Atherosclerosis and disc degeneration/low-back pain--a systematic review.

OBJECTIVES: Atherosclerosis can obstruct branching arteries of the abdominal aorta, including four paired lumbar arteries and the middle sacral artery that feed the lumbar spine. The diminished blood flow could result in various back problems. The aim of this systematic literature review was to assess associations between atherosclerosis and disc degeneration (DD) or low-back pain (LBP). DATA SOURCES: A systematic search of the Medline/PubMed database for all original articles on atherosclerosis and DD/LBP published until October 2008. The search was performed with the medical subject headings atherosclerosis, cardiovascular risk factor, or vascular disease and keywords "disc degeneration", "disc herniation", and "back pain" on the basis of MeSH tree and as a text search. In addition reference lists were studied and searched manually. Observational studies investigating the association of atherosclerosis or its risk factors and lumbar DD/LBP were selected. REVIEW METHODS: The following data were extracted: study characteristics, duration of follow-up, year of publication, findings of atherosclerosis/cardiovascular risk factors and DD/LBP. Disc herniation was regarded as a form of disc degeneration and cardiovascular risk factors were regarded as surrogate for atherosclerosis in epidemiological studies. RESULTS: One hundred and seventy-nine papers were identified. After exclusion of case reports, letters, editorials, papers not related to the lumbar spine, and animal studies, 25 papers were included. Post-mortem studies showed an association between atheromatous lesions in the aorta and DD, as well as between occluded lumbar arteries and life-time LBP. In clinical studies, aortic calcification was associated with LBP, and stenosis of lumbar arteries was associated with both DD and LBP. In epidemiological studies, smoking and high serum cholesterol levels were found to have the most consistent associations with DD and LBP. CONCLUSION: Aortic atherosclerosis and stenosis of the feeding arteries of the lumbar spine were associated with DD and LBP. Cardiovascular risk factors had weaker associations, being clearly apparent only in cohorts on elderly people or in large study samples. More prospective clinical studies are needed to further clarify the association of atherosclerosis and low-back disorders.

Abdominal aortic calcific deposits are an important predictor of vascular morbidity and mortality.

BACKGROUND: The impact of abdominal arterial calcific deposits on the prediction of cardiovascular disease (CVD) over a long follow-up interval deserves greater scrutiny. METHODS AND RESULTS: Lateral lumbar radiographs were studied as a predictor of incident coronary heart disease (CHD), CVD, and CVD mortality in 1049 men and 1466 women (mean age, 61 years) who were followed from 1967 to 1989. Anterior and posterior wall calcific deposits in the aorta at the level of the first through fourth lumbar vertebrae were graded according to increasing severity using a previously validated rating scale for abdominal aortic calcium (AAC) that ranges from 0 to 24 points. There were 454 cases of CHD, 709 cases of CVD, and 365 CVD deaths. Proportional hazards logistic regression was used to test for associations between AAC and later events after adjustment for age, cigarette use, diabetes mellitus, systolic blood pressure, left ventricular hypertrophy, body mass index, cholesterol, and HDL cholesterol. In comparisons with the lowest AAC tertile, the multivariate age-adjusted relative risks (RR) for CVD were increased in tertile 2 (men: RR, 1.33; 95% confidence interval [CI], 1.02 to 1.74; women: RR, 1.25; 95% CI, 0.95 to 1.65) and tertile 3 (men: RR, 1.68; 95% CI, 1.25 to 2.27; women: RR, 1.78; 95% CI, 1.33 to 2.38). Similar results were obtained with CHD and CVD mortality. CONCLUSIONS: AAC deposits, detected by lateral lumbar radiograms, are a marker of subclinical atherosclerotic disease and an independent predictor of subsequent vascular morbidity and mortality.

New indices to classify location, severity and progression of calcific lesions in the abdominal aorta: a 25-year follow-up study.

The purpose of the present study was to assess the location, severity and progression of radiopaque lumbar aortic calcifications and to evaluate the utility of summary scores of lumbar calcification in a population-based cohort. Lateral lumbar films, obtained in 617 Framingham heart study participants, were analysed for the presence of abdominal aortic wall calcification in the region corresponding to the first through fourth lumbar vertebrae. The severity of the anterior and posterior aortic calcification were graded individually on a 0-3 scale for each lumbar segment and the results were summarized to develop four different composite scores: (1) affected segments score (range 0-4); (2) anterior and posterior affected score (range 0-8); and (3) antero-posterior severity score (range 0-24). The prevalence of aortic calcification was 37% in men and 27% in women at baseline and 86% in both genders at the follow-up exam 25 years later. During the follow-up interval, the mean of the affected segments score increased from 0.7 in men (0.5 in women) to 2.7 (2.8 in women), the mean of the anterior and posterior affected score from 1.2 (0.8 in women) (P = 0.012 for difference between genders) and the mean of the antero-posterior severity score increased from 1.5 (1.3 in women) to 9.3 (10.3 in women). The antero-posterior severity score offered a slight advantage over other composite scores and had the highest inter-rater intra-class correlations. In summary, lumbar aortic calcification can be graded and composite summary scores are reproducible. This technique appears to provide a simple, low cost assessment of subclinical vascular disease.

The GPIIIa Pl(A) polymorphism in the progression of abdominal aortic atherosclerosis.

Glycoprotein IIIa is expressed in platelets as part of the fibrinogen receptor and also in vascular endothelium where it mediates smooth muscle cell proliferation. The association between the glycoprotein GPIIIa Pl(A) polymorphism and the stage of atherosclerosis in the abdominal aorta was studied in a prospective autopsy study series of 300 middle-aged men (33-69 years). The Pl(A) genotype was determined by RFLP-PCR. The stage of atherosclerosis in the abdominal aorta was determined by computer-assisted morphometry. Elevated, fibrous lesions were more frequently (P=0.05) found in the abdominal aortas of men with the Pl(A1) homozygous genotype compared to men with the A2 allele (OR 2.3; 95% CI 0.99-5.2). The area of complicated lesions was significantly greater in men with Pl(A2)-positive genotypes compared to A1 homozygotes. The association with complicated lesions was especially strong in men over 60 (P=0.002). These results suggest that Pl(A) polymorphism is involved in the progression of atherosclerosis in the abdominal aorta. The association of men possessing the Pl(A2) allele with slower development of fibrous lesions and with greater area of complicated lesions in the abdominal aorta may result from genotypic differences in the smooth muscle cell proliferation after slight injuries to the endothelium mediated by glycoprotein IIIa or from genotypic differences in platelet fibrinogen binding or both.

Iatrogenic serratus anterior paralysis. Long-term outcome in 26 patients.

STUDY OBJECTIVE: To evaluate the treatment, extent of recovery, and residual disability in 26 iatrogenic cases of serratus paralysis. PATIENTS AND STUDY DESIGN: Seventeen cases of serratus anterior paralysis had occurred following a local invasive procedure along the course of the long thoracic nerve, including seven first-rib resections, four mastectomies with axillary dissection, two scalenotomies, two surgical treatments of spontaneous pneumothorax, and two infraclavicular plexus anesthesia. Eight cases of paralysis had occurred after general anesthesia for patients who had undergone surgery for diverse clinical reasons. One case of paralysis occurred after spinal anesthesia. The length of sick leave, treatment with a shoulder brace, amount of physical therapy, long-term symptoms, and residual disability were evaluated from the medical records and from the questionnaire sent to the patients on average 6 years (range, 2 to 11 years) after the onset of the paralysis. RESULTS: Despite comprehensive and lengthy treatment, all but one had residual symptoms, as well as limitations in the use of the affected limb. Twenty-one (81%) of the patients could not lift or pull heavy objects, 15 (58%) could not play sports, such as tennis or golf, and 14 (54%) found it impossible to work with hands above shoulder level. CONCLUSION: Serratus anterior paralysis, following anesthesia or local invasive procedures on the anterolateral aspect of the thorax, may cause considerable and long-term dysfunction of the shoulder girdle and affect the function of the whole upper limb.

Postmortem pancreatic angiography in 45 subjects with non-insulin-dependent diabetes mellitus and 51 controls.

We evaluated, from 96 postmortem angiographs, the main feeding arteries and degree of vascularity of the pancreas to discover to what extent atherosclerosis affects pancreatic blood supply in subjects with and without non-insulin-dependent diabetes mellitus (NIDDM). Patients with NIDDM more often showed intrapancreatic arteries with irregularities in the body-tail of the pancreas (p = 0.050) and more frequently demonstrated decreased vascularity in both the body-tail and the head of the pancreas (p < 0.001) than did the controls. When the arterial system from the aorta to the intrapancreatic branches was examined as a whole, 26 (58%) of the NIDDM patients and 10 (20%) of the controls (p = 0.0001) showed one or more of the following: >50% stenosis in the celiac or splenic artery, two or more irregular intrapancreatic branches, or a distinctly decreased degree of vascularity in the body-tail portion of the pancreas, the region responsible for most insulin secretion. Only 1 NIDDM patient, compared to 10 controls, showed a totally normal angiogram. In conclusion, vascular disease in the feeding arteries of the pancreas is more common in NIDDM patients than age- and gender-matched controls.

Ingrowth of blood vessels in disc degeneration. Angiographic and histological studies of cadaveric spines.

Angiograms were made of twenty-two cadaveric lumbar spines to determine the presence of any new blood vessels between adjacent lumbar vertebrae and corresponding discs. The annulus and adjacent longitudinal ligaments were also analyzed histologically. A total of 105 intervertebral spaces were studied. It was found that the normal anastomosing arteries in the posterior longitudinal ligament were significantly obliterated with advancing degeneration of the disc (p < 0.001), whereas several tiny tortuous arteries--often running between the osteophytic spurs--were seen in the anterolateral aspects of the intervertebral spaces connecting the adjacent vertebrae. Histological examination of the anterolateral part of the annulus showed that the vascularity of the annulus increased significantly with degeneration of the disc (p < 0.001), and most of the arteries had a vertical orientation. Regression analysis showed that vascular changes occurred before degeneration of the disc at every lumbar level, suggesting that disturbances in the nutritional supply may precede degeneration. The correlation coefficient was 0.77 (95 per cent confidence limit, 0.52 to 0.90) for the increase in annular vascularity with an increase in the age of the individual at the time of death and 0.86 (95 per cent confidence limit, 0.69 to 0.94) for the increase in degeneration of the disc with an increase in age.

Lumbar disc degeneration and atherosclerosis of the abdominal aorta.

STUDY DESIGN: This study analyzed the relationship of disc degeneration to atherosclerotic changes in the abdominal aorta and stenosis of the ostia of the lumbar and middle sacral arteries, 86 plain radiographs of lumbosacral spines, and the corresponding abdominal aortas were evaluated in connection with routine autopsy. RESULTS: Disc degeneration, advanced atherosclerotic manifestations, and stenosis of the ostia of the lumbar and middle sacral arteries all increased with age (P < 0.001). After partial rank correlation analysis, keeping the effect of age constant, there was still a statistically significant association between the grade of disc degeneration and stenosis of the ostia of the arteries supplying the disc. The association was stronger at upper lumbar levels (0.001 < P < 0.01) than at lower ones (0.01 < P < 0.05). Furthermore, with complicated lesions in the abdominal aorta, disc degeneration at all lumbar levels increased. CONCLUSIONS: Atherosclerosis in the abdominal aorta and especially stenosis of the ostia of segmental arteries may play a part in lumbar disc degeneration.

Disc degeneration/back pain and calcification of the abdominal aorta. A 25-year follow-up study in Framingham.

STUDY DESIGN: A 25-year follow-up study of 606 members of the population-based Framingham cohort, who had received lateral lumbar radiographs in 1967-1968 and 1992-1993, and completed an interview on back symptoms at the second examination. OBJECTIVES: To evaluate whether calcific lesions in the posterior wall of the abdominal aorta, the source of the feeding arteries of the lumbar spine, are associated with disc degeneration or back pain, which would suggest that ischemia of the lumbar spine leads to disc degeneration. METHODS: The presence of radiographic aortic calcification was ascertained in front of each lumbar segment from L1 through L4, and disc degeneration at intervertebral spaces from L1-L2 through L4-L5. The associations between aortic calcification, disc degeneration, and back pain were tested using logistic regression with adjustment for age and sex. RESULTS: At the baseline examination, aortic calcification was significantly associated with general disc degeneration, that is, disc space narrowing or endplate sclerosis at any lumbar level (odds ratio 1.6; 95% confidence interval 1.0-2.5; P = 0.034). In longitudinal, level-specific analyses, comparing local aortic calcifications with disc degeneration at the matching level, aortic calcifications predicted disc deterioration, that is, a decrease in disc space or appearance of endplate sclerosis, between the examinations (odds ratio 1.5; 95% confidence interval 1.3-1.8; P < 0.001). Furthermore, subjects in whom aortic calcifications developed between the examinations had disc deterioration twice as frequently as those in whom aortic calcifications did not develop (odds ratio 2.0; 96% confidence interval 1.2-3.5; P = 0.013). Also, individuals with severe (Grade 3) posterior aortic calcification in front of any lumbar segment were more likely than others to report back pain during adult life (odds ratio 1.6; 95% confidence interval 1.1-2.2; P = 0.014). CONCLUSIONS: Advanced aortic atherosclerosis, presenting as calcific deposits in the posterior wall of the aorta, increases a person's risk for development of disc degeneration and is associated with the occurrence of back pain.

Degenerative displacement of lumbar vertebrae. A 25-year follow-up study in Framingham.

STUDY DESIGN: The authors assessed degenerative lumbar displacement in a population-based cohort of 217 men and 400 women who had lateral lumbar radiographs performed at the mean age of 54 years and again at 79 years, and who had completed interviews on back symptoms and functional performance in connection with the follow-up examination. OBJECTIVES: To assess the prevalence and incidence of degenerative slippage and its association with back pain and physical disability. SUMMARY OF BACKGROUND DATA: Degenerative displacement of lumbar vertebrae may cause instability, nerve root compression, and spinal stenosis. Its incidence in the older population and association with back pain and disability are unknown. METHODS: The authors assessed the prevalence and incidence of degenerative slippage from lateral lumbar radiographs performed 25 years apart and its association with back pain and physical disability from interviews performed in connection with the follow-up examination. RESULTS: At the follow-up examination, 23 (12%) men and 100 (25%) women had developed degenerative slippage exceeding 3 mm; two of them had this already at the baseline. A forward displacement was found in 8 men and 76 women (P < 0.0001 for difference between the genders) and a backward one in 16 men and 35 women. On average, forward slip was 18% +/- 5.5, and backward slip, 15% +/- 4.0 of the anteroposterior diameter of the vertebra below. At the time of the second lumbar radiograph, 39 (32%) of the subjects with slippage, compared with 90 (19%) of the controls, had pain, aching, or stiffness in their back on most days (P = 0.001). After adjustment for endplate sclerosis, which was also related to pain (P = 0.015), slippage still had association with daily back symptoms (P = 0.009). However, subjects with slippage had not experienced more back symptoms during the preceding year or in earlier ages of life, and they did not report more disability than the controls. CONCLUSIONS: Degenerative displacement of lumbar vertebrae is common in an older population and is associated with increased prevalence of daily back symptoms. However, two thirds of the subjects with degenerative displacement do not report ongoing back symptoms, and the disorder is also unrelated to long-term back pain and physical disability.

The long thoracic nerve: Possible mechanisms of injury based on autopsy study.

Forty dissections in 21 adult cadavers were analyzed to determine whether the long thoracic nerve could be mechanically damaged or its blood supply threatened along its peripheral course. The mean length of the nerve was 21.9 cm measured from the upper border of the serratus anterior; it ended an average of 8.4 cm distal to the inferior angle of the scapula. Three postmortem arteriographs were done, and the blood supply to the lower part of the nerve was observed radiographically and in the dissections. The nerve and its blood supply were found to be vulnerable for both compression and stretching anterior to the lower part of the scapula. The findings differ from previous theory about nerve injury at the level of the second rib. Marked interindividual differences in the course of the nerve were noted; this may explain why some people experience paralysis while others do not.

Blood supply of the lower thoracic and lumbosacral regions. Postmortem aortography in 38 young adults.

Postmortem aortography was performed in 38 adults, aged 17 to 29 years, to elucidate the normal anatomy of the arteries supplying the lower thoracic and lumbosacral regions. The lowest 3 thoracic segmental arteries, examined in 32 cases, ran symmetrically in 27 cases. In 5 cases (16%) their course was asymmetric; on one side every segment was fed by an artery of its own, whereas on the other side a segmental artery fed 2 or more segments. The course, distribution and size of the 1st to 4th lumbar arteries were constant in every case except one, while the middle sacral artery and its branches, the 5th lumbar arteries, varied in size, being frequently compensated for, partly or wholly, by the iliolumbar arteries derived from the internal iliac arteries. In their course around the vertebral bodies, lumbar arteries frequently passed between and beneath fibrous attachments of the crura of the diaphragm and the psoas muscle.

Prevalence of stenotic changes in arteries supplying the lumbar spine. A postmortem angiographic study on 140 subjects.

OBJECTIVES: To study the prevalence of arterial diseases in the arteries supplying the lumbar spine and their relation to other vascular diseases, as well as to chronic low back pain. METHODS: Five pairs of the lumbar arteries and the middle sacral artery were evaluated from 140 postmortem aortograms, performed in connection with routine medicolegal necropsies on subjects ranging from 16 to 89 years of age. For information about low back pain history, a close relative of each of the deceased was interviewed two to four weeks after the necropsy. RESULTS: Twenty one (22%) men and nine (20%) women had occluded arteries, and an additional 33 (35%) men and 17 (38%) women had narrowed arteries. The mean age for men with occluded or narrowed arteries, or both, was 50 years and for women 59 years. Most of the stenotic changes were seen at the orifices or in the first part of the arteries. The middle sacral artery was most often affected, followed by the fourth lumbar arteries. The number of collateral arteries increased with occluded (p < 0.001) and narrowed arteries (p = 0.001). Stenotic lumbar/ middle sacral arteries were found, on average, five years earlier than atherosclerosis of the coronary arteries. Subjects with one or more occluded/narrowed arteries were 8.5 times more likely to have suffered from chronic (that is, three months or longer) low back pain at some time during their life than were those without such findings (odds ratio adjusted for age and sex 8.5; 95% confidence intervals 2.9, 24; p < 0.001). CONCLUSIONS: The study shows that the lumbar and middle sacral arteries frequently become obliterated by atheromatous lesions during adult life, and that obliteration of these arteries is more common in subjects with a history of chronic back pain than in those without.

Postmortem angiographic findings for arteries supplying the lumbar spine: their relationship to low-back symptoms.

We evaluated 56 postmortem lumbar aortograms to study differences between subjects with and without low-back pain in the lumbar and middle sacral arteries. Twenty-two of 25 (88%) cases with back pain history had one or more missing arteries, 20 (80%) of them had narrow arteries, and 18 (72%) had developed collaterals. The corresponding figures for 22 age-matched controls were 13 (59%), 12 (55%), and 12 (55%), and for nine young (i.e., age < or = 30 years) controls two (22%), two (22%), and two (22%). The cases had on average 2.04 entirely missing and 1.32 narrow (< or = 50% in diameter) arteries, compared with the age-matched controls who had 0.82 missing (p < 0.001 for difference from cases) and 0.59 narrow arteries (p < 0.01). We conclude that insufficient arterial blood flow may be an underlying factor for low-back symptoms. Atheromatous lesions in the abdominal aorta or congenital hypoplasia of the arteries may explain the angiographic findings.

Etiologic factors in isolated paralysis of the serratus anterior muscle: A report of 197 cases.

One hundred ninety-seven cases of isolated paralysis of the serratus anterior muscle were analyzed to discover common etiologic factors and the mechanisms of injury producing this disorder. Exertion preceded 69 (35%) of the cases, and trauma caused 51 (26%) of the cases. Twenty-two (11%) occurred after locally invasive procedures, 13 (7%) after infection, and 10 (5%) after anesthesia. Sleeping position or exposure to cold proved to be causes in a few cases. Twenty-nine (15%) of the cases were of unknown cause. Evaluation of the mechanism of the injury indicated that in most cases the lesion was mechanical in origin. The data suggested that the long thoracic nerve is not unusually susceptible to infectious or toxic neuropathy, as has previously been supposed.

Postmortem angiographic study of degenerative vascular changes in arteries supplying the cervicobrachial region.

OBJECTIVES: To study the prevalence of degenerative changes in the arteries supplying the cervicobrachial region, and their relation to cervical disc degeneration. METHODS: Fifty postmortem aortic arch angiographies were evaluated for occlusions and variations in the diameter of the vertebral arteries and thyro- and costocervical trunks, as well as for tortuosity, average diameter and the highest cervical level to which the ascending cervical artery, an upward continuation of the thyrocervical trunk, and the deep cervical artery, an upward continuation of the costocervical trunk, ascended. RESULTS: Localised segmental narrowings, usually situated close to the ostia of the arteries, were common, whereas total occlusions were rare. Thirty (60%) of the subjects showed a segmental narrowing at least in one of the six arteries analysed, while only two (4%) showed an occluded artery, which in both the cases was the thyrocervical trunk. Narrowings were most common in vertebral arteries, followed by costocervical and thyrocervical trunks. Segmental narrowings, as well as general tortuosity of the arteries, increased with age. It was also found that ascending and deep cervical arteries did not run as high up in the posterior neck muscles in older people as in younger ones. Twenty three subjects with marked cervical disc degeneration showed on average 2.3 arteries with segmental narrowings, while the corresponding figure for twenty seven subjects without disc degeneration was 0.6. Both the segmental narrowings and the disc degeneration, however, were strongly associated with age, and thus the causality between the former two remained unclear. CONCLUSION: The study showed that degenerative changes are common in the arteries supplying the cervicobrachial area, indicating that impaired blood flow might play a part in some cervicobrachial disorders.