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- Occupation: qualified group such as teacher, engineer, doctor, accountant, etc. unqualified group: manual labor.

- Occupation: qualified group such as teacher, engineer, doctor, accountant, etc. unqualified group: manual labor.

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- Evaluate disorder of blood lipid based on National cholesterol

education program in 2001.

2.3.2. Clinical research

- Onset stage: Circumstances (natural or after trauma, misposture). Onset kind: urgent acute, gradual

- Clinical symtoms: Lumbar syndrome, Nerve root syndrome.

- Severity level: based on criterion by Nguyễn Văn Chương.

2.3.3. Study on MRI

Use sagittal section and axial section with FSE (Fast Spine

Echo), vertical FSE T1W and transverse FSE T2W to diagnose

LHD and at the same time describe the herniated disc. Within

this research scope, we use the method of evaluation and

classification of LHD images on MRI based on the classification

of Michigan State University- MSU.

Evaluation of LHD images is conducted on: the position of

herniated disc, number of layers of hernia, kind of LHD, spinal

stenosis level, lumbar spinal degeneration.

2.3.4. Evaluation of the relevance between clinical features and

risk factors of arteriosclerosis

Relevance between severity of LHD and risk factors of

arteriosclerosis (age, gender, lipid level, high blood pressure, BMI,

diabetes, smoking).

2.3.5. Evaluation of the relevance between MRI images and risk

factors of arteriosclerosis

- Relevance between position of LHD and risk factors of

arteriosclerosis (age, gender, lipid level, high blood pressure, BMI, diabetes,

smoking).

- Relevance between the stage of LHD and risk factors of

arteriosclerosis (age, gender, lipid level, high blood pressure, BMI,

diabetes, smoking).



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- Relevance between spinal stenosis level and risk factors of

arteriosclerosis (age, gender, lipid level, high blood pressure, BMI,

diabetes, smoking).

2.4. Data analysis

The data are analyzed by SPSS 20.0. Risk factors are found by:

using the algorithm of OR difference rate, single and multivate

logistic regression analysis.

2.5. Ethical issue

The study was approved by Scientific committee of Military

Academy, director board of 19-8 hospital, Ministry of Military and

commitmentto participate in the study by patients.

CHAPTER 3

RESEARCH RESULT

3.1. Clinical features, MRI images and risk factors of

arteriosclerosis in LHD patients

3.1.1. Clinical features of patients in the study

Distribution of patients according to age and gender (table

3.1.): average age: 45,7 ± 13,96. Male/female = 1,74/1.

Distribution of patients according to occupation (figure 3.1):

patients with high qualification account for highest percentage (76%).

Patients with manual labor account for lowest rate (8,1%).

Distribution of patients according to clinical symptoms (table

3.4): lumbar pain, lack of motoring and Lasègue (+) account for high

percentage.

Distribution of patients according to severity (figure 3.4):

mostly at mild level (80,8%), low percentage of severe level. (6,2%).

3.1.2. MRI images of patients in the study

Distribution of patients according to the position of herniated

disc on MRI (figure 3.5): most common position: L4-L5 (82,7%) and

L5-S1 (66,3%).



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Distribution of patients according to number of layers of LHD

(figure 3.6): one-layer hernia accounts for the highest percentage

(36,5%); percentage of two layers, 3 layers, 4 layers, 5 layers

gradually decreases.

Distribution of patients according to kind of LHD (table 3.5):

most of cases have backward herniated disc (99,3%), herniated

centrum has low percentage (0,7%).

Distribution of patients according to level of spinal stenosis

(figure 3.7): most of the cases have spinal stenosis level I and level II

(96,7%).

3.1.3. Risk factors of arteriosclerosis

Distribution of patients according to blood lipids test result

(table 3.7): triglycerid accounts for highest rate of (39,4%); HDL-C

ranks the second (37,5%); LDL-C is high (35,5%); high cholesterol

tp ranks the lowest (16,3%).

Distribution of patients according to BMI index (table 3.8): BMI

of overweight patients account for high percentage (46,1%). Average

BMI is 22,88 ± 2,44.

Distribution of patients according to percentage of risk factors

(table 3.9): lipid metabolism , increased BMI and female gender are

factors with high percentage 92,3%; 46,1% và 36,5% respectively.

Distribution of patients according to percentage of cooperated

risk factors (table 3.10): patients with 2 risk factors have highest

percentage (36,5%); patients without risk factor account for lowest

percentage (3,9%).

3.2. Relevance between clinical presentation, MRI images and

risk factors of arteriosclerosis in LHD patients

3.2.1. Relevance between clinical presentation and risk factors of

arteriosclerosis

3.2.1.1. Relevance between profession and risk factors



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- Female account for high percentage in heavy manual labor

group (76,5%) and light manual labor group (72,7%) in compared

with mental labor group (24,7%); p <0,001.

- Smoking accounts for highest rate in mental group (17,7%) in

compared with heavy manual labor group (5,9%) and light manual

labor group (0%); p <0,05.

- High triglycerid level has highest rate in light manual labor

group (48,5%); p<0,01.

3.2.1.2. Relevance between severity level and risk factors

Distribution of risk factors according to severity level on clinical

features (table 3.14)

- Risk factors: age above 60, heavy manual labor, high

cholesterol tp and triglycerid has higher rate of severity; p<0,05.

Single and multiple logistic regression about relevance between some

risk factors and severity level on clinical manifestations (table 3.27)

Single logistic regression

OR

95%CI

p

Female

2,130 0,689-6,590 0,189

heavy/ Mental 0,517 0,063-4,229 0,539

Labor

slight/ mental 3,548 0,860-14,631 0,080

Smoking

1,131 0,238-5,386 0,877

High blood pressure 1,131 0,238-5,386 0,426

cholesterol tp

1,145 0,954-1,373 0,146

HDL-C

0,460 0,057-3,688 0,465

LDL-C

1,173 0,905-1,521 0,228

triglycerid

1,046 0,966-0,132 0,269

Age

1,059 1,014-1,106 0,010

BMI

1,382 1,121-1,703 0,002

Blood glocose

0,919 0,547-1,543 0,749

Risk factor



Multiple logistic regression

OR

95%CI

p

1,169 0,267-5,118 0,836

0,444 0,047-4,223 0,480

2,885 0,548-15,190 0,211

1,509 0,244-9,332 0,658

0,726 0,111-4,760 0,738

3,966 1,267-12,415 0,018

0,421 0,24-7,341

0,421

0,272 0,076-0,981 0,057

0,855 0,650-1,125 0,264

1,056 1,004-1,111 0,035

1,335 1,066-1,672 0,012

0,673 0,289-1,567 0,359



After multiple -variables analysis and exclusion of interference

factors, the affect of age and BMI on the severity level stays still,

more finding canbe found in the affect of increased cholesterol tp on

severity, particularly:



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- When age is 1 year older, severity increases 5,6% (95%CI:

1,004-1,111), p=0,035

- When BMI increases 1 index, severity increase 33,5% (95%CI:

1,066-1,672), p=0,012.

- When cholesterol tp increases 1 index, risk of severity

increases 3,966 times (95%CI: 1,267-12,415), p=0,018.

3.2.2. Relevance between MRI images and risk factors

3.2.2.1. Relevance between the position of herniated disc and risk

factors

Distribution of risk factors according to the position of

herniated disc (table 3.16)

- Age ≥ 60 years, herniated disc occurs most often at L2-L3 and

L3-L4 layer, which is higher than than other age groups; p<0,05.

- Female have higher rate of herniated disc at L1-L2, L2-L3 and

L3-L4 than that in male; p<0,05.

- There is no statistical difference between other risk factors and

the postion of LHD.

3.2.2.2. Relevance between some risk factors and number of LHD

layer

Distribution of risk factors according to number of herniated

disc layer (table 3.18)

- Risk factors: age ≥ 60, female and low HDL-C having higher

rate of multiple- layers hernia; p<0,05. There is no statistical

difference between other risk factors and the number of layers of

LHD.

Single and multiple logistic regressions about relevance between

some risk factors and number of layers of herniated disc (table 3.29)



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Risk factor

Female

Labo

r



Single logistic regression

OR

95%CI

2,063 1,114-3,821



p

0,021



heavy/mental 3,348 0,925-12,118 0,066

slight/ mental 2,665 1,092-6,505

Smoking



0,031



2,462 0,955-6,348



0,062



High blood pressure 2,308 0,737-7,225



0,151



cholesterol tp



1,050 0,874-1,261



0,606



HDL-C



0,955 0,431-2,115



0,910



LDL-C



1,040 0,824-1,314



0,739



triglycerid

age



1,060 0,938-1,197 0,349

1,050 1,026-1,074 <0,001



BMI



1,133 1,002-1,281



0,046



Blood glucose



1,414 0,988-2,026



0,058



Multiple logistic

regression

OR

95%CI

p

1,357 0,646-2,854 0,420

2,26

0,567-9,021 0,247

2

2,33

0,874-6,229 0,091

4

3,655 1,334-10,019 0,012

1,22

0,345-4,311 0,758

0

0,90

0,460-1,797 0,785

9

1,332 0,407-4,362 0,635

0,82

0,381-1,782 0,622

4

1,108 0,938-1,308 0,227

1,039 1,014-1,065 0,002

1,09

0,961-1,256 0,167

9

1,26

0,871-1,831 0,218

3



After multiple logistic regression, the affect of age on number of

layer is remained, and more finding in the affect of smoking on

number of layers, particularly:

- When age increases 1 year, risk of multiple-layers

increases 3,9% (95%CI: 1,014-1,065), p=0,02.

- Smoking having higher risk of multiple – layers

increases 3,655 times than non-smoker group (95%CI:

10,019), p=0,012.

3.2.2.3. Relevance between some risk factors and level of

stenosis



hernia

hernia

1,334spinal



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Distribution of risk factors according to level of spinal stenosis

(table 3.22)

- Heavy manual labor has the highest rate of spinal stenosis level

I in compared with other groups; p<0,05.

- High Triglycerid has higher rate of spinal stenosis level III than

other groups; p<0,05.

- There is no statistical difference between other risk factors and

the level of spinal stenosis.

Single and multiple logistic regression about relevance between

some risk factors and the level of spinal stenosis (table 3.31)

Risk factor



Labor



Multiple logistic



Single logistic regression

p



regression



OR



95%CI



OR



95%CI



p



Male



1,207



0,686-2,126



Slight/heavy



7,179 1,720-29,975 0,007 7,398 1,758-31,134 0,006



0,514 1,246 0,624-2,489 0,534



Mental/heavy 4,667 1,291-16,874 0,019 4,740 1,235-18,192 0,023

Smoking



0,965



0,440-2,116



0,929 0,922 0,399-2,132 0,850



High blood pressure



1,481



0,570-3,846



0,420 1,417 0,499-4,020 0,512



cholesterol tp



1,176



0,932-1,485



0,172 0,980 0,538-1,783 0,946



HDL-C



1,163



0,535-2,525



0,703 1,146 0,456-2,880 0,771



LDL-C



1,245



0,918-1,687



0,158 1,348 0,669-2,715 0,404



triglycerid



1,031



0,952-1,115



0,455 0,977 0,843-1,133 0,762



Age



1,002



0,983-1,022



0,851 1,009 0,987-1,031 0,450



BMI



0,985



0,881-1,101



0,792 0,976 0,866-1,099 0,684



Blood glucose



1,103



0,894-1,362



0,362 1,082 0,866-1,352 0,488



After multiple - variables analysis, the affect of mental labor,

manual labor are still remained, particularly:



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- Light manual labor has risk of severe spinal stenosis which is

7,389 times higher than heavy manual labor (95%CI: 1,758-31,134),

p=0,006.

- Mental labor has risk of severe spinal stenosis which is 4,74

times higher than heavy manual labor (95%CI: 1,235-18,192),

p=0,023.

CHAPTER 4

DISCUSISON

4.1. Clinical features, MRI images and risk factors of

arteriosclerosis in LHD patients

4.1.1. Clinical features

4.1.1.1. Features of age and gender

LHD is a common disease which can occur in any age. Table

3.1. shows that the average age is 45,70 (± 13,96). This result is

relatively suitable to other studies in Vietnam and other countries which

show average age of patients is above 40. We think that this is the age

when people have to undergo the most frequent and heaviest working

hour of life, the lumbar spine must be subjected to a great deal of

mechanical stress. At the same time, biodegradation of the disc gradually

increases. From the age of 40 onwards, the amount of fluid in the mucus

decreases sharply, causing loss of tension leading to the decrease in the

normal height of the disc.

Besides, disk nourishment is mainly through the osseous process,

and blood vessels nourishing the disc is very poor. As a result, the

combination of these factors is the root of herniated disc.

LHD can be seen both in male and female. Table 3.1. shows that it

presents more in male with the percentage male/female 1,74/1. Other

studies also show the same result. Some researchers suggest that men are

more likely to do heavy lifting work than women; others suggest that the



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lumbar spine of a man is smaller than that of a woman. However, there

are no definite grounds for such explanations.

4.1.1.2. Features of profession

Figure 3.1 shows that mental labor accounts for the highest rate

(76%), light manual labor ranks the second (15,9%), and the lowest is

heavy manual labor (8,1%). In this study, profession is evaluated

according to 3 levels of labor including mental labor, light manual

labor and heavy manual labor. This evaluation is only relative,

because there is no specific concept of evaluating the level of work.

This result is suitable to other studies, but it is not suitable to

traditional logic that is rate of patients with LHD is higher in heavy

manual labor, as suggested by other researchers. We think that this

difference is due to:

-19-8 hospital is a military hospital with the patients mostly

from state agencies who are unlikely to involve in heavy manual

labor. Most of the patients have health insurance registered here, so

the proportion of patients with heavy labor is less than light labor and

mental labor.

- Secondly, we find that patients with sudden onset of herniated

disc are not always due to heavy work but most of them have the

symtoms after suddenly benting, wristing especially after sitting for a

long period of time, which can be seen frequently in officers.

Therefore, in this study, the percentage of LHD according to

profession is also suitable to the research sample.

4.1.1.3. Lumber spine syndrome and spinal nerve root syndrome

The result from 3.4 shows that there are two most frequent

symptoms: lower back pain (98,1%) and limited movement of lumber

(98,1%). This result is also suitable to the study by Nguyen Van

Chuong et al (2015) that is 89,5% of patients with limited movement



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of lumbar; Study by Daghighi M.H. et al (2014) reveals that 100% of

patients having lower back pain.

4.1.1.4. Severity of LHD on clininal manifestations

Evaluation of the severity of LHD is based on evaluation of

clinical marks of LHD by Nguyen Van Chuong (2009). The figure

3.4 shows that mild level accounts for 80,8%, severe level ranks the

second with 6,2% and no patient with very severe condition. This

result is also relevant to other studies. However, some other studies

show severe condition accounts for high percentage. This difference

canbe due to the authors’ different research purposes, often referring

to a group of patients who are intentionally undergoing surgery, or

who are using rehabilitation treatments or who are combined with

metabolic syndrome. Besides, the difference in the result also due to

the fact that the severity is assessed based on different criteria, so the

percentages are not the same.

4.1.2. MRI images

4.1.2.1. Position, number of level and kind of herniated disc

Figure 3.5 shows that two most frequent positions are L4-L5

level (82,7%) and L5-S1 (66,3%). Figure 3.6 shows that herniated disc

with 1 level accounts for the highest rate (36,5%). Result from table

3.5 shows that backward herniation rank the highest (99,3%). This

result is suitable with other Vietnamese and international studies.

4.1.2.2. Spinal stenosis

Figure 3.7 shows that 51% of patients having spinal stenosis

level I; 45,7% of patients having spinal stenosis level II and only

3,3% of patients having level III. In the study by Tran Thi Bich Thao,

Nguyen Van Chuong (2015): Spinal stenosis level III accounts for the

highest rate (50,7%) and there is no patient with spinal stenosis level

I. A study by Tran Trung (2006) on 500 operated LHD patients

reveals that most of them having severe and moderate condition



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(81,9%). Therefore, it can be seen that our research result is different

from other studies. This difference is because our patients are mostly

having medical treatment and have no surgical intervention, so the

level of moderate and mild is higher than that of other studies.

4.1.3. Risk factors of arteriosclerosis

4.1.3.1. Blood lipid level

Table 3.7 shows that average cholesterol tp is 5,31 ± 1,77

mmol/L; average HDL-C: 1,17 ± 0,35; average LDL-C: 3,21 ± 1,29

mmol/L; average triglycerid: 2,68 ± 4,03 mmol/L.

A study by Longo U.G. et al (2011): average cholesterol tp level

is 5,59 mmol/L which is higher than that of our study (5,31 ± 1,77),

but average triglycerid is 1,82mmol/L, which is lower than that of our

study (2,68 ± 4,03). This difference may be due to difference in

population, sample size and evaluation of lipid metabolism.

4.1.3.2. BMI index

According to table 3.8: average BMI is 22,88; BMI in

overweight group accounts for 46,1%. According to study by Sansoni V.

et al (2016), average BMI is 24,6; by Longo U.G et al (2011) is 26,61;

by Daghighi M.H. et al (2014) is 27,49. Therefore, it canbe seen that

patients with LHD in international studies have high BMI index.

4.2. Relevance between clinical manifestations, MRI images and

risk factors of arteriosclerosis in LHD patients

4.2.1. Relevance between clinical manifestations and risk factors

4.2.1.1. Profession and risk factors

- Female in mental labor group is lower than that in male,

(p<0,001). This is due to the fact that 19 -8 is a military hospital, so

the number of male outnumber the number of female. On the other

hand, in the police sector, the majority of the employees are

administrative and office workers, so the percentage of women in the



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