PREVALENCE OF LUMBAR DEGENERATION GRADES BY GENDER AND AGE

COLOMBINI, MARCELA CASTRO; LIRA, REJELOS CHARLES AGUIAR; PRATALI, RAPHAEL DE REZENDE; PONTES, MARIANA DEMéTRIO DE SOUSA; HERRERO, CARLOS FERNANDO PEREIRA DA SILVA

doi:10.1590/S1808-185120242303289948

ABSTRACT

Objective: To report the prevalence of lumbar degenerative disease (LDD) according to a classification for LDD and correlate it with the gender and age of patients included in the study.

Methods: A sample of the Brazilian population registered in the database of a public tertiary hospital was used for retrospective analysis in this cross-sectional study. Radiographic examinations of patients included in the study were evaluated to identify and classify LDD. The demographic data collected were the age and gender of the patients.

Results: There was no statistical significance in the relationship between prevalence by gender and LDD degree classification. For age, there was significance only in older individuals with grades 1, 2, or 3, and it was impossible to observe the same relevance between the ages of patients with some degree of LDD. Grade 1 LDD was the most prevalent.

Conclusion: Elderly patients with some degree of LDD (1, 2, or 3) demonstrated a higher prevalence compared to those of younger age without signs of lumbar degenerative disease, and female patients were more prevalent in our sample. However, there was no statistical difference between genders. Level of Evidence IV; Cross-Sectional Study.

Keywords: Low Back Pain; Spine; Intervertebral Disc Degeneration

RESUMO

Objetivo: Informar la prevalencia de la enfermedad degenerativa lumbar (EDL) según una clasificación para EDL y correlacionarla con el sexo y la edad de los pacientes incluidos en el estudio.

Métodos: En este estudio transversal se utilizó una muestra de la población brasileña registrada en la base de datos de un hospital público terciario para el análisis retrospectivo. Se evaluaron exámenes radiográficos de los pacientes incluidos en el estudio para identificar y clasificar la EDL. Los datos demográficos recopilados fueron la edad y el sexo de los pacientes.

Resultados: No hubo significación estadística en la relación entre la prevalencia por género y la clasificación del grado de EDL. Para la edad hubo significación sólo en individuos mayores con grados 1, 2 o 3, y no fue posible observar la misma relevancia entre las edades de los pacientes con algún grado de EDL. El EDL de grado 1 fue el más prevalente.

Conclusión: Los pacientes ancianos con algún grado de EDL (1, 2 o 3) demostraron una mayor prevalencia en comparación con los de menor edad sin signos de enfermedad degenerativa lumbar, y los pacientes femeninos fueron más prevalentes en nuestra muestra. Sin embargo, no hubo diferencia estadística entre géneros. Nivel de Evidencia IV; Estudio Transversal.

Descritores: Dor lombar; Coluna vertebral; Degeneração do Disco Intervertebral

RESUMEN

Objetivo: Relatar a prevalência de doença degenerativa lombar (DDL) de acordo com uma classificação para DDL e correlacioná-la com o sexo e a idade dos pacientes incluídos no estudo.

Métodos: Uma amostra da população brasileira cadastrada no banco de dados de um hospital público terciário foi utilizada para análise retrospectiva neste estudo transversal. Os exames radiográficos dos pacientes incluídos no estudo foram avaliados para identificar e classificar a DDL. Os dados demográficos coletados foram idade e sexo dos pacientes.

Resultados: Não houve significância estatística na relação entre prevalência por sexo e classificação do grau de DDL. Para a idade, houve significância apenas nos indivíduos mais velhos com graus 1, 2 ou 3, não sendo possível observar a mesma relevância entre as idades dos pacientes com algum grau de DDL. DDL grau 1 foi o mais prevalente.

Conclusão: Pacientes idosos com algum grau de DDL (1, 2 ou 3) demonstraram maior prevalência em comparação com aqueles de idade mais jovem sem sinais de doença degenerativa lombar, e pacientes do sexo feminino foram mais prevalentes em nossa amostra. Contudo, não houve diferença estatística entre os sexos. Nível de Evidência IV; Estudo Transversal.

Descriptores: Dolor de la Región Lumbar; Columna Vertebral; Degeneración del Disco Intervertebral

INTRODUCTION

Chronic low back pain is a frequent complaint reported by the adult population. The condition’s symptoms are recurrent and may vary in intensity and duration.¹,² Among the risk factors that contribute to the development of chronic low back pain are obesity, smoking, depressive symptoms, and working with heavy weight.¹,³ Treatment can range from non-surgical treatments, such as pharmacological and physiotherapy, to the need for invasive surgical procedures.⁴

Systematic review studies have shown that low back pain has a higher prevalence in women and people aged between 40 and 80 years.⁵,⁶ Studies have also demonstrated a low prevalence in low-income and middle-income countries, suggesting a higher proportion of low back pain chronicity in these countries compared to high-income countries.⁵,⁶ At the national level, more than 50% of the adult population in Brazil is affected due to low back pain annually, while in adolescents, this percentage varies between 13.1% and 19.5%.⁵,⁶ On the other hand, in the Brazilian population, chronic low back pain has a prevalence of 4.2% to 14.7%, and there is little data regarding gender prevalence.⁷

Chronic low back pain can significantly affect the patient’s quality of life and daily activities, in addition to being associated with significant disability and absence from work.⁵ Elderly patients experience more significant functional deficits related to self-care and mobility.⁸ In contrast, younger patients experience difficulties using transport and participating in social and leisure activities.⁸

Among the leading causes of chronic low back pain are Degenerative Disc Disease (DDD) and the Adult Spinal Deformity (ASD) group of diseases, which together can be classified as Lumbar Degenerative Disease (LDD). LDD can be characterized by degenerative changes in the region of the lumbar intervertebral disc and is generally diagnosed through radiographic examinations.¹,⁹ Conversely, ASD is characterized by degenerative changes associated with spinopelvic sagittal malalignment, which can be identified on full-spine exams using angular and linear measurements previously described in the literature.¹⁰,¹¹ Furthermore, a recent study developed an LDD grading system, which presented excellent reproducibility for diagnosing and evaluating the disease. ¹²

Knowledge about lumbar degenerative disease, concerning its prevalence in terms of gender and age in the population and correlating with the classification of the degree of the disease, can contribute to future research in the area and a better understanding of the disease and its treatment. Therefore, this study aimed to highlight the prevalence of LDD and its classification, correlating it to the gender and age of the patients.

METHODS

The research is a cross-sectional study with retrospective analysis of the database of a tertiary hospital where the study was carried out. The study was approved by the Ethics and Research Committee of the Hospital under number CAAE: 9056420.7.0000.5463. All patients participating in the research received and signed an informed consent form approved by the Ethics Committee of the service responsible for the study.

Patients’ selection

The study’s inclusion criteria involved adult patients aged 18 or over who presented complaints associated with the spine (such as pain, functional disability, and deformity) and were submitted to radiographic evaluation, including full-spine x-rays in anteroposterior and lateral views that followed the protocol and characteristics required by the study.

Patients were excluded from the study if they had previous neurological or spinal surgery, diagnosis of neuromuscular and neurological diseases, functional disability in any joint of the lower limbs that could alter joint positions, history of trauma or neoplastic diseases in the spine, and absence of radiographic studies of the spine in an anteroposterior and lateral projection, allowing visualization from C2 to the femoral joint.

Radiographic evaluation

The evaluation of the radiographic exams of the patients included in the study and the identification and classification of lumbar degenerative disease was carried out by one of the researchers, who is an orthopedist specializing in the spine and has more than ten years of experience. Radiographic signs, including loss of height and collapse of the intervertebral disc, the presence of osteophytes, subchondral sclerosis, and signs of instability, such as spondylolisthesis, laterolisthesis or rotatory subluxation, determined the presence of LDD.¹³ Other additional examinations, carried out according to some patients’ needs and clinical conditions, were not included in the research. The presence and severity of LDD were recorded at four levels, following the classification system proposed by Vasconcelos and collaborators (Table 1).¹²

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Table 1
Radiographic Classification of Lumbar Degenerative Disease (LDD).

Demographic data

Study participants underwent assessments related to gender and age to investigate possible associations between these factors and the prevalence and radiographic severity of LDD.

Statistical analysis

The research tests were conducted using the RTM software in its 2021 version, with a significance level of 5%. The Shapiro-Francia Test examined the distribution of variables.

For gender analysis, patients were categorized into male and female, and the chi-square test (X²) was used to evaluate the relationship between the presence and severity of LDD in the categories mentioned above. For the age analysis, the ANOVA test was used to evaluate the relationship between this variable and the severity of LDD.

RESULTS

In total, 120 patients were selected for the study, 57 of which were excluded based on the determined exclusion criteria, totaling 63 participants. The reasons for excluding patients were one patient with a history of hip arthroplasty, two patients with a diagnosis of vertebral fractures, 13 patients with a history of spine surgery, and 41 patients with imaging tests that did not meet the criteria pre-established by the researchers.

Regarding the prevalence of LDD, 18 participants had LDD 0 (no signs of lumbar degenerative disease on their radiographs), and the remaining 45 had some degree of LDD (with 25 patients classified as LDD grade 1, 12 participants as LDD grade 2, and 8 participants in the LDD grade 3 classification). The percentage distribution is illustrated in Figure 1.

Figure 1
Prevalence of lumbar degenerative disease and distribution according to the LDD classification system.

Only 3 study participants did not document their gender, with the remaining 60 distributed as 39 (65%) female and 21 (35%) male. The analysis did not show statistical significance in the association between prevalence by gender and degree of LDD (p= 0.81; X²), as seen in Figure 2.

Figure 2
Gender distribution according to the LDD classification system.

Regarding the age variable, the analysis showed that individuals with grades 1, 2, or 3 of LDD were older compared to those who did not show signs of lumbar degenerative disease (LDD 0). Despite this significance, there was no significant difference between the ages of patients with some degree of LDD (LDD 1, LDD 2, and LDD 3), as demonstrated in Figure 3.

Figure 3
Age distribution according to the LDD classification system.

DISCUSSION

The present study was able to highlight and analyze the prevalence of lumbar degenerative disease in a representative sample of the Brazilian population, with patients who sought care at the outpatient clinic specialized in Spine of the Orthopedics Service of a public tertiary hospital. It also evaluated the relationship between the different LDD classifications and the gender and age of the patients.

Based on the research findings, it can be observed that most participants who seek care in a specialized spine surgery service also have some degree of LDD. This is in agreement with other studies that treat this disease as one of the leading causes of chronic low back pain.²,¹⁴ Our results showed that the predominant classification of LDD was grade 1.

The female gender showed a higher prevalence of the condition; however, our results showed no statistical significance of the association between prevalence by gender and degree of LDD. Previous studies have also demonstrated this higher prevalence of chronic low back pain in females³,¹⁵,¹⁶, a possible cause of this being the increased search for medical care by this group.

Older patients with some degree of LDD (1, 2, or 3) in our study also demonstrated a higher prevalence compared to those of younger age without signs of lumbar degenerative disease. However, there was no statistical significance between the age of participants with LDD and the different disease classifications. The systematic review by Brinjikji et al.¹⁵ showed that radiographic signs of degenerative disease in the spine are present in approximately 90% of the population aged 60 years or older. In most cases, individuals are asymptomatic, suggesting that such spinal changes are part of aging.

In the relationship between low back pain and advanced age, the muscular morphological change of the muscles that make up the supporting chain of the spine must also be considered. A cross-sectional study involving 468 participants, conducted by Jansen et al.¹⁷, showed a reduction in skeletal muscle mass throughout the body during aging. In the retrospective cross-sectional study by Huang et al.¹⁸, it was found that the cross-sectional area of the paravertebral muscles, psoas, erector spinae, and multifidus reduced considerably in older individuals who had LDD, which could be aggravating low back pain, LDD and quality of life of this population.

The present study has limitations that deserve mention. The first concerns the sample obtained from a tertiary-level service, which may lead to selection bias for more severe cases. This detail may explain our results since most patients involved in the study had some degree of LDD. Another weakness is the lack of clinical assessment of the patient through quality-of-life questionnaires, which could correlate imaging findings and the patient’s clinical condition. However, applying such a tool was not the focus of the study, suggesting the need for additional studies that can complement important information.

CONCLUSION

Our results highlighted the correlation between lumbar spine degeneration and the gender and age of the patients. Older patients with some degree of LDD (1, 2, or 3) demonstrated a higher prevalence compared to younger patients without signs of lumbar degenerative disease, and females were more prevalent in our sample but without statistical differences between genders.

Study conducted by the Hospital do Servidor Público Estadual de São Paulo.

REFERENCES

¹ Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017;389(10070):736-47.
² Knezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP. Low back pain. Lancet. 2021;398(10294):78-92.
³ Bento TPF, Genebra CVDS, Maciel NM, Cornelio GP, Simeão SFAP, Vitta A. Low back pain and some associated factors: is there any difference between genders?. Braz J Phys Ther. 2020;24(1):79-87.
⁴ Corp N, Mansell G, Stynes S, Wynne-Jones G, Morsø L, Hill JC, et al. Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines. Eur J Pain. 2021;25(2):275-95.
⁵ Andersson GB. Epidemiological features of chronic low-back pain. Lancet. 1999;354(9178):581-5.
⁶ Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012;64(6):2028-37.
⁷ Nascimento PR, Costa LO. Low back pain prevalence in Brazil: a systematic review. Cad Saude Publica. 2015;31(6):1141-56.
⁸ Fehrmann E, Kotulla S, Fischer L, Kienbacher T, Tuechler K, Mair P, et al. The impact of age and gender on the ICF-based assessment of chronic low back pain. Disabil Rehabil. 2019;41(10):1190-9.
⁹ Kos N, Gradisnik L, Velnar T. A Brief Review of the Degenerative Intervertebral Disc Disease. Med Arch. 2019;73(6):421-4.
¹⁰ Lafage V, Schwab F, Patel A, Hawkinson N, Farcy JP. Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine (Phila Pa 1976). 2009;34(17):E599-606.
¹¹ Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976). 2005;30(18):2024-9.
¹² Vasconcelos IT, Sant’Anna DA, Oliveira CEA, Herrero CFP, Pratali RR. Grading scale of lumbar degenerative disease in full spine x-ray. Coluna/Columna. 2019;18(1):32-6.
¹³ Berjano P, Lamartina C. Classification of degenerative segment disease in adults with deformity of the lumbar or thoracolumbar spine. Eur Spine J. 2014;23(9):1815-24.
¹⁴ Vigatto R, Alexandre NM, Correa Filho HR. Development of a Brazilian Portuguese version of the Oswestry Disability Index: cross-cultural adaptation, reliability, and validity. Spine (Phila Pa 1976). 2007;32(4):481-6.
¹⁵ Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-6.
¹⁶ Yang H, Haldeman S, Lu ML, Baker D. Low Back Pain Prevalence and Related Workplace Psychosocial Risk Factors: A Study Using Data From the 2010 National Health Interview Survey. J Manipulative Physiol Ther. 2016;39(7):459-72.
¹⁷ Janssen I, Heymsfield SB, Wang ZM, Ross R. Skeletal muscle mass and distribution in 468 men and women aged 18-88 yr [published correction appears in J Appl Physiol (1985) 2014;116(10):1342]. J Appl Physiol (1985). 2000;89(1):81-8.
¹⁸ Huang R, Pan F, Kong C, Lu S. Ageand sex-dependent differences in the morphology and composition of paraspinal muscles between subjects with and without lumbar degenerative diseases. BMC Musculoskelet Disord. 2022;23(1):734.

Edited by

Reviewed by:
Erasmo Abreu Zardo

Publication Dates

Publication in this collection
29 Nov 2024
Date of issue
2024

History

Received
01 Sept 2024
Accepted
02 Oct 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

[1] ¹ Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017;389(10070):736-47.

[2] ² Knezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP. Low back pain. Lancet. 2021;398(10294):78-92.

[3] ³ Bento TPF, Genebra CVDS, Maciel NM, Cornelio GP, Simeão SFAP, Vitta A. Low back pain and some associated factors: is there any difference between genders?. Braz J Phys Ther. 2020;24(1):79-87.

[4] ⁴ Corp N, Mansell G, Stynes S, Wynne-Jones G, Morsø L, Hill JC, et al. Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines. Eur J Pain. 2021;25(2):275-95.

[5] ⁵ Andersson GB. Epidemiological features of chronic low-back pain. Lancet. 1999;354(9178):581-5.

[6] ⁶ Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012;64(6):2028-37.

[7] ⁷ Nascimento PR, Costa LO. Low back pain prevalence in Brazil: a systematic review. Cad Saude Publica. 2015;31(6):1141-56.

[8] ⁸ Fehrmann E, Kotulla S, Fischer L, Kienbacher T, Tuechler K, Mair P, et al. The impact of age and gender on the ICF-based assessment of chronic low back pain. Disabil Rehabil. 2019;41(10):1190-9.

[9] ⁹ Kos N, Gradisnik L, Velnar T. A Brief Review of the Degenerative Intervertebral Disc Disease. Med Arch. 2019;73(6):421-4.

[10] ¹⁰ Lafage V, Schwab F, Patel A, Hawkinson N, Farcy JP. Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine (Phila Pa 1976). 2009;34(17):E599-606.

[11] ¹¹ Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976). 2005;30(18):2024-9.

[12] ¹² Vasconcelos IT, Sant’Anna DA, Oliveira CEA, Herrero CFP, Pratali RR. Grading scale of lumbar degenerative disease in full spine x-ray. Coluna/Columna. 2019;18(1):32-6.

[13] ¹³ Berjano P, Lamartina C. Classification of degenerative segment disease in adults with deformity of the lumbar or thoracolumbar spine. Eur Spine J. 2014;23(9):1815-24.

[14] ¹⁴ Vigatto R, Alexandre NM, Correa Filho HR. Development of a Brazilian Portuguese version of the Oswestry Disability Index: cross-cultural adaptation, reliability, and validity. Spine (Phila Pa 1976). 2007;32(4):481-6.

[15] ¹⁵ Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-6.

[16] ¹⁶ Yang H, Haldeman S, Lu ML, Baker D. Low Back Pain Prevalence and Related Workplace Psychosocial Risk Factors: A Study Using Data From the 2010 National Health Interview Survey. J Manipulative Physiol Ther. 2016;39(7):459-72.

[17] ¹⁷ Janssen I, Heymsfield SB, Wang ZM, Ross R. Skeletal muscle mass and distribution in 468 men and women aged 18-88 yr [published correction appears in J Appl Physiol (1985) 2014;116(10):1342]. J Appl Physiol (1985). 2000;89(1):81-8.

[18] ¹⁸ Huang R, Pan F, Kong C, Lu S. Ageand sex-dependent differences in the morphology and composition of paraspinal muscles between subjects with and without lumbar degenerative diseases. BMC Musculoskelet Disord. 2022;23(1):734.

Classification	Description
Grade 0	Absence of radiographic signs of degenerative disease in the lumbar spine.
Grade 1	Presence of radiographic signs of degenerative disease in one or two segments of the lumbar spine, without scoliosis or signs of instability.
Grade 2	Presence of radiographic signs of degenerative disease in three or more segments of the lumbar spine, without scoliosis or signs of instability.
Grade 3	Presence of radiographic signs of degenerative disease in the lumbar spine associated with scoliosis (coronal inclination measured by the Cobb technique greater than or equal to 30°) and signs of instability, with laterolisthesis (>2 mm) and spondylolisthesis (at least Grade 2^* * Slippage between one vertebra and another greater than 50%. ).