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Are “Patterns” of Lumbar Disc Degeneration Associated With Low Back Pain?: New Insights Based on Skipped Level Disc Pathology

Cheung, Kenneth M. C. MBBS, MD, FRCS, FHKCOS, FHKAM (Orth)*; Samartzis, Dino DSc*; Karppinen, Jaro MD, PhD; Luk, Keith D. K. MCh (Orth), FRCSE, FRCSG, FRACS, FHKAM (Orth)*

doi: 10.1097/BRS.0b013e3182304dfc
Clinical Case Series

Study Design. A cross-sectional, population-based cohort study.

Objective. The objective of this study was to evaluate the clinical relevance of skipped level disc degeneration (SLDD) to that of contiguous, multilevel disc degeneration (CMDD) of the lumbar spine. The study also aimed to identify patterns of SLDD, its classification, prevalence, and clinical relevance.

Summary of Background Data. The association of disc degeneration on magnetic resonance imaging with low back pain (LBP) remains questionable. The occurrence of SLDD of the lumbar spine has recently been noted. To date, patterns of disc degeneration have been overlooked in the association with low back symptoms.

Methods. A population-based radiographic and clinical study of 3099 Southern Chinese patients. Individuals with multilevel disc degeneration of the lumbar spine on sagittal T2-weighted magnetic resonance imaging (N = 1457) were stratified to SLDD (n = 301; 20.7%) or CMDD (n = 1156; 79.3%) groups. SLDD was further classified into 5 types by the relative location of nondegenerated normal disc(s) to degenerated disc levels. Subject demographics, presence of LBP, pain intensity, and functional disability were assessed.

Results. In the multivariate analyses, CMDD increased the likelihood of historical LBP (odds ratio [OR]: 1.39; 95% confidence interval [CI]: 1.00–1.93; P = 0.047) and pain severity (OR: 1.83; 95% CI: 1.23–2.73; P = 0.003) in comparison with SLDD. A significant increasing trend of number of levels with disc degeneration, overall disc degeneration severity, and presence of disc bulges/extrusions was noted from SLDD type I (least severe) to SLDD type V (most severe) (P < 0.05). A higher prevalence of LBP and a higher pain intensity were observed in SLDD classification type V. Functional disability scores did not differ between CMDD and SLDD, nor within SLDD classification types (P > 0.05).

Conclusion. Our large-scale study is the first to describe novel variants of SLDD types and their clinical relevance. More important, LBP and severity of pain were more pronounced in individuals with CMDD rather than those with SLDD. Our study suggests that subjects with a similar degree but different patterns of multilevel disc degeneration do differ with respect to low back symptoms. This finding may provide new evidence with regard to the mechanism of LBP.

In a radiographic and clinical population-based study of 3099 Southern Chinese, contiguous multilevel disc degeneration significantly increased the likelihood of historical low back pain and severity of pain in comparison with skipped level disc degeneration (SLDD). Five SLDD classification types were identified and evaluated.

*Department of Orthopaedics and Traumatology, University of Hong Kong, Hong Kong, SAR, China

Institute of Clinical Sciences, Department of Physical and Rehabilitation Medicine, University of Oulu, Oulu, Finland.

Address correspondence and reprint requests to Keith D. K. Luk, MCh (Orth), FRCSE, FRCSG, FRACS, FHKAM (Orth), Deptartment of Orthopaedics and Traumatology, 5/F Professorial Block, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, SAR China; E-mail:

The first 2 authors (Cheung and Samartzis) contributed equally to this work and are joint first authors.

Acknowledgment date: October 15, 2010. First revision date: March 30, 2011. Acceptance date: May 16, 2011.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Area of Excellence Program of Hong Kong funds were received to support this work.

No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

© 2012 Lippincott Williams & Wilkins, Inc.