Original Research

Lumbar Degenerative Disc Disease and Tibiotalar Joint Arthritis: A 710-Specimen Postmortem Study

Am J Orthop. 2015 April;44(4):E100-E105

Research has associated lumbar spinal disease with lower extremity arthrosis. These studies focused solely on the lumbar spine’s connection with hip or knee pathology, failing to investigate potential ankle relationships. We specifically explored the interplay between lumbar disc degeneration and tibiotalar joint arthritis.

Lumbar disc degeneration and tibiotalar joint arthritis was graded 0 to 4, according to osteophytosis of the vertebral rim and talar surface in 710 randomly selected cadaveric specimens. We corrected for confounding factors of age, sex, race, and height.

A significant association was found between lumbar disc degeneration and tibiotalar joint arthritis (P < .01). Lumbar disc degeneration encompassing 3 intervetebral discs demonstrated the highest odds for development of severe tibiotalar joint arthritis. Severe lumbar degenerative disc disease was more prevalent than severe tibiotalar joint arthritis in individuals age 20 years and older. Furthermore, the presence of severe lumbar degeneration significantly predisposes individuals to the development of severe ankle arthritis (P < .05).

Gait changes resulting from disc degeneration or neural compression in the lumbar spine may play a role in ankle osteoarthritis development. This association must be considered when treating patients with lumbar disc degeneration and leg pain.

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References

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Osteoarthritis is the most common joint disorder, resulting in significant morbidity and disability. The worldwide prevalence of osteoarthritis was estimated at more than 151 million people, according to data published in 2004.¹ In the United States, almost 27 million adults age 25 years and older suffer from clinically apparent disease.² The spine is one of the most commonly affected joints of arthritis, and idiopathic low back pain is the most frequent complaint in the adult population.³ In adults with low back pain, evidence of lumbar intervertebral disc degeneration is often found on radiography.⁴ In 1 study, evidence of disc degeneration was found in 90% of adults age 50 to 59 years.⁵

Degenerative spinal disease most commonly affects the lumbar spine due to its high degree of mobility and weight-loading.^6,7 Clinical^8,9 and experimental studies¹⁰ have suggested that the degenerative changes in the lumbar spine begin in the intervertebral discs. Degenerative disc disease (DDD) results from a continuum of dehydration, degradation, and remodeling of the intervertebral discs and neighboring vertebrae to accommodate the changes in physical loading.^11-13 This results in disc-space narrowing, disc bulging and herniation, vertebral rim osteophyte formation, and endplate sclerosis.^7,14 Symptomatic neural compression may occur, often manifested by localized lower back and extremity pain, as well as sensory loss and weakness of the lower extremities.^15-17 Changes in posture and gait may result because of altered sensation, and the consequent abnormal force transmission may predispose joints to accelerated wear and arthrosis.^15,18

Numerous studies have delineated the association between lumbar spinal disorders and lower extremity arthrosis. Of note, research has demonstrated that hip and/or knee pathology and gait alteration may promote low back pain and lumbar disc degeneration.^19-21 Although spinal abnormalities, such as scoliosis, may predispose an individual to accelerated hip degeneration,²⁰ no studies have investigated the relationship between lumbar DDD and ankle osteoarthritis.

Ankle arthritis differs from hip and knee arthritis demographically, occurring approximately 9 times less frequently.²¹ The ankle joint is subjected to more weight-bearing force per square centimeter and is more commonly injured than any other joint in the body.²¹ Trauma and/or abnormal ankle mechanics are the most common causes of degenerative ankle arthritis.²² Other potential causes include inflammatory arthropathies, neuropathic arthropathy, infection, and tumor. The purpose of this study was to determine if a relationship exists between ankle arthrosis and lumbar disc degeneration, and to delineate if one may promote the onset or progression of the other.

Materials and Methods

We randomly chose 710 cadaveric specimens from the Hamann-Todd Osteological Collection in Cleveland, Ohio. The Hamann-Todd Collection contains skeletal remains from more than 3000 individuals who died in Cleveland, Ohio between 1893 and 1938. The cohort for this study included 583 male and 127 female cadavers, ranging in age from 17 to 105 years at the time of death. Table 1 shows the breakdown of these specimens according to age group; of the 710 specimens, 306 were of African American ancestry, and 404 were Caucasian.

Lumbar DDD was graded at each lumbar spinal level by a single examiner using the Eubanks modification²³ of the Kettler and Wilke classification of vertebral endplate osteophytosis²⁴:

Grade 0: normal vertebral endplates;

Grade 1: mild arthrosis, with evidence of osteophytic reaction involving up to 50% of the vertebral endplates;

Grade 2: moderate arthrosis, with evidence of osteophytic reaction involving 50% to 100% of the vertebral endplates;

Grade 3: severe arthrosis, with evidence of osteophytic reaction involving 100% of the vertebral endplates. Osteophytes are hypertrophic and bridging the joint space (Figure 1);

Grade 4: complete ankylosis.

Tibiotalar joint osteoarthritis was evaluated by a single examiner using a modification of the Kellgren-Lawrence classification⁴ for knee osteoarthritis:

Grade 0: no discernable wear/osteophytes;

Grade 1: 1-mm osteophyte(s) and/or <25% surface wear;

Grade 2: 1- to 2-mm osteophyte(s) and/or 25% to 50% joint surface;

Grade 3: 2- to 3-mm osteophyte(s) and/or >50% joint surface (Figure 2);

Grade 4: multiple large osteophytes and/or definite bony end deformity.

Statistical analysis was performed on the compiled data using Stata software (StataCorp, College Station, Texas). Linear and logistic regression analyses correcting for confounding factors of age, sex, race, and height were performed using a standard P-value cutoff (P < .05) and 95% confidence interval to determine statistical significance.

Results

Patients were considered to have osteoarthritis of the tibiotalar joint if either of the extremities measured grade 1 or higher. Of the 710 specimens selected, 14 specimens did not have adequate bone available for bilateral tibiotalar joint measurement, either from extensive bone degradation or amputation. Of the remaining 696 specimens, 586 had some degree of tibiotalar osteoarthritis present (Table 2). Regression analysis showed a significant positive association between right- and left-ankle osteoarthritis (coefficient: 0.491, P < .01). Tibiotalar joint arthritis was classified as severe if either extremity had arthrosis of grade 3 or higher. Of the 586 specimens that had tibiotalar joint arthritis, only 16% (97 specimens) had severe tibiotalar joint arthritis.