RELATION BETWEEN DXA AND VITAMIN D3 WITH LYTIC SPONDYLOLISTHESIS TYPE 2 AMONG URBAN

POPULATION OF INDIA- A PILOT STUDY.

DR.SUHASISH RAY- Consultant Orthopaedic and Spine Surgeon- Ramakrishna Mission Seva Pratishthan

and Woodlands Multispeciality Hospital

DR.SUVANKAR MUKHERJEE- Associate professor- Community Medicine and Epidemiology- WBUHS.

ABSTRACT:

Objective: We aimed to examine the relation between the levels of vitamin D, T and Z score

through Dexa BMD in patients with chronic low back pain (CLBP) and to investigate which of

Vit D3 or Dexa Bmd is an essential investigation for LBP .

Methods: 298 patients (female/male: 153:145) with CLBP, aged between 20 and 60 years (mean

age:45.05 ± 8.14), participated in the study. Patients were classified into three groups based on

their serum vitamin D levels and T score and Z score : normal Vitamin D (30 ng/ml), T score (0

to -1), Z score( 0 to -1). All the three groups were subjected to one way ANOVA, Friedman”s

two way ANOVA, Independent sample Kruskall – Walli’s test.

Results: We found Vitamin D estimation by immunoassay technique a better investigative

method than T and Z score estimation through Dexa BMD.

Conclusion: Vitamin D deficiency may lead to lower functional capacity, musculoskeletal

functional impairment and Low Back Pain and clinically, Vit D levels should be checked in

musculoskeletal pain patients at risk of Vit D deficiency.

Level of Evidence: Level IV, Retrospective diagnostic study.

Key words: Vitamin d3; T score; Z score; Chronic Back Pain; retrospective cohort study.
INTRODUCTION:

Low back pain is one of the most prevalent complaints in musculoskeletal pain, and is a serious

condition that may result in loss of functionality as well as labor.(1). In chronic cases, by

producing a number of pathological changes as well as spondylolisthesis (Fig1 and2), it may lead

to difficulty in the performance of routine tasks.[4] In their studies, Russel et al observed muscle

atrophy in patients with vitamin D deficiency, and the biopsies they conducted on atrophic

muscles provided evidence that atrophyrates were significantly higher in type II-a muscle

fibers.(2). A review of the relevant literature reveals that research into the relationship between

chronic musculoskeletal pain and vitamin D are few in number, with contradictory findings.

AIMS AND OBJECTIVES

To assess the requirement for DEXA BMD and Vitamin D3 in Low back Pain with or without

Spondylolisthesis. Also to see if any or all of the factors Age, Body Weight , T score, Z score

and Vitamin D3 have a role as a causative for Low Back Pain with or without Spondylolisthesis.

PATIENTS AND METHODS:

In this study, laboratory data and files belonging to 298 patients who attended our clinic for

CLBP over the period of November 2012 to December 2017 were retrospectively analyzed.

Patients aged 20 to 60 yrs who had lower back pain for more than 3 months were included in the

study. The patients were put into three groups according to their result estimation-Vit D3, T

score, Z score. Patients with a history of severe trauma such as fall from height or traffic

accident, stroke, spinal surgery, diabetes, malignity, chronic inflammatory lower back pain, or

prolonged use of analgesics or antidepressants were not included in the study sample. In

addition, patients with clinical findings indicating a serious pathology (red flags), or with
abnormal levels of hemogram, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP),

calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), urea, creatinine, aspartate

aminotransferase (AST), alanine aminotransferase (ALT), serum T3, T4, thyroid stimulating

hormone (TSH), or parathormone (PTH) were excluded from the sample. Vitamin D levels were

measured for each patient as well as T and Z score by BMD DEXA scan method only for the

Lumbar spine. Patients were classified according to three categories- Vit D estimation(n=111), T

score estimation (n=98), Z score estimation(n=89). Findings were expressed in mean and

standard deviation (mean ± sd) . Non lytic low back pain subjects without any organic pathology

in radiology or otherwise investigations were taken as cohorts. (Table1).

RESULTS:

PLUM-Regression test taking the variables Age, Sex, Body weight in Kg, T score , Z score,

Vitamin D3 and Type 2 spondylolisthesis (A or B) was non significant (p>0.05) with confidence

interval 0f 95%. Chi- square test was also non significant (p>0.05) for the case series. Reliability

of the tests were 100% using Chronbach’s alpha test. Mann-Whitney U test in this non

parametric retrospective cohort series Age and body weight doesn’t have any significant relation

(p=0.000),(0.021) whereas T score and Z score and vit d3 does have a significant relationship

with Spondylolisthesis Type 2 (p=0.661, p=0.807, p=0.700). (Table 2).

When comparing with a cohort series age has no significant relation (p=0.134) with low back

pain females and males have significantly (p=0.498) similar intensity of pain beyond 60 years of

age,T score (p=0.537) and Z- score (p=0.759) have no relation to the intensity of low back pain

in individuals above 60 years, whereas significantly low (p=0.000) Vitamin D3 is definitively

related to intensity of pain in elders..

DISCUSSION:

Low back pain has a multifactorial origin; mechanical, hereditary, and hormonal factors are all believed

to play a role. Both gravitational and postural forces, acting upon the upright spine, place stress on the

bone and ligamentous structures, making it susceptible to injury. It has been shown that fatigue

fractures develop occassionally. Age, sex body weight , osteoporosis or osteomalacia have significant

contribution to back pain so does microfractures of the pars interarticularis leading to isthmic

spondylolisthesis..In the general population, the reported incidence in near relatives is approximately 25

to 30% [9;5;7;8]. With regard to sex, isthmic spondylolisthesis occurs twice as often in males as females.

Females, however, are fourfold more likely to suffer progression of the slippage. 24 to 70% of isthmic

spondylolisthesis cases, associated spina bifida occulta may be present.[10; 5;8;11]. Gymnasts and

weight lifters, the mean incidence of pars defects is higher.

CONCLUSION:

In this cohort series it is thus concluded Lytic Spondylolisthesis both Types A and B Vitamin

D3 is inevitable to be estimated for both sexes and in any age , but T and Z scores measured by

DEXA BMD have no importance in estimating the cause of Lytic spondylolisthesis. Comparing

with Low back pain cohorts T and Z scores have no relation to detect the cause of the pain so

BMD is not to be considered an essential diagnostic tool for Low Back Pain with or without

Spondylolisthesis. Vitamin D deficiency may lead to lower functional capacity, musculoskeletal

functional impairment and Low Back Pain and clinically, Vit D levels should be checked in

musculoskeletal pain patients at risk of Vit D deficiency.

Fig 1-

Fig 2
DEMOGRAPHY OF PATIENTS

TYPE
MALE=1 1-134 n=298
TYPE2-
FEMALE=2 164 M:F=145:153

MALE=1 TYPE 1-134 n=298

FEMALE=2 TYPE2-164 M:F=145:153
21 -1.3 -2.6
15 -2.5 -2.3
45 -1.8 -2.8
38 -2.5 0
11 -1.8 -1.2
27 -1.3 -2
45 -1.8 -2.8
31 0.2 -2.2
22 -4 -1.2
16 -2 0.2
25 -1.2 -0.9
44 0.2 -2.2
19 -1.6 -2.8
37 -1.4 -0.2
21 -1.2 -1.1
47 -1 -2.8
56 -1.8 -1.2
23 0.1 -1.2
10 -2.3 -2.2
49 -1.3 -2.6
34 -1 -2.5
11 -0.1 -1.1
27 -0.9 0.8
22 -1.2 -1.1
18 -3.4 -1.2
45 -2.3 0
22 -1.3 -1
23 -0.8 -2.5
47 -1.3 -1.6
46 -3.1 -1.6
67 -0.6 -1.8
58 -2.4 -0.8
45 -4.6 -0.9
27 -1.8 0
34 -1 -1.8
29 -2.9 -2.3
45 -1.4 -1.9
33 -2.7 -2.2
11 -2.5 -0.6
18 -1.6 -1
18 -0.8 -1.6
20 -2.5 -2
21 -1.8 -1.2
22 -4.8 -2.2
34 -2.2 -0.6
23 -1.1 0.4
45 -1.1 -1.1
23 -2.6 -0.6
32 -1.8 -1.8
11 -2.1 -1.8
8 -1.2 -2.6
12 -1 -0.8
34 -2.2 -0.3
22 -2.2 -0.8
46 0.1 0
22 -2.7 -1.3
32 -3 0
18 -2.5 1.4
22 -1.8 -1
48 -2.8 1.4
35 -2.4 -1.1
27 -2 1
18 -2.2 -1.6
11 -1.9 -1.3
8 0.1 -1.2
34 0.1 -2
38 -3 -1.2
26 -1.3 -0.9
44 -1 -0.8
21 -1 -1.7
19 -1.4 -2.6
44 -2.2 -1.2
27 -2.9 -2.1
22 -1.1 0.5
29 -1 -1.8
18 -1.2 0.5
49 -2.8 -1.9
 24 -2.4 -0.4
34 -1 -1.8
56 -2.7 -1.3
9 -2.5 -1.3
17 -2 0.9
29 -1.6 0.1
44 -1 -0.4
21 -1 -2.7
6 -2.5
26 -1.8
6 -1.7
34 -2.4
45 -2.8
13 -0.3
33 -1.7
11 -0.7
8 -1.3
10 -1
35 -2.5
22 0
43 -2.5
32
16
24
35
44
34
22
57
25
18
11
28
38

TABLE 2: RESULTS

T
AGE SCORE Z SCORE VIT D3 BW
10.937 1.069 1.153 12.769 8.469 ST DEV(Ca)
-
45.86 -1.97 1.16667 27.58 49.888 MEAN(Ca)
 10.91 1.063 1.08 11.862 7.679 ST DEV (Co)
45.841 -1.575 -1.179 26.65 50.59 MEAN(Co)

REFERENCES:

1. Atkinson JH, Slater MA. Behavioral medicine approaches to chronic low back pain. In:

Rothman RH, Simeone FA, eds. The Spine. Philadelphia: WB. Saunders Company;

1992:1961e1981.

2. . Russell JA. Osteomalacic myopathy. Muscle Nerve. 1994;17(6):578e580.

3. Farfan HF, Osteria V, Lamy C: The mechanical etiology of spondylolysis and spondylolisthesis. Clin

Orthop 117:40–55, 1976.

4. Grobler LJ, Wiltse LL: Classification, non-operative, and operative treatment of spondylolisthesis, in

Frymoyer JW (ed): The Adult Spine: Principles and Practice. New York, Raven Press, 1991, Vol 2, pp

1655–1704.

5. Wiltse LL, Rothman SLG: Spondylolisthesis: classification, diagnosis, and natural history. Semin Spine

Surg 1:78–94, 1989

6. Wiltse LL, Widell EH Jr, Jackson DW: Fatigue fracture: the basic lesion in isthmic spondylolisthesis. J

Bone Joint Surg Am 57:17–22, 1975.

7. Wiltse LL, Winter RB: Terminology and measurement of spondylolisthesis. J Bone Joint Surg Am

65:768–772, 1983

8. Winter RB, Moe JH, Wang JF: Congenital kyphosis. Its natural history and treatment as observed in a

study of one hundred and thirty patients. J Bone Joint Surg Am 55:223–256, 1973

9. Newman PH: Degenerative spondylolisthesis. Orthop Clin N Am 6:197–198, 1975.

10.Grobler LJ, Wiltse LL: Classification, non-operative, and operative treatment of spondylolisthesis, in

Frymoyer JW (ed): The Adult Spine: Principles and Practice. New York, Raven Press, 1991, Vol 2, pp

1655–1704.
11. Saraste H: The etiology of spondylolysis. A retrospective radiographic study. Acta Orthop Scand

56:253–255, 1985.

12. Hensinger RN, Lang JR, MacEwen GD: Surgical management of spondylolisthesis in children and

adolescents. Spine 1: 207–216, 1976.