Association of impaired blood supply with painful lumbar disc degeneration

Mauno Kurunlahti

Department of Diagnostic Radiology, University of Oulu

Abstract

The purpose of this study was to evaluate the role of diminished arterial blood flow in painful disc degeneration.

Diffusion in intervertebral discs of 37 asymptomatic adults measured by magnetic resonance imaging (MRI) and their lumbar arterial blood supply measured by magnetic resonance angiography (MRA) correlated significantly.

End plate degeneration in intervertebral discs evaluated with MRI was analysed with reference to disc distress evaluated with computed tomography (CT) discography, and a significant correlation between end plate degeneration and disc degeneration was found among 36 low back pain patients. Intradiscal pain caused by discography did not correlate with end plate degeneration.

There were significantly more atheromatous plaques in the abdominal aorta among 29 chronic low back pain patients compared to 52 asymptomatic people, especially in the age group under 50 years.

Occlusion of lumbar arteries in MRA correlated significantly with disc degeneration in MRI among 113 sciatica patients. Furthermore, the disc degeneration and the occlusion of lumbar arteries were severe among 41 sciatica patients and 41 asymptomatic people.

During a three-year follow-up, the occlusion of lumbar arteries in MRA correlated significantly with physical and mental ability measured by a self-efficacy questionnaire at every assessment point (1,2,3 years). Furthermore, the intensity of back pain at 1 year and leg pain at 2 years correlated with the occlusion of lumbar arteries. Re-stenosis of lumbar arteries within 3 years correlated significantly with medical consultations for low back pain, prolonged low back pain and prolonged sciatica during one year before the baseline assessment.

Table of Contents
Acknowledgements
Abbreviations
List of original publications
1. Introduction
2. Review of the literature
2.1. Surroundings of the lumbar intervertebral disc
2.1.1. Anatomy of the lumbo-sacral region
2.1.2. Anatomy of the arteries supplying the disc area
2.1.3. Changes in lumbar artery anatomy and blood supply
2.2. Intervertebral disc
2.2.1. Structure and function
2.2.2. Nutrition and metabolism
2.2.3. Diffusion
2.3. Intradiscal changes
2.3.1. Age-related and pathologic disc changes
2.4. Low back pain and disc degeneration
2.4.1. Causes and mechanism of low back pain due to intradiscal changes
2.4.2. Determinants of low back pain and disc degeneration
2.5. Imaging of the intervertebral disc
2.5.1. Plain radiography
2.5.2. Discography
2.5.3. Computed tomography
2.5.4. Ultrasound imaging
2.5.5. Magnetic resonance imaging
2.6. Diffusion imaging
2.6.1. Diffusion imaging of the intervertebral disc
2.6.2. Diffusion-weighted MR imaging
2.7. Imaging of lumbar arteries
2.7.1. Angiography
2.7.2. CT arteriography
2.7.3. MRI angiography
3. Purpose of the study
4. Patients and methods
4.1. Study population
4.1.1. Low back pain patients (II,III)
4.1.2. Controls without low back pain (III) and volunteers(I)
4.1.3. Sciatica patients and controls (IV,V)
4.2. Imaging methods
4.2.1. CT discography(II,III)
4.2.2. Abdominal CT (III)
4.2.3. Magnetic resonance imaging
4.2.4. Statistical methods
5. Results
5.1. Correlation between diffusion in lumbar intervertebral discs and occlusion of lumbar arteries (I)
5.1.1. MRI and MRA findings in asymptomatic adults
5.1.2. Diffusion values of lumbar intervertebral discs compared with MRI and MRA findings
5.2. Association between end plate degeneration and disc degeneration and discogenic pain among chronic low back pain patients (II)
5.2.1. End plate degeneration in MRI compared with image findings in CT discography
5.2.2. Pain provocation in discography compared with end plate degeneration in MRI and disc degeneration in CT discography
5.3. Association of atherosclerosis in the distal abdominal aorta with low back pain and degree of disc degeneration (III)
5.3.1. Association of calcification in the abdominal aorta in CT and degree of disk degeneration in CT discography among chronic low back pain patients
5.3.2. Calcification in the abdominal aorta in CT in subjects with and without low back pain
5.4. Association between occlusion of lumbar arteries and intervertebral disc degeneration among patients with sciatica (IV)
5.4.1. Association between lumbar arteries in MRA and disc degeneration in MRI among sciatica patients (IV)
5.4.2. Occlusion of lumbar arteries observed in MRA and intervertebral disc degeneration observed in MRI of asymptomatic people compared to patients with low back pain and sciatica (IV)
5.5. Association between pain symptoms and occlusion of lumbar arteries among patients with sciatica at three-year follow-up (V)
6. Discussion
6.1. Study populations
6.2. Methods
6.3. Role of end plate degeneration in intradiscal changes among patients with low back pain (II)
6.4. Arterial findings, diffusion and disc degeneration among people without low back pain (I)
6.5. Arterial findings, disc degeneration and low back pain (III,IV,V)
7. Conclusions
References
List of Tables
1. Association between ADC values (mm2/s) and the status of the lumbar arteries at L1/2–L4/5
2. Association between ADC values (mm2/s) and disc degeneration at L1/2–L4/5
3. Correlation between end plate degeneration in MRI and disc degeneration in CT discography
4. Correlation between end plate degeneration in MRI and disc rupture in CT discography
5. Correlation between disc rupture and pain provocation in CT discography
6. Correlation between disc degeneration and pain provocation in CT discography
7. Correlation between end plate degeneration in MRI and pain provocation in CT discography
8. Atherosclerotic findings in cases and controls
9. Correlation of disc degeneration and status of lumbar arteries between volunteers and back pain patients
10. Association between stenosis of lumbar arteries and symptoms during three years
11. Association of new stenosis of the lumbar arteries with medical consultations and duration of LBP symptoms and sciatica
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