Title: Prevalence，Distribution Characteristic and Risk Factors of Lumbar Vertebral Axial rotation in Patients with Lumbar Disc Herniation：A Retrospective Study

doi:10.21203/rs.3.rs-2757022/v1

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Title: Prevalence，Distribution Characteristic and Risk Factors of Lumbar Vertebral Axial rotation in Patients with Lumbar Disc Herniation：A Retrospective Study

https://doi.org/10.21203/rs.3.rs-2757022/v1

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published 04 Apr, 2024

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Disc herniation have shown confirmed biomechanical influence on close neighboring vertebrae but the impact on distant neighboring vertebrae remains unknown. After matching age and gender at a single site, we retrospectively evaluated 516 patients with lumbar disc herniation(LDH group)and an equal number of healthy people༈Control group༉to determine the effect of disc herniation on vertebral axial rotation (VAR) in lumbar spine, and explore potential risk factors for VAR in patients with (LDH). Each lumbar spine vertebra's degree of axial rotation was evaluated using the Nash-Moe index. The prevalence of VAR of lumbar spine is greater in LDH group than in Control group (65.7% vs 46.7%, P༜0.001). L2 vertebra in LDH group had the highest frequency of VAR (49.5%), followed by L1(45.1%), and from L3 to L5༈33.6%,8.9%,3.1%༉. The Control group also displayed a similar pattern (L2,39.8%; L1,34.6%; L3,23.2%; L4,3.1%; L5,0.8%). Disc herniation was associated with a higher incidence of VAR in both close and distant neighboring vertebrae. Multivariate analysis showed that age is an independent risk factor for VAR, (OR = 1.245, 95% CI [1.111,1.394], P༜0.001), while symptoms duration and back pain not.

Health sciences/Anatomy

Health sciences/Diseases

Health sciences/Medical research

Health sciences/Risk factors

Health sciences/Signs and symptoms

vertebral axial rotation (VAR)

lumbar disc herniation (LDH)

range of motion (ROM)

lumbar spine

Nash-Moe

Spinal biomechanics

Vertebral axial rotation (VAR) is one of the most crucial factors in evaluation of spinal stability¹. According to several studies^2–6, VAR plays a crucial role in lumbar degenerative disease such as degenerative lumbar scoliosis (DLS) and lumbar disc herniation (LDH). In DLS, the VAR of apex got the greatest attention, and its significance has been thoroughly investigated. The VAR of apex was a key risk factor for the curve progression, and associated with the degree of pain and disability^7–9. Moreover, planning surgical strategies and instrument placement need a preoperative assessment of AVR of apex ^10,11.

Another spinal degenerative illness with a high incidence rate and seriously affects quality of life is LDH¹². Researchers have attempted to investigate the relationship between VAR and disc degeneration, and they have found some information to a certain extent. Their research suggested that disc herniation might be facilitated by intervertebral axial rotation by increasing the strain on the annular fiber ^13,14. Other researchers, in turn, examined how disc formation affected lumbar kinematics, particularly the range of motion (ROM), using a variety of methodologies. Mimura et al. ¹⁵ found that in axial rotation, ROM increased with disc degeneration. They carried out a biomechanical test to examine the flexibility of 47 discs from 12 whole lumbar spine specimens without preload. In a larger sample of 110 lumbar motion segments from 44 human lumbar spines, Fujiwara et al. ¹⁶ applied moment ranging from 0 to 6.6 Nm. According to their findings, both males and females had more axial rotational motion due to disc degeneration. In addition, a study with a sizable data set supported the notion that intervertebral disc degeneration is associated with a trend of decreasing axial rotation stability¹⁷. Despite the results being nearly consistent, it is important to recognize the limitations of their studies. First of all, there were relatively scarce in vivo investigations; instead, all of the above studies relied on ex vivo assessment. Additionally, the probable alterations of the distant neighboring vertebrae were unclear as these investigations only examined the VAR of the involved degenerative motion segments.

We carried out a retrospective study to provide a more thorough and better knowledge of the VAR of the lumbar spine in patients with LDH. In this research, we assessed VAR using X-ray films and attempted to determine how disc herniation affected distant neighboring vertebrae. In general, the main purpose was to identify the general features of VAR in the lumbar spine in patients with LDH, and the secondary purpose was to investigate any possible clinically relevant factors for VAR in LDH.

We retrospectively identified 2564 inpatients with LDH from L4-S1 and 2590 outpatients during the period of March 2011 and September 2021. After age and gender matched, there were 516 subjects in each group (LDH group and Control group). Between the two groups, there were no differences in demographic and clinical characteristics (Table 1). Both the inter-observer(kappa = 0.85, P༜0.001) and intra-observer (kappa = 0.96, P༜0.001) variability in this research demonstrated excellent consistency.

Table 1

Demographic data and clinical characteristics
	LDH group(n = 516)	Control group(n = 516)	P Value
Age(years)	52.22 ± 11.72	52.22 ± 11.72	1
Gender, n (%)			1
Male	308(59.7)	308(59.7)
Female	208(40.3)	208(40.3)
BMI (kg/m²)	23.88 ± 3.47	24.34 ± 6.45	0.18
Comorbidity
Hypertension	85	72	0.29
Diabetes	28	19	0.23
Osteoporosis	116	92	0.07
Others	86	78	0.55
Level of disc herniation
L4/5	263	-	-
L5/S1	148	-	-
L4/S1	105	-	-
BMI, Body Mass Index

Prevalence of VAR in lumbar spine

The total prevalence of VAR in the entire lumbar spine was 65.7% in LDH group and 46.7% in Control group, which showed a significant difference (P༜0.001). When comparing the prevalence of VAR at each lumbar level, LDH group was significantly higher than Control group (L1, 49.8% vs 34.5%,P༜0.001; L2, 54.7% vs 39.5%,P༜0.001; L3, 37.2% vs 23.3%,P༜0.001; L4, 10.7% vs 3.5%,P༜0.001; L5, 3.5% vs 0.8%,P = 0.03). And, it showed that either in close or distant neighboring vertebrae, the prevalence of VAR was significantly higher in LDH group than Control group.

According to our findings, the prevalence of VAR was not significantly different between males and females in the LDH group (Total, 65.6% vs 65.9%, P = 0.947; L1, 49.7% vs 50.0%, P = 0.942; L2, 55.5% vs 53.4%, P = 0.63; L3, 36.7% vs 38.0%, P = 0.766; L4, 10.7% vs 10.6%, P = 0.96; L5, 3.3% vs 3.9%, P = 0.716). Similarly, there was no evidence of a gender difference in the Control group (Total, 45.8% vs 48.1%, P = 0.608; L1, 33.4% vs 36.1%, P = 0.54; L2, 39.3% vs 40.4%, P = 0.802; L3, 21.8% vs 25.5%, P = 0.326; L4, 3.9% vs 2.9%, P = 0.539; L5, 0% vs 1.9%, P = 0.608).

Distribution characteristic of VAR in lumbar spine

By measuring of the entire lumbar vertebral rotation, we found that in LDH group, the L2 vertebra had the highest prevalence of VAR (49.5%), followed by L1(45.1%), and from L3 to L5, the prevalence decreased gradually(33.6%,8.9%,3.1%). The Control group also noticed a similar tendency (L2,39.8%; L1,34.6%; L3,23.2%; L4,3.1%; L5,0.8%) (Fig. 1a).

The subgroup analysis showed that when the disc herniation occurred at L4-L5 segment, the difference of VAR is significant in each lumbar vertebra from L1 to L5(P༜0.05) ( Fig. 1b). When the disc herniation occurred at L5-S1, the difference is evident in L2, L3, L4, L5, but not in L1 (Fig. 1c). When the disc herniation occurred at L4-S1, the difference is significant in L1, L2 and L3, but not in L4 and L5 (Fig. 1d). It appeared that disc herniation was not only associated with increased prevalence of VAR in close neighboring vertebrae, but also in distant neighboring vertebrae.

Table 2 displayed a thorough comparison of VAR in various segments of disc herniation. There is no significant difference of VAR in either entire lumbar spine or close neighboring vertebrae among the subgroups. Yet, distant neighboring vertebrae showed a significant difference of VAR. L5-S1 subgroup displayed lower prevalence of VAR compared with L4-L5 subgroup (35.41% vs 47.53%, P = 0.015) or L4-S1 subgroup (35.41% vs 52.07%, P = 0.006); while the difference between L4-L5 subgroup and L4-S1 subgroup were not statistical (47.53% vs 52.07%, P = 0.4).

Table 2

Subgroup analysis of lumbar vertebral axial rotation at different disc herniation segment
	L4/5 (n = 263)	L5/S1 (n = 148)	L4/S1 (n = 105)	P value	P value (L4/5 vs L5/S1)	P value (L5/S1 vs L4/S1)	P value (L4/5 vs L4/S1)
Total ✝	409(31.10%)	216(29.19%)	176(33.52%)	0.766	0.653	0.468	0.689
Close neighboring vertebrae✝	34(6.46%)	8 (5.41%)	12 (5.71%)	0.901	0.666	0.916	0.789
Distant neighboring vertebrae✝	375(47.53%)	208(35.41%)	164(52.07%)	0.012*	0.015^#	0.006^#	0.400
✝,the number and percent of vertebrae axial rotation; *,P value༜0.05; The pairwise comparison among these three subgroups was performed by Tukey’s post hoc test, and corrected α was 0.017 ; #, P value༜0.017

The risk factors for VAR in patients with LDH

According to existence of VAR or not, the LDH group was divided into two groups (Rotation group and Non-rotation group). It indicated that each vertebra's Nash-Moe index in the Non-rotation group was 0. While in Rotation group, at least one vertebra was more than Nash-Moe grade 1. The results of univariate analysis revealed that mean age of Rotation group was significantly greater than Non-rotation group(P༜0.001).There was no significant difference in gender, BMI, status of smoking and drinking, and clinical medical comorbidities, with the exception of osteoporosis (P = 0.003). Moreover, there was no statistical difference in VAS back and symptom duration between two groups(Table 3). Age and osteoporosis were suggested to be two potential predicative variables for VAR. After stepwise forward logistic regression, the results showed that age is the only risk factor for VAR (OR = 1.245, 95%CI [1.111,1.394], P༜0.001).༈Table 4༉. In addition, ROC curve indicated that age is associated with incidence of VAR in patients with LDH(AUC = 0.589, cutoff point was 43.5 years)༈Fig. 2༉.

Table 3

Difference of characteristics in LDH group with and without VAR
	Rotation group(n = 265)	Non-rotation group(n = 251)	P value
Age, years✝	46.7(14.9)	42.3(13.7)	༜0.001*
Gender, n (%)			0.615
Male	133(50.2)	131(52.2)
Female	132(49.8)	120(47.8)
BMI, kg/m²✝	24.1(3.5)	23.7(3.4)	0.138
Hypertension	50	35	0.154
Diabetes	16	12	0.565
Osteoporosis	74	42	0.003*
Smoking	47	37	0.404
Drinking	17	16	0.985
VAS Back☨	4(3)	4(5)	0.076
Symptom duration☨	36(76)	24(54)	0.128
✝, mean and standard deviation; BMI, Body Mass Index; ☨,median and interquartile range; *, P༜0.05

Table 4

Multivariate logistic regression analysis of risk factors for vertebral axial rotation in patients with lumbar disc herniation
	OR	95% CI		P value
	OR	lower	upper	P value
Age, per year	1.022	1.011	1.034	༜0.001
OR, Odds ratio; CI, Confidence interval

VAR is a common phenomenon in lumbar degenerative disease and reflect the instability of motion segment in transverse plane. To some extent, previous studies have clarified the relationship between VAR and disc herniation in LDH. Notwithstanding their well-explained points, several issues remain unresolved. Thus, an in vivo investigation is crucial and required as a supplement.

In the current study, the total prevalence of VAR was determined in patients with LDH and healthy individuals (65.7% vs 46.7%,P༜0.001).Kouwenhoven et al. ¹⁸ used CT scans to analyze the VAR of 50 persons (mean age 33.3 years) with normal, nonscoliotic spine, and they found that in both males and females, vertebrae L1 to L5 have a rotation degree in the horizontal plane. Their results demonstrated pre-existent VAR in healthy individuals, and our findings offered new evidence to support this point. To assess the potential effect of disc herniation on VAR, various methods in measurement of ROM of intervertebral axial rotation and different classification systems in assessment of disc degeneration have been utilized. Mimura et al. and Fujiwara et al. took lumbar motion segments from human cadaveric and conducted biomechanical test with preload or not. Their findings consistently demonstrated that each lumbar segment's axial rotational motion was increased by disc degeneration ^15,16. Besides, several other biomechanical and imaging studies also showed positive correlations between Pfirrmann grade and axial rotation ROM^5,19,20. Moreover, research by Haughton and Krismer showed that the presence of an annulus fibrosus tear or a high-intensity zone (HIZ) causes significant axial rotation instability ^21,22. Our results indicated that compared to healthy people, LDH is associated with higher prevalence of VAR, which is consistent with the findings of the earlier research.

In this study, a trend of VAR distribution could be found in lumbar spine that the highest prevalence of VAR is located in L2 vertebra (49.5%), followed by L1(45.1%), and L3 to L5(33.6%,8.9%,3.1%). One argument was that L1 and L2 locate at the thoracolumbar junction and are not constrained by thoracic, muscle, or ligaments, hence, have a large ROM. In contrast, as the lumbar levels descend, stronger muscles and more ligaments are attached to the lower vertebra, improving their stability and minimizing movement. Besides, the facet joints in the upper lumbar segments of a normal spine are oriented more sagittally than those in the lower segments ²³. This special orientation enables upper segments to resist axial rotations more effectively²⁴, which could explain why the VAR of L2 is more common than L1.

Our findings, to our knowledge, firstly demonstrated that the disc herniation not only affects the close neighboring vertebrae, but also increase the VAR of distant neighboring vertebrae.We inferred that there is an underlying mechanism of force conduction in the lumbar spine. Reasons are as follows: firstly, despite varying segments of disc herniation, there was higher prevalence of VAR in distant neighboring vertebrae than that of healthy individuals. Additionally, when disc herniation occurred at L4-5 segment (L4-5 or L4-S1 subgroup), significant difference of VAR in distant neighboring vertebrae might reach L1 but only L2 when disc herniation involved the L5-S1 segment. Nevertheless, uncertainty exists in disc herniation involved double levels (L4-S1 segment), since the close neighboring vertebrae showed no difference with healthy individuals. Further related studies should be conducted to ascertain the potential reasons.

This study firstly explored the potential clinically relevant factors for VAR in LDH. Age is an independent risk factor for VAR, according to the results of multivariate logistic regression analysis (OR = 1.245, 95%CI [1.111,1.394], P༜0.001). This is in accordance with a previous systematic review and meta-analysis, which reported the ROM in axial rotation decline with aging²⁵. Osteoporosis is a prevalent disorder characterized by poor bone quality and has been shown to positively correlate with age²⁶. In the final model, osteoporosis was excluded due to the existence of multicollinearity. One notable result of our research is that VAS back and symptom duration are not relevant with the VAR in LDH. Previous investigators however, reported the contradictory results, they held the belief that vertebral axial rotational instability associated with low back pain (LBP). Using discography, Blankenbaker et al. measured axial rotation in sixteen patients with and without concordant pain. Their research showed L3–L4 and L4–L5 discs' axial rotation increased with concordant pain ²⁷. Basques et al. recruited ninety-nine volunteers (64 asymptomatic/35 LBP) and found that LBP was linked to greater axial rotation at the L4/L5 region²⁸. The fact that we looked at the VAR of the entire lumbar spine while they just focused on the intervertebral axial rotation of the close vertebrae involved in LBP might be one reason for the discrepancy.

There are several limitations of this study that should be acknowledged. First, Nash-Moe index used in our study was measured from plain radiographs of patients in the supine position, which did not fully reflect the VAR in other complicated mechanical environments. Second, the orientation of facet joints and paraspinal muscles may have an impact on VAR but not taken into consideration.

In summary, this preliminary study has determined a few issues of VAR in patients with LDH. From a holistic standpoint, the prevalence and characteristic distribution of VAR was assessed in the body. It has been established that disc herniation is linked to a greater prevalence of VAR in close and distant neighboring vertebrae. In addition, age should be given more consideration, since it is an independent risk factor for VAR in LDH. Last but not least, our research employed a different methodology than before and conducted more in-depth research, which would contribute to better understanding of VAR in LDH.

Patient population

This study was a retrospective case-control study. Inpatient with LDH who received underwent elective lumbar surgery were screened at single center from March 2011 to September 2021. The Ethics Committees of the Air Force Medical University approved this study. Inclusion criteria were as follows: (1) more than 18 years old, (2) MRI scanning showed single or double level herniation in L4-S1, (3) having preoperative anteroposterior radiographs of lumbar spine. Exclusion criteria were as follows: (1) patients with symptoms lasting less than 3 months, (2) those who have lumbar fracture, acute infections, active systemic infections, or infections at the surgical site (3) previous lumbar operation, (4) history of malignant tumors, (5) patients with low-quality preoperative X-ray images, lumbosacral transitional vertebrae, lumbar scoliosis, spondylolisthesis or spondylolysis.

The case-control group was comprised of contemporaneous healthy individuals from outpatient clinic. They all came for health examination and possessed anteroposterior radiographs of lumbar spine. To eliminate potential confounding factors, the subjects of LDH group and Control group were 1:1 matched by age and gender.

Demographic and Clinical Data Collection

The demographic data of the two groups includes sex, age, height, weight, smoking and drinking status, symptom duration, and medical comorbidities. Body mass Index (BMI) was computed according to height and weight, and other data were identified from the medical records. Moreover, data on the preoperative visual analogue scale (VAS) scores for low back pain (0–10) was also collected.

Radiographic Measurement

In plain films, the VAR of lumbar spine (L1-L5) was evaluated using the Nash–Moe index²⁹. Nash-Moe index not less than Grade 1 was defined as vertebral axial rotation (VAR), whereas Grade 0 was non-rotation. The VAR was measured by two independent observers (QSW and ZY) in a blinded fashion. If there was a discrepancy between the two readings, the senior observer's (ZY) judgment was deemed to be final. Weighted kappa values were used to calculate the inter-observer variability (the criteria for judging the consistency strength of a kappa coefficient as follows: 0.20, bad; 0.21–0.40, fair; 0.41–0.60, acceptable; 0.61–0.80, very good; and 0.81-1.00, excellent). The primary observer (QSW) evaluated VAR again after four weeks, and weighted kappa values of intra-observer variability were determined as previously mentioned.

Each lumbar level's prevalence of VAR was evaluated, and the total prevalence of the lumbar spine was estimated. To analyze the effect of disc herniation on VAR of vertebrae, we designated the close neighboring vertebrae as the closest upper and lower vertebrae of the disc, while the distant neighboring vertebrae referred to the other vertebrae of the lumbar spine. For instance, the close neighboring vertebrae in patients with disc herniation at L4-L5 or L4-S1 segment were L4 and L5, whereas the distant neighboring vertebrae were L1, L2 and L3 vertebrae. Patients with disc herniation at the L5-S1 segment had L5 as their close neighboring vertebrae, whereas L1, L2, L3, and L4 were their distant neighboring vertebrae.

Statistical analysis

All statistical analyses were done using Statistical Package for Social Sciences for Windows version 25.0(SPSS Company, USA). Age and BMI, which are continuous variables with a normal distribution, were expressed as mean ± SD, and VAS and symptom duration were given as median and interquartile spacing (IQR). The independent sample One-way analysis of variance (ANOVA) and nonparametric Mann–Whitney test were used to determine whether a statistically significant difference was present. LDH group was divided into three subgroups on the basis of segment of disc herniation. Tukey’s post hoc test was used for the pairwise comparison among these three subgroups. To analyze risk factors for VAR in LDH, multivariate logistical regression was performed by stepwise regression (Forward: LR). Receiver operating characteristic (ROC) of the curve was performed to assess the area under the curve (AUC) of age in relation to VAR.A P value less than 0.05 was regarded as statistically significant.

Acknowledgements

Not applicable.

Authors’ contributions

SZ and XH conceived the study and study design. ZY and QW collected and evaluated the data. PH, ZT, BY, YM and FX contributed to valuable proposal of data analysis and study design. ZL and ZW performed data analysis and data interpretation. SZ wrote the manuscript. XH revised the manuscript. All authors read and approved the final manuscript.

Data availability statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

No fund was received.

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Title: Prevalence，Distribution Characteristic and Risk Factors of Lumbar Vertebral Axial rotation in Patients with Lumbar Disc Herniation：A Retrospective Study

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Introduction

Result

Prevalence of VAR in lumbar spine

Distribution characteristic of VAR in lumbar spine

The risk factors for VAR in patients with LDH

Discussion

Materials And Methods

Patient population

Demographic and Clinical Data Collection

Radiographic Measurement

Statistical analysis

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1