Lumbosacral Transitional Vertebra-Related Low Back Pain: Resolving the Controversy.

STUDY DESIGN: Case control study. PURPOSE: The association of lumbosacral transitional vertebra (LSTV) with low back pain (LBP) is controversial, as is the role of occupational physical activity and radiological spinal abnormalities suggestive of other spinal disorders (OSDs) such as spinal degeneration and instability. This study aimed to determine if any association of LSTV with LBP exists. If so, the association of the level of physical activity and presence of OSD with LSTV-related LBP was determined. OVERVIEW OF LITERATURE: The cause of LBP has been linked to proximal level disc degeneration, arthritic pseudoarticulation between LSTV and the sacral ala, facet joint degeneration, and nerve root compression due to a broadened transverse process. LSTV associated with LBP is present among individuals who are involved in high-level physical activity, including military recruits and athletes. METHODS: This was an unmatched study comprising 372 cases and 224 controls consecutively recruited with clinical and radiographic documentation. The relationship between LSTV and LBP was analyzed, and the effects of LSTV and OSD on this relationship were also assessed and statistically controlled. RESULTS: The presence of LSTV (p =0.039) was significantly associated with LBP, and the presence of OSD was associated with LTSV-related LBP, after statistically controlling for the level of physical activity (p =0.024). The level of physical activity was not associated with LBP. Demographic analysis revealed female predominance with an advanced age (>45 years) among those with LSTV-related LBP who have OSD. CONCLUSIONS: The presence of LSTV was associated with an increased prevalence of LBP. This association was probably due to the confounding effect of OSD. The level of occupational physical activity was not associated with LSTV-related LBP. We speculate that advanced age and female sex caused the spurious association of LSTV with LBP in our study, rendering LSTV-related LBP controversial in published literature.

Adaptation of the Oswestry Disability Index to Kannada Language and Evaluation of Its Validity and Reliability.

STUDY DESIGN: A translation, cross-cultural adaptation, and validation study. OBJECTIVE: The aim of this study was to translate, adapt cross-culturally, and validate the Kannada version of the Oswestry Disability Index (ODI). SUMMARY OF BACKGROUND DATA: Low back pain is recognized as an important public health problem. Self-administered condition-specific questionnaires are important tools for assessing a patient. For low backache, the ODI is used widely. Preferred language of a region can have an effect on interpretation of questions and thus scoring. A search of literature showed no previously validated Kannada version of the ODI. METHODS: Cross-cultural adaptation and translation was carried out according to previously set guidelines. Patients were recruited from the orthopedic outpatient department. They filled out a booklet containing the Kannada version of the ODI, Kannada version of the Roland Morris Disability Questionnaire (RMDQ), and a 10-point visual analog scale for pain (VASpain). RESULTS: The Kannada ODI was answered by 91 patients and retested in 35 patients. After removing questionnaires with stray or ambiguous markings causing difficulty in computation of scores, 76 test questionnaires and 32 retest questionnaires were available for statistical analysis. The Kannada version showed an excellent internal consistency (Cronbach's alpha = 0.92). The Kannada version of the ODI showed good correlation with the RMDQ (r = 0.72) and moderate correlation with VASpain (r = 0.58). It also showed an excellent test-retest reliability (ICC = 0.96). Standard error of measurement (SEM) was also low (4.08) and a difference of 11 points is the "Minimum Detectable Change (MDC)." CONCLUSION: The Kannada version of the ODI that was developed showed consistency and reliability. It can be used for assessment of low back pain and treatment outcomes in Kannada-speaking populations. However, in view of a smaller sample size, it will benefit from verification at multiple centers and with more patients. LEVEL OF EVIDENCE: 3.

Digital tomosynthesis (DTS) for quantitative assessment of trabecular microstructure in human vertebral bone.

Digital tomosynthesis (DTS) provides slice images of an object using conventional radiographic methods with high in-plane resolution. The objective of this study was to explore the potential of DTS for describing microstructural, stiffness and stress distribution properties of vertebral cancellous bone. Forty vertebrae (T6, T8, T11, and L3) from 10 cadavers (63-90 years) were scanned using microCT and DTS. Anisotropy (µCT.DA), and the specimen-average and standard deviation of trabecular bone volume fraction (BV/TV), thickness (Tb.Th), number (Tb.N) and separation (Tb.Sp) were obtained using stereology. Apparent modulus (EFEM), and the magnitude (VMExp/σapp) and variability (VMCV) of trabecular stresses were calculated using microCT-based finite element modeling. Mean intercept length, line fraction deviation and fractal parameters were obtained from coronal DTS slices, then correlated with stereological and finite element parameters using linear regression models. Twenty-one DTS parameters (out of 27) correlated to BV/TV, Tb.Th, Tb.N, Tb.Sp and/or µCT.DA (p<0.0001-p<0.05). DTS parameters increased the explained variability in EFEM and VMCV (by 9-11% and 13-19%, respectively; p<0.0001-p<0.04) over that explained by BV/TV. In conclusion, DTS has potential for quantitative assessment of cancellous bone and may be used as a modality complementary to those measuring bone mass for assessing spinal fracture risk.

The assessment of neuronal status in normal and cervical spondylotic myelopathy using diffusion tensor imaging.

STUDY DESIGN: A prospective observational analysis of diffusion tensor imaging (DTI) datametrics collected from control and patients with cervical spondylotic myelopathy (CSM). OBJECTIVE: The aims were to study the use of DTI in CSM and to probe whether DTI datametrics and tractography will correlate with magnetic resonance imaging and clinical findings. SUMMARY OF BACKGROUND DATA: Magnetic resonance imaging is the current "gold standard" in the assessment of cord status in CSM; however, various parameters such as extent of compression and presence of signal intensity changes do not correlate well with clinical status. DTI is a novel investigation tool with proven applications in brain pathologies but is not routinely used in spinal cord evaluation. METHODS: Patients with CSM (n = 35) who required surgical decompression (mean age = 48 yr) and 40 normal individuals (mean age = 38 yr) were included. Diffusion Tensor Imaging of the cervical spine was obtained using a 1.5T magnetic resonance image. Apparent diffusion coefficient, fractional anisotropy, and eigenvalues (E1, E2, and E3) were obtained at each cervical level. The DTI datametrics of CSM patients were compared with normal volunteers and correlated with individual and grouped Nurick grades, which indicate the neurological status of patients. RESULTS: There was significant difference in DTI datametrics between patients with myelopathy and control (P < 0.05), with decrease in fractional anisotropy (0.49 ± 0.081 vs. 0.53 ± 0.07) and increase in apparent diffusion coefficient (1.8 ± 0.315 vs. 1.44 ± 0.145) and eigenvalues (E1: 2.82 ± 0.395 vs. 2.37 ± 0.221, E2: 1.64 ± 0.39 vs. 1.18 ± 0.198, E3: 0.956 ± 0.277 vs. 0.76 ± 0.142). There was also a significant difference between increasing grades of myelopathy when individuals were grouped as-control, self-ambulant (Nurick grades 1 and 2), and dependent (Nurick grades 3, 4, and 5). CONCLUSION: The study shows that DTI is a promising and useful investigational tool in evaluation of CSM. There was a significant difference in all DTI values between control and patients with CSM, and there was a significant trend of change in values between control, self-ambulant, and dependent patients. Our results encourage further investigation of this important modality. LEVEL OF EVIDENCE: 3.

Variability of trabecular microstructure is age-, gender-, race- and anatomic site-dependent and affects stiffness and stress distribution properties of human vertebral cancellous bone.

Cancellous bone microstructure is an important determinant of the mechanical integrity of vertebrae. The numerous microstructural parameters that have been studied extensively are generally represented as a single value obtained as an average over a sample. The range of the intra-sample variability of cancellous microstructure and its effect on the mechanical properties of bone are less well-understood. The objectives of this study were to investigate the extent to which human cancellous bone microstructure within a vertebra i) is related to bone modulus and stress distribution properties and ii) changes along with age, gender and locations thoracic 12 (T12) vs lumbar 1 (L1). Vertebrae were collected from 15 male (66±15 years) and 25 female (54±16 years) cadavers. Three dimensional finite element models were constructed using microcomputed tomography images of cylindrical specimens. Linear finite element models were used to estimate apparent modulus and stress in the cylinders during uniaxial compression. The intra-specimen mean, standard deviation (SD) and coefficient of variation (CV) of microstructural variables were calculated. Mixed model statistical analysis of the results demonstrated that increases in the intra-specimen variability of the microstructure contribute to increases in the variability of trabecular stresses and decreases in bone stiffness. These effects were independent from the contribution from intra-specimen average of the microstructure. Further, the effects of microstructural variability on bone stiffness and stress variability were not accounted for by connectivity and anisotropy. Microstructural variability properties (SD, CV) generally increased with age, were greater in females than in males and in T12 than in L1. Significant interactions were found between age, gender, vertebra and race. These interactions suggest that microstructural variability properties varied with age differently between genders, races and vertebral levels. The current results collectively demonstrate that microstructural variability has a significant effect on mechanical properties and tissue stress of human vertebral cancellous bone. Considering microstructural variability could improve the understanding of bone fragility and improve assessment of vertebral fracture risk.

Stiffness of the endplate boundary layer and endplate surface topography are associated with brittleness of human whole vertebral bodies.

Stress magnitude and variability as estimated from large scale finite element (FE) analyses have been associated with compressive strength of human vertebral cancellous cores but these relationships have not been explored for whole vertebral bodies. In this study, the objectives were to investigate the relationship of FE-calculated stress distribution parameters with experimentally determined strength, stiffness, and displacement based ductility measures in human whole vertebral bodies, investigate the effect of endplate loading conditions on vertebral stiffness, strength, and ductility and test the hypothesis that endplate topography affects vertebral ductility and stress distributions. Eighteen vertebral bodies (T6-L3 levels; 4 female and 5 male cadavers, aged 40-98 years) were scanned using a flat-panel CT system and followed with axial compression testing with Wood's metal as filler material to maintain flat boundaries between load plates and specimens. FE models were constructed using reconstructed CT images and filler material was added digitally. Two different FE models with different filler material modulus simulating Wood's metal and intervertebral disc (W-layer and D-layer models) were used. Element material modulus to cancellous bone was based on image gray value. Average, standard deviation, and coefficient of variation of von Mises stress in vertebral bone for W-layer and D-layer models and also the ratios of FE parameters from the two models (W/D) were calculated. Inferior and superior endplate surface topographical distribution parameters were calculated. Experimental stiffness, maximum load and work to fracture had the highest correlation with FE-calculated stiffness while experimental ductility measures had highest correlations with FE-calculated average von Mises stress and W-layer to D-layer stiffness ratio. Endplate topography of the vertebra was also associated with its structural ductility and the distribution parameter that best explained this association was kurtosis of inferior endplate topography. Our results indicate that endplate topography variations may provide insight into the mechanisms responsible for vertebral fractures.

Increased microstructural variability is associated with decreased structural strength but with increased measures of structural ductility in human vertebrae.

The lack of accuracy in the prediction of vertebral fracture risk from average density measurements, all external factors being equal, may not just be because bone mineral density (BMD) is less than a perfect surrogate for bone strength but also because strength alone may not be sufficient to fully characterize the structural failure of a vertebra. Apart from bone quantity, the regional variation of cancellous architecture would have a role in governing the mechanical properties of vertebrae. In this study, we estimated various microstructural parameters of the vertebral cancellous centrum based on stereological analysis. An earlier study indicated that within-vertebra variability, measured as the coefficient of variation (COV) of bone volume fraction (BV/TV) or as COV of finite element-estimated apparent modulus (E(FE)) correlated well with vertebral strength. Therefore, as an extension to our earlier study, we investigated (i) whether the relationships of vertebral strength found with COV of BV/TV and COV of E(FE) could be extended to the COV of other microstructural parameters and microcomputed tomography-estimated BMD and (ii) whether COV of microstructural parameters were associated with structural ductility measures. COV-based measures were more strongly associated with vertebral strength and ductility measures than average microstructural measures. Moreover, our results support a hypothesis that decreased microstructural variability, while associated with increased strength, may result in decreased structural toughness and ductility. The current findings suggest that variability-based measures could provide an improvement, as a supplement to clinical BMD, in screening for fracture risk through an improved prediction of bone strength and ductility. Further understanding of the biological mechanisms underlying microstructural variability may help develop new treatment strategies for improved structural ductility.

The associations between mineral crystallinity and the mechanical properties of human cortical bone.

It is well known that the amount of mineralization renders bone its stiffness. However, besides the mere amount of the mineral phase, size and shape of carbonated apatite crystals are postulated to affect the mechanical properties of bone tissue as predicted by composite mechanics models. Despite this predictive evidence, there is little experimental insight on the relation between the characteristics of mineral crystals and hard tissue mechanics. In this study, Raman spectroscopy was used to provide information on the crystallinity of bone's mineral phase, a parameter which is an overall indicator of mineral crystal size and stoichiometric perfection. Raman scans and mechanical tests (monotonic and fatigue; n=64 each) were performed on the anterior, medial, lateral and posterior quadrant sections of 16 human cadaveric femurs (52 y.o.-85 y.o.). The reported coefficient of determination values (R(2)) were adjusted for the effects of age to bring out the unbiased contribution of crystallinity. Crystallinity was able to explain 6.7% to 48.3% of the variation in monotonic mechanical properties. Results indicated that the tissue-level strength and stiffness increased with increasing crystallinity while the ductility reduced. Crystallinity explained 11.3% to 63.5% of the variation in fatigue properties. Moduli of specimens with greater crystallinity degraded at a slower rate and, also, they had longer fatigue lives. However, not every anatomical quadrant displayed these relationships. In conclusion, these results acknowledge crystal properties as an important bone quality factor and raise the possibility that aberrations in these properties may contribute to senile osteoporotic fractures.

The compositional and physicochemical homogeneity of male femoral cortex increases after the sixth decade.

The temporal and spatial fluctuations in the dynamics of secondary osteonal remodeling impart heterogeneity to the compositional quality of bone. Bone mineral density (BMD) fails to reflect this heterogeneity as being a single score, and thus it cannot resolve the overlap between healthy individuals and those who experience fractures. Such information on tissue heterogeneity is lacking in the literature. In the current study, specimens were prepared from mid-diaphyseal portions of human femora (N=16, age range 52-85 years old) and grouped based on the anatomical location (anterior, lateral, medial and posterior quadrants). Raman microscopy was used to obtain multiple measurements from each specimen which allowed the construction of histograms of mineralization, crystallinity and carbonation. The coefficient of variation (COV) and skewness were extracted from histograms as measures of heterogeneity. Results demonstrated that average mineralization of the medial quadrant and the data pooled over quadrants significantly increased with age. The mean carbonation increased within the observed age range for the pooled data. The variations of values about the mean became tighter for mineralization, crystallinity and type-B carbonation with age, indicating an overall reduction in compositional heterogeneity of aging femoral cortex. Skewness values indicated that the distributions of histograms were not Gaussian. We conclude that age-related changes in mean tissue composition are confounded with changes in the variation of tissue make-up about the mean. Future studies will establish as to whether compositional heterogeneity correlates with the mechanical strength of bone.

Microcracks colocalize within highly mineralized regions of cortical bone tissue.

While much work has been performed to quantify the extent of bone damage, its effects on the mechanical integrity of the tissue and its biological impact, the set of factors which gives forth to microdamage are nebulous, particularly the compositional properties local to microdamage. In this context, the current study tested the hypothesis that microcracks initiate within more mineralized regions of bone. Cortical bone specimens were taken from human male donors aged 31, 38, 53, 64, 71, and 84 years at the mid femoral diaphysis in a plane parallel to the osteonal orientation. The mineralization was assessed in a spatially resolved manner using Raman microspectroscopy. Arrays of measurements were taken over the entire area (i.e. global scans) of each sample followed by measurements in the vicinity of microcracks (i.e. local scans). Histograms of mineralization were constructed for global and local scans to determine whether the mineralization of damaged loci differed from the mean overall mineralization. Statistical analysis of this data revealed that the mean mineralization of damaged loci was significantly greater (P < 0.05) than the overall mineralization for each donor, indicating that there exists a highly-mineralized 'brittle volume' in bone. The presence of this damage prone 'brittle volume' has future implications for the assessment of fracture susceptibility.