Microscopic changes in the spinal extensor musculature in people with chronic spinal pain: a systematic review

BACKGROUND CONTEXT: Chronic spinal pain is one the most common musculoskeletal disorders. Previous studies have observed microscopic structural changes in the spinal extensor muscles in people with chronic spinal pain. This systematic review synthesizes and analyzes all the existing evidence of muscle microscopic changes in people with chronic spinal pain.

PURPOSE: To assess the microscopy of spinal extensor muscles including the fiber type composition, the area occupied by fiber types, fiber size/cross sectional area (CSA), and narrow diameter (ND) in people with and without chronic spinal pain. Further, to compare these outcome measures across different regions of the spine in people with chronic neck, thoracic and low back pain.

STUDY DESIGN: Systematic review with meta-analysis.

METHODS: MEDLINE (Ovid Interface), Embase, PubMed, CINAHL Plus, and Web of Science were searched from inception to October 2020. Key journals, conference proceedings, grey literature and hand searching of reference lists from eligible studies were also searched. Two independent reviewers were involved in the selection process. Only studies examining the muscle microscopy of the spinal extensor muscles (erector spinae [ES] and/or multifidus [MF]) between people with and without chronic spinal pain were selected. The risk of bias from the studies was assessed using modified Newcastle Ottawa Scale and the level of evidence was established using the GRADE approach. Data were synthesized based on homogeneity on the methodology and outcome measures of the studies for ES and MF muscles and only four studies were eligible for analysis.

RESULTS: All the five studies included were related to chronic low back pain (CLBP). Meta-analysis (inverse variance method for random effect to calculate mean difference and 95% CI) was performed for the ES fiber type composition by numbers for both type I and type II fibers (I 2=43% and 0% respectively indicating homogeneity of studies) and showed no difference between the people with and without CLBP with an overall effect estimate Z= 1.49 (p=.14) and Z=1.06 (p=.29) respectively. Meta-analysis was performed for ES fiber CSA for both type I and type II fibers (I 2=0 for both) and showed no difference between people with and without CLBP with an overall effect estimate Z=0.08 (p=.43) and Z=0.75 (p=.45) respectively. Analysis was not performed for ES area occupied by fiber types and ND due to heterogeneity of studies and lack of evidence respectively. Similarly, meta-analysis was not performed for MF fiber type composition by numbers due to heterogeneity of studies. MF analysis for area occupied by fiber type, fiber CSA and ND did not yield sufficient evidence.

CONCLUSIONS: For the ES muscle, there was no difference in fiber type composition and fiber CSA between people with and without CLBP and no conclusions could be drawn for ND for the ES. For the MF, no conclusions could be drawn for any of the muscle microscopy outcome measures. Overall, the quality of evidence is very low and there is very low evidence that there are no differences in microscopic muscle features between people with and without CLBP.