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. 2013 Mar;22(3):515-20.
doi: 10.1007/s00586-012-2498-2. Epub 2012 Nov 21.

Dose response and structural injury in the disability of spinal injury

Mohammed Shakil Patel  1 , Philip Sell
Affiliations

Dose response and structural injury in the disability of spinal injury

Mohammed Shakil Patel et al. Eur Spine J. 2013 Mar.

Abstract

Introduction: In traumatic injury there is a clear relationship between the dose of energy involved, structural tissue damage and resultant disability after recovery. This relationship is often absent in cases of non-specific chronic low back pain that is perceived by patients as attributed to a workplace injury. There are many studies assessing risk factors for non-specific low back pain. However, studies addressing causality of back pain are deficient.

Purpose: To establish whether there exists a causal relationship between structural injury, low back pain and spinal disability.

Methods: Retrospective analysis of prospectively gathered validated spinal outcome measures [Oswestry disability index (ODI), low back outcome score (LBO), modified somatic perception (MSP), modified Zung depression index (MZD)] between patients with healed high energy thoracolumbar spinal fractures and patients with self-perceived work-related low back pain. Causality was established according to two of Bradford Hill's criteria of medical causality, temporal and dose-response relationships.

Results: Twenty-three patients with spinal fractures (group 1) of average age 44 years were compared to 19 patients with self-reported back pain in the workplace pursuing claims for compensation (group 2) of average age 48 years. Both groups were comparable in terms of age and sex. The average ODI in group 1 was 28 % (SD 19) compared to 42 % (SD 19) in group 2 (P < 0.05). Similarly, LBOS was 39.7 versus 24.3 (P < 0.05), MSP 4.3 versus 9.3 (P < 0.05) and MZD 20.2 versus 34.8 (P < 0.05) in groups 1 and 2, respectively.

Conclusion: Despite high-energy trauma and significant structural damage to the spine, patients with the high energy injuries had better spinal outcome scores in all measures. There is no 'dose-response' relationship between structural injury, low back pain and spinal disability. This is the reverse of what would be anticipated if structural injury was the cause of disability in workplace reported onset of low back pain.

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Figures

Fig. 1
Fig. 1
Frequencies and levels of thoracolumbar spinal fractures
Fig. 2
Fig. 2
Mean outcome values with 95 % CI between the two groups
Fig. 3
Fig. 3
Dose–response relationship. The dose–response relationship may be linear or more commonly show a sigmoid-shaped curve with a threshold relationship. Before the threshold is reached there is no significant tissue damage with an increasing effect with increasing dose and finally a maximal effect
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