The aim of this study was to assess the cross-sectional area (CSA) of both paraspinal and psoas muscles in patients with unilateral back pain using MRI and to correlate it with outcome measures.
40 patients, all with informed consent, with a minimum of 3 months of unilateral back pain with or without sciatica and one-level disc disease on MRI of the lumbosacral spine were included. Patients were evaluated with self-report measures regarding pain (visual analogue score) and disability (Oswestry disability index). The CSA of multifidus, erector spinae, quadratus lumborum and psoas was measured at the disc level of pathology and the two adjacent disc levels, bilaterally. Comparison of CSAs of muscles between the affected vs symptomless side was carried out with Student's t-test and correlations were conducted with Spearman's test.
The maximum relative muscle atrophy (% decrease in CSA on symptomatic side) independent of the level was 13.1% for multifidus, 21.8% for erector spinae, 24.8% for quadratus lumborum and 17.1% for psoas. There was significant difference (p<0.05) between sides (symptomatic and asymptomatic) in CSA of multifidus, erector spinae, quadratus lumborum and psoas. However, no statistically significant correlation was found between the duration of symptoms (average 15.5 months), patient's pain (average VAS 5.3) or disability (average ODI 25.2) and the relative muscle atrophy.
In patients with long-standing unilateral back pain due to monosegmental degenerative disc disease, selective multifidus, erector spinae, quadratus lumborum and psoas atrophy develops on the symptomatic side. Radiologists and clinicians should evaluate spinal muscle atrophy of patients with persistent unilateral back pain.
No consensus exists on how rehabilitation programs for lumbar discectomy patients with persistent complaints after surgery should be composed. A better understanding of normal and abnormal postoperative trunk muscle condition might help direct the treatment goals.
A three-dimensional CT scan of the lumbar spine was obtained in 18 symptomatic and 18 asymptomatic patients who had undergone a lumbar discectomy 42 months to 83 months (median 63 months) previously. The psoas muscle (PS), the paraspinal muscle mass (PA) and the multifidus muscle (MF) were outlined at the L3, L4 and L5 level. Of these muscles, fat free Cross Sectional Area (CSA) and fat CSA were determined. CSA of the lumbar erector spinae (LES = longissimus thoracis + iliocostalis lumborum) was calculated by subtracting MF CSA from PA CSA. Mean muscle CSA of the left and right sides was calculated at each level. To normalize the data for interpersonal comparison, the mean CSA was divided by the CSA of the L3 vertebral body (mCSA = normalized fat-free muscle CSA; fCSA = normalized fat CSA). Differences in CSA between the pain group and the pain free group were examined using a General Linear Model (GLM). Three levels were examined to investigate the possible role of the level of operation.
In lumbar discectomy patients with pain, the mCSA of the MF was significantly smaller than in pain-free subjects (p = 0.009) independently of the level. The mCSA of the LES was significantly smaller in pain patients, but only on the L3 slice (p = 0.018). No significant difference in mCSA of the PS was found between pain patients and pain-free patients (p = 0.462). The fCSA of the MF (p = 0.186) and of the LES (p = 0.256) were not significantly different between both populations. However, the fCSA of the PS was significantly larger in pain patients than in pain-free patients. (p = 0.012).
The level of operation was never a significant factor.
CT comparison of MF, LES and PS muscle condition between lumbar discectomy patients without pain and patients with protracted postoperative pain showed a smaller fat-free muscle CSA of the MF at all levels examined, a smaller fat- free muscle CSA of the LES at the L3 level, and more fat in the PS in patients with pain. The level of operation was not found to be of importance. The present results suggest a general lumbar muscle dysfunction in the pain group, in particular of the deep stabilizing muscle system.
To evaluate the relationship between the cross sectional area (CSA) and isokinetic strength of the back muscles in patients with chronic low back pain.
Data of twenty-eight middle-aged patients with chronic back pain were analyzed retrospectively. CSAs of both paraspinal muscles and the disc at the L4-L5 level were measured in MRI axial images and the relative CSAs (rCSA: CSA ratio of muscle and disc) were calculated. The degree of paraspinal muscle atrophy was rated qualitatively. Isokinetic strengths (peak torque, peak torque per body weight) of back flexor and extensor were measured with the isokinetic testing machine. Multiple regression analysis with backward elimination was used to evaluate relations between isokinetic strength and various factors, such as CSA or rCSA and clinical characteristics in all patients. The same analysis was repeated in the female patients.
In analysis with CSA and clinical characteristics, body mass index (BMI) and CSA were significant influencing factors in the peak torque of the back flexor muscles. CSA was a significant influencing factor in the peak torque of total back muscles. In analysis with rCSA and clinical characteristics, BMI was significant in influencing the peak torque of the back flexors. In female patients, rCSA was a significant influencing factor in the peak torque per body weight of the back flexors, and age and BMI were influencing factors in the peak torque of back flexors and total back muscles.
In middle-aged patients with chronic low back pain, CSA and rCSA were influencing factors in the strength of total back muscles and back flexors. Also, gender and BMI were influencing factors.
Low back pain; Muscle strength; Muscle strength dynamometer; Magnetic resonance imaging
To quantitatively evaluate the asymmetry of the multifidus and psoas muscles in unilateral sciatica caused by lumbar disc herniation using magnetic resonance imaging (MRI).
Seventy-six patients who underwent open microdiscectomy for unilateral L5 radiculopathy caused by disc herniation at the L4-5 level were enrolled, of which 39 patients (51.3%) had a symptom duration of 1 month or less (group A), and 37 (48.7%) had a symptom duration of 3 months or more (group B). The cross-sectional areas (CSAs) of the multifidus and psoas muscles were measured at the mid-portion of the L4-5 disc level on axial MRI, and compared between the diseased and normal sides in each group.
The mean symptom duration was 0.6±0.4 months and 5.4±2.7 months for groups A and B, respectively (p<0.001). There were no differences in the demographics between the 2 groups. There was a significant difference in the CSA of the multifidus muscle between the diseased and normal sides (p<0.01) in group B. In contrast, no significant multifidus muscle asymmetry was found in group A. The CSA of the psoas muscle was not affected by disc herniation in either group.
The CSA of the multifidus muscle was reduced by lumbar disc herniation when symptom duration was 3 months or more.
Multifidus; Psoas; Cross-sectional area; Lumbar disc herniation
The purpose of this study was to investigate the use of magnetic resonance (MR) imaging and image processing software to determine the functional cross-sectional area (FCSA) (the area of muscle isolated from fat) of the lumbar paraspinal muscles. The measurement of the morphology of the lumbar paraspinal muscles has become the focus of several recent investigations into the aetiology of low back pain. However, the reliability and validity of determining the FCSA of the lumbar paraspinal muscles using MR imaging are yet to be reported. T2 axial MR scans at the L1-S1 spinal levels of six subjects were obtained using identical MR systems and scanning parameters. Lean paraspinal muscle, vertebral body bone and intermuscular fat were manually segmented using image analysis software to assign a grey scale range to the MR signal intensity emitted by each tissue type. The resultant grey scale range for muscle was used to determine FCSA measurements for each of the paraspinal muscles, psoas, quadratus lumborum, erector spinae and lumbar multifidus on each scan slice. As various biological, instrument and measurement factors can affect MR signal intensity, a sensitivity analysis was conducted to determine the error associated in calculating FCSA for paraspinal muscle using a discrete grey scale range. Cross-sectional area and FCSA measurements were repeated three times and reliability indices for the FCSA measurements were obtained, showing excellent reliability, intra class correlation coefficient (mean=0.97, range 0.90–0.99) and %SEM (mean=2.6%, range 0.7–4.8%). In addition, the error associated with miscalculation of the grey scale range for the MR signal intensity of muscle was calculated and found to be low with an error of 20 grey scale units at the upper end of the muscle’s grey scale range resulting in a very small error in the measured muscle FCSA. The method presented in this paper has a variety of practical applications in areas such as evidence-based rehabilitation, biomechanical modelling and the determination of segmental inertial parameters.
Lumbar spine; Magnetic resonance imaging; Cross sectional area; Low back pain; Muscle morphology
Objectives—To determine the effect of different training schedules on the cross sectional area (CSA) of the lumbar multifidus muscle in patients with chronic low back pain.
Methods—Each of 59 nine patients was randomly assigned to one of three programmes: 10 weeks of stabilisation training (group 1; n = 19); 10 weeks of stabilisation training combined with dynamic resistance training (group 2; n = 20); 10 weeks of stabilisation training combined with dynamic-static resistance training (group 3; n = 20). Before and after 10 weeks of training, multifidus CSAs were measured from standard computed tomography images at three different levels (upper end plate of L3 and L4, and lower end plate of L4).
Results—The CSA of the multifidus muscle was significantly increased at all levels after training in group 3. In contrast, no significant differences were found in groups 1 and 2.
Conclusions—General stabilisation exercises and dynamic intensive lumbar resistance training have no significant effect on the CSA of the lumbar multifidus muscle in patients with chronic low back pain. The static holding component between the concentric and eccentric phase was found to be critical in inducing muscle hypertrophy during the first 10 weeks. Treatment consisting of stabilisation training combined with an intensive lumbar dynamic-static strengthening programme seems to be the most appropriate method of restoring the size of the multifidus muscle.
Key Words: back pain; multifidus muscle; stabilisation; dynamic; dynamic-static; hypertrophy
This study examined a set of patients who were symptomatic for low back pain and who had significant lumbar hypolordosis as assessed by visual evaluation of magnetic resonance images to investigate the frequency of comorbid paraspinal muscle spasms as determined via history or physical examination.
A retrospective chart review was performed on 50 patients who had significant hypolordosis on magnetic resonance imaging (MRI) (Cobb angle <20°) to determine whether they were positive for paraspinal muscle spasms by either history or physical examination.
Of the 50 patients with significant hypolordosis on MRI, 66% (33) had a history of paraspinal muscle spasms, 76% (38) had a positive physical examination for palpation of paraspinal muscle spasms, and 48% (24) were positive for both history and physical examination.
This retrospective study suggests that most symptomatic patients with significant hypolordosis on lumbar MRI have a positive history or physical examination for paraspinal muscle spasm. Thus, MRI finding of significant hypolordosis (Cobb angle <20°) could potentially be a valuable tool in addition to medical history and physical examination in aiding clinicians in diagnosing paraspinal muscle spasms in symptomatic patients and in helping them to formulate appropriate and effective treatments.
Lordosis; Spinal curvatures; Spinal diseases; Magnetic resonance imaging; Spasm
The objectives of the study were to evaluate the association between lumbar paraspinal muscle density, evaluated on computed tomography (CT) and age, sex and BMI; and to evaluate the association of those changes with low back pain (LBP) and spinal degeneration features in a community-based sample. This study was an ancillary project to the Framingham Study. A sample of 3,529 participants aged 40–80 years had a CT scan performed to assess aortic calcification. 187 individuals were randomly enrolled in this study. LBP in the last 12 months was evaluated using self-report questionnaire. Density (in Hounsfield units) of multifidus and erector spinae was evaluated on CT. The prevalence of intervertebral disc narrowing, facet joint osteoarthritis (FJOA), spondylolysis, spondylolisthesis and spinal stenosis were also evaluated. We used linear regression models to examine the association of paraspinal muscles density with age, sex, BMI, LBP, and spinal degeneration features. The results show that in our study, men have higher density of paraspinal muscles than women, younger individuals have higher density than older ones and individuals with lower weight have higher muscle density than overweight. No differences between individuals with and without LBP were found. Significant association was found between L4 multifidus/erector spinae density and FJOA at L4–L5; between multifidus at L4 and spondylolisthesis at L4–5; and between erector spinae at L4 and L5 with disc narrowing at L4–5 and L5–S1, respectively. We conclude that the paraspinal muscle density decreases with age, and increases BMI. It is associated with at some levels FJOA, spondylolisthesis and disc narrowing at the same level, but not associated with occurrence of LBP.
Low back pain; Paraspinal muscles; Multifidus; Erector spinae; Computed tomography
The concept of minimally invasive lumbar disc surgery comprises reduced muscle injury. The aim of this study was to evaluate creatine phosphokinase (CPK) in serum and the cross-sectional area (CSA) of the multifidus muscle on magnetic resonance imaging as indicators of muscle injury. We present the results of a double-blind randomized trial on patients with lumbar disc herniation, in which tubular discectomy and conventional microdiscectomy were compared. In 216 patients, CPK was measured before surgery and at day 1 after surgery. In 140 patients, the CSA of the multifidus muscle was measured at the affected disc level before surgery and at 1 year after surgery. The ratios (i.e. post surgery/pre surgery) of CPK and CSA were used as outcome measures. The multifidus atrophy was classified into three grades ranging from 0 (normal) to 3 (severe atrophy), and the difference between post and pre surgery was used as an outcome. Patients’ low-back pain scores on the visual analogue scale (VAS) were documented before surgery and at various moments during follow-up. Tubular discectomy compared with conventional microdiscectomy resulted in a nonsignificant difference in CPK ratio, although the CSA ratio was significantly lower in tubular discectomy. At 1 year, there was no difference in atrophy grade between both groups nor in the percentage of patients showing an increased atrophy grade (14% tubular vs. 18% conventional). The postoperative low-back pain scores on the VAS improved in both groups, although the 1-year between-group mean difference of improvement was 3.5 mm (95% CI; 1.4–5.7 mm) in favour of conventional microdiscectomy. In conclusion, tubular discectomy compared with conventional microdiscectomy did not result in reduced muscle injury. Postoperative evaluation of CPK and the multifidus muscle showed similar results in both groups, although patients who underwent tubular discectomy reported more low-back pain during the first year after surgery.
Creatine phosphokinase; Muscle injury; Atrophy; Microdiscectomy; Herniated disc; Low-back pain
In this study, we compared the paramedian interfascial approach (PIA) and the traditional midline approach (MA) for lumbar fusion to determine which approach resulted in the least amount of postoperative back muscle atrophy. We performed unilateral transforaminal posterior lumbar interbody fusion via MA on the symptomatic side and pedicle screw fixation via PIA on the other side in the same patient. We evaluated the damage to the paraspinal muscle after MA and PIA by measuring the preoperative and postoperative paraspinal muscle volume in 26 patients. The preoperative and postoperative cross-sectional area, thickness, and width of the multifidus muscle were measured by computed tomography. The degree of postoperative paraspinal muscle atrophy was significantly greater on the MA side than on the contralateral PIA side (-20.7% and -4.8%, respectively, p<0.01). In conclusion, the PIA for lumbar fusion yielded successful outcomes for the preservation of paraspinal muscle in these 26 patients. We suggest that the success of PIA is due to less manipulation and retraction of the paraspinal muscle and further studies on this technique may help confirm whether less muscle injury has positive effects on the long-term clinical outcome.
Paraspinal Muscle; Paramedian Approach; Muscle Atrophy; Lumbar Spine
In Duchenne muscular dystrophy (DMD), the muscular degeneration often leads to the development of scoliosis. Our objective was to investigate how anatomical changes in back muscles can lead to scoliosis. Muscular volume and the level of fat infiltration in those muscles were thus evaluated, in non-scoliotic, pre-scoliotic and scoliotic patients. The overlying skin thickness over the apex level of scoliotic deformations was also measured to facilitate the interpretation of electromyographic signals when recorded on the skin surface.
In 8 DMD patients and two healthy controls with no known muscular deficiencies, magnetic resonance imaging (MRI) was used to measure continuously at 3 mm intervals the distribution of the erector spinae (ES) muscle in the T8-L4 region as well as fat infiltration in the muscle and overlying skin thickness: four patients were non-scoliotic (NS), two were pre-scoliotic (PS, Cobb angle < 15°) and two were scoliotic (S, Cobb angle ≥ 15°). For each subject, 63 images 3 mm thick of the ES muscle were obtained in the T8-L4 region on both sides of the spine. The pixel dimension was 0.39 × 0.39 mm. With a commercial software, on each 12 bits image, the ES contour on the left and on the right sides of the spine were manually determined as well as those of its constituents i.e., the iliocostalis (IL), the longissimus (LO) and the spinalis (SP) muscles. Following this segmentation, the surfaces within the contours were determined, the muscles volume were obtained, the amount of fat infiltration inside each muscle was evaluated and the overlying skin thickness measured.
The volume of the ES muscle of our S and PS patients was found smaller on the convex side relative to the concave one by 5.3 ± 0.7% and 2.8 ± 0.2% respectively. For the 4 NS patients, the volume difference of this muscle between right and left sides was 2.1 ± 1.5% and for the 2 controls, it was 1.4 ± 1.2%. Fat infiltration for the S and the PS patients was larger on the convex side than on the concave one (4.4 ± 1.6% and 4.5 ± 0.7% respectively) and the difference was more important near the apex. Infiltration was more important in the lateral IL muscle than in the medial SP and it was always larger near L2 than at any other spinal level. Fat infiltration was much more important in the ES for the DMD patients (49.9% ± 1.6%) than for the two controls (2.6 ± 0.8%). As for the overlying skin thickness measured near the deformity of the patients, it was larger on the concave than on the convex side: 14.8 ± 6.1 vs 13.5 ± 5.7 mm for the S and 10.3 ± 6.3 vs 9.8 ± 5.6 mm for the PS.
In DMD patients, our results indicate that a larger replacement of muscles fibers by fat infiltration on one side of the spine is a factor that can lead to the development of scoliosis. Efforts to slow such an infiltration on the most affected side of the spine could thus be beneficial to those patients by delaying the apparition of the scoliotic deformation. In addition to anatomical considerations, results obtained from the same patients but in experiments dealing with electromyography recordings, point to differences in the muscular contraction mechanisms and/or of the neural input to back muscles. This is similar to the adolescent idiopathic scoliosis (AIS) where a role of the nervous system in the development of the deformation has also been suggested.
To determine whether children with quadriplegic cerebral palsy (QCP) have a greater adipose tissue (AT) infiltration of skeletal muscle than typically developing children (12/group and 5–14 years).
Cross-sectional area (CSA) of AT and muscle in the midthigh were assessed with magnetic resonance imaging. Physical activity was assessed with an activity monitor.
Children with QCP had 2.3-fold higher intermuscular AT CSA and 51% lower muscle CSA in the midthigh than control subjects. Midthigh intermuscular, subfascial, and subcutaneous AT CSA adjusted for midthigh muscle CSA were higher in children with QCP (all P < .05). Moreover, the proportion of intermuscular AT CSA and subfascial AT CSA relative to subcutaneous AT CSA in the midthigh were 2.5-fold and 1.8-fold higher in children with QCP than control subjects (all P < .05). Children with QCP also had 70% fewer physical activity counts, which was inversely related to intermuscular AT CSA (r = −0.76) and subfascial AT CSA (r = −0.63) adjusted for muscle CSA in the midthigh of children with QCP (both P < 0.05), but not in control subjects.
Children with QCP have a greater AT infiltration of skeletal muscle than typically developing children, which is related to their low level of physical activity.
Because training of the lumbar muscles is a commonly recommended intervention in low back pain (LBP), it is important to clarify whether lumbar muscle atrophy is related to LBP. Fat infiltration seems to be a late stage of muscular degeneration, and can be measured in a non-invasive manner using magnetic resonance imaging. The purpose of this study was to investigate if fat infiltration in the lumbar multifidus muscles (LMM) is associated with LBP in adults and adolescents.
In total, 412 adults (40-year-olds) and 442 adolescents (13-year-olds) from the general Danish population participated in this cross-sectional cohort study. People with LBP were identified through questionnaires. Using MRI, fat infiltration of the LMM was visually graded as none, slight or severe. Odds ratios were calculated for both age groups, taking into account sex, body composition and leisure time physical activity for both groups, and physical workload (in adults only) or daily bicycling (in adolescents only).
Fat infiltration was noted in 81% of the adults but only 14% of the adolescents. In the adults, severe fat infiltration was strongly associated with ever having had LBP (OR 9.2; 95% CI 2.0–43.2), and with having LBP in the past year (OR 4.1; 1.5–11.2), but there was no such association in adolescents. None of the investigated moderating factors had an obvious effect on the OR in the adults.
Fat infiltration in the LMM is strongly associated with LBP in adults only. However, it will be necessary to quantify these measurements objectively and to investigate the direction of this link longitudinally in order to determine if the abnormal muscle is the cause of LBP or vice versa.
To contrast the efficacy of two exercise programs, segmental stabilization and strengthening of abdominal and trunk muscles, on pain, functional disability, and activation of the transversus abdominis muscle (TrA), in individuals with chronic low back pain.
Our sample consisted of 30 individuals, randomly assigned to one of two treatment groups: segmental stabilization, where exercises focused on the TrA and lumbar multifidus muscles, and superficial strengthening, where exercises focused on the rectus abdominis, abdominus obliquus internus, abdominus obliquus externus, and erector spinae. Groups were examined to discovere whether the exercises created contrasts regarding pain (visual analogical scale and McGill pain questionnaire), functional disability (Oswestry disability questionnaire), and TrA muscle activation capacity (Pressure Biofeedback Unit = PBU). The program lasted 6 weeks, and 30‐minute sessions occurred twice a week. Analysis of variance was used for inter‐ and intra‐group comparisons. The significance level was established at 5%.
As compared to baseline, both treatments were effective in relieving pain and improving disability (p<0.001). Those in the segmental stabilization group had significant gains for all variables when compared to the ST group (p<0.001), including TrA activation, where relative gains were 48.3% and ‐5.1%, respectively.
Both techniques lessened pain and reduced disability. Segmental stabilization is superior to superficial strengthening for all variables. Superficial strengthening does not improve TrA activation capacity.
Chronic Low Back Pain; Pressure Biofeedback Unit; Segmental Stabilization; Muscle Strength; Transversus Abdominis
Studies of EMG power spectra have established associations between low-back pain (LBP) and median frequency (MF). This 2-year prospective study investigates the association of LBP with EMG variables over time. 120 health care workers underwent paraspinal EMG measurements and assessment of back pain disability. The EMG recordings were performed under isometric trunk extension at 2/3 maximum voluntary contraction and acquired from erector spinae muscles at the level of L4/L5. 108 (90%) subjects were reviewed at a minimum 2-year follow up. 16 out of 93 subjects with no history of chronic low-back pain became worse as measured by time off work, disability, reported pain and self-assessment rating. The value of the EMG variable half-width at inception demonstrated significant association with changes in subject’s outcome measure and their own assessment of their LBP at follow up (p < 0.05). Based on self-assessment data, subjects with no history of chronic LBP with half-width of greater than 56 Hz were at threefold greater risk of developing back pain compared with the remainder of the population (p = 0.045). The value of the initial median frequency (IMF) and MF slope at inception were also associated with the subjects’ own assessment of LBP at follow up. Subjects with an IMF greater than 49 Hz were at 5.8-fold greater risk of developing back pain compared with the remainder of the population (p = 0.014). EMG variables recorded from lumbar paraspinal muscles can identify a sub group of subjects at increased risk of developing low-back pain in the future.
EMG; Low back pain; Paraspinal muscles; Prediction; Cohort study
The purpose of this study was to investigate the differentiation in muscle tissue characteristics and recruitment between the deep and superficial multifidus muscle by magnetic resonance imaging. The multifidus is a very complex muscle in which a superficial and deep component can be differentiated from an anatomical, biomechanical, histological and neuromotorial point of view. To date, the histological evidence is limited to low back pain patients undergoing surgery and cadavers. The multifidus muscles of 15 healthy subjects were investigated with muscle functional MRI. Images were taken under three different conditions: (1) rest, (2) activity without pain and (3) activity after experimentally induced low back muscle pain. The T2 relaxation time in rest and the shift in T2 relaxation time after activity were compared for the deep and superficial samples of the multifidus. At rest, the T2 relaxation time of the deep portion was significantly higher compared to the superficial portion. Following exercise, there was no significant difference in shift in T2 relaxation time between the deep and superficial portions, and in the pain or in the non-pain condition. In conclusion, this study demonstrates a higher T2 relaxation time in the deep portion, which supports the current assumption that the deep multifidus has a higher percentage of slow twitch fibers compared to the superficial multifidus. No differential recruitment has been found following trunk extension with and without pain induction. For further research, it would be interesting to investigate a clinical LBP population, using this non-invasive muscle functional MRI approach.
Multifidus muscle; Deep and superficial multifidus; Muscle functional magnetic resonance imaging; Muscle fiber type
Despite recognized evidence for the importance of the multifidus muscle in stabilizing the lumbar spine, identifying subjects at risk for injury and subsequent loss of intrinsic spinal stabilization remains difficult. Previous research has failed to associate multifidus muscle size and height, weight, or body mass index (BMI). The purpose of this study was to begin to establish normative data for the multifidus muscle cross-sectional area (CSA) at the L5 level and to identify factors associated with size. Twenty-five participants (17 female), with a mean age of 32.5 (SD 11.6) years without history of LBP were considered for inclusion. Participants' height and weight were recorded and BMI calculated. Ultrasound imaging was used to obtain a CSA in cm2 of the subjects' multifidus muscles at the L5 level bilaterally; testing was done by two trained testers. Prior to testing, intra- and inter-tester reliability were determined. Percent body fat was determined using a three-site skinfold caliper measurement, also using two trained testers. Mean BMI was 24.18 and mean body fat (%) was 22.88 for all participants. As expected, age and BMI were moderately correlated. Left and right multifidus muscle CSA were highly correlated (r = 0.92, p < 0.001). The mixed model ANOVA indicated a significant main effect for gender as males exhibited larger CSA than females. Participants without history of low back pain present with symmetrical multifidus muscle CSA at the L5 level. Clear gender differences in CSA show that males tend to have larger multifidus muscles at the L5 level, indicating a need to establish gender-specific norms for clinicians examining the L5 multifidus muscle.
Lumbar Spine; Multifidus; Sonography
Myolipoma is a rare, benign, lipomatous tumour which most commonly occurs in the retroperitoneum, pelvis, and abdomen. A 4-year-old boy presented with a painless enlarging mass in the left paraspinal region. Magnetic Resonance Imaging (MRI) revealed a soft tissue lesion with high fat content and areas of calcification. Excision and histopathological analysis revealed a tumour composed of lobules of mature adipose tissue and broad septa of well-differentiated smooth muscle tissue. The smooth muscle nature of the nonfatty component was demonstrated by a diffuse and strong immunoreactivity for smooth muscle actin and desmin. The mass was reported as a myolipoma. The patient made an unremarkable recovery from surgery and remains healthy with no signs of recurrence at seven years. This paper represents the youngest patient diagnosed with this rare soft tissue tumour which is normally confined to the adult population. A newly reported site of the tumour is also highlighted.
We set out to determine whether a minimally invasive approach for one-level instrumented posterior lumbar interbody fusion reduced undesirable changes in the multifidus muscle, compared to a conventional open approach. We also investigated associations between muscle injury during surgery (creatinine kinase levels), clinical outcome and changes in the multifidus at follow-up. We studied 59 patients treated by one team of surgeons at a single institution (minimally invasive approach in 28 and conventional open approach in 31, voluntarily chosen by patients). More than 1 year postoperatively, all the patients were followed up with the visual analogue scale (VAS) and Oswestry disability index (ODI), and 16 patients from each group were evaluated using MRI. This enabled the cross-sectional area (CSA) of lean multifidus muscle, and the T2 signal intensity ratio of multifidus to psoas muscle, to be compared at the operative and adjacent levels. The minimally invasive group had less postoperative back pain (P < 0.001) and lower postoperative ODI scores (P = 0.001). Multifidus atrophy was less in the minimally invasive group (P < 0.001), with mean reductions in CSA of 12.2% at the operative and 8.5% at the adjacent levels, compared to 36.8% and 29.3% in the conventional open group. The increase in the multifidus:psoas T2 signal intensity ratio was similarly less marked in the minimally invasive group where values increased by 10.6% at the operative and 8.3% at the adjacent levels, compared to 34.4 and 22.7% in the conventional open group (P < 0.001). These changes in multifidus CSA and T2 signal intensity ratio were significantly correlated with postoperative creatinine kinase levels, VAS scores and ODI scores (P < 0.01). The minimally invasive approach caused less change in multifidus, less postoperative back pain and functional disability than conventional open approach. Muscle damage during surgery was significantly correlated with long-term multifidus muscle atrophy and fatty infiltration. Furthermore these degenerative changes of multifidus were also significantly correlated with long-term clinical outcome.
Minimally invasive; Lumbar spine; Multifidus muscle; Interbody fusion
A 32-year-old African male presented with 10 hours of severe back pain. Initial computed tomography scan of the back showed no abnormality, and initial laboratory investigations were consistent with rhabdomyolysis. Despite stopping potential causative medications, aggressive intravenous hydration, and urine alkalinization, his creatinine kinase continued to steadily climb. Thirty-six hours after admission, a magnetic resonance imaging of his back was done because of new swelling over the right paraspinal muscles and loss of sensation in this region. Marked swelling of the right erector spinae muscles was observed, and right and left compartment pressure measurements were 108 and 21 mm Hg, respectively. He had urgent fasciotomy after which his rhabdomyolysis and pain recovered.
Our case highlights the need for early consideration of compartment syndrome as a possible cause of back pain in the setting of rhabdomyolysis. Rhabdomyolysis can present in the absence of late complications such as neurological and vascular compromise.
occult compartment syndrome; nonresolving rhabdomyolysis; spinae muscles; fasciotomy; neurological and vascular compromise
Both the paraspinal muscle sparing approach and percutaneous screw fixation are less traumatic procedures in comparison with the conventional midline approach. These techniques have been used with the goal of reducing muscle injury. The purpose of this study was to evaluate and to compare the safety and efficacy of the paraspinal muscle sparing technique and percutaneous screw fixation for the treatment of L5-S1 spondylolisthesis.
Twenty patients who had undergone posterior lumbar interbody fusion (PLIF) at the L5-S1 segment for spondylolisthesis were prospectively studied. They were divided into two groups by screw fixation technique (Group I : paraspinal muscle sparing approach and Group II: percutaneous screw fixation). Clinical outcomes were assessed by Low Back Outcome Score (LBOS) and Visual Analogue Scale (VAS) for back and leg pain at different times after surgery. In addition, modified MacNab's grading criteria were used to assess subjective patients' outcomes 6 months after surgery. Postoperative midline surgical scarring, intraoperative blood loss, mean operation time, and procedure-related complications were analyzed.
Excellent or good results were observed in all patients in both groups 6 months after surgery. Patients in both groups showed marked improvement in terms of LBOSs all over time intervals. Postoperative midline surgical scarring and intraoperative blood loss were lower in Group II compared to Group I although these differences were not statistically significant. Low back pain (LBP) and leg pain in both groups also showed significant improvement when compared to preoperative scores. However, at 7 days and 1 month after surgery, patients in Group II had significantly better LBP scores compared to Group I.
In terms of LBP during the early postoperative period, patients who underwent percutaneous screw fixation showed better results compared to ones who underwent screw fixation via the paraspinal muscle sparing approach. Our results indicate that the percutaneous screw fixation procedure is the preferable minimally invasive technique for reducing LBP associated with L5-S1 spondylolisthesis.
Spondylolisthesis; Paraspinal muscle sparing approach; Percutaneous screw fixation; Back pain
Objectives: To investigate the trunk strength of elite rowers and the impact of low back pain on these measures in order to determine if asymmetries or weakness were present.
Methods: Twenty two elite rowers were recruited: 13 reported previous low back pain, five current low back pain, and the remainder had no history of low back pain. All subjects were scanned during simulated rowing in an interventional open magnetic resonance imaging scanner. In each simulated rowing position, axial scans were obtained at the level of the L4–5 and L5–S1 disc interspace to determine the cross sectional area of the posterior trunk muscles.
Results: Considerable differences were observed between the three groups of rowers. In contrast with expectations and previous literature, the trunk muscles of rowers with low back pain had significantly larger cross sectional areas (p<0.001). No left/right asymmetries were observed and no differences between oarside and non-oarside in terms of muscle cross sectional area.
Conclusion: These findings suggest that low back pain in rowers does not arise as a result of muscle weakness.
Cross-sectional study with repeated measures design.
To compare the myosin heavy chain isoform distribution within and between paraspinal muscles and to test the theory that fiber type gradients exist as a function of paraspinal muscle depth.
Summary of Background Data
There is still uncertainty regarding the fiber type distributions within different paraspinal muscles. It has been previously proposed that deep fibers of the multifidus muscle may contain a higher ratio of type I to type II fibers, because, unlike superficial fibers, they primarily stabilize the spine, and may therefore have relatively higher endurance. Using a minimally invasive surgical approach, utilizing tubular retractors that are placed within anatomic inter-muscular planes, it was feasible to obtain biopsies from the multifidus, longissimus, iliocostalis and psoas muscles at specific predefined depths.
Under an IRB approved protocol, muscle biopsies were obtained from 15 patients who underwent minimally invasive spinal surgery, using the posterior paramedian (Wiltse) approach or the minimally invasive lateral approach. Myosin heavy chain (MyHC) isoform distribution was analyzed using SDS-PAGE electrophoresis. Since multiple biopsies were obtained from each patient, MyHC distribution was compared using both within- and between-muscle repeated measures analyses.
The fiber type distribution was similar among the posterior paraspinal muscles and was composed of relatively high percentage of type I (63%), compared to type IIA (19%) and type IIX (18%) fibers. In contrast, the psoas muscle was found to contain a lower percentage of type I fibers (42%) and a higher percentage of type IIA (33%) and IIX fibers (26%; P<0.05). No significant difference was found for fiber type distribution among three different depths of the multifidus and psoas muscles.
Fiber type distribution between the posterior paraspinal muscles is consistent and is composed of relatively high percentage of type I fibers, consistent with a postural function. The psoas muscle, on the other hand, is composed of a higher percentage of type II fibers such as in the appendicular muscles. Our data do not support the idea of a fiber type gradient as a function of depth for any muscle studied.
Lumbar multifidus; Muscle mechanics; Lumbar spine
Paraspinal muscle fatigability during various trunk extension tests has been widely investigated by electromyography (EMG), and its task-dependency is established recently. Hip extensor muscle fatigability during the Sorensen test has been reported. The aim of the present experiments was to evaluate the task-dependency of back and hip extensor muscle fatigue during two variants of the Sorensen test. We hypothesized that the rate of muscular fatigue of the hip and back extensor muscles varies according to the test position. Twenty healthy young males with no history of low back pain volunteered to participate in this cross-sectional study. They were asked to perform two body weight-dependent isometric back extension tests (S1 = Sorensen test; S2 = modified Sorensen on a 45° Roman chair). Surface EMG activity of the paraspinal muscles (T10 and L5 levels) and hip extensor muscles (gluteus maximus; biceps femoris) was recorded, and muscular fatigue was assessed through power spectral analysis of the EMG data by calculating the rate of median power frequency change. We observed hip extensor muscle fatigue simultaneously with paraspinal muscle fatigue during both Sorensen variants. However, only L5 level EMG fatigue indices showed a task-dependency effect between S1 and S2. Hip extensor muscles appear to contribute to load sharing of the upper body mass during both Sorensen variants, but to a different extent because L5 level fatigue differs between the Sorensen variants. Our findings suggest that task-dependency has to be considered when EMG variables are compared between two types of lumbar muscle-fatiguing tasks.
Erector spinae; Hip extensors; Sorensen test; Muscle fatigability; Task-dependency
Findings on imaging of noncontractile anatomic abnormalities and the intensity of low back pain have weak associations because of false-positive rates among asymptomatic individuals. This association might be stronger for contractile tissues.
The purpose of this study was to examine the relationship between location and reports of pain intensity in the low back and exercise-induced muscle damage to the lumbar paraspinal muscles.
Nondiagnostic observational study in a laboratory setting.
Delayed onset muscle soreness was induced in the low back of healthy pain-free volunteers. Measures of pain intensity (100-mm visual analog scale [VAS]) and location (area on the pain diagram) were taken before and 48 hours after exercise. Muscle damage was quantified using mechanical pain thresholds, motor performance deficits, and transverse relaxation time (T2)–weighted magnetic resonance imaging (MRI). Changes pre- to postexercise in signal intensity on T2-weighted imaging within the erector spinae, pain intensity, pain area, mechanical pain threshold, and isometric torque were assessed using paired t tests. Bivariate correlations were conducted to assess associations among muscle damage, pain intensity, and pain drawing area.
Twenty participants volunteered (11 women; average age, 22.3 years; average body mass index, 23.5) for study participation. Reports of pain intensity at 48 hours ranged from 0 to 59 mm on the VAS. Muscle damage was confirmed by reductions in mechanical threshold (p=.011) and motor performance (p<.001) and by changes in T2-weighted MRI (p=.007). This study was powered to find an association of at least r=0.5 to be statistically significant. Correlations of continuous variables revealed no significant correlations between pain intensity and measures of muscle damage (ranging between −0.075 and 0.151). There was a significant association between the remaining torque deficit at 48 hours and pain area.
The results of this study indicate that there was no association between the magnitude of muscle damage in the lumbar erector spinae and reported pain intensity in the low back. In future studies, larger cohorts may report statistically significant associations, but our data suggest that there will be low magnitude potentially indicating limited clinical relevance.
Spinal disorders; Imaging; Referred pain