Multifidus Cross-sectional Area Research Articles

Gender Differences in Balance, Lumbar Multifidus Muscle, Pain, and Kinesiophobia in Patients with Lumbar Spinal Stenosis

Aim: The aim of this study was to examine balance, lumbar multifidus muscle thickness and cross-sectional area (CSA), pain, disability and kinesiophobia levels, and to compare these parameters in terms of gender in patients with lumbar spinal stenosis (LSS). Material and Methods: This cross-sectional study included 59 patients, 33 (55.9%) female and 26 (44.1%) male, diagnosed with LSS by magnetic resonance imaging (MRI). Low back and leg pains, dynamic and static balances, disability and kinesiophobia levels of patients with LSS were evaluated. Lumbar multifidus muscle thickness and total CSA were obtained from MRI images. Obtained data were compared according to gender. Results: Females had significantly more low back pain than males (p=0.043), in patients with LSS. Additionally, females with LSS had worse dynamic and static balances (p=0.005, and p=0.001, respectively) and higher levels of disability (p=0.001), and kinesiophobia (p=0.001). Females with LSS had less lumbar multifidus muscle thickness and CSA than males on both the right and left sides. Also, right multifidus muscle thickness correlated with both dynamic (r=-0.289; p=0.027) and static (r=0.349; p=0.007) balances. Significant correlations were detected between low back and leg pain with dynamic and static balances, disability, and kinesiophobia in patients with LSS. Conclusion: Females with LSS have higher levels of pain, disability, and kinesiophobia than males. Also, LSS affects females' balance functions more and causes further degeneration of the multifidus muscle. Therefore, gender differences should be examined during the clinical follow-up process in LSS.

Multifidus lesions: A possible pathological component in patients with low back pain after posterior lumbar surgery.

There are few histological studies on multifidus after lumbar surgery, and it is not clear whether multifidus changes affect the clinical outcome after lumbar surgery. The aim of this study was to investigate the relationship between multifidus changes and clinical outcomes after lumbar surgery. Patients underwent internal fixation removal after lumbar posterior surgery were enrolled. Patients were divided into a low back pain (LBP) group (n = 15) and a non-low back pain (non-LBP) group (n = 10).The Oswestry disability index (ODI) and visual analog scale (VAS) were completed. 18 patients with lumbar fracture surgery were included as the control group. Multifidus morphological changes were observed by hematoxylin and eosin and Masson staining. The expression of TGF-β1 was observed by immunohistochemistry, immunofluorescence and Western blot. The cross-sectional area (CSA) of the multifidus in the non-LBP group and the control group were greater than those in the LBP group. TGF-β1 expression and gray value ratio in the non-LBP group and the control group were lower than those in the LBP group. The multifidus CSA and TGF-β1 expression in multifidus were strongly correlated with ODI and VAS. Patients with LBP after posterior lumbar surgery suffered from atrophy and fibrosis lesions in the multifidus, and the degree of multifidus lesions was closely related to dysfunction and pain, which might be one of the causes of LBP after posterior lumbar surgery.

Short term use of balance pads on postural sway and musculus multifidus cross sectional area in horses

Horses with musculoskeletal injuries have poor postural stability with larger center of mass (COM) movements and asymmetry/atrophy of the musculus (m.) multifidus. The objective of this study was to determine the effect of balance pad use in horses on both COM motions and m. multifidus cross sectional area (CSA). We hypothesized that use of balance pads would decrease COM motions and increase m. multifidus CSA and symmetry. Six healthy adult horses stood on balance pads for 5 min twice daily, 5 days per week for 4 weeks. At baseline and study completion, COM motion was determined using a portable media device, with horse standing on and off balance pads. Ultrasound of m. multifidus was performed bilaterally at select thoracic (T) and lumbar (L) vertebra: T12, T14, T16, T18, L2, and L5. Data were analyzed using mixed-model ANOVA. At baseline, there was significantly more medial-lateral and cranio-caudal motion when horses stood on pads compared to square stance (P < 0.006). When standing on pads, there was a significant decrease in motion at 4 weeks compared to baseline (P < 0.0004). There was a significant increase in m. multifidus CSA at T14 at 4 weeks compared to baseline (P = 0.021). When comparing baseline and 4 weeks CSA, there was no significant difference in m. multifidus asymmetry. These results suggest that implementation of balance pads for 4 weeks can improve postural stability in horses and increase CSA at T14. Longer duration of use may be needed for additional changes to paraspinal musculature.

Lumbar Multifidus Characteristics in University Level Athletes May be Predictors of Low Back Pain and Lower Limb Injury

Introduction: Low back pain (LBP) is highly prevalent in athletes, with decreased lumbar multifidus (LM) crosssectional area (CSA) reported in athletes with LBP and lower limb injury (LLI) as well as decreased LM thickness in athletes with LLI. Previous research has only investigated connections between LM, LBP, and LLI in small samples of athletes in a single sport at a time. This study aimed to (1) examine LM morphology and function across a general sample of male and female university level varsity athletes; (2) investigate whether LM characteristics were predictors of LBP and LLI. Methods: Ultrasound images of LM at L5 were acquired in prone and standing. Body composition was assessed with DEXA and a self-reported questionnaire provided demographics and history of injury. Paired t-tests and independent t-tests compared LM measurements between the sides and sex, respectively. Univariate and multivariate logistic regression analyses were used to assess possible LM characteristic predictors of LBP and LLI. Results: 134 university varsity athletes were evaluated. LM CSA was larger on the non-dominant side in prone. Increased LM thickness was associated with decreased odds of LBP in the previous 4-week (OR=0.49 [0.27, 0.88], p=0.02) and 3-month (OR=0.43 [0.21, 0.89], p=0.02) in the multivariable model, while a greater number of years playing at the university level was associated with increased odds of LBP (OR=1.29 [1.01, 1.65], p=0.04). Greater LM CSA asymmetry (OR=1.14 [1.01, 1.28], p=0.03) and sport (OR=1.44 [1.04, 1.96], p=0.02) were significant predictors of LLI in the previous 12 months. Conclusion: Leg dominance may play a role in unilateral differences. LM thickness and LM CSA asymmetry were predictors of injury. Preseason screening of LM morphology and function could help identify athletes at risk of LBP and LLI, allowing coaches, medical staff, and training staff to target these individuals and provide specific injury prevention programs.

Hamstring and knee injuries are associated with isometric hip and trunk muscle strength in elite Australian Rules and Rugby League players

ObjectivesThis study investigated relationships between isometric trunk and hip extensor strength, lumbar muscle morphology, and the risk of hamstring and knee ligament injuries in Australian Football League and National Rugby League players. DesignProspective cohort study. MethodsTrunk and hip extensor strength, multifidus and quadratus lumborum cross-sectional area were measured during the 2020 pre-season. Logistic regressions and decision trees were employed to explore associations between maximum strength, strength endurance, multifidus and quadratus lumborum cross-sectional area, age, previous injuries, and hamstring and knee ligament injury risk. ResultsGreater strength endurance [odds ratio = 0.42 (0.23–0.74), p = 0.004] and maximum strength [odds ratio = 0.55 (0.31–0.94), p = 0.039] reduced hamstring injury risk. Increased risk of knee ligament injuries was associated with larger multifidus [odds ratio = 1.66 (1.14–2.45), p = 0.008] and higher multifidus to quadratus lumborum ratio (odds ratio = 1.57 (1.13–2.23), p = 0.008]. Decision tree models indicated that low strength endurance (< 99 Nm) characterised hamstring strains, while high (≥ 1.33) multifidus to quadratus lumborum ratio mitigated risk. Knee ligament injuries were associated with larger (≥ 8.49 cm2) multifidus, greater (≥ 1.25) multifidus to quadratus lumborum ratio, and lower maximum strength (< 9.24 N/kg). ConclusionsPlayers with lower trunk and hip extensor maximum strength and strength endurance had increased risk of hamstring injuries, while knee ligament injury risk was elevated with larger multifidus cross-sectional area, higher multifidus to quadratus lumborum ratio, and lower maximum trunk and hip extensor strength.

The Difference in Paraspinal Muscle Parameters and the Correlation with Health-Related Quality of Life among Healthy Individuals, Patients with Degenerative Lumbar Scoliosis and Lumbar Spinal Stenosis.

(1) Background: Paraspinal muscle degeneration affects the quality of life in patients with degenerative lumbar scoliosis (DLS) and lumbar spinal stenosis (LSS). We aimed to describe the characteristics and differences in the paraspinal muscle parameters between patients with DLS and LSS and investigate their correlation with health-related quality of life (HRQOL). (2) Methods: There were forty-four participants in each group, namely the DLS, LSS, and healthy groups, who were matched at a ratio of 1:1 according to age, sex, and BMI. Differences in paraspinal muscle parameters among the three groups were compared using analysis of variance or the Mann-Whitney U test, and paraspinal muscle degeneration and HRQOL were analyzed using Spearman's correlation analysis. (3) Results: In the upper lumbar, the psoas (PS), quadratus lumborum (QL), and multifidus (MF) cross-sectional area (CSA) in the DLS group were smaller than those in the other groups. In the lower lumbar region, the CSA of the PS, QL, erector spinae (ES), and gross CSA (GCSA) of the MF in the DLS group were not significantly different from those in the LSS group. These values were lower than those observed in the healthy group. The lean muscle fat index (LMFI) of the MF and ES groups was higher than those of the other groups. Regarding HRQOL, we found that PS and MF CSA were strongly associated with HRQOL in healthy individuals; however, only MF was associated with HRQOL in the LSS group. (4): Conclusion: PS in the upper lumbar region and MF degeneration were more severe in patients with DLS than in those with LSS. ES degeneration was similar between the LSS and DLS groups. MF muscle atrophy in patients with LSS and asymmetric changes in the MF in DLS are associated with quality of life.

Physical Functional Ability and Quantitative Assessment of the Multifidus Muscle of the Lumbar Spine in the Elderly.

Aging is associated with muscle atrophy and fatty infiltration of skeletal muscle. The multifidus muscle stabilizes the lumbar spine and undergoes adipose accumulation with age, leading to functional decline in the elderly. Therefore, quantitative assessment of the multifidus muscle can be beneficial for the elderly when formulating treatment strategies and reducing future complications. Fifty-seven patients (mean age, 73.89 ± 6.09; 23 male patients) who underwent lumbar Magnetic resonance imaging (MRI) were prospectively recruited. The cross-sectional area (CSA) of the multifidus from the L2-S1 level and the CSA of the L4-5 level psoas muscle were measured. The functional CSA (fCSA) of the multifidus muscle was measured by excluding the fat infiltration area from the multifidus CSA. The CSA to fCSA ratio was obtained by multiplying 100 by the value obtained by dividing CSA by the fCSA. Pfrrmann classification was used to evaluate the degree of disc degeneration. The functional disability measurements were the Short Physical Performance Battery (SPPB), Berg Balance Scale (BBS), grip strength, and functional reach test (FRT). Pearson's correlation analysis was used to examine the relationship between the functional disability measurements and the multifidus muscle. The CSA to fCSA ratio value was relatively constant at each spine level and showed a significant correlation with the SPPB, grip strength, FRT, and psoas index (p < 0.05). However, degree of disc and multifidus muscle degeneration was not statistically significant. So, age-related changes play a significant role in developing back muscle fatty infiltration than disc degeneration. Moreover, Grip strength showed a stronger relationship with the quality of the multifidus muscle than other functional disability measurements.

Reference values for the cross-sectional area of the lumbar multifidus muscle in children.

The multifidus muscle plays a major role in the growth and postural control of children. Therefore, the reference values of the cross-sectional area (CSA) of the lumbar multifidus muscle represent an important tool for assessing muscle development and the early monitoring of musculoskeletal disorders. The aim of this study was to provide percentile scores for the CSA of the lumbar multifidus muscle in eutrophic children aged 5 to 10 years. This was a cross-sectional, observational study, involving 736 children. An anthropometric assessment was conducted and ultrasound (US) imaging was used to assess the CSA of the lumbar (vertebral level L5) multifidus muscle. The CSA was expressed as percentile scores. The CSA in the boys ranged from 1.8 cm2 to 5.3 cm2 and in girls from 1.9 cm2 to 5.9 cm. The CSA in the 50th percentile scores of both sexes was 3.4 cm2. There was an increase in the CSA between 5 and 7 years old in both sexes. The CSA presented a greater variance in girls than in boys. After 8 years of age, the multifidus CSA increased in girls and decreased in boys. The present study has provided percentile scores for the CSA of the lumbar multifidus muscle for eutrophic children aged 5 to 10 years. An increase was observed of the CSA of the multifidus muscle between the ages of 5 and 7 years and there were no differences in the CSA percentiles in relation to sex. An increase in the CSA after 8 years of age was only observed in the girls.

Comparison of Clinical Outcomes and Muscle Invasiveness between Unilateral Biportal Endoscopic Discectomy and Percutaneous Endoscopic Interlaminar Discectomy for Lumbar Disc Herniation at L5/S1 Level

Both unilateral biportal endoscopic discectomy (UBED) and percutaneous endoscopic interlaminar discectomy (PEID) could achieve favorable outcomes for lumbar disc herniation (LDH). There are limited studies comparing the two different methods of endoscopic discectomy. The objective was to comprehensively compare the clinical outcome and muscle invasiveness of UBED and PEID for the treatment of LDH at L5/S1 level with at least 1-year follow-up. The retrospective cohort study enrolled 106 LDH patients of L5/S1 level from January 2018 to December 2020. There were 51 patients who underwent UBED (22 males and 29 females, 43.8 ± 14.2 years old) and 55 patients underwent PEID (28 males and 27 females, 42.3 ± 13.8 years old). Clinical outcomes and surgical invasiveness were compared between the two groups for at least 1 year follow-up. Clinical outcomes included visual analogue scale (VAS) scores, Oswestry Disability Index (ODI), complications, recurrence of LDH, intraoperative anesthesia time, operative time, number of intraoperative fluoroscopies, and postoperative length of stay. Surgical invasiveness was evaluated with serum CPK level and change rate of lean multifidus cross-sectional area (LMCSA). Independent-sample t test and paired sample t test were used to compare continuous data. Chi-square test and Fisher's precision probability tests were used to analyze the categorical data. Both groups achieved favorable clinical outcomes at the last follow-up, including VAS and ODI (all Ps <0.05). The intraoperative anesthesia time for UBED was longer, but with no difference of operative time. As for intraoperative fluoroscopy times (2.5 vs 2.4), postoperative length of stay (2.1 vs 2.0 days), postoperative complications (5.9% vs 3.6%), there were also no significant difference. The serum CPK level and change rate of LMCSA for UBED was higher than PEID at postoperative 1st day. At the last follow-up, there was no significant difference in the change rate of LMCSA between the two groups (P=0.096). Both UBED and PEID could achieve favorable clinical outcomes for the treatment of L5/S1 LDH. Despite UBED is more invasive, the radiological manifestation of paraspinal muscle invasiveness was equal at last follow-up with at least 1 year. UBED is a safe and innovative alternative choice for treatment of LDH at L5/S1 level.

The effect of lumbar multifidus cross-sectional areas on transforaminal epidural steroid injection: An observational clinical study.

Multifidus has an important role in spinal stability, and multifidus degeneration causes long-term disability and low back pain. This study aimed to investigate the effect of multifidus cross-sectional area on transforaminal epidural steroid injections (TFESI). Patients with single-level disc herniation were included in the study. Total multifidus cross-sectional area (TM-CSA) and functional cross-sectional area (FM-CSA) were measured from axial T2 MRI of the patients, and FM-CSA/TM-CSA ratio was calculated for determination of muscle degeneration or fat infiltration. Numerical Rating Scale (NRS) scores at the pre-injection, 3rd week, and 3rd month visits were recorded. A decrease of 50% or more in the NRS score in the 3rd month was accepted as a treatment success (TS), and patients were divided into TS and treatment failure groups. A total of 120 patients were included in the study; 57 of the patients were female, and 63 of them were male. Of the patients included in the study, 68 had herniation at the L5-S1 disc level and 52 had herniation at the L4-L5 disc level. FM-CSA and FM-CSA/TM-CSA ratio were found to be significantly lower below the disc herniation level on the affected side (p<0.05). The affected side TM-CSA and FM-CSA were higher in the TS group and TM-CSA/FM-CSA ratios were equal in both groups. Multifidus CSA was found to be lower on the affected side. However, the effect of multifidus CSA on the success of TFESI has not been determined.

Reliability of Ultrasound Findings in Patients with Lumbar Multifidus Myofascial Pain Syndrome.

Lumbar multifidus muscle provides stability to the spine. The present study aimed to evaluate the reliability of ultrasound findings in patients with lumbar multifidus myofascial pain syndrome (MPS). A total of 24 cases (7 females, 17 males, mean age: 40.13± 5.69, BMI: 26.48±4.96) with multifidus MPS were assessed. The variables were muscle thickness in rest and contraction, thickness changes, and cross-sectional area (CSA) in rest and contraction. Two examiners performed the test and retest sessions. The active trigger points of lumbar multifidus on the right and left side of the cases were 45.8 % and 54.2%, respectively. The intraclass correlation coefficient (ICC) values for muscle thickness and thickness changes showed moderate to very high reliability for both within and between intra-examiner measurements. (ICC, 1st examiner: 0.78-0.96; ICC, 2nd examiner: 0.86-0.95). In addition, the ICC values of within and between-session intra-examiner for CSA were high. (ICC, 1st examiner: 0.83-0.88; ICC, 2nd examiner: 0.84-0.89). The ICC and standard error of measurement (SEM) of inter-examiner reliability ranged between 0.75 to 0.93 and 0.19 to 0.88 for multifidus muscle thickness and thickness changes. The ICC and SEM of inter-examiner reliability ranged between 0.78 to 0.88 and 0.33 to 0.90 for CSA of the multifidus muscle. The within and between-session reliability of multifidus thickness, thickness changes, and CSA was moderate to very high in patients with lumbar MPS when taken by two examiners. Furthermore, the inter-examiner reliability of these sonographic findings was high.

Alteration in the Cross-sectional Area (CSA) Ratio of the Paraspinal Muscles following Vertebral Insufficiency Fractures.

Background Vertebral insufficiency fractures in the elderly are associated with increased morbidity and mortality. Early diagnosis is essential to direct patient-specific rehabilitation. Aims We hypothesize that in patients with vertebral insufficiency fractures, there is atrophy of the psoas and paraspinal muscles with alteration in the cross-sectional area (CSA) of the muscles. Materials and Methods Magnetic resonance imaging (MRI) studies for 100 consecutive patients, older than 60 years presenting with lower back pain, were included in the study. For each MRI study, the CSA of the psoas and paraspinal muscles (multifidus) at the level of L4/5-disc space was measured to calculate the cross-sectional area ratio (CSAR) by two readers. One reader repeated the measurements after an interval of 2 weeks. We divided the patients ( n = 100) into various groups based on the number of vertebral fractures. Results In total, 77 patients with vertebral body fractures (48 with one, 16 with two and 13 with more than two fractures) were identified with a mean age of 73 (range 60-92) years. The ratio of multifidus CSA to psoas CSA was calculated with mean values of each group (1-4) as 2.56, 1.89, 2.09 and 2.16, respectively. There was statistically significance difference of the CSAR between the cohorts ( p -value = 0.0115). Conclusion Vertebral insufficiency fractures in the elderly are associated not only with atrophy of psoas and the multifidus group of muscles as evident by the CSA values, but they also affect the CSAR depending on the number of fractures. This finding may help to direct targeted patient-specific physiotherapy rehabilitation and interventions to prevent further such fractures.

Correlations between trunk muscle cross sectional areas and sagittal spinal curves in Australian Football athletes

Background: Preventing lower limb injuries in Australian Football League (AFL) is a primary focus of medical teams across the competition. Smaller cross-sectional area (CSA) of the multifidus muscle has been identified as an injury risk factor in AFL athletes. Understanding why this is a risk factor has been largely theoretical. It has been shown that increased volume of the multifidus and lumbar erector spinae muscles is related to increased curvature in the lower lumbar spine. Identification of the relationships between the CSA of the multifidus, sagittal spinal angles, as well as CSAs of other trunk muscles could help us better understand why multifidus CSA is an injury risk factor for AFL athletes.

Multifidus muscle cross-sectional area adaptations over two volleyball seasons and one off-season in athletes with and without low back pain.

The multifidus muscle is important in spine stabilization. Atrophy of the multifidus muscle has been associated with low back pain. To examine multifidus muscle cross-sectional area (CSA) adaptations over two volleyball seasons and one off-season in volleyball athletes experiencing low back pain or no low back pain. Twelve female NCAA division 1 volleyball athletes participated. Athletes were placed into a low back pain or no low back pain group. Athlete's multifidus was imaged and measured using ultrasound at four time points across seasons. Imaging time points were before season one, following season one, following off-season, and following season two. A single level mixed-model analysis of variance was used for all analyses. A Tukey HSD post hoc test was used to determine differences between and within the low back pain and the no low back pain groups. Following off-season training the pain group had clinically significant smaller multifidus CSA at the L4 (-2.36 cm2 difference or 17.5%) and L5 (-2.40 cm2 or 12.5%) levels. Non-significant (p> 0.05) decreases in multifidus CSA were seen in both groups following season one and two. Athletes with pain had decreased multifidus CSA at the L4 and L5 vertebral levels at all time points which was non-significant (p> 0.05). Clinically significant decreases in multifidus CSA occurred in female volleyball athletes with low back pain at the L4 and L5 level following off-season training. Volleyball athletes with pain had smaller multifidus CSA averages at all time points measured of the two year period.

Influence of Chronic Lameness on Thoracolumbar Musculus Multifidus Structure in the Horse

The clinical relationship between equine limb lameness and secondary back dysfunction is largely unknown. Proper function of the spine is critical to maintain the integrity of the kinetic chain and attenuate forces from the appendicular skeleton. The musculus multifidus (m. multifidus) is the primary muscle providing spinal intersegmental stabilization and a functional relationship between m. multifidus hypertrophy and equine postural stability has been established. The relationship between equine thoracolumbar m. multifidus cross-sectional area (CSA) and limb lameness is unknown. The objective was to evaluate ultrasonographic changes in thoracolumbar m. multifidus CSA in horses with chronic single limb lameness, compared with sound horses. We hypothesized that the CSA of m. multifidus, ipsilateral to the lame limb would be smaller than the contralateral side, and within the sound group there would be no difference between sides. Thirty-six horses were enrolled, with twelve horses per group: sound, forelimb lame, and hindlimb lame. M. multifidus CSA was measured ultrasonographically at multiple spinal levels and compared between groups, spinal levels, and sides. M. multifidus CSA at the spinal level T18 was significantly larger than at all other measured levels, regardless of group (P ≤ .05). CSA at all levels was significantly larger in sound horses than the forelimb lame group, regardless of side (P = .002). This is the first study to evaluate the impact of chronic lameness on the axial skeleton and showed a decrease in m. multifidus CSA with forelimb lameness. These results support that axial skeletal adaptation occurs in response to naturally occurring chronic lameness.

Low back pain and lumbar multifidus cross-sectional area, multifidus activation, and low back force in healthcare workers

IntroductionHealthcare workers are required to engage in repetitive actions when handling patients which leads to widespread low back pain in this population. Many variables are related to low back pain including repetitive motions and abnormal multifidus size and activation. This research sought to observe the relationship between low back pain and three variables in healthcare workers specifically: peak low back force when boosting a patient, multifidus cross-sectional area, and multifidus activation. Materials and methodsThis cross-sectional, correlational study included 35 healthcare workers who currently work in inpatient hospital, acute hospital, or skilled nursing settings, and engage in patient handling as part of their job. Force and motion data were collected with motion capture and in-ground force plates and processed to estimate low back forces. Multifidus cross-sectional area was measured with ultrasound while activation was measured using surface electromyography. ResultsThere was not a significant difference in peak low back force between pain and nonpain groups. There was a significant difference in multifidus cross-sectional area at 2 of the 3 levels measured (L5 and S1). Lastly, there was not a significant difference in multifidus activation. ConclusionsPeak low back force during patient handling and lumbar multifidus activation do not seem to be a factor in pain in healthcare workers. Multifidus cross-sectional area is correlated with pain in this population indicating smaller multifidus may increase the likelihood of experiencing pain. Further work should be done to confirm this finding and offer potential solutions. Relevance to industryDiscovering factors in and ways to alleviate low back pain in healthcare workers is essential to the longevity of these professionals in their respective careers.

English

BACKGROUND Chronic low back pain is a major health problem which has a negative physical, social and psychological impact on the patient and their family. Chronic low back pain is defined as pain that lasts for more than 3 months duration. We can ultrasonologically assess the spinal stabilizers in a given population and come to a common decision regarding their proper strengthening and rehabilitation. We wanted to assess the ultrasonological finding in lumbar multifidus muscle in chronic low back pain patients and to compare the findings with those who are not suffering from chronic low back pain. METHODS The case control study included 64 cases with chronic low back pain (excluding those with structural deformities, infective, traumatic, and inflammatory aetiology) and 64 controls without low back pain, among the persons who presented to the OPD of PMR Department, Govt. Medical College, Kozhikode, Kerala. The crosssectional area as well as the percentage fatty infiltration of lumbar multifidus muscle at L4, L5 levels were assessed ultrasonologically after obtaining the consent. SPSS data analyser was used to statistically assess the variables. RESULTS The study population consisted of 53 % females and 47 % males with a comparable age group. The study showed persons with chronic low back pain had lower mean value of cross-sectional area (CSA) and higher mean value of percentage fatty infiltration in lumbar multifidus muscle at L4, L5 levels when compared to the values in persons without chronic low back pain. The CSA was significantly dependent on type of occupation they were involved. CSA was also found to be greater among males. CSA statistically showed direct relation to height and weightof the person. CONCLUSIONS The mean CSA of lumbar multifidus is lower in persons with chronic low back pain as compared to persons without low back pain. The CSA was significantly dependent on type of occupation. KEY WORDS Chronic Low Back Pain (LBP), Multifidus Muscle, Cross Sectional Area (CSA), Rehabilitation.

Quantification Threshold Pixel Technique of Magnetic Resonance Imaging in Paraspinal Muscles Atrophy among Discopathy Patients

Purpose: To evaluate the relationship between lumbosacral discopathy status and paraspinal atrophic changes (Cross-sectional area (CSA) and fatty infiltration (FI)) among different age groups. Materials and Methods: We retrospectively evaluated 200 patients with confirmed discopathy who were examined by lumbosacral Magnetic Resonance Imaging (MRI) at the two main governmental hospitals in Gaza Strip. Using ImageJ software and quantification threshold technique, we measured the CSA and FI of paraspinal muscles {multifidus (MF) & erector spinae (ES)}. The interpretation of MRI images was performed by two radiologists with a good inter-observer agreement between the radiological discopathy findings. Results: The highest percentage and severity of discopathy were noticed at the level of L4/5 (89.5%), followed by L5/S1 (14.5%). The FI is increased towards lower levels of L3/4 to L5/S1. No correlation was found between discopathy level, the severity of discopathy, and CSA of MF & ES muscles. In contrast, a correlation was observed between FI of MF & ES muscles, discopathy level, and severity. Also, the results illustrated no significant relation was observed between CSA of MF & ES muscles and age groups (P > 0.05), while a significant correlation was reported between FI and age groups (P < 0.05). Conclusion: The MRI quantification threshold pixel technique for paraspinal muscles reflected the atrophic changes like CSA and FI in discopathy patients.

The Clinical Effect of Manual Reduction Combined with Internal Fixation Through Wiltse Paraspinal Approach in the Treatment of Thoracolumbar Fracture.

ObjectiveTo evaluate the clinical outcome of manual reduction combined with pedicle fixation through Wiltse paraspinal approach (WPA) in the treatment of thoracolumbar fractures.MethodsFrom May 2017 to May 2019, 48 thoracolumbar fractures patients without neurological symptoms were enrolled in this study. Forty‐eight patients were randomly divided into two groups based on the different surgical treatment. Group 1 was manual reduction combined with pedicle screw fixation through Wiltse paraspinal approach treatment group. Group 2 was pedicle screw fixation through traditional posterior approach treatment group. The operation time (OT), intraoperative blood loss (BL), postoperative drainage (PD), time of brace (TB) and the cobb angle recovery of the injured kyphosis in the prone position were obtained and compared between the two groups, respectively. Comparison of cobb angle changes, serum creatine kinase (CK) level, pain visual analogue score (VAS), Oswestry disability index (ODI), and multifidus cross‐sectional (MCS) area changes were achieved between the two groups, respectively.ResultsForty‐eight patients were enrolled in this study and each group had 24 patients. There was no significant difference between the two groups in patient's age, height, weight, and body mass index (BMI). There were 20 males and four females in group 1. The mean age, height, weight, and BMI of patients were 61.99 ± 11.00 years (range, 42–75 years), 175.21 ± 4.49 cm, 76.71 ± 4.87 kg, and 24.98 ± 1.03 kg/m2 in group 1, respectively. Group 2 had 18 males and six females, and the mean age, height, weight, and BMI of patients were 57.95 ± 9.22 years (range, 44–77 years), 176.37 ± 4.56 cm, 77.42 ± 4.61 kg, and 24.87 ± 1.10 kg/m2 in group 2, respectively. The mean bleeding volume of group 1 was significantly less than group 2 (64.13 ± 9.77 ml and 152.13 ± 10.73 ml, respectively) (P < 0.05). The mean operation time, postoperative drainage, and time of brace were 62.95 ± 9.80 min, 66.25 ± 12.75 ml, and 3.62 ± 0.97 days in group 1, respectively, and they were significantly better than those of group 2 (69.29 ± 6.82min, 162.96 ± 14.55ml and 7.88 ± 1.94 days, respectively) (P < 0.05). The mean multifidus cross‐sectional area was significantly smaller than per‐operation after surgery in two groups (P < 0.05). The mean creatine kinase of group 1 was 403.13 ± 39.78 U/L and 292.12 ± 45.81 U/L at 1 and 3 days after surgery, respectively, which was significantly smaller than those in group 2 (654.25 ± 53.13 U/L and 467.67 ± 44.25 U/L, respectively) (P < 0.05). The Oswestry disability index of group 1 were significantly better than those in group 2 especially at 1 month and final follow‐up after surgery (P < 0.05). Moreover, group 1 also had better outcomes in postoperative Cobb angle change than those in group 2, with significant difference on intra‐operation, 1 day and 1 month post‐operation (P < 0.05).ConclusionIn short, this operation is suitable for thoracolumbar fractures without neurologic symptoms. Preoperative manual reduction had advantages of restoring the height of injured vertebrae. Wiltse intermuscular approach can reduce intraoperative blood loss, shorten operation time, and reduce paraspinal muscle damage. Using the traditional posterior approach, it is easy for surgeons to grasp this technique and it should be recommended as conforming with the minimally invasive approach of recent years.

The effect of spinopelvic parameters on transforaminal epidural steroid injection treatment success in lumbar disc herniation.

Spinopelvic parameters (SPP) is closely associated with diseases such as lumbar disc herniation (LDH), disc degeneration and spondylolisthesis. Although there exist many known clinical and radiological factors affecting the success of the transforaminal epidural steroid injection (TFESI) treatment, the effect of SPP has not yet been investigated. This study aims to examine the effects of SPP on treatment success in patients who undergo TFESI because of lumbar disc herniation and to investigate the correlation among multifidus cross-sectional area (MFCSA). This was a prospective, observational study. Patients with low back and/or leg pain, unilateral nerve root compression were applied TFESI. Outcome measures included the numerical rating scale (NRS), Oswestry Disability Index (ODI) and Beck Depression Inventory (BDI). The patients were evaluated at the first hour, third week and third month. The SPP and MFCSA measurements were made on direct radiographs and MRIs. A total of 58 patients, 24 women and 34 men, with an average age of 42.0±9.5 were included. NRS, ODI and BDI scores improved significantly up to three months follow-up (P<.001). Moderately positive correlations were found between leg NRS and PT/PI scores immediately after treatment (r: 0.307 and r: 0.334) and a weak positive correlation was found between BDI and PT at third week (r: 0.269). The MFCSA/vertebral sectional area (VSA) and MFCSA/total multifidus cross-sectional area (TMFCSA) of the affected side was found to be significantly low (P<.001). Subjects with high PI and PT reported less improvement in leg pain immediately after treatment and patients with high PT had fewer BDI improvements. MFCSA had no correlations with SPPs in patients who underwent TFESI.