We analyzed the result of a questionnaire that asked “Which area is referred to by the term low back pain?”. The study involved 270 outpatients with a history of low back pain and 62 orthopaedic surgeons. The display patterns of the posterior aspect were classified into 4 types by both patients and orthopaedic surgeons. Type 1 involved those who described the low back pain area as only the waist; this type was not above the iliac crest and did not include the buttocks. Type 2 was the area that contained the upper part of the buttocks. Type 3 contained the buttocks, and type 4 involved the area that extended to the lower extremity over the gluteal folds. By patients, 62% described type 1, 27% type 2,8% type 3 and 3% type 4. By orthopaedic surgeons 39% stated type 1, 48% type 2, 11% type 3, and 2% type 4. Some individuals of each group pointed out not only the posterior aspect but also the anterior aspect in the body, for example,the area of anterior superior iliac spine and groin (10% by patients and 3% by orthopaedic surgeons). Thus, the area where patients and orthopaedic surgeons thought of as described by the phrase “low back pain” varied, especially buttock pain, suggesting that the definition of low back area is needed when the low back pain and leg pain are evaluated by JOA score.
The relationships between low back pain (LBP) and the abnormal findings on MRI, such as lumbar disc degeneration, disc herniation and Schmorl node were examined. One hundred twenty students in medical or nursing school (3 medical and 117 nursing students, 116 females and 4 males). Mean age of the participants was 22.0 years. Subjects responded to a low back pain questionnaire, and an MRI of the lumbar spine was taken for all subjects. Films were analyzed by four observers. The grade of disc degeneration was determined by Schneiderman’s four-grade classification and the disc herniation was evaluated by the criteria of MacNab’s classification. Lumbar disc degeneration and disc herniation were revealed and examined by MRI in 42 (41 females and 1 male) and 21 subjects (20 females and 1 male), respectively. The demonstrated disc degeneration in the group with LBP (grade 1: 15 subjects, 42%; grade 2: 6, 16%; grade 3:15, 42%) was more severe than that in the group without LBP (grade 1: 63 subjects, 75%; grade 2: 13, 15.5%; grade 3: 8, 9.5%) (p<0.05). The incidence of the disc herniation was more frequent in the group with LBP (12 subjects, 33%), compared to the group without LBP (9 subjects, 11%) (p<0.05). However, the sensitivity and specificity both of the disc degeneration and disc herniation for the LBP were not high. (disc degeneration for LBP; sensitivity 50%, specificity 81%, disc herniation for LBP; sensitivity 57%, specificity 76%). Thus, we concluded that disc degeneration and herniation might be related to LBP. However, it is difficult to distinguish between LBP caused by lumbar disc diseases or by other factors, because of the low sensitivity and specificity.
This study sought to determine the relationship between Neck-Shoulder Stiffness (NSS) and Low Back Pain (LBP). A sample of 208 nurses was studied. The subjects were divided into two groups; Group I: Nurses with NSS and LBP (n=67) and Group II: Nurses with NSS without LBP (n=141). Results: Subjects in Group I reported more and varied symptoms as compared to subjects in Group II (p<0.001). Subjects in Group I were more likely to seek treatment for NSS than subjects in Group II (p=0.057). Subjects in Group I thought that sleep disturbances (p=0.021) and the use of personal computers (p=0.043) were related to NSS. Therefore, LBP should be considered one of a number of symptoms accompanying NSS.
The purpose of this study was to investigate the relationship between backache and functional status of the elderly. 78 persons, 28 males and 50 females, residing in the Tohoku District (a largely agricultural area) with a mean age of 72.81 years± 5.4 years were investigated. Based on the reported severity of backaches, the subjects were divided into the three groups: Group I- subjects without backaches (n=25); Group II- subjects with backaches and without disability in activities of daily living (n=28); Group III- subjects unable to walk due to backaches (n=25). Data collection: subjects were examined and data collected regarding the following variables: age, gender, backache (yes or no), knee pain, physical abnormalities of lumbar spine, neurological abnormalities of lower extremities, radiological measurement of thoracolumbar spine (lumbosacral angle, pelvic tilt angle, number of fractured vertebrae), bone mineral density of the calcaneus, ability of ADL and QOL. The data was subjected to statistical analyses to determine if there was a relationship between the severity of backache and other variable. Findings: There was a statistically significant correlation between the number of fractured vertebrae, severe backache, and the presence of spinal deformity. Significant relationships were observed between severe backache, mobility, level of socialization/social interaction, and QOL. Persons with severe backache experienced difficulty in walking long distances and/or participating in social activities outside the home. They had low opinion of themselves. We concluded that the backache in the elderly was related with age, the knee pain, the deformities of spinal alignments and these variables had an adverse effect on ADL and QOL.
Seven hundred and sixty five employees of a hospital were surveyed to determine causative and preventive factors for Occupational Low Back Pain (OLBP). Six hundred and fouty six employees (84%) completed and returned the survey instrument, of that number 518 persons (80%) -292 nurses, 43 doctors, 80 co-workers, 63 office/clerical workers, and 40 maintenance workers- reported instances of OLBP. Of individuals reporting instances of OLBP, 5 persons (1%) required rest and release from their normal duties during their workday, 52 persons (10%) reported absence from work because of OLBP, while 11 persons (2%) sought medical attention or hospitalization for OLBP. In the group surveyed, no individuals reported surgical intervention for OLBP, and OLBP was generally thought to be “slight.” Respondents indicated that learning “correct posture,” -posture designed to protect the lower back in the performance of their jobs- was important in preventing the occurrence of OLBP. To that extent, working conditions and worker education need to be improved in order to prevent and/or minimize instances of OLBP.
Our study sought to determine risk factors associated with Occupational Low Back Pain (OLBP) by surveying and interviewing workers in two distinct setting: workers engaged in manufacturing and teachers. We studied these two groups in two locations: Amagasaki City in 1996 and Osaka Prefecture in 2000. We were able to sample 3,204 persons from these two groups: 1,821 manufacturing workers from Amagasaki City, and 1,383 teachers from schools in Osaka Prefecture. Subjects were asked to complete a survey form that included the Visual Analog Scale (VAS) and the Pain Drawing (PD), where appropriate. Based on their responses, teachers and manufacturing workers were divided into three groups each: (1) Group 1. Those individuals who reported OLBP, as verified by surveys, VAS - with pain scores of 1.0 or higher - and PD - showing pain in low back and/or buttock area - ; (2) Group 2. Those individuals who reported OLBP but whose responses were equivocal in the survey, VAS and PD; and (3) Group 3. Those subjects who reported no OLBP. Results: While 73% of the respondents reported a history of OLBP (83% of teachers and 61% of manufacturing workers, respectively), the percentage of teachers and manufacturing workers whose OLBP was verified by this study averaged 39% (32% teachers and 49% of manufacturing workers, respectively). Group 1. 30% of teachers and 39% of manufacturing workers fell into this group. Group 3. 43% of teachers and 31% of manufacturing workers reported no OLBP in this survey. A univariate analysis carried out between the two populations showed some significant risk factors associated with OLBP, among which were: (1) age of subject, (2) BMI, and (3) previous reported history of another illness. The creation and use of our multi-level survey instrument was useful in determining the incidence and rate of OLBP and associated risk factors between different occupations.
Delivery workers in a general merchandise store, which mainly deals with food and groceries, were assessed with regard to their occupational environment in order to study the risk factors for back pain and other difficulties. Then, the data were analyzed for planning and development of the preventive measures. The samples were composed of 365 males (31.4 years of age on average) in 1997, 360 males (31.9) in 1998, and 362 males (32.1) in 1999. Based on the assessment results, exercise routines at workplace were created and instructed. The workers also received instruction on work methods and postures, and a test of physical strength and fitness was performed. In addition, training of the leader, assessment of back pain, and exercise classes for back pain relief were carried out. As a result, cases with back pain were decreased from 62.7% to 47.2%. A physical examination by a physician demonstrated that the ratio of cases without symptom of back pain was increased from 30.5% to 90.2%. A test of physical strength and fitness revealed that muscular strength and muscle tenacity were significantly improved. Although the merchandise company previously tried to reduce the back pain of the workers by means of improving the occupational environment and introducing labor-saving machines, there was no significant improvement. After introducing the preventive measures and exercise, marked improvements were attained. This success is considered to be achieved by detailed investigation of the working situation, prevention and cure, and education of the workers. The establishment of comprehensive support system appeared to be important.
A survey was conducted in 1998 on 5,846 workers employed in a large-scale manufacturing facility in order to determine the relationship between the working environment and the occurrence of Occupational Low Back Pain (OLBP). • Of the subjects studied, 69.3% of males and 60.9% of females reported experiencing OLBP prior to employment at this company, with the percentage rising to 75.9% in males and decreasing to 58.1% in females subsequent to employment. The incidence of reported OLBP peaked for new employees during the first year of employment. Outpatient records for 388 males and 39 females, in 1998, who presented with OLBP were secured and evaluated. Of this number approxim ately 70% of outpatients returned to work with a week of reporting OLBP. Only 0.9% (4 workers) required surgical treatment for OLBP. Additionally, our analysis pointed to a trend among long time employees (those who had worked for the company for more than 25 years) reporting OLBP to require more than a month to return to work. Since the majority of employees reporting OLBP were found among newly hired workers, it is important for companies to undertake systematic educational initiatives designed to train workers to protect their low back from exposure to trauma and injury in order to reduce instances of OLBP.
Prevalence of low back symptoms was investigated. Questionnaires were performed to 2778 workers, of which occupations included nurse, office, transportation, and security. Approximately 50% of all respondents reported experiencing some form of low back pain, saying that their low back pain developed since undertaking their current job. 94% of nurses and 92% of transportation workers felt that their low back pain was job related. Nurses and office workers who experienced low back pain reported that their pain developed gradually, while the security guards and the transportation workers reported sudden onset of their low back pain. Study respondents identified lifting, half-sitting and some unusual postures (necessary for the performance of their jobs) as probable risk factors for developing low back pain. The study found that nurses were at high risk for developing low back pain beginning in their first year of employment. Early and ongoing workplace education, prevention and workplace improvement are important factors in addressing the reduction of low back pain in workers.
189 patients(151 men and 38 women)with an average age of 45.2, diagnosed with lumbar disc herniation were treated by nerve root block. They presented with an average JOA score of 12.5 points. The level, localization and migration of the disc herniation were determined by MRI. 105 of 189 cases were deemed unsuitable for surgical intervention. 91 of those 105 cases were followed for more than 6 months. The outcome for these 91 patients was “excellent” in 39 cases, “good” in 45 cases and “poor” in 7 cases. In cases of paracentral type herniation without migration and lateral herniation, spinal nerve root block proved to be ineffective in many 62 cases, and surgery was performed in 57 cases. Our study concluded that spinal nerve root block was more effective in addressing central lumbar disc herniation with migration.
We report on the efficacy of the concomitant use of nerve blocks and trigger-point injections for pain reduction in the low back and legs. A total of 63 subjects, 32 males and 31 females, with a mean age of 65.6 years were included in this study. We measured the duration of time that patients felt no pain and reduced pain and were able to calculate pain remission rates. The severity of pain was evaluated using a 5 point Numerical Rating Scale (NRS), with remission rates obtained through the analysis of the scores of pain pre-post nerve block treatment. Subjects were treated primarily with 1% mepivacaine hydrochloride. For 90% of subjects with NRS above 2 degree, co-administration of 1.9mg to 3.8mg of dexamethasone phosphate is performed to 90% of subjects with NRS at 2 degree based on the subjects age. Results: The mean NRS score before and after blocks performed was 2.4, and 0.7 respectively. The remission rate was 73% and the mean duration of pain relief or reduction was 8.1 days. 53 subjects 83% obtained remission rates of 60% or better. No aggravation / side effects were observed in any subjects. Conclusions: We concluded that local anesthetics are safe and can be expected to cause little or no adverse reactions when compared to analgesics. The concomitant use of several nerve blocks or trigger point injections is effective in addressing low back and leg pain. This treatment could meet patients’ satisfaction enough, even given the transient nature of relief. We believe that this would be the first applicable treatment for both occasional and chronic pain in the lower back or legs in our growing geriatric population.
Lumbar tumors of the ligamentum flavum have traditionally been considered a rare cause of nerve root or spinal canal compression, but in recent years, with the advent of MR imaging, more tumors have been discovered. This study reports on the clinical features of recognizable symptomatic lumbar tumors of the ligamentum flavum in 19 patients, as determined by MR imaging. Patients were studied from January 1997 to October 2000. Clinical Sample: Our sample population 19 patients was composed of 11 men and 8 women (average age of 65.3 years, ranging from 39-82 years). Two tumors were located at L2/3, 4 tumors at L3/4, 9 tumors at L4/5, 1 tumor at L5/6, and 3 tumors at L5/S1. Seventeen patients underwent surgery, with the average period for surgery from symptom onset being 12 months (ranging from 1-78 months). We examined symptoms, imaging studies, surgical procedures, results and pathological findings. Nine patients presented with radiculopathy and 10 patients presented with cauda equinopathy; six patients complained of low back pain. Standard X-rays of the lumbar spine revealed some instability in 12 patients (63.1%). Five of 9 myelograms revealed the interruption of the root sleeve in those patients suffering from radiculopathy, while the others exhibited central stenosis. All myelograms revealed central stenosis in those patients suffering from cauda equinopathy. Twelve of 13 facetgrams revealed masses, and in combination with CT scan, the location and size of the tumors could be determined. On MR imaging, iso intensity on T1-weighted images, high intensity on T2-weighted images, and ling enhancement on Gd-enhanced T1-weighted images are the most common views for tumors. Surgical Procedures: A wide fenestration was performed on 6 patients, a hemi laminectomy was performed on one patient, and a hemi wide fenestration was performed on those two patients suffering from radiculopathy. A wide fenestration was performed on 7 patients, and a laminectomy was performed on one patient who suffered from cauda equinopathy. Outcomes: None of these patients experienced a worsening of symptoms following operation. Histological findings revealed 11 ganglions, 3 granulation tissues, 2 hematomas and 1 synovial cyst. Clinical features of the ligamentum flavum tumors are based on its anatomical features, which is dorsal to the dural sac and forms the anterior and medial capsule of the facet joint -- and the degeneration of the ligamentum flavum under segmental instability is the promotional factor of forming tumors.
Epiconus syndrome presents complex features, including muscle atrophy, hypo-reflexia and several kind of sensory disturbance. Of 37 patients who were treated for spine and spinal cord diseases at thoracolumbar junction, 8 patients, 5 men and 3 women, aged 14 to 81 years, demonstrated the epiconus syndrome. We evaluated each patient for clinical symptoms, including the determination of the level of spinal cord involvement affecting their neurological features. All patients presented uni- or bilateral muscle atrophy as well as sensory deficit. The patellar and Achilles tendon reflex were hypoactive in 6 patient, while pathological reflexes were seen in 2 cases and bladder dysfunction were seen in 6 cases. Three patients were initially misdiagnosed. Epiconus syndrome with radicular sensory disturbance is often missed, because its neurological symptoms are analogous to peripheral neuropathies, such as lumbar radiculopathy and peroneal nerve palsy. The level of spinal cord termination was between the middle third of T12 and the lower third of L3, but most frequency at the L1 vertebra. The presence of different neurological features related to epiconus compromise should be carefully examined with reference to the level of the spinal cord.
The lumbar spines of 45 patients were examined by plain radiography and magnetic resonance imaging (MRI) to determine if there was a statistically significant correlation between disc height and degree of disc degeneration. Disc height was measured using three different methods: Method A; (a+b+c)/d, a; anterior disc height, b; middle disc height, c; posterior disc height, d; sagittal diameter of vertebral body. Method B; (a’+b’+c’)/d’, where a’, b’ and c’ were equivalent to a, b, c, in Method A, but which also included the osteophytes. Method C; S1/S2, where S1 and S2 (S1; disc area, S2; vertebral area) were analyzed by computer, and relative ratios were devised. Determination of disc degeneration at L3-4 and L4-5 were evaluated using Schneiderman’s criteria on MRI. Methods A and B correlated with the grade of disc degeneration on MRI. However, method C did not yield statistically significant correlation with MRI data As a conclusion, the disc height indices on plain radiography, as determined by Methods A and B above, are useful as indicators of disc degeneration. L3-4 disc ratios of 0.71 or less, L4-5 disc ratios 0.60 or less (method A), L3-4 disc ratios 0.64 or less, and L4-5 disc ratios of 0.60 or less (method B), when compared with Schneiderman’s classification of disc degeneration yielded a result of“marked”or“absent”. These indices/ratios determined by Methods A and B may be considered threshold values for determining disc degeneration when using plain radiography as opposed to MRI.