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Link Between Atherosclerosis and Degenerative Disc Disease

Interview with W. Jeremy Beckworth, MD

Research is beginning to shed light on how cholesterol levels and vascular disease correlates with spinal complications, including degenerative disc disease (DDD).

“It’s something that people don’t always realize, that there may be an association between vascular disease and a spine issue,” W. Jeremy Beckworth, MD, an assistant professor of orthopedics at the Emory University School of Medicine in Atlanta, Georgia, told Practical Pain Management.

CTA in a normal patient (A) and a patient with severe atherosclerosis in the abdominal aorta (B). The lumbar artery origins are labelled (arrows) as is the atherosclerotic plaque (asterisk). Oblique reformats in the same patients (C, D) demonstrate the lumbar artery origins in profile (arrows) along with a severe atherosclerotic plaque (asterisk in D). Oblique volume rendered images also show the normal vessel origins (arrows in E) compared to the diseased vessel origins (arrows in F). Again note the severe calcified plaque (asterisk in F).Dr. Beckworth and his team analyzed 30 consecutive computed tomography angiograms (CTAs), which had been performed for various reasons at a university hospital. The CTAs provided a visualization of the patients’ lumbar artery atherosclerosis, as the researchers assessed the severity of the vascular disease in the lumbar arteries and aorta.1

After adjusting for age, the researchers found a statistically significant correlation between lumbar artery atherosclerosis and DDD (P<0.05). Interestingly, the correlation was strongest in younger patients (≤61 years; P<0.0001).

“The correlation was across all age groups, but it was more notable in the younger age group,” said Dr. Beckworth, who noted this was the first study to his knowledge that reported a stronger correlation in the younger age group of patients.

While the correlation was highest looking at vascular disease with DDD, the researchers also found some lesser associations with aortic atherosclerosis. DDD, facet arthritis, and spinal stenosis were all associated with aortic atherosclerosis to some extant after adjusting for age (P<0.05). Again, the findings were most notable in the younger age group.

Link Between Arterial and Spinal Disease

The correlation between vascular disease and DDD is not novel. Previous autopsy and radiology studies have documented the phenomenon,2-6 however this was the first study to note a correlation between vascular disease and facet arthritis and lumbar spinal canal stenosis.

According to Dr. Beckworth, in order to elucidate how the intervertebral disc could be affected by atherosclerotic disease, it’s important to understand that the structure relies on passive diffusion from peripheral arteries for nutrition.7

“The [intervertebral] disc is the largest nonvascular structure in the body, and so maybe as blood flow goes to the disc—and it relies on this transfusion of nutrients to the disc—if there’s poor blood flow to the disc margins, then it makes sense that it may lead to degenerative changes in the disc," he noted. "And that might be like a cascade of events from there leading to arthritis in the joints and spinal stenosis.”

It may seem atypical that DDD, facet arthritis, and spinal stenosis had stronger correlation coefficients for the relatively younger patient group. However, according to Dr. Beckworth, this isn’t necessarily inexplicable.

“As we age, everyone gets some wear and tear and degenerative changes,” noted Dr. Beckworth. “There are a lot of studies showing that vascular disease is starting a lot earlier than we think. It’s starting really from childhood.” By the early 20s, patients typically will have some degree of atherosclerotic disease, “so that occurs earlier than we probably realize,” Dr. Beckworth told Practical Pain Management.

Indeed, various studies have reported a prevalence of degenerated disc issues for young adults and pediatric patients.8,9 And while this is the first study to describe correlations between vascular disease and facet arthritis and spinal stenosis, the correlations appear logical, since they are related to spinal degeneration. “It’s all a degenerative process, so where one thing starts crumbling, the other things follow,” said Dr. Beckworth.

Interestingly, the study authors preferred analyzing the CTA scans to evaluate the lumbar artery atherosclerosis as opposed to the magnetic resonance angiograms (MRAs) that have been used in prior studies. “We thought CTA was actually a better tool at looking at the small vessels than the MRA was” as they seemed to offer a superior resolution of the atherosclerotic narrowing, Dr. Beckworth told Practical Pain Management.

Lifestyle Factors Play a Role

“I think the bottom line is that you can educate the patient about things that are related to vascular disease,” like smoking or poor diet choices, which appear to show a clear impact on negatively affecting the integrity of the spine. “Lifestyle choices play a key role in keeping a healthy spine,” said Dr. Beckworth.

Granted, the statistical results did not factor in certain lifestyle correlations. However, this was done purposefully since it is already known that poor lifestyle choices can increase the risk of vascular disease, Dr. Beckworth said.

In the future, Dr. Beckworth said he is interested in researching this topic further, specifically looking into how lifestyle interventions can play a positive role in aiding patients’ spinal issues.

 

References

  1. Beckworth WJ, Holbrook JF, Ward L, et al.  Atherosclerotic disease and its relationship to lumbar degenerative disc disease, facet arthritis, and stenosis using CT angiography. Poster presentation at: 32nd Annual Meeting of the American Academy of Pain Medicine; February 18-21, 2016; Palm Springs, CA. Poster #101.
  2. Kauppila LI, Tallroth K. Postmortem angiographic findings for arteries supplying the lumbar spine: Their relationship to low back symptoms. J Spinal Disord. 1993;6:124e9.
  3. Kauppila LI. Prevalence of stenotic changes in arteries supplying the lumbar spine: A postmortem angiographic study on 140 subjects. Ann Rheum Dis. 1997;56:591e5.
  4. Kurunlahti M, Tervonen O, Vanharanta H, et al. Association of atherosclerosis with low back pain and the degree of disc degeneration. Spine. 1999;24;2080-2084.
  5. Kurunlahti M, Karppinen J, Haapea M, et al. Three year follow-up of lumbar artery occlusion with magnetic resonance angiography in patients with sciatica: Associations between occlusion and patient-reported symptoms. Spine. 2004;29:1804-1808.
  6. Kurunlahti M, Kerttula L, Jauhianien J, et al. Correlation of diffusion in the lumbar intervertebral disks with occlusion of the lumbar arteries: A study in adult volunteers. Radiology. 2011;221:779-786.
  7. Urban J, Smith S, Fairbank J. Nutrition of the intervertebral disc. Spine. 2004;29(23):2700-2709.
  8. Takatalo J, Karppinen J, Niinimäki J, et al. Prevalence of degenerative imaging findings in lumbar magnetic resonance imaging among young adults. Spine (Phila Pa 1976). 2009;34(16):1716-1721.
  9. Ramadorai U, Hire J, DeVine JG, et al. Incidental findings on magnetic resonance imaging of the spine in the asymptomatic pediatric population: A systematic review. Evid Based Spine Care J. 2014;5(2):95-100.
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