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ORIGINAL ARTICLE
Year : 2018  |  Volume : 18  |  Issue : 2  |  Page : 79-84

Correlation between clinical and imaging finding of symptomatic degenerative lumbar spine disease


Department of Orthopedics, Burdwan Medical College, Bardhaman, West Bengal, India

Date of Web Publication16-Oct-2018

Correspondence Address:
Soumyadeep Duttaroy
Room No. 11, J. R. Hostel, Burdwan Medical College, Bardhaman - 713 104, West Bengal
India
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DOI: 10.4103/sjsm.sjsm_24_17

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  Abstract 


Background: Back pain resulting from degenerative disease of the spine is one of the most common causes of disability in working age adults. Clinical symptomatology of these patients varies widely with imaging findings.
Materials and Methods: This study was conducted in Burdwan Medical College and Hospital.
Study Population: Inclusion criteria: (a) Patient age ≥35 years (b) Clinically suffering from degenerative lumbar spine disease (c) Imaging evidence were included in the study. Exclusion criteria: (a) Traumatic lumbar spine, metastatic disease, previous neurovascular pathology, or associated lower limb fractures were excluded from the study.
Sample Size: Two hundred patients were included in the study.
Study Design: This was an institution-based cross-sectional study.
Study Tools: All cases have undergone X-ray, but magnetic resonance imaging has been most effective.
Data Analysis: For statistical analysis, we have calculated Chi-square statistic value and P value.
Results: In this study, single disc involvement (49.4%) and multiple disc involvement (50.6%) pattern was equally prevalent. For single level disc changes, disc bulge was the most common pathology in our study (75%) followed by disc protrusion (25%). Among the patients with severe degree of nerve compression, 72.9% of patients had claudication. In our study, 81% of patients with anteroposterior (AP) canal diameter <8 mm had distal extremity radiculopathy. In our study, among spinal canal stenosis patients, association of AP canal diameter with motor weakness is found to be statistically significant (P = 0.0229). In patients of degenerative spondylolisthesis (DSL), occurrence of axial back pain and extremity pain as per clinical and radiographic degenerative spondylolisthesis classification (P = 0.0129) correlated well.
Conclusion: There has been positive correlation between clinical and imaging finding for severe degree of disc degeneration and spinal canal stenosis but variable for DSL.

  Abstract in Arabic 

خلفية الدراسة: يعد ألم الظهر الناتج عن الأمراض التنكسية في العمود الفقري أحد أكثر الأسباب شيوعًا لدى البالغين في سن العمل. وتختلف الأعراض السريرية لهؤلاء المرضى بشكل كبير من نتائج التصوير.

المواد والطرق: أجريت هذه الدراسة في كلية ومستشفى بوردوان. وكانت عينة الدراسة كالاتي: معايير الاشتمال: (أ) عمر المريض ≥35 سنة (ب) ان يعاني سريريا من مرض العمود الفقري القطني التنكسسي (ج) والتصويرالاشعاعى كأدلة. معايير الاستبعاد: (أ) تم استبعاد العمود الفقري القطني نتجه للصدمات، الأمراض المنتشرة والأمراض الوعائية العصبية السابقة وكسور الأطراف السفلية.

حجم العينة: تم تضمين مائتي مريض في الدراسة. تصميم الدراسة: كانت هذه دراسة مقطعية اجريت مؤسسة. أدوات الدراسة: جميع الحالات خضعت للأشعة السينية، ولكن التصوير بالرنين المغناطيسي كان الأكثر تأثيرا.

تحليل البيانات: من أجل التحليل الإحصائي، قمنا بحساب قيمة إحصائية مربع Chi وقيمة P.

النتائج: في هذه الدراسة، كان انتشار مشاركة قرص فقرات الظهر الواحد (49.4 ٪) ومشاركة اقراص متعددة (50.6 ٪) سائدا المساواة فى المشاركة. بالنسبة لتغيرات القرص أحادية المستوى، كان تضخم القرص أكثر الأمراض شيوعًا في دراستنا (75٪) متبوعًا ببروز القرص (25٪). بين المرضى الذين يعانون من درجة شديدة من ضغط العصب، كان 72.9 ٪ من المرضى العرج. وتم العثور على 81 ٪ من المرضى الذين يعانون من قطر القناة الأمامي الخلفي (AP) مع ضعف الحركة لتكون ذات دلالة إحصائية (P = 0.0229). في المرضى الذين يعانون من الانزلاق الفقاري الانحلالي (DSL)، واتضح ان وجود آلام الظهر المحوري وألم الحد الأقصى وفقا لتصنيف الانزلاق الفقاري الشعاعي السريرية (P = 0.0129) ترتبط بشكل جيد.

الخلاصة: لقد كان هناك ارتباطا إيجابيا بين النتائج السريرية والتصوير للحصول على درجة حادة من انحطاط القرص وتضيق القناة الشوكية ولكنه متغيرا فى ال DSL.

Keywords: Clinical correlation, low back pain, lumbar spine disease


How to cite this article:
De C, Ray MK, Chatterjee B, Duttaroy S, Ghosh PK, De C. Correlation between clinical and imaging finding of symptomatic degenerative lumbar spine disease. Saudi J Sports Med 2018;18:79-84

How to cite this URL:
De C, Ray MK, Chatterjee B, Duttaroy S, Ghosh PK, De C. Correlation between clinical and imaging finding of symptomatic degenerative lumbar spine disease. Saudi J Sports Med [serial online] 2018 [cited 2018 Dec 14];18:79-84. Available from: http://www.sjosm.org/text.asp?2018/18/2/79/243348




  Introduction Top


Back pain resulting from degenerative disease of the spine is one of the most common causes of disability in working age adults.[1],[2],[3],[4] Most common location of these changes is lumbar spine followed by cervical spine.[5] Clinical symptomatology of these patients varies widely. Magnetic resonance imaging (MRI) has become the modality of choice in the evaluation of lumbar spine degenerative diseases.[6],[7],[8],[9]

This study has tried to correlate the clinical and imaging findings of degenerative lumbar spine disease.


  Materials and Methods Top


  • Study area: This study was conducted in Burdwan Medical College and Hospital
  • Study population:


    • Inclusion criteria:


      1. Patient age ≥35 years
      2. Clinically suffering from degenerative lumbar spine disease
      3. Imaging evidence were included in the study


    • Exclusion criteria:


      1. Traumatic lumbar spine, metastatic disease, previous neurovascular pathology, or associated lower limb fractures were excluded from the study


  • Study period: This study was conducted from January 2014 to June 2015
  • Sample size: Two hundred patients were included in the study
  • Study design: This was an institution-based cross-sectional study
  • Study tools: All our cases have undergone X-ray [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]. MRI has been the most effective tool for assessment
  • Plan for analysis of data: For statistical analysis, we have calculated Chi-square statistic value and p - value.
Figure 1: L4–L5 disc bulge

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Figure 2: Disc protrusion. Posterior longitudinal ligament is intact

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Figure 3: Spinal canal stenosis with multiple level disc bulge

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Figure 4: Axial cut showing spinal canal stenosis

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Figure 5: Standing flexion and extension lateral view X-ray. L4–L5 degenerative spondylolisthesis

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  Results Top


In this study, single disc involvement (49.4%) and multiple disc involvement (50.6%) pattern was equally prevalent.

For single level disc changes, disc bulge was the most common pathology in our study (75%) followed by disc protrusion (25%).

Among the patients with severe degree of nerve compression, 72.9% of patients had claudication.

In our study, 81% of patients with AP canal diameter <8 mm had distal extremity radiculopathy.

In our study, among spinal canal stenosis patients, association of AP canal diameter with motor weakness is found to be statistically significant (p - value= 0.0229).

In patients of degenerative spondylolisthesis (DSL), occurrence of axial back pain and extremity pain as per clinical and radiographic degenerative spondylolisthesis (CARDS) classification (p - value= 0.0129) correlated well.


  Discussion Top


In this study, males were 59.8% and females were 40.2%; male-to-female ratio was 1.5:1. This correlates well with most of the national and international studies. Our study shows that a maximum number of patients were in the fourth decade (34%) and the same is true in the study of Younis F, Shahzad R and Rasool F.[10] (30%) and Janardhana AP, Rajagopal, Rao S and Kamath A.[11] In our study, the most common level of disc involvement was L4–L5 (45.8%) followed by L5–S1 (30.0%) [Table 1]. This also correlates with the study of Younis F, Shahzad R and Rasool F.[10] and Janardhana AP, Rajagopal, Rao S and Kamath A.[11]
Table 1: Distribution of affected disc level among patients (for multi-level pathology, most prominent disc level has been considered); (n=170)

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In this study, among the patients of degenerative disc disease, single disc involvement (49.4%) and multiple disc involvement (50.6%) pattern was equally prevalent with 1: 1 ratio. These findings correlate with the study of Younis F, Shahzad R and Rasool F.[10] and Janardhana AP, Rajagopal, Rao S and Kamath A.[11] but do not correlate with work of Iftikhar AB, Noman M, Javed M, Faisal N, Humayun P.[8] They showed that multiple disc involvement was more common (65%) as compared to single disc involvement (35%); however, common level of involvement was same, i.e., L4–L5 followed by L5–S1 in both these studies.

For single level disc changes, disc bulge was the most common pathology in our study (75%) followed by disc protrusion (25%), and this does not correlate with the early work of Siddiqui AH, Rafique MZ, Ahmad MN, Usman MU[12] who showed that disc protrusion was common pathology. However, our findings match with the recent study of Younis F, Shahzad R and Rasool F.[10] who found disc bulge (74.4%) more common than disc protrusion (25.6%).

The results of this study indicate that patients can be reliably correlated on the basis of segmental pain distribution and distal extremity radiation with their imaging findings. This association is statistically significant with p - value < 0.001 and high Chi-square value [Table 2]. However, axial back pain correlates poorly with the cases of degenerative disc disease (p- value- = 0.334) and spinal canal stenosis (p- value = 0.7927). In both these pathologies, correlation with axial back pain is found to be statistically insignificant with p- value > 0.05 and low Chi-square value [Table 3] and [Table 4]. Both these findings also correlate with work of other authors, i.e., Siddiqui AH, Rafique MZ, Ahmad MN, Usman MU.[12]
Table 2: Association between Severity of Nerve Compression and Backache (Axial back pain). (n=170)

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Table 3: Association between Severity of Nerve Compression and Distal Extremity Pain. (n=170) Radiation

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Table 4: Association of side of nerve compression with distal extremity pain. (n=170)

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Correlation of the criteria of pain referral distal to the knee showed strong association with severe ipsilateral nerve compression. This was also statistically significant (p- value = 0.002).

In our study, severe nerve root compression was more commonly associated with radiculopathy (42.2%, p- value = 0.0001) as compared to axial back pain (28.9%) with p- value < 0.05. Study of Modic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN, Grooff PN, Mazanec DJ, et al.[13] also matches with our results that severe nerve root compression is more commonly associated with radiculopathy (23%) as compared to lower back pain (3%) with p- value < 0.001.

In our study, disc protrusion is found to be more correlated to clinical findings than disc bulge. This correlation is found to be statistically significant for radiculopathy and distal extremity radiation (95.2%), sensory findings (71.4%), and altered deep tendon reflex (66.6%). In all three associations, p- value < 0.05, which is statistically significant.

In our study, motor weakness did not correlate with the degree of nerve compression. Only 10.4% of patients with severe degree of nerve compression had motor weakness. The association was found to be statistically insignificant with p- value = 0.059 and Chi-square value of 5.36.

In our study, 81% of the patients with AP canal diameter < 8 mm had distal extremity radiculopathy. However, for the other two groups with canal diameter 8–10 mm and >10 mm, this value was 43.9% and 31.6%. This result matches with the study of Modic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN, Grooff PN, Mazanec DJ, et al.[13] In spinal canal stenosis patients, association of AP canal diameter with distal extremity pain is found to be statistically significant (p- value = 0.0012) and distal extremity pain is increased with narrowing of the spinal canal diameter. But the variation among the two groups with AP diameter 8–10 mm (43.9%) and >10 mm (31.6%) is narrow with low Chi-square value.

However, association between axial back pain and canal diameter narrowing was statistically insignificant (p- value = 0.7972), hence poor correlation.

In our study, among spinal canal stenosis patients, association of AP canal diameter with motor weakness is found to be statistically significant (p- value= 0.0229), and the incidence of motor weakness is more with progressive narrowing of the spinal canal diameter. Nearly 19% of patients with canal diameter <8 mm had motor weakness.

Association of radiculopathy with DSL was statistically insignificant (p-value = 0.4076) with p -value > 0.05. Modic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN, Grooff PN, Mazanec DJ, et al.[13] had also found the similar outcome.

Motor weakness (p-value = 0.3457) showed statistically insignificant association Saraste H[14] and Wiesel SW, Tsourmas N, Feffer HL, Citrin CM, Patronas N.[15] had similar results regarding association of sensory and motor weakness.

In our study, 75% of patients with DSL with spinal canal stenosis had claudication. It matches with the result of Lohman CM, Tallroth K, Kettunen JA, Lindgren KA.[16] who found this value to be 69%. In our study, this association was statistically significant (p- value = 0.0191) at p- value < 0.05.

In our study, correlation between altered DTR and DSL was statistically insignificant (p- value = 0.1867). However, there is some association when there was associated spinal canal stenosis together with DSL (57.2%).

In our study, patients with facet joint angle more than 45° had more consistent clinical finding [Table 5]. Clinical findings such as axial back pain (66%), distal extremity pain (66%), and claudication (60%) were associated with facet joint angle of more than 45°.
Table 5: Association between Facet Joint Angle with clinical findings.(n=24)

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Among the patients with severe degree of nerve compression, 72.9% of patients had claudication. However, only 40% of patients with mild-to-moderate nerve compression had claudication. For this association, p- value = 0.00014, which showed statistically significant correlation. This matches with the study of Lohman CM, Tallroth K, Kettunen JA, Lindgren KA.[16] They also found that severity of nerve correlates with the clinical findings of claudication.

In patients of DSL, occurrence of axial back pain (p- value = 0.0129) and extremity pain as per CARDS[17] classification [Table 6] (p- value = 0.0129) correlated well with the imaging. About 80% of patients without associated spinal canal stenosis with DSL had axial back pain (p- value = 0.0129). On the other hand, extremity radiation (p- value = 0.0129) was absent among 80% of patients of this group. Both these associations are statistically significant at p- value < 0.05. It also matches with the study of Saraste H.[14] who found similar association during long follow-up of 20 years on 255 patients.
Table 6: Association of various symptoms as per CARDS classification in cases of Degenerative Spondylolisthesis.(n=24)

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  Conclusion Top


There has been positive correlation between clinical and imaging finding for severe degree of disc degeneration and spinal canal stenosis but variable for DSL.

Acknowledgement

We would like to thank Prof. Dr. Chinmay De, Professor and Head of the Department of Orthopedics. His valuable advice and supervision were instrumental for completion of this project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Annexure Top


Annexure 1

  • Clinical and radiographic degenerative spondylolisthesis classification17
  • There are two grading systems included in this classification.


    1. Radiographic grades
    2. Leg pain scoring


  • Radiographic grades


    1. Advanced disc space collapse without kyphosis
    2. Disc partially preserved with translation of 5 mm or less
    3. Disc partially preserved with translation of >5 mm
    4. Kyphotic alignment


  • Leg pain scoring
  • Score 0: No leg pain
  • Score 1: Unilateral leg pain
  • Score 2: Bilateral leg pain.


(*Spine J; August' 2015; (8:1804-11). Ref. Kepler CK, Vaccaro AR et al.)

Quebec Task Force

For the purpose of statistical analysis, classification system based on the categories 1, 2, and 3 of Quebec Task Force was used. Quebec Task Force has merged seven groups according to segmental distribution into three groups.

  • First group was with low back pain with thigh pain
  • Second group has distal lower extremity (distal to knee) pain in addition
  • Third group included weakness, numbness, and paresthesia in addition to second group.


In our study, we have used Quebec Task Force grading system only to assess the back pain characters and radiculopathy. Therefore, we had used only first and second group categorization.



 
  References Top

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Frymoyer JW, Cats-Baril WL. An overview of the incidences and costs of low back pain. Orthop Clin North Am 1991;22:263-71.  Back to cited text no. 1
    
2.
Benneker LM, Heini PF, Anderson SE, Alini M, Ito K. Correlation of radiographic and MRI parameters to morphological and biochemical assessment of intervertebral disc degeneration. Eur Spine J 2005;14:27-35.  Back to cited text no. 2
    
3.
Hyodo H, Sato T, Sasaki H, Tanaka Y. Discogenic pain in acute nonspecific low-back pain. Eur Spine J 2005;14:573-7.  Back to cited text no. 3
    
4.
Leone A, Constantine AM, Guglalami G, Taneioni V, Moschini M. Degenerative disease of lumbo-sacral spine: Disc herniation and stenosid. Rays 2000;25:35-48.  Back to cited text no. 4
    
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Guglielmi G, De Serio A, Leone A, Agrosì L, Cammisa M. Imaging in degenerative disease of the lumbar spine. Rays 2000;25:19-33.  Back to cited text no. 5
    
6.
Jarvik JG, Hollingworth W, Martin B, Emerson SS, Gray DT, Overman S, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: A randomized controlled trial. JAMA 2003;289:2810-8.  Back to cited text no. 6
    
7.
Mullan CP, Kelly BE. Magnetic resonance (MR) imaging of lumbar spine: Use of a shortened protocol for initial investigation of degenerative disease. Ulster Med J 2005;74:29-32.  Back to cited text no. 7
    
8.
Iftikhar AB, Noman M, Javed M, Faisal N, Humayun P. Magnetic resonance patterns of lumber disc disease. J Rawal Med Coll 2004;8:53-60.  Back to cited text no. 8
    
9.
Rankine JJ, Fortune DJ, Hutchison CE. Pain drawing in the assessment of nerve root compression: A comparitive study with magnetic resonance imaging. Spine 1998;23:1668-76.  Back to cited text no. 9
    
10.
Younis F, Shahzad R, Rasool F. Correlation of magnetic resonance patterns of lumber disc disease with clinical symptomatology of patients. Ann Kemu 2011;17:41-7.  Back to cited text no. 10
    
11.
Janardhana AP, Rajagopal, Rao S, Kamath A. Correlation between clinical features and magnetic resonance imaging findings in lumbar disc prolapse. Indian J Orthop. 2010;44:263-9.  Back to cited text no. 11
    
12.
Siddiqui AH, Rafique MZ, Ahmad MN, Usman MU. Role of magnetic resonance imaging in lumbar spondylosis. J Coll Physicians Surg Pak 2005;15:396-9.  Back to cited text no. 12
    
13.
Modic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN, Grooff PN, Mazanec DJ, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology 2005;237:597-604.  Back to cited text no. 13
    
14.
Saraste H. Long-term clinical and radiological follow-up of spondylolysis and spondylolisthesis. J Pediatr Orthop 1987;7:631-8.   Back to cited text no. 14
    
15.
Wiesel SW, Tsourmas N, Feffer HL, Citrin CM, Patronas N. A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients. Spine (Phila Pa 1976) 1984;9:549-51.  Back to cited text no. 15
    
16.
Lohman CM, Tallroth K, Kettunen JA, Lindgren KA. Comparison of Radiologic signs and clinical symptoms of spinal stenosis. Spine 2006;31:1834-40.  Back to cited text no. 16
    
17.
Kepler CK, Hilibrand AS, Sayadipour A, Koerner JD, Rihn JA, Radcliff KE. Clinical and radiographic degenerative spondylolisthesis(CARDS) classification. Spine J 2015;15:1804-11.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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