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.
Journal of military parmaco-medicine n07-2017 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 L4-L5 herniation was the most common (82.7%); single lumbar disc herniation was the highest (36.5%) Combined herniation between double herniation of L4-L5 and L5-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 Lumbar intervertebral disc herniation is a common disease, explaining most of the cases which were treated due to problems caused by the lumbar spine and it severely affects quality of life The pathological mechanism is complicated, related to the process of intervertebral disc degeneration Intervertebral discs are poorly perfused via penetration and diffusion The vessel perfusing intervertebral discs branches, under sectional principle, from the abdominal aorta of big diameter, after many subdivisions it finally branches into very tiny arterioles supplying nutrition to the discs The discs themselves always stand the heavy load of the body weight, the penetration and diffusion of substances to the discs will reduce and disc degeneration is unavoidable Atherosclerosis also contributes to the constraint of blood perfusion to the discs making disc degeneration even worse Recently, overseas researchers have mentioned that blood lipid is considered as another risk factor of atherosclerosis in lumbar intervertebral disc herniation More thorough comprehension of intervertebral disc herniation and associated factors are the background for new options of diagnosis and treatment of lumbar intervertebral disc herniation * 198 Hospital Corresponding author: Do Thi Le Thuy (lethanhbinhhts@gmail.com) Date received: 10/07/2017 Date accepted: 18/08/2017 104 Journal of military phrmaco-medicine nO7-2017 SUBJECTS AND METHOD Subjects 208 patients were diagnosed as LIDH, treated at Neurology Department, 198 Hospital of Police Ministry from January, 2012 to January, 2016 * Selection criteria: Clinical criterion is based on the diagnosis and treatment of low back pain - the Joint Clinical Practice Guidelines from the American College of Physicians and the American Pain Society: - Low back pain associated with leg pain with the distribution of nerve roots L4, L5, S1 - Positive straight Lasegue’s sign or positive crossed Lasegue test - Symptoms persisted longer than one month - Subclinical: There are LIDH images on the MRI film * Exclusion criteria: LIDH patients associated with other spinal pathologies such as spinal tuberculosis, spinal tumor, nerve root tumor, cerebrospinal fluid pathologies, trauma, postoperative LIDH or neuromuscular problems Methods Prospective, cross-sectional descriptive study Clinical examination of all patients: collect personal characteristics, history, clinical signs and symptoms of LIDH problem Blood test, patient’s height, weight, MRI scan of the lumbar spine were measured * Research content: The clinical symptoms of LIDH: The clinical severity is based on the clinical estimate LIDH scale by Nguyen Van Chuong: normal: point; mild: - points; moderate: - 12 points; severe: 13 - 18 points; extremely severe: 19 - 25 points - Checking the MRI images of the lumbar spine: Classify locations of interverterbral disc herniation on MRI films in accordance with MSU classification: + Zone A: central herniation + Zone B: near central herniation + Zone C: lateral herniation - Check blood lipid levels: assess blood lipid quantitative results based on ATP III classification table 105 Journal of military parmaco-medicine n07-2017 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 ) Thinness < 18.5 Normal range 18.5 - 22.9 Overweight Pre-obese 23 - 24.9 Obese class I 25 - 29.9 Obese class II ≥ 30 RESULTS Table 3: Age, sex Age group Male Female Total No % No % No % < 30 27 20.4 2.6 29 13.9 30 - 39 41 31.1 11 14.5 52 25.0 40 - 49 17 12.9 11.9 26 12.5 50 - 59 36 27.3 34 44.7 70 33.7 106 Journal of military phrmaco-medicine nO7-2017 ≥ 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 presentation (n = 208): of clinical * Location of herniation associated with level on MRI (n= 208): Mild: 27 patients (13.0%); moderate: 168 patients (80.8%); severe: 13 patients (6.2%); very severe: patient Herniated disc: L3-L4 and L4-L5: 77 patients (37.0%); L4-L5 and L5-S1: 108 patients (51.9%); L3-L4, L4-L5 and L5-S1: 57 patients (27.4%); L2-L3, L3-L4, L4-L5 and L5S1: 14 patients (6.7%); L1-L2, L2-L3, L3-L4, L4-L5 and L5-S1: patients (1.9%) Severity of clinical presentation was mainly moderate (80.8%) * Location of herniated intervertebral disc on MRI (n = 208): Combined herniation was often seen between level L4-L5 and L5-S1 herniation (51.9%) L1-L2: 14 patients (6.7%); L2-L3: 28 patients (13.5%); L3-L4: 81 patients (38.9%); L4-L5: 172 patients (82.7%); L5-S1: 138 patients (66.3%) * Types of disc herniation (n = 433): Herniation at L4-L5 were the highest: 82.7% Posterior central herniation: 234 patients (54.0%); posterior - lateral (right, left): 196 patients (45.3%); intravertebral disc herniation (Schmorl’s node): patients (0.7%); foraminal herniation: patient; simple anterior herniation: patient * Levels of herniation on MRI (n = 208): level: 76 patients (36.5%); levels: 65 patients (31.3%); levels: 45 patients (21.6%); levels: 18 patients (8.7%); levels: patients (1.9%) One level herniation was the highest (36.5%) The rates of 2, 3, and levels reduced gradually Posterior herniation was the most common, accounting for 99.3% Table 4: BMI classification of the patients BMI n = 208 % Thinness 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 Journal of military parmaco-medicine n07-2017 Table 5: Blood lipid test results Blood tests n = 208 % Optimal 105 50.5 Borderline high 69 33.2 High 34 16.3 Total cholesterol 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 High 74 35.5 LDL-C X ± SD 3.21 ± 1.29 Min - max 1.02 - 17.65 Optimal 89 42.8 Borderline high 37 17.8 High 82 39.4 Triglyceride 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 Clinical manifestation and MRI images of LIDH - Average age of the research subjects: 45.70 ± 13.96, cosistent with the findings by many authors that the average age of LIDH patients were above 40 years of age [2, 5] The average age of male patients was 41.96 ± 13.94, lower than that of female 108 patients (52.18 ± 11.48) This difference is statistically significant - Sex: male outnumbered female patients, male/female ratio = 1.74/1 Many other domestic and worldwide researches have shown constantly higher male rates than female [1, 3, 4, 5, 8] To explain this fact, some authors suggested that males often work as heavy load carrier, some others revealed that male lumbar spinal canel is Journal of military phrmaco-medicine nO7-2017 smaller than that of female, etc However, there has not been any solid basis affirming the above explanations - Severity levels: Moderate levels were the highest, accounting for 80.8% Le Thi Bich Thuy, Nguyen Van Chuong et al [2, 3] provided similar results to ours However, the rates of severe, very severe and mild levels are different between the researches The difference can be due to different goals of the research or different criteria employed for assessment and determination of severity levels - Herniation location: The most common at L4-L5 (82.7%) and L5-S1 (66.3%), which coincided with many other authors’ findings [2, 3] - Levels of herniation: Single herniation accounted for the highest rate (36.5%) Our research results were similar to many other authors’ findings [2, 3, 4] Jensen’s review of MRI films of 98 subjects without any low back pain symptoms had shown that most of the subjects with signs of herniation had single intervertebral disc degenerations (52%), 38% of subjects had at least double intervertebral disc degenerations [7] - Combination between the levels of intervertebral disc herniation: mainly occured between L4-L5 and other levels of intervertebral discs, of which the rate of combined herniation of L4-L5 and L5-S1 accounted for the highest (51.9%) Janardhana’s study on 119 patients found 75% at level intervertebral disc degeneration, of which 45% of patients had three and more intervertebral discs degeneration and also found 290 herniated intervertebral discs Hence, on average, each of the patients suffered from herniation of at least two discs [6] Pokhraj Suthar’s study on 109 patients also revealed the most frequent location of intervertebral disc herniation at L5-S1, the herniation was often combined, especially combined with L4-L5 [9] - Types of herniation: Mainly posterior herniation (99.3%), other types of herniation represented low rate Our research results complied with Nguyen Van Chuong’s and Tran Trung’s with posterior herniation of 96.06% and 91.0%, respectively [2, 4] The characteristics of BMI scores and blood lipid levels in LIDH patients - BMI score: Mean BMI score was 22.88 The rate of excessive body weight patients accounted for 46.1% In the study by Le Thi Bich Thuy, 27.58% of LIDH patients with BMI score of obese category [3] According to Longo’s research, the mean BMI score was 26.6 [8], Daghighi recorded high BMI score of 27.49 [5] Hence, LIDH patients in the worldwide studies had very high BMI scores This can be due to differences in body features of the Vietnamese and the other races in the world It is therefore recommended that there should be separated criteria to assess obesity levels of Vietnamese people In this research, we employ recommended criteria by WHO 2000 for Asian communities for nations with community nutritional problems to assess the obesity levels and that is why the outcome rates are different from other research worldwide 109 Journal of military parmaco-medicine n07-2017 - Blood lipid test results: Average total cholesterol was 5.31 ± 1.77 mmol/L Patients with high total cholesterol was 16.3% Average HDL-C: 1.17 ± 0.35 Patients with low HDL-C accounted for 37.5% Average LDL-C: 3.21 ± 1.29 mmol/L 35.5% of the patients suffered from high LDL-C Average triglyceride 2.68 ± 4.03 mmol/L Patients with increased triglyceride explained 39.4% Le Thi Bich Thuy’s research met 93.7% of patients with increased triglyceride and 79.2% with reduced HDL-C of the LIDH group with metabolic syndrome [3] Le Van Cuong’s study showed 39.2% of patients with lipid metabolism disorder; including increased total cholesterol of 35.3%, increased LDL-C of 31.4%, increased triglyceride of 28.4% and reduced HDL-C of 8.8% [1] Longo’s research [8] on 169 patients showed average total cholesterol of 5.59 mmol/L, which was higher than our results (5.31 ± 1.77); however, the average triglyceride was 1.82 mmol/L; which was much lower than our findings (2.68 ± 4.03) This difference can be due to different ethnicity and sample size up the highest rate (36.5%); combined double herniation of L4-L5 and L5-S1 were the most frequent (51.9%); posterior herniation was mostly observed (99.3%) Characteristics of BMI score and blood lipid levels in LIDH patients 46.1% of the LIDH patients in the study group had excessive body weight BMI score 16.3% of LIDH patients suffered from high total cholesterol; 37.5% with low HDL-C; 35.5% with high LDL-C; 39.4% with high triglyceride Average total cholesterol of LIDH was 5.31 mmol/L; average HDL-C: 1.17 mmol/L; average LDL-C: 3.21 mmol/L; average triglyceride: 2.68 mmol/L There needs more researches to assess the correlation between atherosclerotic risk factors with LIDH problems REFFERENCE Le Van Cuong Research on clinical, subclinical manifestation and some prognostic factors of LIDH Medical Master Thesis Military Medical Institute 2012 Nguyen Van Chuong et al Research on CONCLUSION lumbar intervertebral disc herniation at the Clinical manifestation and MRI images of LIDH Neurology Department, 103 Hospital Military Mean age of the subject group was 45.70; male had higher disease rates than female The male/female ratio was 1.74/1 Moderate severity accounted for the highest rate (80.8%) The most common location of intervertebral disc herniation was L4-L5 (82.7%); single herniation made 110 Medical Institute Military Medical and Pharmaceutical Magazine 2015, issue 3, pp.5-16 Le Thi Bich Thuy Research on clinical manifestation, MRI images and treatment for lumbar intervertebral disc herniation with metabolic syndrome Medical Master Thesis Military Medical Institute 2012 Journal of military phrmaco-medicine nO7-2017 Tran Trung Research on MRI images of LIDH Practical Medical Magazine 2006, issues 12, pp70-72 Daghighi M.H, Pouriesa M, Maleki M et al Migration patterns of herniated disc fragments: a study on 1,020 patients with extruded lumbar disc herniation The Spine Journal 2014, 14 (9), pp.1970-1977 Janardhana A.P, Rajagopal, Rao S et al Correlation between clinical features and magnetic resonance imaging findings in lumbar disc prolapse, Indian J Orthop 2010, 44 (3), pp.263-269 Jensen M.C, Brant-Zawadzki M.N, Obuchowski N et al Magnetic resonance imaging of the lumbar spine in people without back pain N Engl J Med 1994, 331 (2), pp.69-73 Longo U.G, Denaro L, Spiezia F et al Symptomatic disc herniation and serum lipid levels Eur Spine J 2011, 20 (10), pp.16581662 Suthar P, Patel R, Mehta C et al MRI evaluation of lumbar disc degenerative disease, J Clin Diagn Res 2015, (4), p TC04-9 doi: 10.7860/JCDR/2015/11927.5761 111 ... resonance imaging findings in lumbar disc prolapse, Indian J Orthop 2010, 44 (3), pp.263-269 Jensen M.C, Brant-Zawadzki M.N, Obuchowski N et al Magnetic resonance imaging of the lumbar spine in people... 119 patients found 75% at level intervertebral disc degeneration, of which 45% of patients had three and more intervertebral discs degeneration and also found 290 herniated intervertebral discs... Combination between the levels of intervertebral disc herniation: mainly occured between L4-L5 and other levels of intervertebral discs, of which the rate of combined herniation of L4-L5 and