Proportional lumbar spine inter-vertebral motion patterns: a comparison of patients with chronic, non-specific low back pain and healthy controls.

INTRODUCTION: Identifying biomechanical subgroups in chronic, non-specific low back pain (CNSLBP) populations from inter-vertebral displacements has proven elusive. Quantitative fluoroscopy (QF) has excellent repeatability and provides continuous standardised inter-vertebral kinematic data from fluoroscopic sequences allowing assessment of mid-range motion. The aim of this study was to determine whether proportional continuous IV rotational patterns were different in patients and controls. A secondary aim was to update the repeatability of QF measurement of range of motion (RoM) for inter-vertebral (IV) rotation. METHODS AND MATERIALS: Fluoroscopic sequences were recorded of passive, recumbent coronal and sagittal motion, which was controlled for range and velocity. Segments L2-5 in 40 primary care CNSLBP patients and 40 matched controls were compared. Patients also completed the von Korff Chronic Pain Grade and Roland and Morris Disability Questionnaire. Sequences were processed using automated image tracking algorithms to extract continuous inter-vertebral rotation data. These were converted to continuous proportional ranges of rotation (PR). The continuous proportional range variances were calculated for each direction and combined to produce a single variable representing their fluctuation (CPRV). Inter- and intra-rater repeatability were also calculated for the maximum IV-RoM measurements obtained during controlled trunk motion to provide an updated indication of the reliability and agreement of QF for measuring spine kinematics. RESULTS: CPRV was significantly higher in patients (0.011 vs. 0.008, Mann-Whitney two-sided p = 0.008), implying a mechanical subgroup. Receiver operating characteristic curve analysis found its sensitivity and specificity to be 0.78 % (60-90) and 0.55 % (37-73), respectively (area under the curve 0.672). CPRV was not correlated with pain severity or disability. The repeatability of maximum inter-vertebral range was excellent, but range was only significantly greater in patients at L4-5 in right side bending (p = 0.03). CONCLUSION: The variation in proportional motion between lumbar vertebrae during passive recumbent trunk motion was greater in patients with CNSLBP than in matched healthy controls, indicating that biomechanical factors in passive structures play a part.

An objective spinal motion imaging assessment (OSMIA): reliability, accuracy and exposure data.

BACKGROUND: Minimally-invasive measurement of continuous inter-vertebral motion in clinical settings is difficult to achieve. This paper describes the reliability, validity and radiation exposure levels in a new Objective Spinal Motion Imaging Assessment system (OSMIA) based on low-dose fluoroscopy and image processing. METHODS: Fluoroscopic sequences in coronal and sagittal planes were obtained from 2 calibration models using dry lumbar vertebrae, plus the lumbar spines of 30 asymptomatic volunteers. Calibration model 1 (mobile) was screened upright, in 7 inter-vertebral positions. The volunteers and calibration model 2 (fixed) were screened on a motorized table comprising 2 horizontal sections, one of which moved through 80 degrees. Model 2 was screened during motion 5 times and the L2-S1 levels of the volunteers twice. Images were digitised at 5fps. Inter-vertebral motion from model 1 was compared to its pre-settings to investigate accuracy. For volunteers and model 2, the first digitised image in each sequence was marked with templates. Vertebrae were tracked throughout the motion using automated frame-to-frame registration. For each frame, vertebral angles were subtracted giving inter-vertebral motion graphs. Volunteer data were acquired twice on the same day and analysed by two blinded observers. The root-mean-square (RMS) differences between paired data were used as the measure of reliability. RESULTS: RMS difference between reference and computed inter-vertebral angles in model 1 was 0.32 degrees for side-bending and 0.52 degrees for flexion-extension. For model 2, X-ray positioning contributed more to the variance of range measurement than did automated registration. For volunteer image sequences, RMS inter-observer variation in intervertebral motion range in the coronal plane was 1.86 degrees and intra-subject biological variation was between 2.75 degrees and 2.91 degrees. RMS inter-observer variation in the sagittal plane was 1.94 degrees. Radiation dosages in each view were below the levels recommended for a plain film. CONCLUSION: OSMIA can measure inter-vertebral angular motion patterns in routine clinical settings if modern image intensifier systems are used. It requires skillful radiography to achieve optimal positioning and dose limitation. Reliability in individual subjects can be judged from the variance of their averaged inter-vertebral angles and by observing automated image registration.

Ionizing radiation exposure and the development of intervertebral disc degeneration--no case to answer.

In the following perspective article, Mellor and Breen provide a counterpoint to a previous perspective on the potential link between ionizing radiation exposure and intervertebral disc degeneration in humans [1]. The previous perspective asked, is this link a myth or reality? It suggested the potential for such a link. Mellor and Breen offer a drastically alternate view, in essence, that the question itself is flawed. To support their perspective, they explain the different units of radiation measurement and their conversion to risk in humans and how this impacts the previous perspective. They explain the variable sensitivity of different body tissues to radiation and highlight that neither human research nor any of the multiple international regulatory agencies have ever suggested that the intervertebral disc is sensitive to radiation. Finally, they claim that it is impossible to predict with any certainty the effects of low-level radiation on the intervertebral discs.

Measurement of intervertebral motion using quantitative fluoroscopy: report of an international forum and proposal for use in the assessment of degenerative disc disease in the lumbar spine.

Quantitative fluoroscopy (QF) is an emerging technology for measuring intervertebral motion patterns to investigate problem back pain and degenerative disc disease. This International Forum was a networking event of three research groups (UK, US, Hong Kong), over three days in San Francisco in August 2009. Its aim was to reach a consensus on how best to record, analyse, and communicate QF information for research and clinical purposes. The Forum recommended that images should be acquired during regular trunk motion that is controlled for velocity and range, in order to minimise externally imposed variability as well as to correlate intervertebral motion with trunk motion. This should be done in both the recumbent passive and weight bearing active patient configurations. The main recommended outputs from QF were the true ranges of intervertebral rotation and translation, neutral zone laxity and the consistency of shape of the motion patterns. The main clinical research priority should initially be to investigate the possibility of mechanical subgroups of patients with chronic, nonspecific low back pain by comparing their intervertebral motion patterns with those of matched healthy controls.

Midlumbar lateral flexion stability measured in healthy volunteers by in vivo fluoroscopy.

STUDY DESIGN: Prospective fluoroscopic and electromyographic study of coronal plane lumbar spine motion in healthy male volunteers. OBJECTIVES: Assess the intervertebral motion profiles in healthy volunteers for symmetry, regularity, and neutral zone laxity during passive recumbent lateral bending motion. SUMMARY OF BACKGROUND DATA: Previous continuous in vivo motion studies of the lumbar spine have mainly been limited to active, weight-bearing, flexion-extension (sagittal plane) motion. No data are available for passive lateral bending or to indicate the motion profiles when muscle activity is minimized. METHODS: Thirty asymptomatic male volunteers underwent video-fluoroscopy of their lumbar spines during passive, recumbent lumbar lateral bending through 80 degrees using a motor-driven motion table. Approximately 120 consecutive images of segments L2-L5 were captured, and the position of each vertebra was tracked throughout the sequence using automated frame-to-frame registration. Reference intervals for intervertebral motion parameters were calculated. Surface electromyography recordings of erector spinae were obtained in a similar group of volunteers using the same protocol without fluoroscopy to determine to what extent the motion was completely passive. RESULTS: Correlations between intervertebral and lumbar motion were always positive in controls and asymmetry was less than 55% of intervertebral range. The upper reference interval for the slope of intervertebral rotation in the first 10 degrees of trunk motion did not exceed 0.46 for any level. Muscle electrical activity during the motion was very low. Examples from patient studies showed markedly different results. CONCLUSION: These results suggest that reference limits from asymptomatic data for coronal plane passive recumbent intervertebral motion may be a useful resource for investigating the relationship between symptoms of chronic (nonspecific) low back pain and biomechanics and in the clinical assessment of patients and interventions that target the passive holding elements of the spine. Data pooling from multiple studies would be necessary to establish a complete database.