BACK PAIN & RADIOGRAPHIC APPEARANCE







Torgerson WR, Dotter WE "Comparative Roentgenographic Study of the Asymptomatic and Symptomatic Lumbar Spine." 1976 J Bone Joint Surg AM: 58(6):850-853

[ DDD | Spondylosis | Spondylolisthesis & lysis ]

In 1976, Torgerson et al. conducted one of the few investigations into the radiographic prevalence (occurrence rate) of Degenerative Disc Disease ("DDD"), Spondylosis ("DJD"), Spondylolisthesis, and Spondylolysis in both pain-free people and lower back pain sufferers.

The bottom line was this: if the patient has the x-ray appearance of disc height loss, spondylolisthesis or spondylolysis, there is a good chance that he/she is/was suffering from lower back pain. On the other hand, the presents of spondylosis (aka: degenerative joint disease, osteophytes, or bone spurs) was not at all predictive of back pain.

THE COHORT:

The research team gather two groups of people for study: (1) an asymptomatic (pain-free) group of 217, which was made from patients who never reported a history of low back pain and where in the hospital for X-rays of their Kidneys (which also yielded perfect pictures of their lumbar spines). (2) a symptomatic (pain-suffering) group of 387, which was made prospectively from patients entering an Orthopedic Surgery unit for complaints of lower back pain. The ages of all patients were between 40-70 years of age.

DEGENERATIVE DISC DISEASE: (as defined by decreased disc height)

In this investigation, DDD was defined as disc space narrowing by more than 2mm as measured at the center of the respective vertebral endplates as compared to the disc space of the vertebrae above and below.

In middle aged folks (40-50), only 6% of asymptomatic folds demonstrated decreased disc height on X-ray; however, 48% of the back pain sufferers of the same age demonstrated decreased disc height. This finding lead the authors to concluded:

"The findings in this study also suggest that degenerative disc disease [defined as disc height loss] is a major cause of low-back pain. Disc degeneration was significantly more prevalent in patients complaining of low-back pain than in the group of asymptomatic patients in the same age range."

Results:

In the combined asymptomatic group, 22% (48/217) were found to have DDD despite the fact they had no pain. People in their 40s only had a 6% prevalence of DDD.

In the combined symptomatic group, 47% (208/387) were found to have DDD associated with their back pain. People in their 40s had a 48% prevalence of DDD.

"Statistical interpretation of these data indicated that disc degeneration [DDD] was highly probable (p > 0.005) if symptoms were observed."

SPONDYLOSIS: (as defined by endplate osteophyte formation)

There was no discernable difference in the prevalence of spondylosis (aka: degenerative joint disease) between the two groups. More explicitly, its prevalence in the asymptomatic group was 47% (102/217), and its prevalence in the symptomatic group was 57% (208/387). It was also noted that the prevalence of spondylosis increased in frequency in a "direct linear fashion" as related to increase in patient age. In other words, the older patient, the more spondylosis was viewed in both groups. These findings lead the authors to state:

"Spondylosis [osteophyte formation] was almost as prevalent in the asymptomatic patients as in the symptomatic patients, and it occurred with equal frequency in men and women.... These findings suggest that spondylosis has a direct relationship to aging and may not be a cause of back pain."

And:

"Spondylosis (osteophyte formation) in the lumbar spine did not appear to bear any relation to low-back pain; it occurred as often in the 217 asymptomatic patients as it did in the 387 symptomatic patients."

SPONDYLOLISTHESIS & SPONDYLOLYSIS:

In this study, these two conditions were "tabulated together." Only 1.4% (3/217) of the asymptomatic people had this condition. In the symptomatic group, however, 4.7% (8/387) demonstrated spondylolisthesis and/or spondylolysis. These results lead the authors to state:

"Our findings indicate that this lesion [spondylolisthesis and spondylolysis] is often symptomatic.... Statistical interpretation indicated a significantly greater correlation between symptoms and the existence of spondylolysis and spondylolisthesis (p > 0.005). "

And:

"Spondylolisthesis or spondylolysis was observed more frequently in symptomatic than in asymptomatic patients. Both conditions are generally considered to cause back pain."

My only criticism with this area of the investigation is that no lumbar oblique radiographs were performed in either of the groups. This would make it difficult to identify spondylolysis and was probably the reason for the extremely low prevalence rate. (The prevalence rate is usually around 7%. (1))

References:

(1) Beck RW, Holt KR, et al. "Radiographic anomalies that may alter chiropractic intervention strategies found in a New Zealand population." J Manipulative Physiol Ther. 2004 Nov-Dec;27(9):554-9

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