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To identify the prevalence of lumbar scoliosis in breast cancer patients and to investigate the potential risk factors of lumbar scoliosis.
A retrospective chart review was performed in breast cancer patients aged more than 40 years who underwent dual energy X-ray absorptiometry (DEXA) scanning between January 2014 and December 2014. We divided the patients into control and experimental groups in order to investigate the influence of breast cancer treatment. The curvature of the lumbar spine was measured by using the Cobb method on a DEXA scan. Scoliosis was defined by the presence of a curvature 10° or larger. The variables, including age, bone mineral density (BMD), body mass index (BMI), and breast cancer treatments, were also obtained from the medical chart. Prevalence of lumbar scoliosis was evaluated, and it was compared between the two groups. The relationships between lumbar scoliosis and these variables were also investigated.
Lumbar scoliosis was present in 16 out of our 652 breast cancer patients. There was no difference in the prevalence of lumbar scoliosis between the control group (7/316) and the experimental group (9/336) (p=0.70). According to the logistic regression analysis, lumbar scoliosis had no significant association with operation, chemotherapy, hormone therapy, BMI, and BMD (p>0.05). However, age showed a significant relationship with prevalence of lumbar scoliosis (p<0.001; odds ratio, 1.11; 95% confidence interval, 1.054–1.170).
Prevalence of lumbar scoliosis in patients with breast cancer was 2.45%. Lumbar scoliosis had no association with breast cancer treatments, BMD, and BMI. Age was the only factor related to the prevalence of lumbar scoliosis.
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To evaluate the usefulness of various magnetic resonance imaging (MRI) findings in the prognosis of neurological recovery in paraplegics with thoracolumbar fracture using association analysis with clinical outcomes and electrodiagnostic features.
This retrospective study involved 30 patients treated for paraplegia following thoracolumbar fracture. On axial and sagittal T2-weighted MRI scans, nerve root sedimentation sign, root aggregation sign, and signal intensity changes in the conus medullaris were independently assessed by two raters. A positive sedimentation sign was defined as the absence of nerve root sedimentation. The root aggregation sign was defined as the presence of root aggregation in at least one axial MRI scan. Clinical outcomes including the American Spinal Injury Association impairment scale, ambulatory capacity, and electrodiagnostic features were used for association analysis.
Inter-rater reliability of the nerve root sedimentation sign and the root aggregation sign were κ=0.67 (p=0.001) and κ=0.78 (p<0.001), respectively. A positive sedimentation sign was significantly associated with recovery of ambulatory capacity after a rehabilitation program (χ2=4.854, p=0.028). The presence of the root aggregation sign was associated with reduced compound muscle action potential amplitude of common peroneal and tibial nerves in nerve conduction studies (χ2=5.026, p=0.025).
A positive sedimentation sign was significantly associated with recovery of ambulatory capacity and not indicative of persistent paralysis. The root aggregation sign suggested the existence of significant cauda equina injuries.
To investigate changes in lumbar multifidus (LM) and deep lumbar stabilizing abdominal muscles (transverse abdominis [TrA] and obliquus internus [OI]) during transcutaneous neuromuscular electrical stimulation (NMES) of lumbar paraspinal L4-L5 regions using real-time ultrasound imaging (RUSI).
Lumbar paraspinal regions of 20 healthy physically active male volunteers were stimulated at 20, 50, and 80 Hz. Ultrasound images of the LM, TrA, OI, and obliquus externus (OE) were captured during stimulation at each frequency.
The thicknesses of superficial LM and deep LM as measured by RUSI were greater during NMES than at rest for all three frequencies (p<0.05). The thicknesses in TrA, OI, and OE were also significantly greater during NMES of lumbar paraspinal regions than at rest (p<0.05).
The studied transcutaneous NMES of the lumbar paraspinal region significantly activated deep spinal stabilizing muscle (LM) and the abdominal lumbar stabilizing muscles TrA and OI as evidenced by RUSI. The findings of this study suggested that transcutaneous NMES might be useful for improving spinal stability and strength in patients having difficulty initiating contraction of these muscles.
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To compare the treatment effects of epidural neuroplasty (NP) and transforaminal epidural steroid injection (TFESI) for the radiating pain caused by herniated lumbar disc.
Thirty-two patients diagnosed with herniated lumbar disc through magnetic resonance imaging or computed tomography were included in this study. Fourteen patients received an epidural NP and eighteen patients had a TFESI. The visual analogue scale (VAS) and functional rating index (FRI) were measured before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment.
In the epidural NP group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.00±1.52, 4.29±1.20, 2.64±0.93, 1.43±0.51 and those of FRI were 23.57±3.84, 16.50±3.48, 11.43±2.44, 7.00±2.15. In the TFESI group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.22±2.05, 4.28±1.67, 2.56±1.04, 1.33±0.49 and those of FRI were 22.00±6.64, 16.22±5.07, 11.56±4.18, 8.06±1.89. During the follow-up period, the values of VAS and FRI within each group were significantly reduced (p<0.05) after the treatment. But there were no significant differences between the two groups statistically.
Epidural NP and TFESI are equally effective treatments for the reduction of radiating pain and for improvement of function in patients with a herniated lumbar disc. We recommend that TFESI should be primarily applied to patients who need interventional spine treatment, because it is easier and more cost-effective than epidural NP.
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To identify the volumes of contrast material needed to reach the specific landmarks and contrast pattern during Kambin's triangle approach (KB-A) in lumbar spinal stenosis.
Sixty patients undergoing KB-A were investigated. Fifty-six patients were included in this study. KB-A were performed with the use of contrast-enhanced fluoroscopic visualization. After confirming the appropriate spinal needle position, a slow injection of up to 5.0 ml of nonionic contrast material was carried out. Under intermittent fluoroscopic guidance, contrast volumes were recorded as flow reached specific anatomic landmarks: ipsilateral inferior or superior neural foramen.
After 2.0 ml of contrast was injected, 93.2% of KB-A cases spread to the medial aspect of the inferior pedicle of the corresponding level of injection and 86.3% of KB-A spread to the medial aspect of the superior pedicle of the corresponding level of injection. After 3 ml of contrast was injected, 95.3% of KB-A spread to cover both the medial aspect of the inferior pedicle and the superior pedicle of the corresponding level of injection. A volume of 2 ml of injectate reaches the anterior epidural space 100% of the time.
This study demonstrates injectate volumes needed to reach the specific anatomic landmarks in KB-A. A volume of 3.0 ml of injectate reaches both the medial aspect of theinferior pedicle and the superior pedicle 94.6% of the time. Therefore, Interventionalists may consider a 1-level instead of a 2-level injection for patients with a bleeding risk or for 2 level central pathology.
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To evaluate the effect of hyaluronidase in patients with failed back surgery syndrome (FBSS) treated with interlaminar lumbar epidural injection (ILEI).
Sixty patients suffering from severe low back pain and sciatica were randomly allocated into three groups. Group T received ILEI with 2 ml triamcinolone 40 mg/ml and 5 ml bupivacaine 0.25%. Group H received ILEI with 1500 IU hyaluronidase and 5 ml bupivacaine 0.25%. Group TH received interlaminar lumbar epidural injection (ILEI) with 1500 IU hyaluronidase, 2 ml triamcinolone 40 mg/ml and 5 ml bupivacaine 0.25%. The effect was evaluated using Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) at pre-injection, 2 weeks, 6 weeks and 12 weeks after ILEI.
After 2 weeks and after 6 weeks, patients in both Group T and Group TH had significant effectiveness more than Group H in decrease of VAS and ODI. After 12 weeks, only patients in Group TH had significant effectiveness in decrease of VAS and ODI (p<0.05). In every period, Group TH had the most effectivess in decrease of VAS and ODI after ILEI.
ILEI for FBSS with triamcinolone and hyaluronidase is considered to have more long term effectiveness to reduce pain and improve function after ILEI than injection with triamcinolone alone or hyaluronidase alone.
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To compare the short-term effect and advantage of transforaminal epidural steroid injection (TFESI) performed using the Kambin's triangle and subpedicular approaches.
Forty-two patients with radicular pain from lumbar spinal stenosis were enrolled. Subjects were randomly assigned to one of two groups. All procedures were performed using C-arm KMC 950. The frequency of complications during the procedure and the effect of TFESI at 2 and 4 weeks after the procedure between the two groups were compared. Short-term outcomes were measured using a visual numeric scale (VNS) and a five-grade scale. Multiple logistic regression analyses were performed to evaluate the relationship between possible outcome predictors (Kambin's triangle or subpedicular approach, age, duration of symptoms and sex) and the therapeutic effect.
VNS was improved 2 weeks after the injection and continued to improve until 4 weeks in both groups. There were no statistical differences in changes of VNS, effectiveness and contrast spread pattern between these two groups. No correlation was found between the other variables tested and therapeutic effect. Spinal nerve pricking occurred in five cases of the subpedicular and in none of the cases of the Kambin's triangle approach (p<0.05).
The Kambin's triangle approach is as efficacious as the subpedicular approach for short-term effect and offers considerable advantages (i.e., less spinal nerve pricking during procedure). The Kambin's triangle approach maybe an alternative method for transforaminal epidural steroid injection in cases where needle tip positioning in the anterior epidural space is difficult.
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To compare the technical strengths and weaknesses between retrodiscal (RD) and conventional subpedicular (SP) approaches of transforaminal epidural block (TF-EPB).
Sixty-one patients with L5 radiculopathy who planned to undergo TF-EPB were consecutively enrolled as study subjects. Subjects were randomly assigned to one of two groups. For the RD approach, the positioning of the patient and the C-arm were similar to that for lumbar discography. We compared the pattern of dye spreads, the frequency of complications during the procedures, and the effect of the pain block 2 weeks after the procedure between the two groups.
For the RD group (n=24), the contrast dye diffused around the L5 and S1 nerve roots in 16 cases (67%), but it diffused around only the L5 root in 27 cases (73%) in the SP group (n=37) (p<0.05). Two weeks after the procedure, the visual analogue scale (VAS) decreased by the same amount in both groups (RD group: 3.1±1.6, SP group: 3.2±2.6). Symptoms of nerve root irritation occurred in 1 case of the RD group and in 10 cases of the SD group (p<0.05).
The RD approach was as efficient as the SP approach for temporary diagnostic relief and offered considerable advantages, such as lower nerve root irritation possible lower risk of vascular injection. Thus, it could be a useful technique when a herniated disc segment is stuck or when the foraminal stenosis is severe.
Citations
Effect of Needle Tip Position on Contrast Media Dispersion Pattern in Transforaminal Epidural Injection Using Kambin’s Triangle Approach
The purpose of this study was to obtain the normative values for variable parameters of lumbar function with the isoinertial triaxial dynamometer in normal subjects and to compare these values with those of the patients with chronic low back pain.
In 82 normal subjects and 27 patients with chronic low back pain, the variable parameters including lumbar range of motion (ROM), maximum isometric torques, and maximum isoinertial velocities were measured with the isoinertial triaxial dynamometer in three axes (rotation, flexion-extension, and lateral flexion). In normal subjects, all parameters except lumbar ROM of all three axes were significantly higher in the male group than the female group. However, other anthropometric variables such as age, height, weight, and body mass index were little correlated with each parameter. Therefore, the normative values were obtained only in consideration of the gender. In patients with chronic low back pain, all parameters except the maximum isometric torques in the female group were significantly lower than those in normal subjects. In addition, the decrease of maximum velocities during the isoinertial exercise was highly correlated to verbal rating scales (VRS) in most axes, especially in the female patient group, but the duration of low back pain was little correlated with the various parameters measured with the isoinertial triaxial dynamometer.
In conclusion, all parameters measured with the isoinertial triaxial dynamometer in all three axes were significantly lower in patients with chronic low back pain than those in normal subjects except maximum isometric torques of female group. It was suggested that maximum isoinertial velocities were more reliable and significant than maximum isometric torques for the objective assessment of chronic low back pain.
Objective: To evaluate the effects of back extensor strengthening exercise on improving the pain, activities of daily living (ADL) and bone mineral density in the chronic low back pain patients.
Method: 21 patients with chronic low back pain participated in back school program. Before program, measurement of lumbar extensor strength with MedXⰒ (Ocala, USA), visual analogue scale (VAS) for pain, level of ADL and bone mineral density (BMD) with DEXA (LunarⰒ, GE, USA) were done. For 12 weeks subjects had received the training for strengthening of back extensor and then, checked up with the above variables again.
Results: The results were as follows: 1) After 12 weeks of lumbar extensor strengthening program, isometric lumbar extensor strength was increased significantly (p＜0.01), 2) VAS and ADL were significantly improved from 5.1 to 3.3, and 8.1 to 9.9, respectively (p＜0.01), 3) BMD of lumbar spine were significantly improved from 1.1 to 0.8 (p＜0.05)
Conclusion: Twelve weeks lumbar extensor strengthening program with pelvic stabilization may be the effective therapeutic program for patients with chronic low back pain. (J Korean Acad Rehab Med 2002; 26: 576-580)
Objective: To evaluate how to influence static lumbar lordosis by different heel heights in normal adults and patients with spondylolisthesis.
Method: The lumbolumbar angles, lumbosacral angles and slip angles were examined while standing on barefoot, on heel support with 5 cm heel, and with 10 cm heel in 14 normal adults and 10 patients with first grade of spondylolisthesis. Standing lumbar spine lateral view was performed by one half hour adaptation with corresponding shoe types.
Result: The lumbolumbar angles (angles between upper margin of 2nd lumbar body and low margin of 5th lumbar body) and the lumbosacral angles (between upper margin of 2nd lumbar body and low margin of 1st sacral body) in normal are 36.8⁑6.5o, 50.1⁑9.5o on barefoot, 36.0⁑7.3o, 49.6⁑7.4o on heel support with 5 cm heel, and 36.1⁑7.6o, 49.7⁑8.3o with 10 cm heel. Lumbolumbar angles and lumbosacral angles in 10 patients with spondylolisthesis 38.8⁑8.3°on barefoot, 47.2⁑10.4o on heel support with 5 cm heel, 38.3⁑7.0o, 47.7⁑9.2o with 10 cm heel. The slip angles in 10 patients with spondylolisthesis are 29.8⁑1.2o on barefoot, 30.2⁑1.8o on heel support with 5 cm heel, and with 10 cm heel.
Conclusion: The changes of heel height did not significantly influence the lumbar lordosis in normal adults and patients with spondylolisthesis. There were no significant differences in average slip angle according to heel height in patients with spondylolisthesis were found.
Objective: To classify the findings of magnetic resonance imaging of the lumbar interspinous ligaments in relation to the lumbar disc herniation, disc degeneration, and lordosis.
Method: The subjects were 45 herniated intervertebral disc (HIVD) patients and 35 normal subjects on MRI finding. The magnetic resonance features of the interspinous ligament were classified into five categories according to their signal intensities: type 1A (low intensity on T1- and T2- weighted images without hypertrophy of spinal process); type 1B (same signal pattern as in type 1A with hypertrophy of spinal process); type 2 (low intensity on T1- and high intensity on T2-weighted images); type 3 (high intensity on T1-weighted images); type 4 (others).
Results: The most common type in both HIVD patients and normal subjects was type 3. The mean age and disc degeneration grade of the type 1B ligaments were significantly higher. Lordosis of type 1B of L5-S1 interspinous ligament was increased with significant difference.
Conclusion: The classification of the MRI findings of interspinous types didn't show statistical difference between HIVD patients and normal subjects, but was helpful in assessing the degree of the degeneration of the intervertebral disc and age. (J Korean Acad Rehab Med 2002; 26: 449- 455)
Objective: This research aimed to define the relationship between the lower lumbar disc herniation and the morphology of the iliolumbar ligaments using magnetic resonance imaging.
Method: 24 male and 36 female patients were classified into two groups according to their disc herniation grade- those in whom the L5-S1 disc was less herniated than L4-5 disc, those in whom the L5-S1 disc was more herniated than the L4-L5 disc on magnetic resonance images. The lengths of iliolumbar ligaments were measured on T1- weighted coronal images. The angles of iliolumbar ligaments were measured on T1-weighted axial images.
Results: The length of iliolumbar ligament was not different between L4-L5 disc herniation and L5-S1 disc herniation. The degree of iliolumbar ligament angle difference (asymmetry of direction) at L5-S1 disc herniation was more deviated in paracentral disc herniation compared with central disc herniation.
Conclusion: The morphology of the iliolumbar ligament, especially its asymmetry of direction, may be a factor influencing the development of disc herniation at L5-S1. (J Korean Acad Rehab Med 2002; 26: 439-444)
Magnetic resonance imaging(MRI) is clearly more reliable than computer tomography and myelography in radiological diagnosis of lumbar herniated intervertebral disc. Moreover, MRI can also detect degenerative changes of intervertebral discs. The purpose of this study was to determine the utility and accuracy of MRI in conjuntion with the diagnosis of lumbar herniated intervertebral disc and to compare findings with operative findings.
Comparisons of operative findings and MRI were done in 133 cases. Each patients had been diagnosed by MRI as having lumbar herniated intervertebral disc. MRI findings included those of spin echo T1-weighted images and T2-weighted images, gradient echo T1-weighted images and T2-weighted images, and gadolinium-DTPA enhancement when needed.
In 32 protrusion disc cases diagnosed by MRI, 28 cases were confirmed by operation and four were actually extrusion disc. In 77 cases diagnosed by MRI as extrusion disc, 72 cases were confirmed by operative findings, while 5 cases were found to be protrusion disc. 4 cases of sequestration disc diagnosed by MRI were confirmed by operative findings. Specific dimensions of MRI use yielded the following results: protrusion disc indicated 84.8% in sensitivity, 95% specificity, 87.5% in accuracy; extrusion disc showed 94.7%, 86.5%, 93.5%, respectively; and sequestration disc revealed 100% in all categories. In this study, the average accuracy of lumbar herniated intervertebral disc diagnosed by MRI was 93.6% on average.
Accordingly, MRI has shown itself to be a good diagnostic tool for determining anatomical and biological change in lumbar herniated intervertebral disc.
Objective: The purpose of the this study was to determine whether pain location indicated in pain drawings was related to the specific lumbo-sacral radiculopathy.
Method: The study group consisted of 153 patients (62 men, 91 women) complaining low back pain with or without radiating pain. Nerve conduction study and electromyographic evaluation were performed for the diagnostic purpose. Chi-square test and multivariate stepwise discriminant analysis were used to identify the patients with radiculopathy on the basis of their pain drawings.
Results: There was significant relationship between pain location indicated in the pain drawing and the lumbar radiculopathy (p＜0.05). In patient without the anterolateral thigh pain, the positivity of S1 radiculopathy was high. In patients with anterolateral thigh and leg pain without posterior thigh pain, the positivity of L5/S1 radiculopathy was high. For predicting the level of the lesion there were three discriminant functions (p＜0.05). Patients with S1 radiculopathy showed negative correlation with anterolateral thigh pain. L5/S1 radiculopathy showed negative correlation with posterior thigh pain but were predicted by pain drawing on anterolateral lower leg.
Conclusion: The results of this study indicate that pain drawings may be helpful in identifying specific radiculopathy. As with any evaluation, the drawings should be considered in combination with findings from other diagnostic methods and interpreted with caution and in light of the full clinical picture.
Method: Fourteen iliolumbar ligaments of seven human cadavers were dissected and measured distance from the lumbar spinous process to the iliolumbar ligament and vertical depth of iliolumbar ligament from the skin surface.
Results: All 14 iliolumbar ligaments were originated at the L5 transverse process and inserted in anterior surface of the iliac crest. Direct distance from lumbar spinous process to the origin siteof the iliolumbar ligament was 7.67⁑0.39 cm (distance from the spinous process to presumed skin point of the termination site of the ligament, 6.71⁑0.4 cm). Vertical depth from skin surface was 3.94⁑0.57 cm to the origin site of the iliolumbar ligament, and 3.67⁑0.54 cm to the termination site of the iliolumbar ligament.
Conclusion: The iliolumbar ligament was deep seated anatomical structure in the lumbosacral region. Superficial landmark of the lumbar spinous process may be useful in approach to iliolumbar ligament. (J Korean Acad Rehab Med 2003; 27: 974-977)
Previous studies proved that, the high-heeled shoes caused postural changes, a loss of foot function, and deformities of foot. However the lumbar lordosis in gait is rarely measured. The purposes of this study were to compare kinematics and kinetics between high-heeled and high-forefoot gait by skin markers, and to find the influence of heel height to lumbar vertebral alignment. We used the Vicon 370 three-dimension Gait Analysis System.
In the present study, the lower extremity biomechanics in high-heeled and high-forefoot shoes were examined in 20 Korean female subjects. Results showed that the double support phase increased in high-forefoot gait in linear parameters. In sagittal plane kinematics, the lumbar lordosis slightly increased in high-forefoot gait, but that did not increase in high-heeled gait. The knee flexion and ankle plantarflexion increased in high-heeled gait, but ankle pantar flexion reduced in high-forefoot gait. Clinically the change of ankle motion was not significantly influenced to the lumbar lordosis. However, high-heeled shoe users with low back pain are probably influenced by the overstress of paraspinal muscles and vertebral ligments. Further studies are required for more precise analysis of high-heeled and high-forefoot gaits.
Objective: The purposes of this study were to observe the radiographic changes of lumbar facet joints by magnetic resonance imaging (MRI) in conservatively and operatively treated groups of patients with herniated intervertebral disc, and to compare the biomechanical effects to lumbar facet joints according to the treatment methods
Method: The patients composed of 20 conservatively treated control group and 40 operatively treated group who had disc herniation at lower lumbar spine. Follow-up MRIs were performed in order to assess the radiographic changes of intervertebral disc and lumbar facet joints, such as disc degeneration, lumbar facet joint angle and tropism in either treatment groups individually.
Results: There are significant increase in lumbar facet joint angle in operatvely treated group at the level of both L4/5, right L5/S1 compared to that of conservately treated group, but the disc degeneration and facet joint tropism were not changed after treatment in both groups. There's no relationship between treatment period and each parameters.
Conclusion: The radiographic biomechanical lumbar facet joint changes on MRI seems to be related to degenerative change of lumbar facet joint in operatively treated group with a lumbar disc herniation. Therefore, careful selection of optimal operation time and criteria would be important.
Twelve patients with lumbar arachnoiditis were investigated by means of magnetic resonance imaging. The results showed three groups of different anatomic features: The group I showed conglomeration of nerve roots residing centrally within the thecal sac. The group II demonstrated clumped nerve roots attached peripherally to the meninges. The group III showed increased soft tissue signal within thecal sac. The overall clinical manifestations and electromyographic findings were also investigated; Ten(83%) patients complained of increased, non-radicular, leg pain with activities, such as standing or walking. There were muscle spasms and cramps in the legs in seven(58%). There appears to be no specific clinical and electromyographic findings characteristic to each of the three groups, except that the group III showed more prominent clinical symptoms than those of the other two.
In conclusion, MRI is useful in establishing the diagnosis of lumbar arachnoiditis, as well as seperating three different anatomic features. And we found that increased, non-radicular pain with activities and muscle spasms and cramps appeared to be characteristic to lumbar arachnoiditis, and the group III showed more prominent clinical symptoms than the other two groups.
Intrathecal administration of methotrexate is one of the standard therapies in the acute lymphocytic leukemia (ALL). Spinal puncture and tapping for intrathecal administration of methotrexate is considered as a routine procedure but this procedure carries risks of spinal hematoma in ALL patients. Spinal hematoma after spinal puncture is an uncommon
condition, but it can occur more often in patients with thrombocytopenic or coagulation disorder. We report 4 year-4 month-old boy of ALL with spinal hematoma leading to paraplegia following lumbar puncture for intrathecal methotrexate treatment. (J Korean Acad Rehab Med 2002; 26: 104-107)
Objective: To investigate the relationship between commonly used radiologic parameters and occurrence of low back pain (LBP) through prospective study using pre-employment radiologic examination in high risk workplace.
Method: One hundred and fifty four male workers in high risk workplace were evaluated. Lumbar lordosis, lumbosacral angle, lumbar gravity line and lumbar disc height- related parameters were measured using simple radiologic films of lateral lumbosacral view taken during pre-employment medical check. Relationship between occurrence of LBP during post-employment period with a mean 1.7⁑1.0 years and radiologic parameter was investigated.
Results: Lumbar lordosis, lumbosacral angle and lumbar disc height were not significantly correlated to the occurrence of LBP. Amount of anterior shift of lumbar gravity line did not showed correlation to occurrence of LBP, but subjects with posterior displacement of lumbar gravity line showed significantly low rate of occurrence of LBP.
Conclusion: These results suggest that commonly used radiologic parameters are not so useful to predict occurrence of LBP in high risk workers. The possibile preventive effect of posterior shift of lumbar gravity line seems to be worth further researching. (J Korean Acad Rehab Med 2002; 26: 67-72)
Objective: This study was performed to evaluate the prevalence of new neuromuscular symptoms and disabilities and the psychological characteristics-depressioin, anxiety, type A behavior, loneliness, and also to determine any relationships between physical and neuropsychological characteristics in a group of post-polio syndrome (PPS).
Method: By 70 answered questionnaire, the polio survivors were grouped into PPS and Non- PPS. This questionnaire consisted of questions about acute polio problems; new health problems, fatigue severity scale, visual analog scale, weakness scale, Frenchay activity index, ambulation disability index; socio-economic problems; neuro-psychological inventories, Beck depression index, Spielberger state-trait anxiety inventory, revised UCLA loneliness scale, type A personality score.
Results: The median time from polio to the onset of new health problems was 27.6 years. Fatigue, muscle and/or joint pain, weakness in previously affected and unaffected muscles were most common newly appearing problems. The symptoms of PPS was consistent with the distribution of the anterior horn cell; spinal cord, brain stem, cerebral hemisphere, Reticular Activating System (RAS). Neuro-psychological evaluations revealed that fatigue scale was correlated with depression, type A personality.
Conclusion: In PPS group, pain, weakness, fatigue, autonomous symptoms, decreased concentration were more serious than in Non-PPS group. The fatigue in PPS group was correlated with type A personality, depression, sleep disturbance and concentration problem.
Objective: To evaluate the effects of strengthening exercise for isolated lumbar extensor muscles on chronic low back pain patients.
Method: 28 patients with chronic low back pain in back school program participated in this study. Initially, isometric lumbar extensor strength, 10 point of Visual analog scale (VAS) and questionnaires related to self-experienced symptoms and daily activity (ADL) were checked. Isometric lumbar extensor strength test and strengthening exercise were performed with MedXTM lumbar extensor machine, which was designed to stabilize the pelvis. After 8 weeks of training program, isometric lumbar extensor strength & other pain related variables were checked again in the same way.
Results: The results were as follows: 1) After 8 weeks of lumbar extensor strengthening program, isometric lumbar extensor strength was increased at all the measured points significantly (p＜0.01). 2) VAS and ADL were improved from 6.7 to 3.7, and from 6.9 to 9.1 respectively (p＜0.05).
Conclusion: 8 weeks of lumbar extensor strengthening program with pelvic stabilization was effective therapeutic tools for patients with chronic low back pain.
Objective: To evaluate the correlation of the cross-sectional areas (CSA) of paraspinal muscles (back extensors and psoas muscles) and full range-of-motion isometric lumbar extension strength in the individuals with low back pain.
Method: Twenty four subjects (14 men and 10 women) with low back pain completed a maximum isometric lumbar extension strength test at seven angles through a 72o range of motion (0, 12, 24, 36, 48, 60, 72 degrees of lumbar flexion). CSA of back extensors and psoas muscles were measured from standardized transaxial view by CT scanner.
Results: CSA of lumbar extensor and psoas were correlated with isometric lumbar extension strength from full flexion to extension in the low back pain patients. The greater the lumbar flexion angle, the greater the coefficient of determination (R2). The correlation coefficients of psoas muscles were greater than those of lumbar extensors.
Conclusion: Both back extensors and psoas muscles do their important role during isometric lumbar extension. Isometric lumbar extension strength of full lumbar flexion is well correlated with CSA of paraspinal muscles.
Objective: The purposes of this study were to evaluate the relation of the lumbar plexus with the psoas compartment, to measure the distance from skin to psoas compartment, and to determine the efficacy of psoas compartment block for the unilateral leg pain and/or low back pain.
Method: Six cadavers were dissected and the computed tomography of the lumbar region were performed in 22 subjects. The psoas compartment block of 10 ml of 0.5 percent lidocaine were performed in 31 patients with unilateral leg pain and/or low back pain. Visual Analog Scale (VAS) and sensory, motor functions were assessed before the block and 5, 30 minutes, and 1, 2, 3 hours and 1 week after the block. The distance from skin to psoas compartment were measured during the procedure. The questionnaires on the procedure were completed after 1 week.
Results: Cadaver dissections demonstrated that the 3 main nerves of lumbar plexus were within the psoas compartment between the level of L4 and L5. Computed tomography provided that the average distances of anterior and posterior borders of psoas major from the low back skin were 10.8 & 6.3 cm and that of medial & lateral borders from the median sagital plane were 2.9 & 7.1 cm respectively. There were statistically significant correlations between distance from skin to psoas compartment and body weight, abdominal circumference as well as body mass index (p＜0.0001). The VAS was 7.7 before the block and 5.4 1 week after the block (p＜0.05) and satisfactory outcomes were shown in 71 percent of the subjects.
Conclusion: Psoas compartment block was effective for the patients with unilateral leg pain and/or low back pain without major side effects and complications.
Objective: To analyze morphologic differences between only spondylolysis group and mild spondylolisthesis one in young-aged persons and to find useful parameters for radiological assessment of mild spondylolisthesis.
Method: Twenty patients with only lumbar spondylolysis, 18 patients with mild lumbar spondylolisthesis and 19 normal subjects were recruited in this study. Their radiological findings were examined. The films of subjects were evaluated with respect to variables describing wedging of the spondylolytic vertebra, relative thickness and lengths of the transverse processes. The evaluation was made with attention to possible signs which could mean vertebral slipping. The lumbar index reflects the degree of wedge deformity of the spondylolytic vertebra.
Results: Lumbar index was significantly lower in spondylolisthesis group than only spondylolysis group. There was no significant difference in relative thickness of L5 transverse process between two groups. The incidence of a midline lumbar or sacral defect in the spondylolisthesis group was higher than other groups.
Conclusion: Our results support the usefulness of lumbar index as a supplement parameter for radiological assessment of mild spondylolisthesis.
Method: Ten healthy adult volunteers were included. We attached surface markers at the corresponding skin surface of each lumbar vertebral bodies and measured lumbar segmental ROM in flexion-extension, right bending, left bending, axial rotation with 3-D motion analysis. We compared some of the results with radiologic segmental ROM measurements.
Results: In 3-D motion analysis, segmental ROM of flexion and extension, right bending, left bending, right rotation, left rotation were, respectively: 10.1o, 45o, 3.5o, 1.7o and 1.9o (L1-L2); 17.9o, 6.2o, 5.1o, 1.4o and 1.1o (L2-L3); 15.0o, 7.2o, 4.9o, 2.1o and 1.1o (L3-L4); 14.9o, 5.8o, 4.6o, 1.7° and 1.6° (L4-L5); 10.6o, 4.9o, 3.8°, 2.6° and 0.8° (L5-S1). There was no statistically significant difference in segmental ROM between 3-D motion analysis measurements and radiologic measurements except L5-S1 right bending, L2-L3 and L5-S1 left bending. No statistical significant difference in lumbar flexion and bending ROM was found between two methods.
Conclusion: 3-D motion analysis is a useful method when measuring the lumbar segmental range of motion and it has an advantage to analyze segmental lumbar motion with three directions simultaneously. (J Korean Acad Rehab Med 2003; 27: 424-432)
Method: Sixty patients of low back pain with the age below 60 were enrolled. They didn't have spondylolisthesis or the history of spine surgery. MRI films of these patients were reviewed. Anteroposterior and transverse diameter of endplates, height of vertebral body and intervertebral discs were measured. The relation of these data and intervertebral disc herniation, body weight, height, body mass index (BMI) were statistically studied.
Results: Patients' weight, BMI, the vertebral body area and the shape of the endplate were related to disc herniations. Furthermore, the larger and circular vertebral body was observed in the patients with disc herniation. In the patients with lower back pain, men were diagnosed disc herniations of the MRI finding more than women.
Conclusion: In anatomical aspect, the area and the shape of the vertebral body at the endplate level were important factors contributing to the development of disc herniations at L4-L5 and L5-S1. (J Korean Acad Rehab Med 2003; 27: 399-403)
Objective: The purpose of this study was to evaluate the whole spine of the patients with chronic low back pain.
Method: The cervico-thoraco-lumbar spine were evaluated in 128 patients with chronic low back pain. We analyzed radiologic and clinical findings of the cervico-lumbar spine and electrodiagnostic findings.
Results: Most of all cases showed abnormal findings in plain radiography and electrodiagnostic study. The radiologic findings were as follow: cervical X-ray with straightening of cervical lordotic curve in 85 cases; thoracic X-ray with scoliosis in 55 cases; lumbar X-ray with disc space narrowing in 85 cases. The electrodiagnostic study revealed lumbosacral radiculopathy in 87 cases. There were significant positive relationship between increased lumbosacral angle and straightening of cervical lordotic curve, and between lumbar scoliosis and thoracic scoliosis.
Conclusion: Cervico-thoracic spinal abnormalities were shown in most of the patients with chronic low back pain. Therefore, The evaluation of whole spine would be needed comprehensive rehabilitation approach for the patients with chronic low back pain.
The purposes of this study were to identify lumbar lordosis in low back pain patients and to investigate differences in lumbar lordosis in low back pain patients according to etiologies.
On the basis of the findings of spinal roentgenogram, MRI, and SPECT imagies, the patients were divided into four groups; 1) facet syndrome with facet joint inflammation or degenerative change, 2) disc herniation including disc bulging or extrusion, 3) combined low back pain accompaning facet joint lesion with disc herniation, 4) simple low back pain with no abnormal imaging findings.
There were statistically significant decrease in low back pain patients compared with normal controls in terms of lumbosacral curvature. No sex and age differences were observed within low back pain patients and normal controls in terms of lumbosacral curvature. The review disclosed a significant decrease of the lumbosacral angle in order of simple low back pain, disc herniation, combined low back pain compared with normal controls. But facet syndrome patients showed no change of lumbosacral angle. Patients with disc bulging showed no significant decrease of lumbosacral angle compared with normal controls but patients with disc extrusion showed significant decrease.
It is believed that the decrease of lumbosacral angle in low back patients results from a pathokinesiological effort to keep facet joint from pressure stemed from facet overlying and to minimize the shearing force over lumbosacral joint. The facet joint stiffness due to inflammation may play a major role in no change of lumbosacral angle in facet syndrome patients. In conclusion, different causes of low back pain should be taken into consideration for the assessment of lumbosacral angle.
Objective: To investigate the correlation of multifidus muscle atrophy on MRI findings with clinical findings in low back pain patients.
Method: Medical records of 80 patients presenting with low back pain were retrospectively reviewed. Their MR images were visually analysed to know lumbar multifidus muscle atrophy, disc herniation, disc degeneration, spinal stenosis and nerve root compression.
Results: Multifidus muscle atrophy increased from the upper lumbar level to the most caudal intervertebral level. It was bilateral in the majority of the cases. Multifidus muscle atrophy was well correlated with patient's age, referred leg pain, and disc degeneration. However, duration of low back pain, disc herniation, spinal stenosis, nerve root compression, sex, weight, height and BMI had no correlation with multifidus muscle atrophy.
Conclusion: Examination of multifidus muscle atrophy should be considered when assessing MR images of lumbar spine. It may help for further evaluation and planning the treatment modalities of low back pain.
Objective: To assess the abnormal spontaneous activities in needle electromyography (EMG) according to the type of herniated lumbar disc and anteroposterior the diameter of dural sac in magnetic resonance imaging (MRI).
Method: We performed the MRI on 120 patients with low back pain (LBP) and measured the midline anteroposterior diameter of dural sac in a MRI axial view. Fifty patients with a disc protrusion or extrusion in MRI were reviewed for the clinical findings on physical examination and assessed for the abnormal spontaneous activities (ASA) in needle EMG.
Results: Seventy cases with a normal finding in MRI did not have differences in a dural sac diameter regardless their age or sex. Fifty cases with a protrusion or extrusion in MRI showed that the dural sac size decreased more in an extrusion than in a protrusion, and more in a paracentral type than in a central type. The incidence of ASA in a needle EMG increased more in an extrusion than in a protrusion, and more in a paracentral type than in a central type. The incidence also increased according to the decrement of a dural sac diameter. The incidence of ASA were 100% in a group with both motor and sensory signs, 94% in a group with a motor sign, 86% in a group with a sensory sign, 26% in a group without motor or sensory sign.
Conclusion: We concluded that the abnormalities in needle EMG must be correlated with the direction of herniated lumbar disc and anteroposterior diameter of the dural sac in MRI as well as clinical findings.
The purposes of this study were to measure the normal value of peak torque of lumbar extensors at various degrees of lumbar flexion and to compare this with the chronic low back pain patient. 100 normal subjects, 70 men(age, 49.0±5.3) and 30 women(age, 48.1±7.4), completed isometric lumbar extension strength test. 26 low back pain subjects, 9 men(age, 35.3±14.7) and 17 women(age, 42.6±10.1), completed isometric lumbar extension strength test. Normal male peak torques of lumbar extensors were 125±38 Ft-lbs at 0 degree, 164±43 at 12 degree, 200±43 at 24 degree, 221±46 at 36 degree, 241±50 at 48 degree, 257±50 at 60 degree, and 262±51 at 72 degree of lumbar flexion. Normal female peak torques of lumbar extensors were 78±24 at 0 degree, 105±27 at 12 degree, 120±38 at 24 degree, 135±35 at 36 degree, 142±37 at 48 degree, 151±40 at 60 degree, and 157±41 at 72 degree of lumbar flexion. Normal peak torques of lumbar extensors increase as degrees of lumbar flexion increase. Body weight is more correlated with peak torque than body mass index. Male peak torques of lumbar extensors with low back pain were 91±47 Ft-lbs at 0 degree, 129±46 at 12 degree, 156±57 at 24 degree, 178±61 at 36 degree, 197±54 at 48 degree, 217±61 at 60 degree, and 218±52 at 72 degree of lumbar flexion. Female peak torques of lumbar extensors with low back pain were 45±24 at 0 degree, 73±28 at 12 degree, 98±32 at 24 degree, 117±44 at 36 degree, 130±40 at 48 degree, 138±41 at 60 degree, and 148±36 at 72 degree of lumbar flexion. Peak torques of lumbar extensors with low back pain increase as degrees of lumbar flexion increase. Comparison of the normal male peak torque of lumbar extensors with low back pain group revealed statistical differences at 48 and 72 degree of lumbar extensors. And the female group revealed statistical difference at 0, 12, and 24 degree of lumbar flexion.
Objective: To clarify the relationship between the morphologic changes of disc herniation and the clinical course of conservatively treated herniated lumbar disc patients.
Method: Follow-up MRIs and clinical assessments by the Visual Analogue Scale and Japanese Orthopaedic Association(JOA) Score were performed in 20 patients at a mean interval of 11.3 month.
Results: An average reduction ratio of herniation on the sagittal and axial images, were 21.4% and 20.8% respectively. The clinical features improved significantly and the degree of clinical improvement correlated with the reduction ratio of herniation, althougy 4 patients improved symptomatically despite increased or unchanged degree of herniation. Ten patients with extruded discs showed a higher reduction ratio of heniation with better clinical outcome than those with protruded discs.
Conclusion: The morphologic change verified on MRI of conservatively treated patients with a lumbar disc herniation is responsible for the clinical outcome although the anatomical factor alone is not enough to explain the outcome. The patients with extruded disc herniation shows more morphologic changes on MRI and better clinical outcomes than the patients with protruded discs.
Objective: Sagittal imbalance in lumbar degenerative kyphosis (LDK) is usually more evident when walking, suggesting its dynamic nature. Radiographic examination which only revealed the static status of the spine was considered to be inadequate for assessment of this condition. Gait analysis allows estimation of dynamic spinal imbalance associated with the pelvis and lower extremities in LDK. This study was designed to predict the success of surgery for LDK with gait analysis.
Method: Twenty-six patients who had corrective surgery after gait analysis and had been followed up for more than two years were included in this study. All patients were female, and in average 57.1 years of age (42∼70). Group I consisted of 21 satisfactory patients with marked improvement in stooping, and Group II consisted of five patients with persistent stooping, whose condition remained unsatisfactory despite surgery. In order to find the cause of postoperative persistent stooping, various radiographic and preoperative gait parameters were compared between the two groups.
Results: The average angle of anterior pelvic tilt, hip, and knee flexion were more increased in Group II than Group I. The pattern of hip internal moment in stance phase of gait cycle was biphasic in Group I, similar to the normal pattern, whereas it was monophasic and internal hip extensor hip moment was increased throughout the stance phase in Group II.
Conclusion: An available tool that permitts practical evaluation of dynamic sagittal imbalance of the spine is gait analysis as substantiated by the results of this study.
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