurgical Korean integrative treatments for symptomatic lumbar spinal stenosis: A three-armed randomized controlled pilot trial protocol.
Evidence-Based Complementary and Alternative Medicine. Dasenbrock HH, et al. The impact of provider volume on the outcomes after surgery for lumbar spinal stenosis. Rochester, Minn. Minimally invasive lumbar decompression MILD. Abt NB, et al. Thirty day postoperative outcomes following anterior lumbar interbody fusion using the National Surgical Quality Improvement Program database.
The narrowing of the spaces in the spine is known as Spinal Stenosis. The narrowing in your spine can put pressure on the spinal cord, nerves, and nerve roots traveling through your spine, which is what leads to spinal stenosis. This condition mostly occurs in the lower back and neck area.
Wear and tear in the spine over time can cause spinal stenosis, which is related to osteoarthritis. For some people, symptoms of spinal stenosis are not visible, whereas, for others, there is pain, numbness, tingling, and muscle weakness.
Over time, these symptoms can worsen. It is possible to suffer from more than one kind of spinal stenosis in your back. The two types of this condition are divided according to the location in the spine where the disease occurs. The two kinds of spinal stenosis are:. In this type, the space narrowing occurs in the cervical part of the spine. This corresponds to the neck and part of the upper back.
This is the most common type of spinal stenosis and it occurs when the space narrowing takes place in the lower section of your spine, which is the lower back. Most often, symptoms of space narrowing, or spinal stenosis, are not evident. When the condition occurs, it tends to get worse over time. Symptoms of spinal stenosis depend on the location of its onset within the spine and which nerves, or nerve roots are affected.
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