Clinical manifestation, magnetic resonance imaging and some atherosclerotic risk factors in patients with lumbar intervertebral disc herniation

Nội dung text: Clinical manifestation, magnetic resonance imaging and some atherosclerotic risk factors in patients with lumbar intervertebral disc herniation

1. Journal of military parmaco-medicine n 07-2017 CLINICAL MANIFESTATION, MAGNETIC RESONANCE IMAGING AND SOME ATHEROSCLEROTIC RISK FACTORS IN PATIENTS WITH LUMBAR INTERVERTEBRAL DISC HERNIATION Do Thi Le Thuy* SUMMARY Objectives: To review clinical characteristics, magnetic resonance imaging (MRI) and identify blood lipid levels, BMI score of patients with lumbar intervertebral disc herniation (LIDH). Subjects and methods: A prospective, cross-sectional descriptive study on 208 patients with LIDH treated at 198 Hospital of the Police Ministry. Results and conclusion: LIDH was more common in male than female (63.5% vs. 36.5%), with a male/female ratio of 1.74. Mean age 45.70 ± 13.96. The severity was predominant (80.8%). The location of L 4-L5 herniation was the most common (82.7%); single lumbar disc herniation was the highest (36.5%). Combined herniation between double herniation of L 4-L5 and L 5-S1 was frequently observed (51.9%). The most common herniation was posterior herniation (99.3%); overweight patients (with risks and obesity) accounted for 46.1%. There were 16.3% of patients with high total cholesterol; 37.5% with low HDL-C; 35.5% with high LDL-C; 39.4% with high triglyceride. Average total cholesterol level was 5.31 mmol/L; average HDL-C 1.17 mmol/L; average LDL-C level 3.21 mmol/L; average triglyceride 2.68 mmol/L. * Keywords: Lumbar intervertebral disc herniation; Atherosclerotic risk factors; Magnetic resonance imaging; Clinical manifestation. INTRODUCTION The discs themselves always stand the heavy load of the body weight, the Lumbar intervertebral disc herniation is penetration and diffusion of substances to a common disease, explaining most of the the discs will reduce and disc degeneration cases which were treated due to problems is unavoidable. Atherosclerosis also caused by the lumbar spine and it severely contributes to the constraint of blood perfusion affects quality of life. The pathological to the discs making disc degeneration even mechanism is complicated, related to the worse. Recently, overseas researchers process of intervertebral disc degeneration. have mentioned that blood lipid is considered Intervertebral discs are poorly perfused as another risk factor of atherosclerosis in via penetration and diffusion. The vessel lumbar intervertebral disc herniation. More perfusing intervertebral discs branches, thorough comprehension of intervertebral under sectional principle, from the abdominal disc herniation and associated factors are aorta of big diameter, after many sub- the background for new options of diagnosis divisions it finally branches into very tiny and treatment of lumbar intervertebral arterioles supplying nutrition to the discs. disc herniation. * 198 Hospital Corresponding author: Do Thi Le Thuy (lethanhbinhhts@gmail.com) Date received: 10/07/2017 Date accepted: 18/08/2017 104
2. Journal of military phrmaco-medicine n O7-2017 SUBJECTS AND METHOD pathologies, trauma, postoperative LIDH or neuromuscular problems. 1. Subjects. 208 patients were diagnosed as LIDH, 2. Methods. treated at Neurology Department, 198 Prospective, cross-sectional descriptive Hospital of Police Ministry from January, study. Clinical examination of all patients: 2012 to January, 2016. collect personal characteristics, history, * Selection criteria: Clinical criterion is clinical signs and symptoms of LIDH problem. based on the diagnosis and treatment of Blood test, patient’s height, weight, MRI low back pain - the Joint Clinical Practice scan of the lumbar spine were measured. Guidelines from the American College of * Research content: Physicians and the American Pain Society: The clinical symptoms of LIDH: The - Low back pain associated with leg pain clinical severity is based on the clinical with the distribution of nerve roots L 4, L 5, S 1. estimate LIDH scale by Nguyen Van Chuong: - Positive straight Lasegue’s sign or normal: 0 point; mild: 1 - 6 points; positive crossed Lasegue test. moderate: 7 - 12 points; severe: 13 - 18 points; extremely severe: 19 - 25 points. - Symptoms persisted longer than one month. - Checking the MRI images of the lumbar spine: Classify locations of interverterbral - Subclinical: There are LIDH images disc herniation on MRI films in accordance on the MRI film. with MSU classification: * Exclusion criteria : LIDH patients + Zone A: central herniation. associated with other spinal pathologies such as spinal tuberculosis, spinal tumor, + Zone B: near central herniation. nerve root tumor, cerebrospinal fluid + Zone C: lateral herniation. - Check blood lipid levels: assess blood lipid quantitative results based on ATP III classification table. 105
3. Journal of military parmaco-medicine n 07-2017 Table 1: LDL cholesterol (mg/dL) < 100 Optimal 100 - 129 Near optimal or above optimal 130 - 159 Borderline high 160 - 189 High ≥ 190 Very high Total cholesterol (mg/dL) < 200 Desirable 200 - 239 Borderline high ≥ 240 High HDL cholesterol < 40 Low ≥ 60 High Triglyceride (mg/dL) < 150 Optimal 150 - 199 Borderline high 200 - 499 High ≥ 500 Very high * BMI score: Based on BMI classification for Asian by WHO (2000). Table 2: Classification BMI (kg/m 2) Thinness < 18.5 Normal range 18.5 - 22.9 Pre-obese 23 - 24.9 Overweight Obese class I 25 - 29.9 Obese class II ≥ 30 RESULTS Table 3: Age, sex. Age Male Female Total group No % No % No % < 30 27 20.4 2 2.6 29 13.9 30 - 39 41 31.1 11 14.5 52 25.0 40 - 49 17 12.9 9 11.9 26 12.5 50 - 59 36 27.3 34 44.7 70 33.7 106
4. Journal of military phrmaco-medicine n O7-2017 ≥ 60 11 8.3 20 26.3 31 14.9 Total 132 100 76 100 208 100 X ± SD 41.96 ± 13.94 52.18 ± 11.48 45.70 ± 13.96 Min, max (20 - 86) Min, max (23 - 77) Min, max (20 - 86) p < 0.001 Mean age of the study group: 45.70 ± 13.96. Average age of female is higher than male. * Severity distribution of clinical * Location of herniation associated with presentation (n = 208): level on MRI (n= 208): Mild: 27 patients (13.0%); moderate: Herniated disc: L -L and L -L : 77 168 patients (80.8%); severe: 13 patients 3 4 4 5 patients (37.0%); L -L and L -S : 108 (6.2%); very severe: 0 patient. 4 5 5 1 patients (51.9%); L -L , L -L and L -S : 57 Severity of clinical presentation was 3 4 4 5 5 1 mainly moderate (80.8%). patients (27.4%); L2-L3, L 3-L4, L 4-L5 and L 5- S : 14 patients (6.7%); L -L , L -L , L -L , * Location of herniated intervertebral 1 1 2 2 3 3 4 disc on MRI (n = 208): L4-L5 and L 5-S1: 4 patients (1.9%). L1-L2: 14 patients (6.7%); L2-L3: 28 patients Combined herniation was often seen (13.5%); L3-L4: 81 patients (38.9%); L4-L5: between 2 level L 4-L5 and L 5-S1 herniation 172 patients (82.7%); L5-S1: 138 patients (51.9%). (66.3%). * Types of disc herniation (n = 433) : Herniation at L -L were the highest: 82.7%. 4 5 Posterior central herniation: 234 patients * Levels of herniation on MRI (n = 208) : (54.0%); posterior - lateral (right, left): 1 level: 76 patients (36.5%); 2 levels: 196 patients (45.3%); intravertebral disc 65 patients (31.3%); 3 levels: 45 patients (21.6%); 4 levels: 18 patients (8.7%); herniation (Schmorl’s node): 3 patients 5 levels: 4 patients (1.9%). (0.7%); foraminal herniation: 0 patient; simple anterior herniation: 0 patient. One level herniation was the highest (36.5%). The rates of 2, 3, 4 and 5 levels Posterior herniation was the most common, reduced gradually. accounting for 99.3%. Table 4: BMI classification of the patients. BMI n = 208 % Thinness 7 3.4 Normal range 105 50.5 Excessive body weight (at risk and obesity) 96 46.1 Total 208 100 X ± SD 22.88 ± 2.44 Min 17.31 Max 31.14 Excessive body weight was found in 46.1% of the patients. 107
5. Journal of military parmaco-medicine n 07-2017 Table 5: Blood lipid test results. Blood tests n = 208 % Optimal 105 50.5 Borderline high 69 33.2 Total cholesterol High 34 16.3 X ± SD 5.31 ± 1.77 Min - max 2.59 - 25.70 Suboptimal 78 37.5 Optimal 111 53.4 High 19 9.1 HDL-C X ± SD 1.17 ± 0.35 Min - max 0.40 - 4.03 Optimal 44 21.2 Near optimal 90 43.3 LDL-C High 74 35.5 X ± SD 3.21 ± 1.29 Min - max 1.02 - 17.65 Optimal 89 42.8 Borderline high 37 17.8 Triglyceride High 82 39.4 X ± SD 2.68 ± 4.03 Min - max 0.57 - 50.75 Patients with increased total cholesterol accounted for 16.3%; HDL-C at low levels 37.5%; increased LDL-C 35.5%; increased triglyceride 39.4%. DISCUSSION patients (52.18 ± 11.48). This difference is statistically significant. 1. Clinical manifestation and MRI images of LIDH. - Sex: male outnumbered female patients, male/female ratio = 1.74/1. Many other - Average age of the research subjects: domestic and worldwide researches have 45.70 ± 13.96, cosistent with the findings shown constantly higher male rates than by many authors that the average age of female [1, 3, 4, 5, 8]. To explain this fact, LIDH patients were above 40 years of age some authors suggested that males often [2, 5]. The average age of male patients work as heavy load carrier, some others was 41.96 ± 13.94, lower than that of female revealed that male lumbar spinal canel is 108
6. Journal of military phrmaco-medicine n O7-2017 smaller than that of female, etc. However, found 290 herniated intervertebral discs. there has not been any solid basis affirming Hence, on average, each of the patients the above explanations. suffered from herniation of at least two - Severity levels: Moderate levels were discs [6]. Pokhraj Suthar’s study on 109 the highest, accounting for 80.8%. Le Thi patients also revealed the most frequent Bich Thuy, Nguyen Van Chuong et al [2, 3] location of intervertebral disc herniation at provided similar results to ours. However, L5-S1, the herniation was often combined, the rates of severe, very severe and mild especially combined with L 4-L5 [9]. levels are different between the researches. - Types of herniation: Mainly posterior The difference can be due to different herniation (99.3%), other types of herniation goals of the research or different criteria represented low rate. Our research results employed for assessment and determination complied with Nguyen Van Chuong’s and of severity levels. Tran Trung’s with posterior herniation of - Herniation location: The most common 96.06% and 91.0%, respectively [2, 4]. at L -L (82.7%) and L -S (66.3%), which 4 5 5 1 2. The characteristics of BMI scores coincided with many other authors’ findings and blood lipid levels in LIDH patients. [2, 3]. - BMI score: Mean BMI score was 22.88. - Levels of herniation: Single herniation The rate of excessive body weight patients accounted for the highest rate (36.5%). accounted for 46.1%. In the study by Le Thi Our research results were similar to many Bich Thuy, 27.58% of LIDH patients with other authors’ findings [2, 3, 4]. Jensen’s BMI score of obese category [3]. According review of MRI films of 98 subjects without to Longo’s research, the mean BMI score any low back pain symptoms had shown that most of the subjects with signs of was 26.6 [8], Daghighi recorded high BMI herniation had single intervertebral disc score of 27.49 [5]. Hence, LIDH patients degenerations (52%), 38% of subjects in the worldwide studies had very high BMI had at least double intervertebral disc scores. This can be due to differences in degenerations [7]. body features of the Vietnamese and the - Combination between the levels of other races in the world. It is therefore intervertebral disc herniation: mainly recommended that there should be separated criteria to assess obesity levels of occured between L 4-L5 and other levels of intervertebral discs, of which the rate of Vietnamese people. In this research, combined herniation of L 4-L5 and L 5-S1 we employ recommended criteria by WHO accounted for the highest (51.9%). 2000 for Asian communities for nations Janardhana’s study on 119 patients found with community nutritional problems to 75% at level 4 intervertebral disc degeneration, assess the obesity levels and that is why of which 45% of patients had three and more the outcome rates are different from other intervertebral discs degeneration and also research worldwide. 109
7. Journal of military parmaco-medicine n 07-2017 - Blood lipid test results: Average total up the highest rate (36.5%); combined cholesterol was 5.31 ± 1.77 mmol/L. double herniation of L 4-L5 and L 5-S1 were Patients with high total cholesterol was the most frequent (51.9%); posterior 16.3%. Average HDL-C: 1.17 ± 0.35. herniation was mostly observed (99.3%). Patients with low HDL-C accounted for 2. Characteristics of BMI score and 37.5%. Average LDL-C: 3.21 ± 1.29 mmol/L. blood lipid levels in LIDH patients. 35.5% of the patients suffered from high 46.1% of the LIDH patients in the study LDL-C. Average triglyceride 2.68 ± 4.03 mmol/L. Patients with increased triglyceride group had excessive body weight BMI explained 39.4%. score. 16.3% of LIDH patients suffered from high total cholesterol; 37.5% with low Le Thi Bich Thuy’s research met 93.7% of HDL-C; 35.5% with high LDL-C; 39.4% patients with increased triglyceride and with high triglyceride. Average total 79.2% with reduced HDL-C of the LIDH cholesterol of LIDH was 5.31 mmol/L; group with metabolic syndrome [3]. Le Van average HDL-C: 1.17 mmol/L; average Cuong’s study showed 39.2% of patients LDL-C: 3.21 mmol/L; average triglyceride: with lipid metabolism disorder; including 2.68 mmol/L. increased total cholesterol of 35.3%, increased LDL-C of 31.4%, increased There needs more researches to assess triglyceride of 28.4% and reduced HDL-C of the correlation between atherosclerotic risk 8.8% [1]. Longo’s research [8] on 169 factors with LIDH problems. patients showed average total cholesterol of 5.59 mmol/L, which was higher than our REFFERENCE results (5.31 ± 1.77); however, the average triglyceride was 1.82 mmol/L; 1. Le Van Cuong. Research on clinical, which was much lower than our findings subclinical manifestation and some prognostic (2.68 ± 4.03). This difference can be due factors of LIDH. Medical Master Thesis. Military to different ethnicity and sample size. Medical Institute. 2012. 2. Nguyen Van Chuong et al . Research on CONCLUSION lumbar intervertebral disc herniation at the 1. Clinical manifestation and MRI Neurology Department, 103 Hospital. Military images of LIDH. Medical Institute. Military Medical and Pharmaceutical Magazine. 2015, issue 3, Mean age of the subject group was pp.5-16. 45.70; male had higher disease rates than female. The male/female ratio was 1.74/1. 3. Le Thi Bich Thuy. Research on clinical Moderate severity accounted for the manifestation, MRI images and treatment for highest rate (80.8%). The most common lumbar intervertebral disc herniation with location of intervertebral disc herniation metabolic syndrome. Medical Master Thesis. was L 4-L5 (82.7%); single herniation made Military Medical Institute. 2012. 110
8. Journal of military phrmaco-medicine n O7-2017 4. Tran Trung . Research on MRI images of 7. Jensen M.C, Brant-Zawadzki M.N, LIDH. Practical Medical Magazine. 2006, Obuchowski N et al . Magnetic resonance issues 12, pp70-72. imaging of the lumbar spine in people without 5. Daghighi M.H, Pouriesa M, Maleki M back pain. N Engl J Med. 1994, 331 (2), et al . Migration patterns of herniated disc pp.69-73. fragments: a study on 1,020 patients with 8. Longo U.G, Denaro L, Spiezia F et al . extruded lumbar disc herniation. The Spine Symptomatic disc herniation and serum lipid Journal. 2014, 14 (9), pp.1970-1977. levels. Eur Spine J. 2011, 20 (10), pp.1658- 6. Janardhana A.P, Rajagopal, Rao S. 1662. et al . Correlation between clinical features and 9. Suthar P, Patel R, Mehta C et al . MRI magnetic resonance imaging findings in lumbar evaluation of lumbar disc degenerative disease, disc prolapse, Indian J Orthop. 2010, 44 (3), J Clin Diagn Res. 2015, 9 (4), p. TC04-9. doi: pp.263-269. 10.7860/JCDR/2015/11927.5761. 111