Journal of the Neurological Sciences 192 Ž2001.

17–25
www.elsevier.comrlocaterjns

Back disorders žlow back pain, cervicobrachial and lumbosacral radicular

syndromes/ and some related risk factors
V. Kostova a , M. Koleva b,)
a
Department of Neurology, Center of Occupational Diseases, Medical UniÕersity, Sofia, Bulgaria
b
Department of Hygiene, Ecology and Occupational Health, Medical UniÕersity, 15 BlÕd. Dimitar NestoroÕ, Sofia 1431, Bulgaria
Received 29 September 2000; received in revised form 9 July 2001; accepted 11 July 2001

Abstract

The aim of this study was to estimate the prevalence rates of low back pain ŽLBP., cervicobrachial and lumbosacral radicular
syndromes ŽCBR and LSRS. in workers from a fertilizer plant and also to analyze the impact of several important work-related and
non-occupational risk factors. Subjects of this comprehensive cross-sectional study were 898 workers and employees from the four main
departments of the plant. The following complex of methods was applied: neurologic history, complete neurologic status and statistical
method. Results. Age is the first risk factor, discussed by authors. The data showed highly significant differences in the prevalence of
CBS—16.2% in the risk group vs. 10.0% in the referent group ŽOR 1.73, 95% CI 1.14–2.63.; LBP—25.8% vs. 17.0% ŽOR 1.70, 95% CI
1.21–2.38. and LSRS–16.0% vs. 5.8% ŽOR 3.09, 95% CI 1.89–5.08.. Gender is the second risk factor strongly related to LBP, CBS and
LSRS. The prevalence of radicular syndromes is higher for women that for men: OR for CBS is 3.27 and 1.93 for LSRS. There is an
interesting trend in the case of combined impact of age and gender among men and women of 40 or under and over 40—the risk,
estimated by OR, is higher. In men over 40, overweight, obesity and heaviness of smoking, estimated by duration of smoking and daily
cigarette consumption Žmore than 20 years and more than 20 cigarettes per day., increase the risk of developing back disorders ŽBD.. At
this stage of the research, there is no proof of the impact of hypercholesterolemia, non-occupational or work-related strain on the
development of BD. The authors’ conclusion is that these results may support programs for health promotion and health prevention.
q 2001 Elsevier Science B.V. All rights reserved.

Keywords: Back disorders; Radicular syndromes; Low back pain; Risk factors; Age; Gender; Obesity; Smoking; Work-related and non-occupational strain

1. Introduction jobs. So BP often causes severe emotional, physical, eco-

Back pain ŽBP. is an unpleasant and noxious sensation
of varying severity localized in the different regions of the
back, mostly cervical or lumbar w1x. The simplified etio-
logicrpathogenetic classification of BP includes myofas-
cial, articular Žincluding degenerative disc changes. and
neurogenic. Usually more than one type of pain exists
simultaneously in a patient at any given time w2x. BP is a
serious problem because of the ever increasing number of
cases of low back pain, cervicobrachial or lumbosacral
radicular syndrome. These complaints are the conditions
most commonly involved in personal injury and disability
compensation cases w3x. Back disorders ŽBD. affect people
in their active work life and often become chronic w4x. The
data show that patients are unable to work or lose their
nomic and social stress and has a negative impact on the
patients and their families w5x. Therefore, BP is associated
with high costs, psychosocial and disabling effects. Al-
though BD constitutes an important public health problem,
there is a paucity of knowledge about risk factors and
causal mechanisms w6,7x.
The aim of this study was to estimate the prevalence
rates of the cervico-brachial syndrome, low back pain and
lumbosacral radicular syndrome in workers from a fertil-
izer plant and also to analyze the impact of several impor-
tant work-related and non-occupational risk factors on the
prevalence of these neurologic syndromes.
2. Subjects and methods

This comprehensive cross-sectional study was carried

)
Corresponding author. Tel.: q359-2-59-60-37. out in the main departments of a fertilizer plant from 1995
E-mail address: mkoleva@mail.bol.bg ŽM. Koleva.. to 1998. Eight hundred ninety-eight workers and employ-

0022-510Xr01r$ - see front matter q 2001 Elsevier Science B.V. All rights reserved.
PII: S 0 0 2 2 - 5 1 0 X Ž 0 1 . 0 0 5 8 5 - 8
18 V. KostoÕa, M. KoleÕar Journal of the Neurological Sciences 192 (2001) 17–25
Fig. 1. Distribution of the workers according to the main personal data Žage, sex, profession..
ees were examined. The subjects were divided into seven
different groups1 Žaccording to their occupation and condi-
tions at their work place. and their basic personal charac-
teristics Žage, gender, occupation, smoking, overweight-
BMI, etc.., presented in Fig. 1.
The information was gathered by means of a selective
questionnaire and a complete neurologic examination. The
following complex of methods was applied in the examina-
tion of the nervous system.
Ž1. Neurologic history with an emphasis on questions
about back pain and paresthesias—questions focusing on
1
This investigation is part of a 5-year project for the exhaustive study
of the health of the workers in the main departments of a mineral
fertilizer plant. The project has been supported by the workers’ union for
the purposes of developing an effective program for health promotion and
prevention.
the history of prior episodes and the current episode of
back pain: the onset, duration, location, radiation, quality,
intensity, and aggravating factors. Paresthesias around the
affected root were common. A history of motor or sensory
nerve root irritation was important. The neurologic history
also included a structured interview with questions about
the premorbid condition of the individual, hisrher living
conditions, movement, activities, and life style Žsmoking,
alcohol consumption, etc...
Ž2. Complete neurologic status
vtest of the cranial nerves;
v assessment of the motor function: analysis of the
active and passive motions, muscle tone, posture, gait, and
voluntary strength. The following rating scale was used in
order to test the latter: 0 s no movement; 1 s flicker;
2 s able to move with gravidity eliminated; 3 s able to
move against gravidity; 4 s able to move against resis-
tance; 5 s normal strength;
 V. KostoÕa, M. KoleÕar Journal of the Neurological Sciences 192 (2001) 17–25
v test of the activity of the exteroceptive and proprio-
ceptive reflexes—possible asymmetries between the two
sides Žin our study the most important reflexes to test were
the biceps, triceps, patellar and Achilles tendon. and of
possible qualitative disturbances of the reflex functions
Ži.e. pathological reflexes.;
v assessment of sensory functions: symmetry and differ-
ences in cutaneous dermatomes areas, proximal and distal
perception in all four extremities, light touch, pinprick
perception, and proprioceptive sensation Žrepeated testing
was often done to determine the reliability of a patient’s
response..
The testing was conducted at the health center of the
fertilizer plant: the subjects were given sufficient time off
from work to participate in the examinations. Fifteen per-
sons per day underwent the neurological examination,
which was carried out by the same neurologist.
Ž3. Statistical method: all the results were statistically
systematized at a level of reliability of p - 0.05, by means
of the AEpi-InfoB program for assessment of the relative
risk and odds ratio.
The criteria for cervicobrachial syndrome ŽCBS. were
stiffness and neck pain, the latter radiating to one or both
arms along the damaged nerve root, limited neck move-
ments, numbness of the hands, spontaneous or provoked
paresthesias and pain with radicular distribution; objective
symptoms such as dermatomic sensory diminution Žoften
impairment of the sense of touch.; depressed biceps or
brachioradialis reflexes and weakness and atrophy of the
corresponding muscles Žinfrequent in our cases..
The criteria for low back pain ŽLBP. included discom-
fort Žgrowing with increased activity., limited mobility in
the region of the low back, pain of varying intensity—often
mild or moderate Ževery day for a week or more during the
examination period. —restricted to the low back, without
distribution over the extremities.
The criteria for lumbosacral radicular syndrome ŽLSRS.
were subjective complaints regarding pain in the low back
of varying intensity following a radicular distribution in
one or both legs Žsometimes the pain is relieved when the
patient lies down., loss of lordosis or flattening of the
lumbar spine, reduced range of movement and tenderness
of paraspinal muscles of the same region, numbness and
paresthesias in the region of the affected root, positive
signs of Lasseque, Neri, Wassermann, etc., objective
symptoms for sensory deficit with radicular distribution,
occasional weakness in the leg Žsometimes of the dorsi-
flexion of the big toe., andror depressed ankle or Achilles
reflexes.
3. Results
Figs. 1 and 2 represent the distribution of the subjects
as a total, by gender–age and professional groups, and
according to the some risk factors: smoking, obesity and
19
dislipidemia. It can be seen from Fig. 1 that the age and
gender groups are homogeneous and comparable. Fig. 2
shows that over the half of all individuals Ž60.2%. were
AsmokersB; 68.2% fell into Aoverweight and obesityB cate-
gories; and only 13.8% exhibited a level of total choles-
terol over 6.2 mmolrl Ž240 mg%..
In order to analyze the impact of age on the occurrence
and development of BP syndromes, the subjects of this
study were divided into two different age groups: risk
group—450 persons aged over 40 and referent group—448
persons aged 40 or under and the results were compared.
The data showed considerably higher prevalence rates for
the persons over 40 than for those under 40. There were
statistically significant differences in the prevalence of
CBS—16.2% as compared to 10.0% ŽOR 1.73; 95% CI
1.14–2.63.; LBP—25.8% as compared to 17.0% ŽOR
1.70; 95% CI 1.21–2.38. and for LSRS—16.0% as com-
pared to 5.8% ŽOR 3.09; 95% CI 1.89–5.08. ŽTable. 1..
The gender-based differences in BP syndromes re-
vealed a very interesting aspect of the problem of BD risk
factors. Two different groups were studied in this respect:
297 women and 601 men. There was a strong correlation
between gender and BD. The prevalence of radicular syn-
dromes was higher for women than for men: for example
CBS—22.9% as compared to 8.3% ŽOR 3.27; 95% CI
2.16–4.96. and LSRS—15.5% as compared to 8.6% ŽOR
1.93; 95% CI 1.24–3.02.. The prevalence of LBP in
women is also greater than in men, but these differences
were not statistically significant ŽOR 1.08; 95% CI 0.93–
3.03..
Back disorders generally revealed an interesting trend
when we analyzed the combined impact of age and gen-
der. When dividing the subjects of the study into groups:
men and women over 40 Žrisk group., and men and women
of 40 or under Žreferent group., the data showed that LBP
and other radicular syndromes in men increased signifi-
cantly with age ŽCBS—11.8% in men over 40, as com-
pared to 4.71% in men of 40 or under; OR 2.72 and 95%
CI 1.38–5.42; LBP—25.3% as compared to 16.5%; OR
1.72 and 95% CI 1.13–2.62; LSRS—13.8% as compared
to 3.4%; OR 4.60 and 95% CI 2.17–9.99.. In women, this
relationship is more prominent only with respect to LSRS
—the greater prevalence rates were found in the group of
women over 40, when contrasted to women of 40 or under
ŽOR 2.18; 95% CI 1.08–4.43.. The women over 40 show
higher prevalence rates of CBS and LBP than women of
40 or under, i.e., OR greater than 1.0, but this difference is
not statistically significant ŽTable 1..
The impact of obesity on the development of back pain
and radicular syndromes was evaluated by means of BMI
Žthe ratio of the body mass in kilograms and the square of
the height in meters.: overweight was diagnosed when the
BMI was over 25.1 kgrm2 . It was established that the
prevalence rates of BD were greater and OR was higher
than 1.0 among persons with a BMI over 25 kgrm2 than
in those with a BMI up to 25 kgrm2 , but there was a
20 V. KostoÕa, M. KoleÕar Journal of the Neurological Sciences 192 (2001) 17–25

Fig. 2. Distribution of the workers according to the some risk factors.

statistical significance only with respect to LBP ŽOR 1.46;
95% CI 1.01–2.13.. In general, there were no age or
gender differences in back disorders based on BMI, with
the exception of men over 40, where the prevalence of
LBP was higher than in men of 40 or under Ž28.6% as
compared to 12.7%, OR 2.76; 95% CI 1.19–6.63..
Smoking is the risk factor for back problems that have
given rise to much controversy. Our study revealed no
strong relationship between smoking and back disorders.
Two groups were compared: smokers, non-smokers and
ex-smokers ŽTable 2.. No significant differences were
found in the prevalence of CBS, LBP and LSRS among
 V. KostoÕa, M. KoleÕar Journal of the Neurological Sciences 192 (2001) 17–25
Table 1
Prevalence of CBS, LBP and LSRS in the workers of the fertilizer industry—impact of age, gender, obesity and dislipidemia
Group and main syndrome Risk group Ref. group CBS LBP LSRS
Variables n n Prev. risk Prev. ref. OR 95% CI Prev. risk Prev. ref. OR 95% CI Prev. risk Prev. ref. OR 95% CI
gr. % gr. % gr. % gr. % gr. % gr. %
Age 450 448 16.2 10.0 1.73 1.14–2.63 25.8 17.0 1.70 1.21–2.38 16.0 5.8 3.09 1.89–5.08
Gender 297 601 22.9 8.3 3.27 2.16–4.96 22.2 21.0 1.08 0.76–1.53 15.5 8.6 1.93 1.24–3.02
Menrage 304 297 11.8 4.71 2.72 1.38–5.42 25.3 16.5 1.72 1.13–2.62 13.8 3.4 4.60 2.17–9.99
Womenrage 146 151 25.3 20.5 1.31 0.74–2.34 26.7 17.9 1.67 0.93–3.03 20.5 10.6 2.18 1.08–4.43
BMI 612 284 13.6 12.3 1.12 0.72–1.74 23.4 17.2 1.46 1.01–2.13 11.7 9.1 1.32 0.81–2.18
BMIrmen up to 40 190 107 5.3 3.7 1.43 0.40–5.57 17.4 14.9 1.20 0.60–2.41 2.6 4.7 0.55 0.13–2.26
BMIrmen over 40 241 63 11.6 2.7 0.90 0.37–2.29 28.6 12.7 2.76 1.19–6.63 13.7 14.3 0.95 0.41–2.29
BMIrwomen up to 40 75 74 24.0 17.6 1.48 0.62–3.55 16.0 20.0 0.75 0.30–1.87 13.3 8.1 1.74 0.54–5.77
BMIrwomen over 40 106 40 25.5 25.0 1.03 0.41–2.57 27.4 25.0 1.13 0.46–2.83 22.6 15.0 1.66 0.58–4.99
Cholesterolemia 126 772 12.7 13.2 0.96 0.52–1.73 24.6 20.8 1.24 0.78–1.97 11.9 10.8 1.12 0.60–2.08

CBS—cervicobrachial syndrome; LBP—low back pain; LSRS—lumbosacral radicular syndrome; OR—odds ratio; CI—confidence interval.

21
 22
Table 2

V. KostoÕa, M. KoleÕar Journal of the Neurological Sciences 192 (2001) 17–25

Prevalence of CBS, LBP and LSRS by smoking, work-related and non-occupational physical strain
Groupsrmain syndromes Risk group Ref. group CBS LBP LSRS
Variables n n Prev. risk Prev. ref. OR 95% CI Prev. risk Prev. ref. OR 95% CI Prev. risk Prev. ref. OR 95% CI
gr. % gr. % gr. % gr. % gr. % gr. %
Smoking a 539 356 10.6 17.1 0.57 0.38–0.86 20.0 23.3 0.82 0.59–1.15 8.9 14.0 0.60 0.38–0.93
Smoking durationb 113 755 14.2 13.0 1.11 0.60–2.01 24.8 20.9 1.24 0.76–2.02 18.6 9.9 2.07 1.17–3.62
Smoking duration over 20 years 5 281 NS NS NS c NS 40.0 16.0 3.59 0.40–26.70 NS NS NS c NS
Žmen up to 40.
Smoking duration over 20 years 98 192 13.3 11.0 1.25 0.56–2.76 22.4 27.1 0.78 0.40–1.43 19.4 10.9 1.96 0.96–4.05
Žmen over 40.
Smoking duration over 20 years 2 147 NS NS NS c NS 50.0 16.8 4.65 0–17.7 NS NS NS c NS
Žwomen up to 40.
Smoking duration over 20 years 8 135 37.5 25.2 1.78 0.32–9.21 37.5 25.9 1.71 0.31–8.85 25.0 20.7 1.27 0.17–7.59
Žwomen up to 40.
Daily cigarettes consumption 75 811 8.0 13.6 0.55 0.21–1.37 18.7 21.7 0.83 0.43–1.57 5.3 11.6 0.43 0.13–1.26
above 20 d
Daily cigarettes consumptionr 27 265 14.8 3.4 4.95 1.17–19.32 17.4 20.4 0.85 0.24–2.77 NS NS NS c NS
men up to 40
Physical work-related overuse 279 613 12.2 13.5 0.89 0.57–1.39 22.9 20.4 1.16 0.81–1.66 8.6 11.9 0.70 0.42–1.16
Physical non-occupational strain 588 304 11.2 16.8 0.63 0.41–0.95 22.1 19.4 1.18 0.82–1.69 11.4 9.9 1.17 0.73–1.90

CBS—cervicobrachial syndrome; LBP—low back pain; LSRS—lumbosacral radicular syndrome; OR—odds ratio; CI—confidence interval.
a
Referent group includes non-smokers and ex-smokers.
b
Risk group includes persons who smoke over 20 years, referent group—all the rest.
c
NS—the prevalence of the risk group is zero.
d
Risk group includes persons who smoke above 20 cigarettes daily, referent group – all the rest.
 V. KostoÕa, M. KoleÕar Journal of the Neurological Sciences 192 (2001) 17–25
members of the two groups. Odds ratios significantly
higher than 1.0 were found only as regards the prevalence
rate of following radicular syndromes:
v LSRS among persons who have smoked for over 20
years Ž18.6%. when contrasted to that in persons who
have smoked for less than 20 years Ž9.9%. —OR 2.07
and 95% CI 1.17–3.62;
v CBS in men of 40 or under who are heavy smokers
Žabove 20 cigarettes daily. —14.8%, as compared to
3.4% in men who do not smoke as heavily Žless than
20 cigarettes daily., OR 4.95 and 95% CI 1.17–19.32.
Other risk factors for BP were also examined—hyper-
cholesterolemia, occupational strain, and non-occupa-
tional oÕeruse. Several distinct groups emerge on the basis
of these three risk factors:
v 162 subjects with hypercholesterolemia—total choles-
terol above 6.2 mmolrl compared to the referent group
Ž n s 772. —total cholesterol under 6.2 mmolrl ŽFig. 2.;
v risk group Žworkers with work-related overuse.: 279
workers exposed to moderately strenuous tasks at the work
place Žrepair staff, loaders, transport equipment machine
operators, pump machine operators. and 613 subjects as
referents Žwho were not exposed to repetitive motion,
overexertion, heavy physical work, etc., in their jobs:
operators, compressor operators, laboratory assistants, ad-
ministrators. ŽTable 2.;
v risk group—588 subjects who have undergone non-
occupational strain Žperiodically, i.e., 5–6 h daily on the
weekend they do physically strenuous work. and referent
group—304 persons, not exposed to any non-occupational
physical exertion ŽTable 2..
The prevalence rates of CBS, LBP, and LSRS through-
out the different groups mentioned above varied consider-
ably but none of these data showed any significant odds
ratios or revealed any clear trend as to the importance of
hypercholesterolemia, work-related or non-occupational
strain as risk factors for BP and BD.
4. Discussion
The present study has clearly shown that certain factors
like age and gender are strongly connected with low back
pain, cervicobrachial and lumbosacral radicular syndrome.
Other factors, such as overweight and smoking under
certain circumstances, are also related to the occurrence of
BD, where as there is no proof of the impact of hyperc-
holesterolemia, non-occupational or work-related strain on
the development of back pain syndromes.
Many factors Že.g., mechanical and various individual
causes. contribute to the development of back pain syn-
dromes w8–13x.
A strong correlation has been found between age, gen-
der and the prevalence of back disorders. CBS, LBP and
23
LSRS are more common among persons over 40 and men
show high prevalence rates of radicular syndromes. Many
authors argue that the occurrence and development of back
disorders increase with age w12–15x. Most studies demon-
strate a higher rate of back disorders in the period up to
about the fifth w16x or sixth decade of life w13x. Our finding
that age constitutes a risk factor for BD coincide with the
above claims, although our data shows a lower range for
development of BPs Ž40 years. than other authors’. Some
prospective studies have, however, revealed that there is
no distinct relation to age w17,18x.
The impact of gender on the development of back
disorders has also been widely researched, more often
regarding LBP, rarely regarding CBS or LSRS w14,15x.
Most studies show a higher rate of injury for men, but
when the strain on the job is considered, the gender
difference disappears w16x. Past the age of forty, the risk
for women increases much faster than for men Žperhaps
related to osteoporosis, obesity, etc... Our results support
the thesis of some authors that back disorders are related to
gender and that men are probably more susceptible to
developing BP syndromes than women w19x. With age, the
risk of back disorders increases again much more obvi-
ously for men than for women: the prevalence rates of all
back pain syndromes are significantly higher in men over
40 than in those of 40 or under. The case of LSRS in
women constitutes an exception. Perhaps other factors play
a part here: for example, the wearing out of different back
structures in the lumbar region due to gravidity loading,
endocrine disbalance and osteoporosis typical for the cli-
macteric period, etc.
Analyzing the relative importance of obesity as a risk
factor for BP syndromes by means of calculating the BMI
in different groups, we found a statistically significant link
between obesity and LBP, but the relationship between
radicular back disorders and obesity is not significant.
Obesity and back disorders in men and women over 40
exhibited a similar trend. In fact, the risk for developing
LBP and back problems due to obesity may be even more
significant in older men who tend to gain weight as they
age. A positive relation between excess body weight and
risk for back disorders was shown in most studies
w12,17,20,21x, but the authors revealed that there is no
distinct dependence on obesity w9x.
Many authors suggest that smoking in particular seems
to increase the risk of LBP, disk disease and LSRS
w17,19,22,23x. Some physiologic studies have shown that
smoking impairs the blood supply to the vertebral endplate
and thereby decreases the nutrition of the intervertebral
disk. In the present study, we found no relationship be-
tween smoking and BP syndromes. An exception can be
identified when analyzing the link between the heaviness
of smoking and back disorders. A statistically significant
correlation has been found between the duration of smok-
ing and LSRS. It is important to note here that this data
assessment suffers due to the incomplete control over
24 V. KostoÕa, M. KoleÕar Journal of the Neurological Sciences 192 (2001) 17–25
some additional factors Žespecially age.. CBS and LBP
also show higher prevalence rates for smokers with long
smoking practice, but there is no statistical significance to
this data. Despite the fragmentary nature of the results
regarding smoking, our data corroborate to some extent the
argument that smoking Žespecially in cases with long
smoking practice, i.e., more than 20 years. may be related
to the occurrence of BD.
The most widely discussed risk factors for BD include
strain and overuse at work w24–32x or in the subject’s
non-occupational lifestyle w9,12x. Many work-related fac-
tors, such as heavy physical work, prolonged sitting Žstatic
work posture., lifting and forceful movements, repetitive
bending and whole-body vibration, have been reported to
be of importance in the development of BD w12,33–37x. In
contrast to these findings, our results do not demonstrate
any significant connection between work-related strain and
BD. This may be due partially to the fact that the workers
in the exposure group Žwith work related overuse. were
repair staff, loaders, transport equipment machine opera-
tors, pump machine operators, whose occupational physi-
cal strain is mild. The AclassicalB occupational factors w15x
for the development of BP syndromes such as constrained
working postures w38x and back-straining tasks, heavy
physical work and repetitive manual handling, pulling,
pushing, etc., are not part of the physical activities required
for their jobs. At this stage of our research, there is also no
clear proof of the impact of non-occupational overuse on
the development of back disorders. There is probably
another explanation of this fact: occasional and irregular
gardening and other non-occupational physical tasks car-
ried out mostly on weekends. This overuse is followed by
periods of rest from physical labor, which permits the
AtiredB back structures to recover. In other cases, the
degree of non-occupational physical activity is insignifi-
cant and cannot cause damage to the back structures and
nerve roots.
The present study support the view that some individual
factors like age and gender are strongly connected with
back disorders, whereas other causes Žoverweight, smok-
ing. demonstrate varied results. These results may support
programs to prevent the development of BD: for example,
activities to stabilize the back structures and measures
against osteoporosis, especially in jobs involving heavy
physical labor, prevention of obesity, smoking control and
cessation programs, etc. Nonetheless, our study has not
identified the nature of the relationship between hyperc-
holesterolemia, non-occupational or work related overuse
and back disorders, and we consider it necessary to pursue
this line of research in the future.
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