Radiological signs of Scheuermann disease and low back pain: retrospective categorization of 188 hospital staff members with 6-year follow-up

Abstract

Study design: Retrospective cohort study.

Objective: To investigate the relationship between radiological signs of Scheuermann disease (SD) and low back pain (LBP) in a local population using lumbar magnetic resonance (MR) images.

Summary of background data: SD is a spinal disorder, and both its classic and atypical (lumbar) forms are associated with LBP. However, radiological signs of SD are present in 18% to 40% of the general population, in whom the clinical significance of "SD-like" spine remains largely unknown.

Methods: This retrospective cohort study included 188 staff members from a single hospital. Participants' lumbar MR images and self-administered questionnaires concerning demographic information, LBP status, consequences, and functional limitations were collected. Participants were classified into 2 groups according to whether lumbar MR images met SD diagnostic criteria, and LBP status, consequences, and functional limitation were compared. Follow-up interviews were conducted after 6 years to compare LBP progression.

Results: Thirty-four participants (18.1%) had SD-like spine. Rates of lifetime, previous 1-year, and point LBP did not significantly differ between groups. However, among participants who had ever had LBP, SD-like spine was associated with higher rates of work absence (42.1% vs. 9.5%, χ = 9.620, P = 0.002) and seeking medical care (68.4% vs. 39.2%, χ = 5.216, P = 0.022) due to LBP, as well as significantly greater intensity of the most severe LBP episode in the past 2 years (6.4 ± 2.5 vs. 4.1 ± 2.5, t = 3.564, P = 0.001). Among the 159 participants who completed the 6-year follow-up, a significantly higher proportion of people with SD-like spine reported aggravated LBP during the follow-up.

Conclusion: Our results suggest that in the general population, lumbar MR images of many people meet SD diagnostic criteria, and having SD-like spine seemed to be associated with the severity and progressive nature of LBP. Our findings should inspire further research in this field.

Level of evidence: 3.

Figure 1.

What makes up “Scheuermann disease”? The definition of SD is not uniform or fixed. Instead, it depends on the form being referred to and a corresponding combination of pathological changes. Classic SD (the upper surface of the cube) is characterized by K and 3 or more WV occurring in the TS. Atypical SD (the left surface) tends to occur in the LS, and patients typically have 1 or 2 WV and lack notable kyphosis, but have characteristic disc/endplate lesions, including SN, IE, and DSN. The 2 forms often overlap in the same patient (the right surface). This comprehensive definition of SD has been accepted by many authors: as of December 31, 2013, a literature search revealed 15 studies (15 national flags representing the nationalities and locations of the primary authors, Table 1) that included specific criteria for diagnosing atypical or lumbar SD. We searched PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) for articles published in English, with the terms “atypical” and “lumbar” in successive combination with the terms “Scheuermann” and “Scheuermann's” in the title/abstract. This search strategy revealed 115 articles, from which these 15 were identified on the basis of the criterion mentioned in the earlier text. SD indicates Scheuermann disease; K, kyphosis; WV, wedged vertebrae; TS, thoracic spine; LS, lumbar spine; SN, Schmorl node; IE, irregular endplate; DSN, disc space narrowing.

Figure 2.

Lumbar MR classification of “Scheuermann (SD)-like” and non–SD-like participants. Left image. This participant has 3 consecutive more than 5° WV (T12–L2) and was identified as “SD-like” according to Sorensen criterion. Middle image. This participant has SN (yellow arrow) and IEs (orange arrows). Although only 2 WV (T12 and L2) were observed, WV, SN, and IE were simultaneously present in lumbar MR images. Therefore, she was also identified as SD-like, according to the modified Heithoff criteria. Right image. This participant has no Scheuermann signs and was classified as non–SD-like. WV indicates wedged vertebrae; SN, Schmorl node; IE, irregular endplate; SD, Scheuermann disease; LS, lumbar spine; MR, magnetic resonance.

Figure 3.

The level distribution of Scheuermann signs in SD-like spine. These signs were clustered in the thoracolumbar junction area between T10–T11 and L2–L3 and sparse in the lower lumbar region. SD indicates Scheuermann disease; SN, Schmorl node; IE, irregular endplate; WV, wedged vertebra.

Figure 4.

Causes of LBP in SD-like LBP sufferers and in non-SD-like LBP sufferers. SD indicates Scheuermann disease; LBP, low back pain.