CERVICAL SPINE DEGENERATIVE CHANGES (NARROWED INTERVERTEBRAL DISC SPACES AND OSTEOPHYTES) IN COAL MINERS

International Journal of Occupational Medicine and Environmental Health, 2003; 16(1): 49 53 CERVICAL SPINE DEGENERATIVE CHANGES (NARROWED INTERVERTEBRAL DISC SPACES AND OSTEOPHYTES) IN COAL MINERS JAN E. ZEJDA 1 AND BARTŁOMIEJ STASIÓW 2 1 Department of Hygiene and Epidemiology Faculty of Public Health 2 Department of Radiology Medical University of Silesia Katowice, Poland Abstract. A series of 685 x-ray films of the cervical spine obtained in coal miners was analyzed to explore the occurrence of narrowed disc spaces and osteophytes in this occupational group, and to examine the association of x-ray changes with age, duration of employment, and duration of occupational exposure to hand-arm vibration. All data were extracted from individual medical files of coal miners examined for suspected hand-arm vibration-related disorders in 1989-1999 at the Occupational Medicine Center in Katowice. The narrowed intervertebral disc spaces were found in 188 coal miners (26.9%) and osteophytes in 332 coal miners (47.5%). The occurrence of degenerative changes in coal miners was similar to that observed in a small group of 68 blue-collar workers (no exposure to hand-arm vibration) employed in the coal industry. Univariate comparisons showed that narrowed intervertebral disc spaces and osteophytes were more frequent among older subjects and among subjects with longer duration of employment. The prevalence of changes also showed some relationship with the number of years of exposure to hand-arm vibration. The results of logistic regression analysis confirmed statistically significant effect of age, but not of other factors included in the model. When both x-ray changes were grouped together (a combined dependent variable) age remained the only statistically significant explanatory variable. The findings do not support the view that the examined degenerative changes in the cervical spine are more prevalent in coal miners and depend on duration of physical work or local exposure to hand-arm vibration in this occupational group. Key words: Cervical spine, X-ray, Coal-miners INTRODUCTION The effect of occupational factors on the spine is subject to a number of studies that usually focus on work-related complaints. The occurrence of low back pain syndrome and its relation to job-related factors is well documented in various occupational populations [1 5]. Much less is known about complaints related to other parts of the spine, although published evidence reveal the association of the neck pain syndrome with physical demands of the job. Body position at work, dynamic and static loads of the arms as well as the exposure to long-term whole-body (and sporadically local) vibration have been considered among risk factors for pain in the neck [6 12]. Work environment in underground coal mines in Poland is characterized by high physical load and exposure to hand-arm vibration. The complaints of pain in the low back and the neck are common in coal miners, and at least in Poland constitute an important public health issue [13]. A recent survey performed in this country The study was supported by the grant from the Medical University of Silesia (NN-2-240/01). Received: April 24, 2002. Accepted: February 6, 2003. Address reprint requests to Prof. J.E. Zejda MD, PhD, Department of Hygiene and Epidemiology, Faculty of Public Health, Medical University of Silesia, Medyków 18, 40-752 Katowice, Poland (e-mail: epikat@slam.katowice.pl). IJOMEH 2003; 16(1) 49

JE. ZEJDA, B. STASIÓW showed that 23 28% of coal miners suffered from the neck pain, whereas its prevalence among control subjects was 4% [14]. Ethical considerations exclude x-ray examination from research tools in occupational epidemiology studies on spine disorders. Although symptoms do not have to mirror x-ray changes, it might be of interest to explore the occurrence of x-ray changes in the spine in high risk workers. Having an access to a large number of x-ray films of the neck obtained in coal miners referred to the Occupational Medicine Center in Katowice because of suspected vibration-related disorders, we decided to analyze the occurrence of the x-ray changes and their jobrelated correlates. The objectives of our study were: (a) to examine the occurrence of x-ray changes (narrowed intervertebral disc spaces and osteophytes) in the cervical spine in coal miners, and (b) to analyze the association of these changes with age, duration of employment, and duration of occupational exposure to hand-arm vibration. MATERIALS AND METHODS All x-ray films of the cervical spine (standard lateral projections) were obtained in 697 professionally active coal miners, employed underground in coal mines of Upper Silesia (Poland) and referred to the Occupational Medicine Center in Katowice for suspected hand-arm vibration syndrome. The medical examinations were performed in 1989 1999, thus the analysis involved already existing medical records. Approximately 100 files included anteroposterior projections of the cervical spine, however due to the small number and in many cases poor quality, they were excluded from interpretation. Also, the lack of systematic information on subjects complaints and physical status restricted the final analysis of x-ray changes found on lateral projection of the cervical spine. The following occupational history data were extracted from the subjects personal records: age (years), duration of employment in a mine (years), duration of exposure to local vibration (years) and average daily duration of exposure to local vibration (h). Cervical spine x-rays were read by a certified radiologist (one of the authors B.S.). Two types of degenerative changes were identified: narrowed intervertebral disc space and osteophytes. The frequency of x-ray changes was compared between the subgroups of miners, and defined according to age and exposure to local vibration by means of a chi-square test. Criterion p < 0.05 was used in examining the statistical significance of differences. The results of univariate analyses were verified by multivariate analyses. The models were tested using logistic regression method with backward elimination of statistically non-significant independent variables. The dependent variable was an x-ray change (either narrowed disc space model I or osteophytes model II; both x-ray changes model III). The set of independent variables included age, coal mine, number of years of employment, number of years of exposure to hand-arm vibration, and average number of hours of daily exposure to hand-arm vibration. Statistical significance of the regression coefficients of independent variables was evaluated against the criterion p < 0.05. The frequency of x-ray changes found in coal miners was compared with the summary figure obtained in 68 bluecollar workers (maintenance, transportation no exposure to hand-arm vibration) employed in surface services at coal mines and examined in the same Occupational Medicine Center for non-specific musculatory complaints. RESULTS The subjects were men aged between 21 and 69 years (mean age and the standard deviation: 46.3 ± 6.5 years). All were employed underground for 22.2 ± 4.8 years (range: 5 35 years) on average. Duration of occupational exposure to hand-arm vibration ranged between 1 and 31 years (mean: 15.1 ± 16.0 years), and of daily average exposure to hand-arm vibration between 30 min and 6 h (mean: 1.9 ± 0.9 h). On 685 technically acceptable x-ray films, the narrowed intervertebral disc space was found in 188 coal miners (26.9%) and osteophytes in 332 coal miners (47.5%). Combined degenerative changes (both narrowed intervertebral disc space and osteophytes) were seen in 163 coal miners (23.3%). Narrowed intervertebral disc space was 50 IJOMEH 2003; 16(1)

CERVICAL SPINE IN COAL MINERS O R I G I N A L P A P E R S Table 1. Occurrence of degenerative changes in the cervical spine by the age groups in 685 coal miners Age group (years) 21 35 36 40 41 45 46 50 51 55 56 69 Narrowed intervertebral disc space (%)* 6.2 9.2 20.5 28.7 48.8 45.0 Osteophytes (%)* 18.7 26.8 43.8 50.4 63.3 71.6 * Statistically significant difference between the defined age groups (p = 0.001). Table 2. Occurrence of degenerative changes in the cervical spine by duration of employment in 685 coal miners Duration of employment (years) 5 10 11 15 16 20 21 25 26 30 30 35 Narrowed intervertebral disc space (%)* 30.7 14.5 17.2 28.8 36.4 47.6 Osteophytes (%)* 15.3 32.2 41.6 48.4 58.5 71.4 * Statistically significant difference between the defined groups (p = 0.001). Table 3. Occurrence of degenerative changes in the cervical spine by duration of occupational exposure to hand-arm vibration in 685 coal miners Duration of occupational exposure to hand-arm vibration (years) 1 5 6 10 11 15 16 20 21 25 26 31 Narrowed intervertebral disc space (%)* 21.7 24.3 19.2 33.1 28.5 42.8 Osteophytes (%)** 41.3 44.4 40.9 48.5 57.1 66.6 * Statistically significant difference between the defined groups (p = 0.02). **Statistically significant difference between the defined groups (p = 0.04). found mostly in the lower part of the cervical spine: C2- C3 in 4 (2.1%), C3-C4 in 12 (6.3%), C4-C5 in 15 (7.9%), C5-C6 in 109 (57.9%), and C6-C7 in 100 (53.1%) subjects. Osteophytes were distributed in a similar mode: C1 0 (0.0%), C2 2 (0.6%), C3 30 (9.0%), C4 74 (22.2%), C5 235 (70.7%), C6 294 (88.5%) and C7 139 (41.7%) subjects. No defined x-ray changes were found on 342 x- ray films (48.9%). In a convenience set of 68 x-rays of blue-collar workers employed in coal mines on the surface and not exposed to vibration, osteophytes were found in 38.5% and narrowed intervertebral disc space in 21.4% of subjects. Both groups (miners and non-miners) were similar in terms of age and duration of employment. The occurrence of the changes according to age, duration of employment and duration of exposure to hand-arm vibration is shown in Tables 1 3. Univariate comparisons showed that narrowed intervertebral disc space and osteophytes were more frequent among older subjects (Table 1) and among subjects with longer duration of employment (Table 2). The changes also showed some relationship with the number of years of exposure to hand-arm vibration (Table 3). There were no differences between the occurrence of the x-ray changes in subgroups of miners, defined according to the average daily duration of exposure to hand-arm vibration. The results of univariate analyses were verified by means of logistic regression analysis, with either narrowed intervertebral distance (model I) or osteophytes (model II) changes as the dependent variable. A set of independent variables was tested in various configurations. For both dependent variables, the analyses confirmed statistically significant effects of age only. Age and the duration of employment correlated at the level r = 0.63, and age remained the only statistically significant variable when both variables were included in a model tested by a back- IJOMEH 2003; 16(1) 51

JE. ZEJDA, B. STASIÓW ward elimination procedure. When both x-ray changes were grouped together (a combined dependent variable model III), the results of logistic regression analysis did not change; age remained the only statistically significant explanatory variable. DISCUSSION The objective of the study was to assess the frequency of two x-ray changes (narrowed intervertebral disc spaces and osteophytes) in the cervical spine in coal miners, and to explore their associations with age, duration of employment and duration of occupational exposure to local, hand-arm vibration. In coal miners aged 21 69 years, approximately 50% of subjects showed degenerative changes in the cervical spine. This figure was similar to an estimated prevalence of degenerative changes in the general population of middle-aged men in Poland [15,16]. In the study group of miners, the frequencies of osteophytes (47.5%) and narrowed intervertebral disc space (26.9%) were slightly higher than the values found in a convenience set of 68 x-rays of surface blue-collar workers employed in coal mines (38.5% and 21.4%, respectively). Although both groups were similar in terms of employment duration, a more specific elaboration of the difference is not justified because of unrepresentativeness of the groups. The findings do not suggest job-related x-ray changes in the cervical spine and such an interpretation is supported by the consistent effect of age but not of occupational variables on the occurrence of changes, either examined as a combined variable or as its components. Reference data on the prevalence of x-ray changes in the spinal cord in coal miners are hardly available. The 1952 British study, involving x-ray examination in 84 coal miners aged 40 50 years, showed that the narrowed cervical discs and changed vertebral plates were more frequent in this group (54%) than in 45 reference manual workers (42%), or in 42 office workers (38%) [17]. Compared to the evidence concerning work-related low back pain, the neck disorders in occupational populations are less known. Physical workload, whole-body vibration exposure, psychosomatic and psychological factors are thought to play a role as predictive factors for symptoms or treatment of the problem, but specific occupational risk factors for radiological changes of the cervical spine remain unknown [9,18,19]. Available, although limited data may indicate the role of a mechanical strain at work. A record linkage project revealed a statistically significant risk of hospital admissions because of prolapsed cervical intervertebral disc among professional drivers, thus suggesting a role of whole-body vibration, sedentary position, heavy lifting or accelerations/decelerations [20]. In a group of professionally active dockers, the prevalence of degenerative x-ray changes in cervical spine was 34% and in the authors opinion it depended on the degree of physical load at work [21]. Our findings do not support the concept of work-related degenerative x-ray changes in the cervical spine of coal miners. However, it remains unknown to what extent our findings could be generalized in respect to the occupational setting under study. The data used in our analysis were obtained in a case series and not in a representative sample. However, the number of x-ray films of the cervical spine was large enough to examine internal correlations between x-ray changes and work-related variables, and to examine the differences between subgroups of miners defined according to the exposure characteristics. The range of employment duration and of exposure to local, hand-arm vibration was quite wide, thus permitting this kind of analyses. The composition of our case series could favor an overestimation of the occurrence of degenerative changes in the cervical spine, hence the obtained figures could reflect the upper limit of the estimate for this occupational group. Another potential limitation of causative inference could stem from the lack of data on antero-posterior projections of the cervical spine. We only analyzed two x-ray changes and it remains unknown whether other x-ray abnormalities correlate with exposure variables in question. However, it cannot be excluded that the exposure-effect relationship, if present, would appear already in relation to two x-ray changes included in the study. Another potential limitation (although of lesser relevance to the study objective) was lack of data on neck-related complaints. Available information, derived from the medical 52 IJOMEH 2003; 16(1)

CERVICAL SPINE IN COAL MINERS O R I G I N A L P A P E R S files, did not allow to explore subjects complaints in a systematic way. However, there is no apparent correlation between x-ray signs of the cervical spine degenerative changes and patients complaints or functional limitations, and even magnetic resonance imaging and discography do not provide a reliable insight in this issue [22 24]. In conclusion, our findings do not support the claim that the occurrence of narrowed intervertebral disc space and osteophytes in the cervical spine is more prevalent in coal miners and depends on duration of physical work or local exposure to hand-arm vibration in this occupational group. ACKNOWLEDGEMENTS The authors would like to thank Dr Andrzej Stasiów, the former Head of the Occupational Medicine Center in Katowice for permitting an access to medical records used in the study. REFERENCES 1. Andersson GB. Epidemiology of low back pain. Acta Orthop Scand 1998; Suppl 281: 28 31. 2. Bueff HU, van der Reis W. Low back pain. Prim Care 1996; 23: 345 64. 3. Keyserling WM. Workplace risk factors and occupational musculoskeletal disorders. Part I. AIHAJ 2000; 61: 39 50. 4. Matsui H, Maeda A, Tsuji H, Naruse Y. Risk factors of low back pain among workers in Japan. Association of familial and physical factors with low back pain. Spine 1997; 33: 1242 7. 5. Shelerud R. Epidemiology of occupational low back pain. Occup Med 1998; 13: 1 22. 6. Ariens GA, van Mechelen W, Bongers PM, Bouter LM, van der Wal G. Physical risk factors for neck pain. Scand J Work Environ Health 2000; 26: 7 19. 7. Ariens GA, Bongers PM, Douwes M, Miedema MC, Hoogendoorn WE, van der Wal G, et al. Are neck flexion, neck rotation, and sitting at work risk factors for neck pain? Results of a prospective cohort study. Occup Environ Med 2001; 58: 200 7. 8. Bogduk N. The neck. Baillieres Best Pract Res Clin Rheumatol 1999; 13: 261 85. 9. Magnusson ML, Pope MH, Wilder DG, Areskong B. Are occupational drivers at an increased risk for developing musculoskeletal disorders? Spine 1996; 21: 710 7. 10. Rainville J, Sobel JB, Banco RJ, Levine HL, Childs L. Low back and cervical spine disorders. Orthop Clin North Am 1996; 27: 729 46. 11. Scutter S, Turker KS, Hall R. Headaches and neck pain in farmers. Aus J Rural Health 1997; 5: 2 5. 12. Viikari-Juntura E, Riihimaki H, Tola S, Videman T, Mutanen P. Neck trouble in machine operating, dynamic physical work and sendentary work: a prospective study on occupational and individual risk factors. J Clin Epidemiol 1994; 47: 1 411 22. 13. Limburska I, Gaździk TS, Zejda JE. Low-back-pain syndrome in coal miners: results of a pilot study. Med Pr 1996; 47: 339 46 [in Polish]. 14. Zejda JE, Gaździk TS, Czekaj I. Low-back-pain syndrome in coal miners: preliminary results of an epidemiological study. Med Pr 1998; 49: 353 61 [in Polish]. 15. Borejko M, Dziak A. Radiological Examinations in Orthopedics. Warsaw: PZWL; 1988 [in Polish]. 16. Bruhl W. Diseases of the Musculoskeletal System. Warsaw: PZWL; 1996 [in Polish]. 17. Kellgren JH, Lawrence JS. Rheumatism in miners. Part II: x-ray study. Brit J Ind Med. 1952; 9: 197 207. 18. Krause N, Ragland DR, Greiner BA, Fisher JM, Holman BL, Selvin S. Physical workload and ergonomic factors associated with prevalence of back and neck pain in urban transit operators. Spine 1997; 22: 2117 26. 19. Leclerc A, Niedhammer I, Landre MF, Ozguler A, Etore P, Pietri-Taleb F. One-year predictive factors for various aspects of neck disorders. Spine 1999; 24: 1445 52. 20. Jensen MV, Tuchsen F, Orhede E. Prolapsed cervical intervertebral disc in male professional drivers in Denmark, 1981 1990. Spine 1996; 21: 2352 5. 21. Waskiewicz J. The effect of heavy work on the musculoskeletal system of dockers. Bull Inst Marit Trop Med Gdynia 1996; 47: 25 32. 22. Kopacz KJ, Conolly PJ. The prevalence of cervical spondylolisthesis. Orthopedics 1999; 22: 677 9. 23. McClure P. The degenerative cervical spine: pathogenesis and rehabilitation concepts. J Hand Ther 2000; 13: 163 74. 24. Schellhas KKP, Smith MD, Gundry CR, Pollei SR. Prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers. Spine 1996; 21: 300 11. IJOMEH 2003; 16(1) 53