title: Are "patterns" of lumbar disc degeneration associated with low back pain?: new insights based on skipped level disc pathology.
abstract: METHODS
  A cross-sectional, population-based cohort study.
  
  
  OBJECTIVE
  The objective of this study was to evaluate the clinical relevance of skipped level disc degeneration (SLDD) to that of contiguous, multilevel disc degeneration (CMDD) of the lumbar spine. The study also aimed to identify patterns of SLDD, its classification, prevalence, and clinical relevance.
  
  
  BACKGROUND
  The association of disc degeneration on magnetic resonance imaging with low back pain (LBP) remains questionable. The occurrence of SLDD of the lumbar spine has recently been noted. To date, patterns of disc degeneration have been overlooked in the association with low back symptoms.
  
  
  METHODS
  A population-based radiographic and clinical study of 3099 Southern Chinese patients. Individuals with multilevel disc degeneration of the lumbar spine on sagittal T2-weighted magnetic resonance imaging (N = 1457) were stratified to SLDD (n = 301; 20.7%) or CMDD (n = 1156; 79.3%) groups. SLDD was further classified into 5 types by the relative location of nondegenerated normal disc(s) to degenerated disc levels. Subject demographics, presence of LBP, pain intensity, and functional disability were assessed.
  
  
  RESULTS
  In the multivariate analyses, CMDD increased the likelihood of historical LBP (odds ratio [OR]: 1.39; 95% confidence interval [CI]: 1.00-1.93; P = 0.047) and pain severity (OR: 1.83; 95% CI: 1.23-2.73; P = 0.003) in comparison with SLDD. A significant increasing trend of number of levels with disc degeneration, overall disc degeneration severity, and presence of disc bulges/extrusions was noted from SLDD type I (least severe) to SLDD type V (most severe) (P < 0.05). A higher prevalence of LBP and a higher pain intensity were observed in SLDD classification type V. Functional disability scores did not differ between CMDD and SLDD, nor within SLDD classification types (P > 0.05).
  
  
  CONCLUSIONS
  Our large-scale study is the first to describe novel variants of SLDD types and their clinical relevance. More important, LBP and severity of pain were more pronounced in individuals with CMDD rather than those with SLDD. Our study suggests that subjects with a similar degree but different patterns of multilevel disc degeneration do differ with respect to low back symptoms. This finding may provide new evidence with regard to the mechanism of LBP.
authors.affiliation: Department of Orthopaedics and Traumatology, University of Hong Kong, Hong Kong, SAR, China.
authors.forename: Kenneth M C
authors.initials: KM
authors.lastname: Cheung
authors.forename: Dino
authors.initials: D
authors.lastname: Samartzis
authors.forename: Jaro
authors.initials: J
authors.lastname: Karppinen
authors.forename: Keith D K
authors.initials: KD
authors.lastname: Luk
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D055959:Intervertebral Disc Degeneration / Q000000981:diagnostic imaging* / Q000473:pathology / Q000503:physiopathology; D017116:Low Back Pain / Q000000981:diagnostic imaging* / Q000473:pathology / Q000503:physiopathology; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging* / Q000473:pathology / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012720:Severity of Illness Index; D011795:Surveys and Questionnaires