European Spine Journal

, Volume 19, Issue 7, pp 1136–1144 | Cite as

Changes in paraspinal muscles and their association with low back pain and spinal degeneration: CT study

  • Leonid Kalichman
  • Paul Hodges
  • Ling Li
  • Ali Guermazi
  • David J. Hunter
Original Article


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 



This work was supported by the National Heart, Lung and Blood Institute’s Framingham Heart Study contract (No. N01-HC-25195) for the recruitment, enrollment, and examination of the Offspring and Third Generation Cohort and the imaging by computed tomography scan.

Conflict of interest statement

None of the authors have any conflict of interest regarding the contents of this article. L. K. is supported by an Arthritis Foundation Postdoctoral Grant. P. H. is supported by a Research Fellowship from the National Health and Medical Research Council of Australia.


  1. 1.
    Barker KL, Shamley DR, Jackson D (2004) Changes in the cross-sectional area of multifidus and psoas in patients with unilateral back pain: the relationship to pain and disability. Spine 29:E515–E519CrossRefPubMedGoogle Scholar
  2. 2.
    Bolender NF, Schonstrom NS, Spengler DM (1985) Role of computed tomography and myelography in the diagnosis of central spinal stenosis. J Bone Joint Surg Am 67:240–246PubMedGoogle Scholar
  3. 3.
    Bulcke JA, Termote JL, Palmers Y, Crolla D (1979) Computed tomography of the human skeletal muscular system. Neuroradiology 17:127–136PubMedGoogle Scholar
  4. 4.
    Cooper RG, St Clair Forbes W, Jayson MI (1992) Radiographic demonstration of paraspinal muscle wasting in patients with chronic low back pain. Br J Rheumatol 31:389–394CrossRefPubMedGoogle Scholar
  5. 5.
    Crisco JJ 3rd, Panjabi MM (1991) The intersegmental and multisegmental muscles of the lumbar spine. A biomechanical model comparing lateral stabilizing potential. Spine 16:793–799CrossRefPubMedGoogle Scholar
  6. 6.
    Danneels LA, Vanderstraeten GG, Cambier DC, Witvrouw EE, De Cuyper HJ (2000) CT imaging of trunk muscles in chronic low back pain patients and healthy control subjects. Eur Spine J 9:266–272CrossRefPubMedGoogle Scholar
  7. 7.
    Demoulin C, Crielaard JM, Vanderthommen M (2007) Spinal muscle evaluation in healthy individuals and low-back-pain patients: a literature review. Joint Bone Spine 74:9–13CrossRefPubMedGoogle Scholar
  8. 8.
    Dovrat E, Katz-Leurer M (2007) Cold exposure and low back pain in store workers in Israel. Am J Ind Med 50:626–631CrossRefPubMedGoogle Scholar
  9. 9.
    Elliott JM, Jull GA, Noteboom JT, Durbridge GL, Gibbon WW (2007) Magnetic resonance imaging study of cross-sectional area of the cervical extensor musculature in an asymptomatic cohort. Clin Anat 20:35–40CrossRefPubMedGoogle Scholar
  10. 10.
    Flicker PL, Fleckenstein JL, Ferry K, Payne J, Ward C, Mayer T, Parkey RW, Peshock RM (1993) Lumbar muscle usage in chronic low back pain. Magnetic resonance image evaluation. Spine 18:582–586CrossRefPubMedGoogle Scholar
  11. 11.
    Ghaffari M, Alipour A, Jensen I, Farshad AA, Vingard E (2006) Low back pain among Iranian industrial workers. Occup Med (Lond) 56:455–460CrossRefGoogle Scholar
  12. 12.
    Gibbons LE, Latikka P, Videman T, Manninen H, Battie MC (1997) The association of trunk muscle cross-sectional area and magnetic resonance image parameters with isokinetic and psychophysical lifting strength and static back muscle endurance in men. J Spinal Disord 10:398–403CrossRefPubMedGoogle Scholar
  13. 13.
    Grimby G, Saltin B (1983) The ageing muscle. Clin Physiol 3:209–218CrossRefPubMedGoogle Scholar
  14. 14.
    Hicks GE, Simonsick EM, Harris TB, Newman AB, Weiner DK, Nevitt MA, Tylavsky FA (2005) Cross-sectional associations between trunk muscle composition, back pain, and physical function in the health, aging and body composition study. J Gerontol A Biol Sci Med Sci 60:882–887PubMedGoogle Scholar
  15. 15.
    Hicks GE, Simonsick EM, Harris TB, Newman AB, Weiner DK, Nevitt MA, Tylavsky FA (2005) Trunk muscle composition as a predictor of reduced functional capacity in the health, aging and body composition study: the moderating role of back pain. J Gerontol A Biol Sci Med Sci 60:1420–1424PubMedGoogle Scholar
  16. 16.
    Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH (1994) Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine 19:165–172CrossRefPubMedGoogle Scholar
  17. 17.
    Hodges P, Holm AK, Hansson T, Holm S (2006) Rapid atrophy of the lumbar multifidus follows experimental disc or nerve root injury. Spine 31:2926–2933CrossRefPubMedGoogle Scholar
  18. 18.
    Hoffmann U, Siebert U, Bull-Stewart A, Achenbach S, Ferencik M, Moselewski F, Brady TJ, Massaro JM, O’Donnell CJ (2006) Evidence for lower variability of coronary artery calcium mineral mass measurements by multi-detector computed tomography in a community-based cohort-consequences for progression studies. Eur J Radiol 57:396–402CrossRefPubMedGoogle Scholar
  19. 19.
    Hultman G, Nordin M, Saraste H, Ohlsen H (1993) Body composition, endurance, strength, cross-sectional area, and density of MM erector spinae in men with and without low back pain. J Spinal Disord 6:114–123CrossRefPubMedGoogle Scholar
  20. 20.
    Hyun JK, Lee JY, Lee SJ, Jeon JY (2007) Asymmetric atrophy of multifidus muscle in patients with unilateral lumbosacral radiculopathy. Spine 32:E598–E602CrossRefPubMedGoogle Scholar
  21. 21.
    Jinkins JR (2003) Lumbosacral interspinous ligament rupture associated with acute intrinsic spinal muscle degeneration. JBR-BTR 86:226–230PubMedGoogle Scholar
  22. 22.
    Jones DA, Rutherford OM, Parker DF (1989) Physiological changes in skeletal muscle as a result of strength training. Q J Exp Physiol 74:233–256PubMedGoogle Scholar
  23. 23.
    Kader DF, Wardlaw D, Smith FW (2000) Correlation between the MRI changes in the lumbar multifidus muscles and leg pain. Clin Radiol 55:145–149CrossRefPubMedGoogle Scholar
  24. 24.
    Kalichman L, Cole R, Kim DH, Li L, Suri P, Guermazi A, Hunter DJ (2009) Spinal stenosis prevalence and association with symptoms: the Framingham Study. Spine J 9:545–550CrossRefPubMedGoogle Scholar
  25. 25.
    Kalichman L, Hunter D (2007) Lumbar facet joint osteoarthritis: a review. Semin Arthritis Rheum 37:69–80CrossRefPubMedGoogle Scholar
  26. 26.
    Kalichman L, Kim DH, Li L, Guermazi A, Berkin V, Hunter DJ (2009) Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine (Phila Pa 1976) 34:199–205Google Scholar
  27. 27.
    Kalichman L, Li L, Kim D, Guermazi A, Berkin V, O’Donnell C, Hoffmann U, Cole R, Hunter D (2008) Facet joint osteoarthritis and low back pain in the community-based population. Spine 33:2560–2565CrossRefPubMedGoogle Scholar
  28. 28.
    Keller A, Brox JI, Gunderson R, Holm I, Friis A, Reikeras O (2004) Trunk muscle strength, cross-sectional area, and density in patients with chronic low back pain randomized to lumbar fusion or cognitive intervention and exercises. Spine 29:3–8CrossRefPubMedGoogle Scholar
  29. 29.
    Keller A, Gunderson R, Reikeras O, Brox JI (2003) Reliability of computed tomography measurements of paraspinal muscle cross-sectional area and density in patients with chronic low back pain. Spine 28:1455–1460CrossRefPubMedGoogle Scholar
  30. 30.
    Keller A, Johansen JG, Hellesnes J, Brox JI (1999) Predictors of isokinetic back muscle strength in patients with low back pain. Spine 24:275–280CrossRefPubMedGoogle Scholar
  31. 31.
    Kelley DE, Slasky BS, Janosky J (1991) Skeletal muscle density: effects of obesity and non-insulin-dependent diabetes mellitus. Am J Clin Nutr 54:509–515PubMedGoogle Scholar
  32. 32.
    Kjaer P, Bendix T, Sorensen JS, Korsholm L, Leboeuf-Yde C (2007) Are MRI-defined fat infiltrations in the multifidus muscles associated with low back pain? BMC Med 5:2CrossRefPubMedGoogle Scholar
  33. 33.
    Kuorinka I, Jonsson B, Kilbom A, Vinterberg H, Biering-Sorensen F, Andersson G, Jorgensen K (1987) Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms. Appl Ergon 18:233–237CrossRefPubMedGoogle Scholar
  34. 34.
    Laasonen EM (1984) Atrophy of sacrospinal muscle groups in patients with chronic, diffusely radiating lumbar back pain. Neuroradiology 26:9–13CrossRefPubMedGoogle Scholar
  35. 35.
    Lexell J (1995) Human aging, muscle mass, and fiber type composition. J Gerontol A Biol Sci Med Sci 50 Spec No:11–16Google Scholar
  36. 36.
    Lexell J, Downham D (1992) What determines the muscle cross-sectional area? J Neurol Sci 111:113–114CrossRefPubMedGoogle Scholar
  37. 37.
    MacDonald DA, Moseley GL, Hodges PW (2006) The lumbar multifidus: does the evidence support clinical beliefs? Man Ther 11:254–263CrossRefPubMedGoogle Scholar
  38. 38.
    Macintosh JE, Bogduk N (1987) 1987 Volvo award in basic science. The morphology of the lumbar erector spinae. Spine 12:658–668CrossRefPubMedGoogle Scholar
  39. 39.
    Mannion AF, Kaser L, Weber E, Rhyner A, Dvorak J, Muntener M (2000) Influence of age and duration of symptoms on fibre type distribution and size of the back muscles in chronic low back pain patients. Eur Spine J 9:273–281CrossRefPubMedGoogle Scholar
  40. 40.
    Mayer TG, Vanharanta H, Gatchel RJ, Mooney V, Barnes D, Judge L, Smith S, Terry A (1989) Comparison of CT scan muscle measurements and isokinetic trunk strength in postoperative patients. Spine 14:33–36CrossRefPubMedGoogle Scholar
  41. 41.
    McLoughlin RF, D’Arcy EM, Brittain MM, Fitzgerald O, Masterson JB (1994) The significance of fat and muscle areas in the lumbar paraspinal space: a CT study. J Comput Assist Tomogr 18:275–278CrossRefPubMedGoogle Scholar
  42. 42.
    O’Sullivan PB, Phyty GD, Twomey LT, Allison GT (1997) Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 22:2959–2967CrossRefPubMedGoogle Scholar
  43. 43.
    Panjabi MM (2006) A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction. Eur Spine J 15:668–676CrossRefPubMedGoogle Scholar
  44. 44.
    Panjabi MM (1992) The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. J Spinal Disord 5:383–389 (Discussion 397)CrossRefPubMedGoogle Scholar
  45. 45.
    Parikh NI, Hwang SJ, Larson MG, Cupples LA, Fox CS, Manders ES, Murabito JM, Massaro JM, Hoffmann U, O’Donnell CJ (2007) Parental occurrence of premature cardiovascular disease predicts increased coronary artery and abdominal aortic calcification in the Framingham Offspring and Third Generation cohorts. Circulation 116:1473–1481CrossRefPubMedGoogle Scholar
  46. 46.
    Parkkola R, Kormano M (1992) Lumbar disc and back muscle degeneration on MRI: correlation to age and body mass. J Spinal Disord 5:86–92CrossRefPubMedGoogle Scholar
  47. 47.
    Parkkola R, Rytokoski U, Kormano M (1993) Magnetic resonance imaging of the discs and trunk muscles in patients with chronic low back pain and healthy control subjects. Spine 18:830–836CrossRefPubMedGoogle Scholar
  48. 48.
    Peltonen JE, Taimela S, Erkintalo M, Salminen JJ, Oksanen A, Kujala UM (1998) Back extensor and psoas muscle cross-sectional area, prior physical training, and trunk muscle strength—a longitudinal study in adolescent girls. Eur J Appl Physiol Occup Physiol 77:66–71CrossRefPubMedGoogle Scholar
  49. 49.
    Savage RA, Whitehouse GH, Roberts N (1997) The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J 6:106–114CrossRefPubMedGoogle Scholar
  50. 50.
    Sihvonen T, Herno A, Paljarvi L, Airaksinen O, Partanen J, Tapaninaho A (1993) Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine 18:575–581CrossRefPubMedGoogle Scholar
  51. 51.
    Sortland O, Magnaes B, Hauge T (1977) Functional myelography with metrizamide in the diagnosis of lumbar spinal stenosis. Acta Radiol Suppl 355:42–54PubMedGoogle Scholar
  52. 52.
    Storheim K, Holm I, Gunderson R, Brox JI, Bo K (2003) The effect of comprehensive group training on cross-sectional area, density, and strength of paraspinal muscles in patients sick-listed for subacute low back pain. J Spinal Disord Tech 16:271–279PubMedGoogle Scholar
  53. 53.
    Termote JL, Baert A, Crolla D, Palmers Y, Bulcke JA (1980) Computed tomography of the normal and pathologic muscular system. Radiology 137:439–444PubMedGoogle Scholar
  54. 54.
    Verbiest H (1979) The significance and principles of computerized axial tomography in idiopathic developmental stenosis of the bony lumbar vertebral canal. Spine 4:369–378CrossRefPubMedGoogle Scholar
  55. 55.
    Videman T, Battie MC, Gibbons LE, Maravilla K, Manninen H, Kaprio J (2003) Associations between back pain history and lumbar MRI findings. Spine 28:582–588CrossRefPubMedGoogle Scholar
  56. 56.
    Videman T, Battie MC, Ripatti S, Gill K, Manninen H, Kaprio J (2006) Determinants of the progression in lumbar degeneration: a 5-year follow-up study of adult male monozygotic twins. Spine 31:671–678CrossRefPubMedGoogle Scholar
  57. 57.
    Waddell G (1996) Low back pain: a twentieth century health care enigma. Spine 21:2820–2825CrossRefPubMedGoogle Scholar
  58. 58.
    Weishaupt D, Zanetti M, Boos N, Hodler J (1999) MR imaging and CT in osteoarthritis of the lumbar facet joints. Skeletal Radiol 28:215–219CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Leonid Kalichman
    • 1
    • 2
  • Paul Hodges
    • 3
  • Ling Li
    • 2
  • Ali Guermazi
    • 4
  • David J. Hunter
    • 1
    • 2
  1. 1.Boston University School of MedicineBostonUSA
  2. 2.Division of ResearchNew England Baptist HospitalBostonUSA
  3. 3.Centre of Clinical Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation SciencesThe University of QueenslandBrisbaneAustralia
  4. 4.Department of RadiologyBoston University School of MedicineBostonUSA

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