© Springer-Verlag Berlin Heidelberg 2016
João Luiz Pinheiro-Franco, Alexander R. Vaccaro, Edward C. Benzel and H. Michael Mayer (eds.)Advanced Concepts in Lumbar Degenerative Disk Disease10.1007/978-3-662-47756-4_55. Epidemiology of Lumbar Degenerative Disk Disease
(1)
Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
(2)
Spine Surgery Center, Clinique du Diaconat, Strasbourg, France
(3)
Neurological and Spine Surgery, Samaritano Hospital, São Paulo, Brazil
Deceased
Keywords
Degenerative disk diseaseStenosisHerniated diskAgingGenetics✠ Author was deceased at the time of publicationDr. Pierre Kehrli, Chairman of Neurosurgery of the Strasbourg University, France, tragically died before completing this chapter. He died suddenly, in May 2014, at the age of 50, from an aortic aneurysm. His legacy to the privileged people who worked with him included his extreme technical ability as a neurosurgeon and his gentle character. The coauthors pay a small tribute to this fantastic human being with this chapter to the book.
It is of the highest interest for surgeons to study the epidemiology of symptomatic lumbar degenerative disk disease: A basic question to pose is “What is DDD?”
In the recent literature, DDD covers a wide spectrum of symptoms and radiological findings, from low back pain to acquired spinal canal stenosis and symptomatic herniated disk-related symptoms. Symptoms at first glance appear to result from the cumulative exposure of the spinal elements to excessive loading, sports, and principally work. However, this simple theory is not consistent with our contemporary understanding of developmental biology and genetics. A fundamental question arises too: Are we studying radiological aspects or real illness?
5.1 Disk Degeneration: A Spectrum of Definitions
It is not always clear if the term “disk degeneration” is routinely employed for normal or pathological states, reflecting the most difficult challenge in treatment: In a given case, are the symptoms related to what is seen on even the most sophisticated radiological images?
For example, the definition taken from Battié and Videman’s paper [1] includes the paradox of simultaneous occurrences of normal and abnormal states: “disk degeneration is a product of lifelong degradation of the intervertebral disk with synchronized remodeling of the disk and neighboring vertebrae, including simultaneous adaptation of the discal structures to changes in physical loading and responses to occasional injury.”
In this definition, the word “injury” is referring to trauma, reflecting an acute event, but may also include the concept of cumulative stresses from the environment, i.e., way of life, history of accidents, heavy work, etc.
This cumulative load may reflect chronic injury to the spine, a sort of premature aging.
The term “disk degeneration” is an ambiguous term which covers the spectrum of radiographic images not always correlated to pain. This findings on images such as plain X-ray films, CT, and MRI include disk height narrowing, osteophytes, bulging disk, disk herniation, low-signal appearance on T2-weighted MRI, end plate changes, fatty marrow degeneration, posterior facet changes, etc. [2].
5.2 Traditional Epidemiological Studies
5.2.1 Age and Sex
“Normal aging” presupposes proportional “normal disk alterations or changes” over time; however, the findings of advanced early disk degeneration are well known in certain individuals [3].
Similar disk degenerative changes occur in women as in men, but with a delay usually of 10 years [4, 5]. Females may report low back pain associated with hormonal changes related to changes in systemic exposure to progesterone treatment common in pregnancy. A confusing clinical scenario is a woman with an ovarian cyst in mid-menstrual cycle with concomitant lumbar DDD and symptomatic low back pain. In this situation, the spinal surgeon has to be very careful in proposing surgery, even if radiological findings demonstrate significant DDD.
It is quite common in the elderly to see impressive DDD on radiological films in the absence of symptoms.
5.2.2 Postural Factors
Postural factor has often been cited as a cause for low back pain. This has not been fully supported by the peer review literature. For example, there is no relationship between retrolisthesis in patients with L5-S1 disk degeneration and baseline pain or function [6].
A comparison of lumbar degenerative changes between primates and humans demonstrated similar aging DDD patterns species nonspecific. This suggests “that the bipedal posture may not be the singular, or even the most important, biomechanical factor in the development of human DDD” [7].
5.2.3 Weight
In symptomatic patients with sciatica, excessive weight has often been cited as a causative factor for sciatica [8]. Studies indicated that overweight and obesity could increase the risk of chronic or severe low back pain [9, 10]. However, a definitive association between sciatica and excessive weight is just suggested, not widely proven in the literature.
5.2.4 Loading Efforts
Lifting heavy loads, torsional stress, and motor vehicle driving are among the best-identified environmental risk factors associated with symptomatic DDD. A definitive association between loads carried and symptomatic lumbar degenerative disease has also not been proven. Routine heavy physical loading demands at work or at leisure explain only a minor portion of the overall variance in lumbar disk degeneration in Battié’s study of twins [11, 12].
5.2.5 Work/Sports
Excessive loading due to repetitive work activities was shown in one study to be second to inheritance as a causative factor in symptomatic disk degeneration [13]. A study by Ong et al. [14] in athletes found that elite athletes have a greater prevalence and degree of lumbar disk degeneration than the normal population. This may also vary with the type of sport.
5.2.6 Vibrations
There was no clear correlation in a study of 45 pairs of monozygotic twins, highly discordant for exposure to motorized vehicles and associated whole-body vibration, between lumbar disk degeneration on MRI and extensive lifetime driving histories [15].
However, the study of Weber found that after a long duration to whole-body vibration exposure, an increased degree of spondylotic changes was noted at the thoracolumbar junction and mid-lumbar spine [16].
5.2.7 Cigarette Smoking
Results from twins studies are inconclusive on the influence of cigarette use and symptomatic lumbar DDD. An association with cigarette use and heavy work style has been associated with vertebral inflammatory disease [17]. If this finding can be reproduced in other studies, it may have consequences in relation to both primary and secondary prevention measures for low back pain.
5.2.8 Genetic Factors
The recent literature on DDD has been enriched with genetic studies which have given us new insight on the influence of inheritance and symptomatic DDD [18]. In 1991, Varlotta et al. [19] found that 32 % of adolescent patients with a symptomatic disk herniation had a family history.
As Ala-Kokko in 2002 concluded a study, “Even though several environmental and constitutional risk factors have been implicated in this disease, their effects are relatively minor. And recent family and twin studies have suggested that sciatica, disk herniation and disk degeneration may be explained to a large degree by genetic factors” [20].
In 1992, Matsui et al. [21] reported that there is familial clustering of symptomatic lumbar disk herniation among the young (18-year-old or younger). In 1997, Matsui et al. [22] surveyed 3,042 Japanese factory workers regarding a history of acute low back pain. The authors found that the average age of initial symptoms in workers whose parents also suffered from the same condition was significantly younger than that in workers with no familial history.
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