Low Back Pain and Lumbar Spine Osteoarthritis: How Are They Related?
Lumbar spine osteoarthritis (OA) is very common, with estimates of prevalence ranging from 40–85 %. The process of degeneration of the spine has commonly been classified as OA (disc space narrowing together with vertebral osteophyte formation); however, anatomically, the facet joint is the only synovial joint in the spine that has a similar pathological degenerative process to appendicular joints. Low back pain (LBP) is also a common condition, with nearly 80 % of Americans experiencing at least one episode of LBP in their lifetime. The complex relationship between spine radiographs and LBP has many clinical and research challenges. Specific conservative treatments for spine degeneration have not been established; there has, however, been recent interest in use of exercise therapy, because of some moderate benefits in treating chronic LBP. An understanding of the relationship between spine degeneration and LBP may be improved with further population-based research in the areas of genetics, biomarkers, and pain pathways.
KeywordsLow back pain Osteoarthritis Spine osteoarthritis Disc space narrowing Intervertebral disc degeneration Vertebral osteophytes Facet joint osteoarthritis Epidemiology Treatment Risk factors Prevalence Gender Race
Dr Goode is supported by the NIH Loan Repayment Program, the National Institute of Arthritis Musculoskeletal and Skin Diseases (1-L30-AR057661-01), and by the Agency for Health Care Research and Quality (AHRQ) K-12 Comparative Effectiveness Career Development Award grant number HS19479-01. The contents of this paper are solely the responsibility of the authors and do not necessarily represent the official views of the NIAMS or AHRQ.
The authors would like to thank Holly R. Thompson, BA, for her careful editing of the manuscript.
Dr Goode has received grant support from the Agency for Health Care Research and Quality. Dr Carey has served as a consultant for Blue Cross and the Blue Shield Association. Dr Jordan has received grant support from Johnson and Johnson, has received honoraria from LEK Consulting and Marston Consulting, holds stock options in Algynomics, and has had travel and/or accommodation expenses covered and/or reimbursed by the Osteoarthritis Research Society International and the Arthritis Foundation.
Paper of particular interest, published recently, have been highlighted as: • Of importance, •• Of major importance
- 5.Battie MC, Videman T, Parent E. Lumbar disc degeneration: epidemiology and genetic influences. Spine (Phila Pa 1976). 2004;29(23):2679–2690.Google Scholar
- 12.Weiner DK, Haggerty CL, Kritchevsky SB, Harris T, Simonsick EM, Nevitt M, et al. How does low back pain impact physical function in independent, well-functioning older adults? Evidence from the Health ABC Cohort and implications for the future. Pain Med. 2003;4(4):311–20.PubMedCrossRefGoogle Scholar
- 13.Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey. Spine (Phila Pa 1976). 1995;20(1):11–19.Google Scholar
- 16.Smith-Bindman R, Miglioretti DL, Larson EB. Rising use of diagnostic medical imaging in a large integrated health system. Health Aff (Millwood). 2008;27(6):1491–1502.Google Scholar
- 18.Carey TS, Freburger JK, Holmes GM, Castel L, Darter J, Agans R, et al. A long way to go: practice patterns and evidence in chronic low back pain care. Spine (Phila Pa 1976). 2009;34(7):718–724.Google Scholar
- 25.Antoniou J, Steffen T, Nelson F, Winterbottom N, Hollander AP, Poole RA, et al. The human lumbar intervertebral disc: evidence for changes in the biosynthesis and denaturation of the extracellular matrix with growth, maturation, ageing, and degeneration. J Clin Invest. 1996;98(4):996–1003.PubMedCrossRefGoogle Scholar
- 26.Menkes CJ, Lane NE. Are osteophytes good or bad? Osteoarthritis and cartilage 2004;12 Suppl A:S53–54.Google Scholar
- 30.• Suri P, Miyakoshi A, Hunter DJ, Jarvik JG, Rainville J, Guermazi A, et al. Does lumbar spinal degeneration begin with the anterior structures? A study of the observed epidemiology in a community-based population. BMC Musculoskelet Disord. 2011;12:202. This was an ancillary study using data from the Framingham Heart Study to determine if the anterior structures of the spine degenerate in sequence to the posterior structures of the spine. For most participants, anterior structure degeneration occurred before posterior; however, there were cases of posterior structure degeneration in isolation of anterior structures, suggesting that facet joint OA may occur without intervertebral disc degeneration. Google Scholar
- 32.•• Muraki S, Akune T, Oka H, Ishimoto Y, Nagata K, Yoshida M, et al. Incidence and risk factors for radiographic lumbar spondylosis and lower back pain in Japanese men and women: the ROAD study. Osteoarthritis Cartilage. 2012;20(7):712–718. This is one of few longitudinal studies aimed at determining the incidence of lumbar spondylosis changes and risk factors for progression. Findings from this study indicate an overall high proportion of Kellgren–Lawrence (K-L) graded lumbar spondylosis. The incidence of K-L ≥ 2 was greater among men, as was the progression of lumbar spondylosis. Severe K-L grade at baseline was significantly associated with the incidence of low back pain. Google Scholar
- 34.•• de Schepper EI, Damen J, van Meurs JB, Ginai AZ, Popham M, Hofman A, et al. The association between lumbar disc degeneration and low back pain: the influence of age, gender, and individual radiographic features. Spine (Phila Pa 1976). 2010;35(5):531–536. This is the largest population-based study describing the prevalence and associations with low back pain of individual radiographic features of disc space narrowing and vertebral osteophytes. Their findings indicate a significant association between disc space narrowing and vertebral osteophytes and low back pain. However, the associations with vertebral osteophytes were small and have not been replicated in other studies. This is also the first study to determine the relationship between spine radiographic features and physical function with some associations being stronger than with low back pain alone. Google Scholar
- 35.•• Goode A, Marshall, SW, Renner, JB, Carey, TS, Kraus, VB, Irwin, DE, Sturmer, T, Jordan, JM. Lumbar spine radiographic features and demographic, clinical and concomitant knee, hip and hand OA: The Johnston County Osteoarthritis Project [in press]. Arthritis Care Res. 2012. This is the only community-based study in the US of spine radiographic features and their relationship between hip, knee, and hand OA and low back symptoms. Only disc space narrowing was significantly associated with low back symptoms. Associations differed by appendicular joint OA with significant associations between facet joint OA and knee and hand OA, but no associations between disc space narrowing and knee or hand OA. No radiographic feature in the spine was associated with hip OA. This was also the first study to determine that associations between spine radiographic features differed by race. Google Scholar
- 38.Dionne CE, Dunn KM, Croft PR, Nachemson AL, Buchbinder R, Walker BF, et al. A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine (Phila Pa 1976). 2008;33(1):95–103.Google Scholar
- 40.•• Scheele J, de Schepper EI, van Meurs JB, Hofman A, Koes BW, Luijsterburg PA, et al. Association between spinal morning stiffness and lumbar disc degeneration: the Rotterdam Study. Osteoarthritis and cartilage 2012. This study is the first to describe the involvement of morning stiffness in combination with low back pain among those with spine degeneration. The associations between self reported morning stiffness in conjunction with low back symptoms were stronger than self reported low back pain alone. These findings are of particular importance because self-reported low back pain has only had modest associations with spine degeneration. Google Scholar
- 45.Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005(3):CD000335.Google Scholar
- 47.•• Sherman KJ, Cherkin DC, Wellman RD, Cook AJ, Hawkes RJ, Delaney K, et al. A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med. 2011;171(22):2019–2026. This randomized clinical trial examined stretching, yoga, and self-care books for primary care patients. Although not specific to spine degeneration, these findings indicate that yoga was more effective than self-care books but no more effective than stretching classes for the treatment of chronic low back pain. Both types of intervention resulted in improved symptoms and increased physical function with benefits lasting for several months. These results support several other reports that some exercise is better than no exercise for low back pain. Google Scholar
- 48.Karppinen J, Shen FH, Luk KD, Andersson GB, Cheung KM, Samartzis D. Management of degenerative disk disease and chronic low back pain. Orthop Clin North Am. 2011;42(4):513–528, viii.Google Scholar
- 54.Meulenbelt I, Kloppenburg M, Kroon HM, Houwing-Duistermaat JJ, Garnero P, Hellio Le Graverand MP, et al. Urinary CTX-II levels are associated with radiographic subtypes of osteoarthritis in hip, knee, hand, and facet joints in subject with familial osteoarthritis at multiple sites: the GARP study. Ann Rheum Dis. 2006;65(3):360–5.PubMedCrossRefGoogle Scholar
- 55.•• Goode A, Marshall, SW, Kraus, VB, Renner, JB, Sturmer, T, Carey, TS, Irwin, DE, Jordan, JM. Association between serum and urine biomarkers and individual radiographic features in the spine: The Johnston County Osteoarthritis Project [in press]. Osteoarthritis Cartilage. 2012. This study examined a broad range of urine and serum biomarkers and their associations with either disc space narrowing or vertebral osteophytes. Associations between biomarkers and disc space narrowing were stronger than association of biomarkers with vertebral osteophytes. This is the only study to compare a wide range of biomarkers among those with and without low back symptoms. Interestingly, serum COMP was significantly associated with disc space narrowing among those with low back symptoms but not among those without low back symptoms. Google Scholar
- 60.Kao PY, Chan D, Samartzis D, Sham PC, Song YQ. Genetics of lumbar disk degeneration: technology, study designs, and risk factors. Orthop Clin North Am. 2011;42(4):479–486, vii.Google Scholar
- 63.Goode A, Shi, XA, Renner, JR, Gracely, R, Maleki-Fischban, M, Jordan, JM. Association Between Pain Threshold, Symptoms and Radiographic Knee and Hip Osteoarthritis: The Johnston County Osteoarthritis Project [accepted abstract]. Arthritis Rheum. 2012.Google Scholar