|Year : 2021 | Volume
| Issue : 2 | Page : 67-71
Demographic profile of the patients with lumbar disc herniation presented in a tertiary care center, Manipur
Jungindro Singh Ningthoujam1, Ajit Singh Naorem1, Shugeta Devi Ningthoukhongjam2
1 Department of Physical Medicine and Rehabilitation, J N Institute of Medical Sciences, Imphal, Manipur, India
2 Department of Community Medicine, J N Institute of Medical Sciences, Imphal, Manipur, India
|Date of Submission||18-Aug-2021|
|Date of Acceptance||21-Aug-2021|
|Date of Web Publication||27-Nov-2021|
Jungindro Singh Ningthoujam
Department of Physical Medicine and Rehabilitation, J N Institute of Medical Sciences, Imphal, Manipur
Source of Support: None, Conflict of Interest: None
Background: Lumbar intervertebral disc herniation presents with a wide variety of demographic profiles among the patients of various regions. Depending on the regional factors such as environmental, socioeconomic and genetic factors, the demography may vary.
Objectives: This study aimed to observe the demographic profile of patients with lumbar disc herniation and to find the association and correlation among the different variables.
Materials and Methods: It is a cross-sectional study. Descriptive analysis was performed for parameters such as age, weight, height, and body mass index (BMI). Chi-square test was performed to see the association of different variables. A Spearman's regression analysis was performed to see any correlation between the quantitative variables. Results were evaluated with a confidence interval of 95% and significance level at P < 0.05.
Results: We had 348 patients with a mean age of 52.49 (±13.34) years, out of which 194 (55.7%) were female. Visual analog scale score ≥7 was found in 194 (55.7%) patients. Of the patients, 228 (65.5%) were overweight and 40 (11.5%) were obese with a mean BMI of 26.99 (±2.61). In the physical activity, 159 (45.7%) fall in heavy group, 135 (38.8%) moderate, and 54 (15.5%) in light activity groups. L4L5 (183, 52.6%) and L5S1 (133, 38.2%) were the most common site of prolapsed. Grade 6 disc degeneration was the most common (101, 29.0%) followed by Grade 7 (96, 27.6%) and Grade 5 (77, 22.1%). 2ab was the most common pattern of prolapsed with 22.4%.
Conclusion: Disc herniation is more common among females and in the middle age group. Overweight or obese people are at more risk of disc degeneration. L4L5 and L5S1 are the most common level of prolapse. Grades 6 and 7 of disc degeneration are more symptomatic and are associated with advancing age. Posterolateral disc herniation is the most common type and people engaged with heavy physical activities are at higher risk of disc degeneration.
Keywords: Disc degeneration, disc herniation, physical activity
|How to cite this article:|
Ningthoujam JS, Naorem AS, Ningthoukhongjam SD. Demographic profile of the patients with lumbar disc herniation presented in a tertiary care center, Manipur. J Med Soc 2021;35:67-71
|How to cite this URL:|
Ningthoujam JS, Naorem AS, Ningthoukhongjam SD. Demographic profile of the patients with lumbar disc herniation presented in a tertiary care center, Manipur. J Med Soc [serial online] 2021 [cited 2022 Aug 15];35:67-71. Available from: https://www.jmedsoc.org/text.asp?2021/35/2/67/331336
| Introduction|| |
Low back pain is one of the most common musculoskeletal complaints presented to a treating physician, with an estimated lifetime prevalence of 54%–59% in India. Of all the low back pains, the incidence of back pain with radicular symptoms ranges from 12% to 40%. There are various causes of back pain with radiculopathy, of which herniated disc is the most common cause. The demographic profile of these patients differs from region to region due to certain factors such as genetic factor, environmental factors, working culture, and socio-economic status. With changing time, and as the world population ages, the presenting age of back pain vary. Different studies show different gender predominance.,,, The relation of the low back pain or lumbar disc degeneration with the activity level of the patients also varies. Some studies show positive and some negative correlation.,,, Due to all these variables, we performed the study to give an idea of the demography of the patients with lumbar disc herniation, locally and to find the association and correlation among the different variables
| Materials and Methods|| |
Our study is a cross-sectional study, conducted in a tertiary care center. The data are taken on the patients' first visit and magnetic resonance imaging (MRI) reports as available. We included both male and female patients of all age groups with prolapsed lumbar intervertebral disc, confirmed both clinically and with MRI. These patients are those who attended as outpatient or admitted inward for intervention during the period of July 2018 to June 2020. Only those patients who had taken MRI of the lumbosacral spine region were included. Patients who had already undergone any form of surgery of the lumbar spine were not included in the study. All patients satisfying the inclusion and exclusion criteria were taken for the study.
The sagittal and transverse plane T-2 weighted sequences were used to grade the level of disc degeneration and site of prolapse. The Modified Pfirrmann Grading System (MPG) with a good inter- and intraobserver agreement was used to assess the degree of disc degeneration. For assessing the site of prolapse, the Michigan State University (MSU) classification was used. For our study purpose, MPG is divided into two groups, one with less severe (grade <6) and the other more severe (grade ≥6). In case of multiple level disc prolapsed, the level with the most severe degree of prolapsed and that correlates with clinical findings is taken. Similarly, for multiple-level disc degeneration, the one with the most degenerated disc is taken.
Height, body weight, and age of the patients were recorded. Body mass index (BMI) is calculated and classified into normal, overweight, and obese according to the WHO classification. The physical activity level of the patients was classified as mild, moderate, and heavy depending on the nature of work they are engaged in most of the time. People with desk jobs, students, and teachers are classified into mild group. Health-care workers, drivers, and housewives are grouped in moderate physical activity groups. Farmers, carpenters, masons, army personals, sports personals, and patients having similar works are grouped in heavy physical activity. The side (left or right) of the radicular pain is noted at the time of presentation. The intensity of the pain is assessed using visual analog scale (VAS) as reported by the patient. Considering the ease of patient response, we take ≥7 as severe and <7 as moderate pain.
Descriptive analysis was performed for parameters such as age, weight, height, and BMI and frequency tables for qualitative variables. Pearson Chi-square test was performed to see the association of different variables such as age, disc degeneration, pain score, and BMI. A Spearman's regression analysis was performed to see any correlation between quantitative variables such as physical activity and disc degeneration. Results were evaluated with a confidence interval of 95% and significance level at P < 0.05. Data were analyzed using IBM SPSS software version 22 (IBM corp., Armonk, NY).
| Results|| |
Altogether, data for 348 patients were collected in 2 years' duration, of which 194 (55.7%) were female with a mean age of 52.49 (±13.34) years and median age of 52 year, ranging from 18 to 82 years [Figure 1]. One hundred and ninety-one (54.9%) patients presented with radicular pain on left lower limb, 147 (42.2%) on right lower limb, and 10 (2.9%) on both sides. A little more than half, i.e. 194 (55.7%), presented with VAS score ≥7. Majority of the patients, 228 (65.5%), were overweight and 40 (11.5%) were obese with a mean BMI of 26.99 (±2.61). Heavy activity group had 159 (45.7%) patients, moderate 135 (38.8%), and 54 (15.5%) in light activity groups. L4L5 (183, 52.6%) and L5S1 (133, 38.2%) were the common levels of disc herniation. These variables with frequency data are summarized in [Figure 2].
Grade 6 disc degeneration was the most common (101, 29.0%) followed by Grade 7 (96, 27.6%) and Grade 5 (77, 22.1%), [Figure 3]. In the MSU classification of the patients, 2ab was the most common pattern of prolapsed with 22.4% and 1ab was the least common pattern with 1.7%. The whole distribution pattern is depicted in [Figure 4].
On performing Chi-square test, significant association (P < 0.05) was present between age with disc degeneration and pain score with disc degeneration, but an insignificant association between BMI with pain score and BMI with disc degeneration. A Spearman's regression analysis was performed which shows a statistically significant positive correlation between physical activity and disc degeneration (P < 0.05, P = 0.600).
| Discussion|| |
Various studies have shown variation in gender distribution regarding the lumbar disc herniation. Some studies show male predominance and in some, female.,,, In our study, we record a higher incidence in female with 55.7%. The age distribution range in our study is more or less similar to the findings available in literature, ranging from 18 to 82 years, but the mean age of presentation is little older than what was found in other studies. In most of the findings in the literature, the mean age ranges from 34.7 to 45 years or below 50 years.,, In our study, the mean age of the patients is 52.49 (±13.34) years. More commonly, patients present radicular pain on the left lower limb comprising 54.9% of the total study population which is more or less similar to the findings of Delen et al., though in their study they calculated the side from MRI findings, we record as per patients' report. Some few patients, 2.9%, reported having symptoms on both sides of the lower limb with more pain on one side. In literature, there is no clear-cut demarcation of VAS score to differentiate between moderate and severe pain. Depending on the statistical methods used, it is 5.8 or 6.5 or 7.5. In our study, 55.7% of patients reported of having severe pain (VAS ≥7).
Among patients with normal BMI, patients having MPG ≥6 is 58.2%, among patients with overweight BMI is 65.8%, and among obese patients is 77.5%. Even though there is a gradual increase level of disc degeneration with increasing BMI, statistically, we could not find a significant association between the two (P = 0.111) unlike many other studies where overweight or obese is a strong determinant of disc degeneration of the lumbar spine., BMI also does not have any association with the degree of pain (P = 0.531), i.e., people with overweight or obese not necessarily experience more pain or vice versa.
The most frequent levels of disc prolapsed or disc degeneration occur at L4L5 and L5S1 which are 52.6% and 38.2% of the study population, respectively. This is as par with the findings of many studies in the literature.,,, There is a significant association of disc degeneration with pain score (P = 0.003) which means patients with higher MPG grade (≥6) shall experience more pain (VAS ≥7). Among the study population, MPG Grades 6 and 7 were the major groups, 29.0% and 27.6%, respectively, followed by Grade 5 (22.1%), 4 (11.8%), and 8 (8.9%). From this, we take the inference that Grades 6 and 7 are more symptomatic than Grade 8 even though is of higher grade but need further study with larger sample size and more focus on degeneration and symptom presentation. With age, disc degeneration shows a significant association (P = 0.000) showing that disc degeneration increases with advancing age.
MSU classification, with interexaminer reliability of 98%, helps us to document the precise site of disc prolapsed, objectively. We find that the most common site of disc herniation is 2ab (22.4%), followed by 2b (12.6%) and 1bc (11.8%) which is similar to the findings of Mysliwiec et al. These sites are the posterolateral aspect of the disc which is relatively weaker part of the disc due to thinner annulus fibrosus and lack of structural support from the posterior longitudinal ligaments. The intensity of physical activity and its impact on disc degeneration has many conflicting results. There are reports with positive correlations and also with insignificant associations. Delen et al. reported a positive correlation between disc pathology and physical activity. In our study, we also found a significant positive correlation between physical activity and disc degeneration (P < 0.05, P = 0.600), showing that people engaged with heavy physical activities are prone to develop more severe disc degeneration. Macedo and Battié in a meta-analysis and review of literatures reported a modest association of occupational loading and disc degeneration. Studies with contradictory results are also reported. A study by Maurer et al. reported that people with less physical activity are more prone to develop disc degeneration. They concluded that physical inactivity has a strong correlation with disc degeneration. Topuz et al. in support of the idea that physically inactive have more chance of disc degeneration try to explain with the principle of “Adaptive remodeling.” Lack of exercise leads to tissue weakening, and these weakened spinal tissues are vulnerable to injury. In view of these conflicting reports, more studies in relation to physical activity and disc degeneration are warranted.
| Conclusion|| |
Disc herniation is more common among females and in the middle age group. Left side is slightly commoner than the right side. Even though statistically not significant, overweight or obese peoples are at more risk of disc degeneration. L4L5 and L5S1 are the most common level of prolapse. Grades 6 and 7 of disc degeneration are more symptomatic and are associated with advancing age. Posterolateral disc herniation is the most common type and people engaged with heavy physical activities are at higher risk of disc degeneration.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bansal D, Asrar MM, Ghai B, Pushpendra D. Prevalence and impact of low back pain in a community-based population in Northern India. Pain Physician 2020;23:E389-98.
Alexander CE, Varacallo M. Lumbosacral radiculopathy. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2021.
Kaplan W, Wirtz VJ, Mantel-Teeuwisse A, Stolk P, Duthey B, Laing R. Priority Medicines for Europe and the World-2013 Update. 20 Avenue Appia, 1211 Geneva 27, Switzerland: WHO Library Cataloguing-in-Publication Data; 2013. p. 165-8.
Topuz K, Eroglu A, Simsek H, Atabey C, Cetinkal A, Colak A. Demographical aspects of central large lumbar disc herniation. Turk Neurosurg 2016;26:111-8.
Al Shurbaji A, Said A, Al Qroom R, Salam ZA. Surgery for lumbar disc herniation, demographic data and analysis of complications at King Hussein Medical City. JRMS 2017;24:55-8.
Ongeti KW, Ogeng'o J, Gakuu LN, Saidi H, Pulei A. Prolapsed intervertebral disc in an African population: Kenyan experience. EAOJ 2012;6:12-5.
Ma D, Liang Y, Wang D, Liu Z, Zhang W, Ma T, et al
. Trend of the incidence of lumbar disc herniation: Decreasing with aging in the elderly. Clin Interv Aging 2013;8:1047-50.
Delen E, Akinci AT, Tutunculer B, Memis M, Kunduracilar NM, Sahin S. Demographic characteristic of 796 patients operated for lumbar disc herniation in Thrace region, Turkey. J Clin Anal Med 2016;7:585-8.
Macedo LG, Battié MC. The association between occupational loading and spine degeneration on imaging – A systematic review and meta-analysis. BMC Musculoskelet Disord 2019;20:1-15.
Maurer E, Klinger C, Lorbeer R, Rathmann W, Peters A, Schlett CL, et al
. Long-term effect of physical inactivity on thoracic and lumbar disc degeneration-an MRI-based analysis of 385 individuals from the general population. Spine J 2020;20:1386-96.
Griffith JF, Wang YX, Antonio GE, Choi KC, Yu A, Ahuja AT, et al
. Modified pfirrmann grading system for lumbar intervertebral disc degeneration. Spine 2007;32:E708-12.
Kuppuswamy S, George JC, Chemmanam M. Prevalence of lumbar disc herniation and disc degeneration in asymptomatic Indian subject: An MRI based study. IJOS 2017;3:357-60.
Boonstra AM, Preuper HR, Balk GA, Stewart RE. Cut-off points for mild, moderate and severe pain on the visual analogue scale for pain in patients with chronic musculoskeletal pain. Pain 2014;155:2545-50.
Samartzis D, Karppinen J, Chan D, Luk KD, Cheung MM. The association of lumbar intervertebral disc degeneration on magnetic resonance imaging with body mass index in overweight and obese adults. A population-based study. Arthritis Rheum 2012;64:1488-96.
Sheng B, Feng C, Zhang D, Spitler H, Shi L. Associations between obesity and spinal diseases: A medical expenditure panel study analysis. Int J Environ Res Public Health 2017;183:1-11.
Mysliwiec LW, Cholewicki J, Winkelpleck MD, Eis GP. MSU classification for herniated lumbar discs on MRI: Toward developing objective criteria for surgical selection. Eur Spine J 2010;19:1087-93.
Dydyk AM, Massa RN, Mesfin FB. Disc herniation. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2021.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]