Association between Age, Gender and Body Mass Index with MRI findings and
postoperative outcome in patients with Lumbar Disc Herniation
Purpose: We studied patients with lumbar disc herniation (LDH) and the possible association between
MRI findings and postoperative outcome with age, gender and body mass index (BMI).
Materials and Methods: This study included 67 patients (45 men, 22 women, mean age 42.68 years,
range 18-71 years) with lumbar disc herniation. In 6 cases the disc herniation as located at L3/4 level,
in 39 at L4/5, in 27 at L5/S1. In 24 cases there was a sequestration, in 35 an extrusion and in 8 a
protrusion of the disc. The disc degeneration was classified in 5 degrees according to MRI findings.
The lesions in terminal plates were classified in 3 degrees. Pain was assessed with the Visual Analogue
Scale (VAS) pre- and postoperative.
Results: Fifty patients were treated with microdiscectomy and 17 with laminectomy. The average BMI
was 26,65. Obese patients had greater degeneration of the intervertebral discs (p=0.04). There was not
a significant association between gender and age with disc degeneration score (p=0.06 and p=0.2
respectively). There was an association tendency with pain (p=0.057). Postoperatively there was a
statistically significant correlation of pain (according to VAS score) with Body Mass Index (p=0.04).
Conclusions: BMI is associated with the intervertebral disc degeneration score. Obese patients are
presented with more degenerated discs and were characterized by more severe symptoms and less
satisfactory improvement in comparison to patients with normal BMI and overweight.
Introduction
Intervertebral disc herniation has been claimed to be caused by failed nutrient supply to the disc. 56
Diffusion of fluid is the primary mean of nutrient and glucose transport into and out of the avascular
intervertebral disc, onto which its metabolism depends. Because there is prolonged low glucose
concentration disc cells do not survive.57,58 Increased cell death is the first degenerative change
observed, along with cleft and radial tear formation, and cracks in the endplates. Changes can be seen
already at 11 years of age. At that point, the vessels penetrating into the disc through the endplates are
obliterated and the discs start to become avascular.31 At molecular level, there is a loss of
proteoglycans, which leads to disk degeneration and desiccation.32,33 MRI is a useful diagnostic tool for
desiccation as it can be seen as decreased signal intensity of the nucleus pulposus. Gradual formation of
osteophytes, disc narrowing and spinal stenosis typically follow as the time lapses. 59,60 A high
prevalence of disk degeneration is already present in adolescence or early adulthood as it appears from
MRI and histological studies.33-37 Although, there is a high prevalence of disc degeneration among
asymptomatic subjects which questions its clinical relevance.54,55 However many symptoms such as
neck pain or low back pain may be caused by disc degeneration. 61-64
The aim of this study is to assess the correlation of age, gender and body mass index with MRI findings
and postoperative outcome in patients with lumbar disc herniation.
Methods
Participants
We conducted a clinical study of 67 patients that underwent surgery and were hospitalized afterwards
in our Neurosurgery Clinic at the University Hospital of Ioannina. We included patients that had
surgery and were hospitalized for Lumbar Disc Herniation from September 2010 to June 2016. The
inclusion criteria were presence of data and willingness to participate to the study.
The following data were collected throughout the study: age, gender, Body Mass Index (BMI), Level
of the Herniation, Disc Herniation Score (Extrusion, Protrusion and Sequestration), Disc Degeneration
Score (Grades 1-5), Endplate Classification (Grades 0-2), Symptoms (Sciatica and οσφυαλγία),
Surgical Intervention (Microdiscectomy, Petalectomy, Hemipetalectomy) Comorbidities (previous
surgery, hypertension, diabetes mellitus, heart disease, hyperuricemia, atrial fibrillation,cerebrovascular
diasease, dyslipidemia, trauma, smoking, other malignancies and alcohol consumption), Visual
Analogue Scale (VAS) pre- and postoperative.
We included forty-five men and 22 women (Figure 1) from 18 years to 71 years of age (Figure 2&3).
We did not include other demographic features of the patients to the present study. Symptoms included
sciatica for 1 patient and pain in the lumbar region of the spine for 21 patients, while we had no data
for 2 patients. Which means that we had 43 patients with both sciatica and pain in the lumbar region of
the spine (Figure 4).
MRI
We used our MRI machine of the hospital (1.5 T, Ioannina, Greece) in this study to determine the
lesions on the intervertebral discs. The participants were supine during the MRI.
Methods used to study each variable
The Disc Herniation Score was calculated as mentioned below. A disk was considered protruded if the
greatest plane in any direction between the edges of the disk material beyond the disk space was less
than the distance between the edges of the base when measured in the same plane. A disk was
considered extruded if, in at least one plane, any one distance between the edges of the disk material
beyond the disk space was greater than the distance between the edges of the base measured in the
same plane. A sequestrated disk herniation was diagnosed when the herniated disk material was clearly
separate from the originating disk or when the signal intensity of the herniated material was different
from that of the originating disk.
The Disc degeneration Score was determined as mentioned below . Grade I indicates the presence of a
homogeneously hyperintense nucleus pulposus that is clearly distinct from the hypointense outer
annular fibers. In grade II degeneration, the nucleus pulposus is inhomogeneous, and horizontal
hypointense bands may be present in a sandwich like configuration. In grade III degeneration, the inner
parts of the disk are inhomogeneous and have intermediate signal intensity. In grade IV degeneration,
the distinction between the inner and outer parts of the disk is lost, and the inner parts of the disk have
intermediate or low signal intensity. In grade V degeneration, the disk is collapsed.
The Endplates were classified according to the MRI findings. So we have 3 grades,(1) no abnormality,
(2) low signal intensity on T1-weighted images and high signal intensity on T2-weighted images in
comparison with the intensity of normal fatty bone marrow (high signal intensity type I), or (3) high
signal intensity on both kinds of images (high signal intensity type II).
The Visual Analog Scale (VAS) consists of a horizontal line 100 mm in length, with one end
mentioning ‘‘No pain’’ and the other ‘‘Worst imaginable pain’’. Based on that patients were asked to
mark a point at this line that best represents the intensity of pain they were experiencing pre- and
postoperatively (Figure 10).
Results
From the included patients 26,5% reports hypertension, 6,25% diabetes mellitus, 6,34% dyslipidemia,
1,56% had atrial fibrillation, 1,61% reported previous trauma and nobody reported heart disease,
hyperurecemia and cerebrovascular disease. Fifty-nine point two percent were smokers, 24,48% dinked
socially and 29,85% has had a previous surgery (not for lumbar disc herniation)(Figure 5). Also BMI
was calculated as BMI= weight (kg)/ height2(m2) and the average was 26,65 (Figure 2&3). As far as
the level of herniation is concerned, six patients had the lesion on L3/4 level, 39 at L4/5 level and 27 at
L5/S1 level(Figure 6). Thirty-three patients had a lesion on the left side of the vertebral disc, 31 had the
lesion on the opposite side and 4 patients had lesions on both sides while we (Figure 7). Eighteen
patients were treated by petalectomy, 2 with discectomy, 8 by hemipetalectomy, 4 by partial
petalectomy and 38 by microdiscectomy (Figure 8).
The lesions as were classified with the Disc Herniation Score: twenty-four patients had sequestration,
35 had extrusion and 8 had protrusion(Figure 9). The lesions as classified with the Disk Degeneration
Score: seven patients had grade 1 lesion, 13 patients had grade 2 lesion, 23 patients had grade 3 lesion,
21 patients had grade 4 lesion and 3 patients had grade 5 lesion(Figure 11). The Endplates
Classification: Fifty-five patients had no lesions, five patients had high signal intensity type I lesion
and 7 patients has high signal intensity type II lesion(Figure 12).
The VAS score preoperatively: Two patients had 4, 3 patients had 5, 5 patients had 6, 12 patients had 7,
14 patients had 8, 14 patients had 9, 13 patients had 10 while we have no data about 4 patients. The
VAS score postoperatively: Two patients had 1, 5 patients had 2, 6 patients had 3, 7 patients had 4, 3
patients had 5, 6 patients had 6, 2 patients had 7 while we have no data about 36 patients.
From the data analysis we concluded that obese patients had greater grade lesions in the intervertebral
discs (p=0.04). There was no connection between gender and age with the grade of lesions (p=0.06 and
p=0.2 respectively). As far as the pain is concerned, there was a correlation tendency (p=0.057).
Postoperatively there was a significant correlation between pain and BMI (p=0.04).
Conclusions
Association of LDH with BMI
We concluded that BMI is related with the observable lesions at the intervertebral discs. Obese patients
present with more severe lesion and symptoms, less satisfactory improvement in comparison to normal
BMI patients and overweight. We found in international literature that BMI was significantly
associated with the severity of lumbar disc degeneration among 83 Southern Chinese subjects among
13-20 years old, while smoking was not and their sample size did not allow gender stratification. 38 In
one Finnish study39 BMI was associated with disc degeneration among males, in individuals born in
1986. Individuals were assessed while they were 16 and 19 years old to study this association. Same
results came from another study in Finland, where association was found between persistent
overweight in 25 and 40-45 years and lumbar disc degeneration in L2/3 and L4/5 in MRI. 40 BMI was
also associated with disc degeneration in a Dutch study only when disc degeneration was not present at
baseline.41 Summing, some studies with cross-sectional designs that studied overweight and disc
degeneration found either positive38,42 or negative43 association. In some studies BMI was associated
with specific phenotypes of disc degeneration, such as spondylolysis and Modic changes. 44-47 Among
weight-disconcordant twins, overweight possibly leads to slow adaption to mechanical loading and thus
lesser desiccation.48 However another British twin study disputes these results. 49
The possible mechanism through which BMI and disc degeneration may be connected is low-grade
systemic inflammatory state. A process caused by obesity and causes or accelerates disc
degeneration.50,51 However gene-environmental factor interactions, such as obesity and the COL9A3,
cannot be excluded either.52 Recent study supports the detrimental effect of overweight on
intervertebral discs’ well-being. This study correlates overweight with histological degenerative
abnormalities.53
Obesity has been associated with patient satisfaction in total knee replacement, total knee arthroplasty
for osteoarthritis,27- 29 and surgery for spinal stenosis.30 Hui Wang et1 al reports that obesity is
significantly and independently associated with patients’ postoperaive satisfaction. Also the magnitude
of obesity can be assessed preoperatively through Body Mass Index (BMI). Other factors such as age
or gender didn’t act as cofounders in this study. A widely held impression, that obesity is a risk factor
for poor postoperative satisfaction, is also confirmed. This can be explained by either of the two
hypotheses. First, there is a potential negative predisposition of many healthcare providers towards
obese people, they often assume that obese people lack of motivation and are lazy. 2,3 Patients expect
this discrimination based on weight and in this way a general stigma of obesity is created, 4 which in
turn may predispose towards depressive symptoms. Secondly it is also known that obesity may reduce
functioning and decrease range of motion, which may affect the effectiveness of surgery. However
obese patients can be benefited from surgery and the results are equivalent to those of patients with
lower BMI.
Association of LDH and GENDER
We observed a possible correlation between gender and lesions severity but because of the small
sample we did not observe a statistical significant correlation. Apart from that in an elderly population,
lumbar disc herniation tend to be a little more severe in female patients than in their male
counterparts.66 While at the same time in a study in cadavers there was more degeneration present in
male discs than in female ones.67
Association of LDH and AGE
It is widely accepted that lumbar disc degeneration’s incidence increases with age. This is a general
view which is supported by some studies.65 We did not come to that conclusion to our study possibly
due to our limitations mainly in the size of the studied group.
The ages predominantly studied for lumbar disc herniation are between 40-45 years, this is not
surprising as the individuals most often affected are in their early 40s. 5 Older individuals really have a
diminished incidence.6 These few studies that were conducted in the age group older than 45 years
have found a satisfactory outcome from the surgical treatment.7-15 There have been some comparative
studies between elderly patients and younger ones, which showed a better outcome in the latter group.
7,8,11-15
However these results are extracted from retrospective or small perspective studies, so this
created a debate in the subject. Strömqvist, Fredrik, et al16 retrospectively analyzed the data and
reached to some conclusions. Elderly patients when they are referred for surgery have a significant
worse quality of life and worse clinical status than young and middle aged patients. Surgery proved to
be less beneficial for elderly patients than their young and middle aged counterparts. Neither group
came back to normative age- and sex-matched values for quality of life with no dissatisfaction. The
reasons are unclear but the patient’s age played an important role in choosing a surgical procedure due
to increasing risk of complications with age. Rendering older individuals more prone to complications
than young and middle-aged ones in LDH surgery, mostly urinary tract infections and cardiovascular
complications- but not surgical related.9 However some studies concluded in a different result 12,18,19
and found complications such as durotomy to be more frequent. This fact does not have significant
relationship with surgeon’s expertise and clinics’ degree of specialization as spine-specialized units do
not have a smaller complication rate than less experienced ones.12,16,20 Another interesting result is that
elderly patients are more often operated in higher lumbar segments. 13,14,16
The data for the outcome of LDH surgery is conflicting. One retrospective study, which is the largest
published, found good outcome in 78 elderly patients without however validated PROMs. 12 Another
retrospective evaluation using the Japanese Orthopedic Association (JOA) score reports similar
improvement in 12 individuals above age 65 and 25 below. 21 Other studies have reached a contrary
result and found that persistent back pain is present in 20-30% of elderly patients with LDH
surgery.12,20 Another study that came to a similar result concluded that elderly patients have worse
clinical outcomes since they present with more sever clinical problems than their young and middleaged counterparts.16 From this information we may speculate that the worse PROM outcome value and
the subjective satisfaction after the surgery may be influenced by elderly patients’ acceptance of worse
health status, which is supported by nominative data that show inferior scores in older patients. Error!
Reference source not found.,22
Why children, adolescentsError! Reference source not found.,24 and young adults25 have more improvement than
elderly is unknown. Several animal models have be speculated26 but the etiology in human remains to
be identified.
Limitations
Our study suffers some limitations so we cannot extract many conclusions. First of all, our study group
composed of a total 67 patients with Lumbar Disc Herniation which is apparently small. This is
possibly the reason we did not reach statistical significant correlations. Another drawback of our study
group is the missing data. We had to exclude many patients from the study group because their data
were incomplete or absent in their clinical files.
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Gender
Female
33%
Male
67%
Figure 1. Gender of the patients group
80
70
60
50
Age
40
BMI
30
20
10
0
80
71
70
60
50
42.68
40
38
30
26.65
20
19
18
10
0
Age
Figure 2&3. Age and BMI
BMI
Symptoms
Sciatica
Οσφυαλγία
Οσφυαλγία and sciatica
No data
Figure 4. Symptoms
Comorbidities
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Hyperte Diabetes Dyslipid Atrial Previous Smokers Previous Social
nsion mellitus
emia
fibrillati trauma
surgery
drink
on
NO 73.50% 93.75% 93.66% 98.44% 98.39% 40.80% 70.25% 75.52%
YES 26.50%
Figure 5. Comorbidities
6.25%
6.34%
1.56%
1.61%
59.20%
29.85%
24.48%
Level
40
35
# of patients
30
25
20
15
10
5
0
L3/4
6
Level
L4/5
39
L5/S1
27
Figure 6. Level of lesion
Side
Both
Left
Right
Figure 7. Side of the lesion
Surgical procedure
Petalectomy
Discectomy
Hemipetalectomy
Partial Petalectomy
Microdiscectomy
Figure 8. Surgical procedure
Disc Herniation Score
Sequestration
Protrusion
Extrusion
Figure 9. Disc Herniation Score
VAS Score
Worst
imaginable
pain
No pain
Figure 10. VAS Score
Disc Degeneration Score
25
20
15
10
5
0
Disc Degeneration Score
Figure 11.Disc Degeneration Score
Grade I
7
Grage II
13
Grade III
23
Grade IV
21
Grage V
3
Endplates Classification
60
50
40
30
20
10
0
Endplates Classification
No lesion
55
High signal
intensity type
I
5
High signal
intensity type
II
7
Figure 12. Endplates Classification
Study group characteristics
Age (Mean/Range)
Gender (Male/Female)
BMI (Mean/Range)
Comorbidities
Hypertension
Diabetes Mellitus
Previous Surgery
Atrial fibrillation
Dyslipidemia
Previous Trauma
Smokers
Social Drinkers
Table 1. Study Group Characteristics
46.68 years/ 18-71 years
45/22
26.65/19-38
26.5%
6.25%
29.85%
1.56%
6.34%
1.61%
59.2%
24.48%