Bergmann 2017

SPINE An International Journal for the study of the spine Publish Ahead of Print
DOI: 10.1097/BRS.0000000000002296
Do occupational risks for low back pain differ from risks for specific lumbar disc
diseases? Results of the German Lumbar Spine Study (EPILIFT)
Annekatrin Bergmann, MD1, Ulrich Bolm-Audorff, MD8, Dirk Ditchen, PhD4, Rolf Ellegast,
PhD4 , Joachim Grifka, MD6, Johannes Haerting, PhD1, Friedrich Hofmann, PhD10, Matthias
Jäger, PhD3, Oliver Linhardt, MD, PhD6, Alwin Luttmann, PhD3, Hans Jörg Meisel, MD,
PhD2, Martina Michaelis, PhD7, Gabriela Petereit-Haack, MD, PhD8, Barbara Schumann,
PhD, 11, Andreas Seidler, MD, MPH9
1
Section Occupational Medicine, Institute for Medical Epidemiology, Biostatistics, and
Informatics, Martin-Luther-University Halle-Wittenberg, Magdeburger Str. 20, 06097
Halle/Saale, Germany
2
Departement of Neurosurgery, BG-Clinic Bergmannstrost, Halle, Germany
3
Leibniz Research Centre for Working Environment and Human Factors at Dortmund
University of Technology, Ardeystraße 67, 44139 Dortmund, Germany
4
Institute for Occupational Safety and Health of the German Social Accident Insurance - IFA,
Alte Heerstraße 111, 53757 Sankt Augustin, Germany
5
Institute of Occupational Medicine, Frankfurt University, Johann Wolfgang Goethe-
University, Theodor Stern-Kai 7, 60590 Frankfurt am Main, Germany
6
Orthopaedic Clinic, University of Regensburg, Kaiser-Karl-V-Allee 3, 93077 Bad Abbach,
Germany
7
Research Center for Occupational and Social Medicine Freiburg, Bertoldstraße 27, 79098
Freiburg, Germany
8
Labor Inspection, Occupational Health Division, Regional Government of South Hesse,
Simone-Veil-Straße 5, 65197 Wiesbaden, Germany
9
Institut and Policlinic of Occupational and Social Medicine, Faculty of Medicine, Carl-
Gustav-Carus- University, Fetscherstr. 74, 01307 Dresden, Germany
10
Dep. of Applied Physiology, Occupational Medicine and Infectiology, University of
Wuppertal, Gauß-Str. 20, 42097 Wuppertal, Germany
11
Epidemiology and Global Health, Department of Public Health and Clinical Medicine,
Umeå University, 901 85 Umeå, Sweden
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Address for correspondence:
Dr. Annekatrin Bergmann
Section Occupational Medicine

Institute for Medical Epidemiology, Biostatistics, and Informatics
Martin-Luther-University Halle-Wittenberg
Magdeburger Str. 20,
06097 Halle/Saale, Germany
Tel. 0049- 345-5571932
Fax 0049-345-5571933
e-mail: annekatrin.bergmann@uk-halle.de
Acknowledgement: July 6, 2016
1st Revise: October 4, 2016
2nd Revise: November 29, 2016
3rd Revise: January 17, 2016
Accept: January 24, 2017
The manuscript submitted does not contain information about medical device(s)/drug(s).
The German Statutory Accident Insurance, DGUV (formerly HVBG) grant funds were
received in support of this work.
Relevant financial activities outside the submitted work: consultancy, royalties, stocks.
Structured Abstract
Study Design
A multicentre population based case-control study.
Objective
The aim of the present analysis is to clarify potential differences in the “occupational risk
profiles” of structural lumbar disc diseases on the one hand, and low back pain (LBP) on the
other hand.
Summary of Background Data
Physical workplace factors seem to play an important aetiological role.
Methods
We recruited 901 patients with structural lumbar disc diseases (disc herniation or severe disc
space narrowing) and 233 control subjects with “low-back-pain”. Both groups were
compared with 422 “low-back pain free” control subjects. Case history, pain data,
neurological deficits and movement restrictions were documented. Low back pain was
recorded by the Nordic questionnaire on musculoskeletal symptoms. All MRI, CT and X-rays
were inspected by an independent study radiologist. The calculation of cumulative physical
workload was based on a computer-assisted interview and a biomechanical analysis by 3-D-
dynamic simulation tool. Occupational exposures were documented for the whole working
life.
Results
We found a positive dose-response relationship between cumulative lumbar load and low
back pain among men, but not among women. Physical occupational risks for structural
lumbar disc diseases (OR 3.7; CI 2.3-6.0) are higher than for low back pain (OR 1.9; 95% CI
1.0-3.5).
Conclusions
Our finding points to potentially different aetiological pathways in the heterogeneous disease
group of LBP. Results suggest that not all of the structural disc damage arising from physical
workload leads to low back pain.
Key Words: lumbar disc disease; lumbar disc herniation; disc narrowing; physical workload;
low back pain; dose-response relationship; Occupational risks; aetiologic factor; physical
workplace factors
Level of Evidence: 4
Do occupational risks for low back pain differ from risks for specific lumbar disc
diseases? Results of the German Lumbar Spine Study (EPILIFT)
1. Introduction
The aetiology of low back pain (LBP) is complex and multifactorial. Physical workplace
factors seem to play an important etiologic role, as summarised in detailed reviews of
epidemiological studies (1,2,3,4).Aside fromitsincidence, the course of low back pain (e.g.,
duration of sick leave) has been shown as well to be related to physical workload (5). Low
back pain may have multiple origins, and whendifferent disease entities are combined in
epidemiological studies the challenge is in separating and identifying potential etiological
factors. Radiographically confirmed lumbar disc herniation as well as severe disc narrowing
constitutesspecific pathological conditions potentially being accompanied by low back pain
(6,7,8,9).
Our analysis is based on the German multicentre case-control study EPILIFT,which

investigated the aetiological relevance of cumulative occupational physical work load to
lumbar disc diseases (10). In the EPILIFT study, cases with lumbar disc herniation (286
males, 278 females) or symptomatic lumbar disc narrowing (145 males, 206 females) were
compared with population control subjects (453 males, 448 females)with regard to their work
load. The results showed a positive dose-responserelationship between occupational lumbar
load and lumbar disc diseases.
The aim of the present analyses was to clarify potential differences in the occupational risk
profiles of structural lumbar disc diseases on the one hand, and low back pain on the other
hand. Weinvestigate the effect of physical workload on both LBP and development of lumbar
disc diseases.
2. Materials and Methods
The German Spine Study EPILIFT was designed as a multicentrepopulation-based case-

control study that included patients from four study regionsin Germany.All patients with
symptomatic lumbar disc herniation or severe disc space narrowing who were treatedin a
hospital or special orthopaedic and neurosurgical practicesand population control subjects
were included (response rate of patients eligible for the study =66%). To establish
arelationship between diagnosis and working life, only subjects between 25 and 70 years
oldwere askedtoparticipate.
Originally, the population-based control group summarisedsubjects with and without chronic
low back pain. To clarify potential differences in the “risk profiles” of structural lumbar disc
diseases on the one hand, and low back pain on the other hand, the present analysis defined a
new control group (as a subset of the original control group) comprised of subjects without
low back pain. First, we compared the original case groups with the new “low-back pain
free” control subjects. Second, as a new casegroup, we compared subjects with low-back pain
(as another subset of the original control group) with “low-back pain free” control subjects.
Original case groups of the EPILIFT study
• Case group 1 (males),and2 (females): disc herniation of the lumbar spine diagnosed by
CT or MRI,withradiculopathy(pain in radicular pattern and motor or sensory deficits)
related to the herniated segment.
• Case group 3 (males),and4 (females): severe disc space narrowing of the lumbar
spine,withradiculopathy (pain in radicular pattern and motor or sensory deficits) relatedto
the degenerative segment or subjects without neurological deficitand a pronounced
movement restriction (finger-floor distance of more than 25 cm). Patients of case group 3
and 4 had no lumbar disc herniation in radiological examinations.
Exclusion criteria for all case groups comprised Bechterew’s disease, inflammatory diseases
involving the lumbar spine, and tumours of the spine. Patients were not eligible for the study
if the initial diagnosis of lumbar disc disease had been made more than ten years ago.
Clinical examination
Ashort case history, pain pattern and an examination (neurological deficits and movement
restrictions)of the patient were documented. A pain questionnaire (Oswestry-low-back-pain
score) and a visual-analogue-scale for strength and localisation of pain were filled by the
patient. For reasons of quality assessment, the consistency of reported symptoms and
diagnoses was checked by experienced study staff.
Radiological examination
Final qualification for case grouping occurred afterallMRI, CT and X-rays had been
inspected by anindependent study radiologist. As an assurance ofquality control,100 patients’
images were independently assessed by another reference radiologist (Kappa value for
interobserverreliability was 0.8).
Lumbar herniation (case groups 1 and 2)
In the terminology of lumbar disc herniation, a separation between disc extrusion and
protrusion is generally accepted. Based on morphological criteria of the herniation,the
recommendation of the AJNR “Nomenclature and classification of lumbar disc
pathology”was used (11).In the German context of defined occupational diseases “consensus
criteria” for the diagnosis of disc herniation were developed (see Table 1), which quantify
criteria based ondisc displacement metrics (12).
“Table 1 here”
Disc narrowing/chrondrosis (case groups 3 and 4)
Toevaluatedisc narrowing, disc height was measured inthe sagittal planefrom MRT/CT
images and fromthe lateral native x-rays. If the lumbar spine was not met orthogonally, the
centre of the vertebral body end-plates was determined and the central disc space was
measured from this point.The radiological height of vertebral disc was multiplied by a
segment-specific factor (13).
Radiologic and clinical findings
The mean age of the patients with lumbardisc herniation was 48.1 (SD± 11.1) years among
men and 47.1 (SD±11.8) years among women. Patients with lumbar disc space narrowing
were on average about 10 years older; the mean age was 55.0 (SD±10.7) years among men
and 56.0 (±9.8) years among women.
Disc herniations of the lowest two segments of the lumbar spine predominated. About half of
all patients with lumbar herniation had only experiencedsensory, but not motor
radiculopathy(Table 2). Isolated motor deficits were rare.
Definition of a new case group “Low back pain” (Control subjects with low back pain
leading to medical consultation)
Control subjects with low back pain constituted a subset of the original control group which
had beenrandomly drawn from a one percent sample of residents aged 25 to 70 years
(response rate 53.4%). Low back pain was recorded by a modified “Nordic questionnaire on
musculoskeletal symptoms” (14). To be classified as a low back pain patient, the following
two questions had to be answered with “yes”:
- At any time during the last 12 months have you had complaints in the lower back?
- Haveyou sought medical advice because of the complaints in the lower back during
the last 12 months?
Control subjects received no examination. Therefore we have no knowledge about clinical or
radiologic findings in these subjects.
Of the 901 subjects included in the original control group, 233 (26%; 24% of males, 28% of
females) stated they had sought medical advice because of complaints in the lower back
during the last 12 months. These 233 subjects were allocated to the new case group with low
back pain.
Control subjects without low back complaints
Of the 901 control subjects, 422 (47%; 49% of males, 45% of females) stated they did not
have complaints in the lower back during the last 12 months. These 422 subjects were
allocated to the new control group without low back pain.
Evaluation of occupational exposure
The evaluation of cumulative physical workloadwas based on a two-stage procedure. First, in

a standardised computer-assisted interview the complete occupational history of all subjects
was elicited.The interviewers also documented psychosocial workload, sports activities, and
distress through critical life events. All interviewers were trained in standardised interview
techniques and a non-differential approach to cases and controls. Participants were not
informed about the specific aims of the study. Second, those subjects were identified who in
their working lives had been exposed to certain minimum thresholds of workloads. Of 1816
study participants, 1317 met these criteria. 1154 participants agreed to receive a detailed
semi-standardised interview by technical experts of the social accident insuranceinstitutions.
The following occupational exposures were documented for the whole working life:
- manual material handling of loads: lifting, carrying, pulling, pushing, throwing,

shovelling loads weighing at least 5 kg;
- intensive-load working postures: forward trunk inclination, lateral trunk bending,
trunk torsion, over-head working, kneeling, squatting, heel-sitting;
- forces: assembly work and lever activities, manual patient handling;
- whole-body vibration (horizontal and vertical direction considered).
For each of these working activities, intensity, frequency and duration of typical work shifts
during the occupational lifeweredocumented.
Biomechanical analysis and calculation of cumulative lumbar load
To calculate the cumulative lumbar load during occupational life, tendose models were
applied comprising various thresholds for the lumbosacral compressive force, trunk
inclination or shift related minimum threshold (9). Models consider loads 5 kg or moreand
trunk inclination from 20° to 90°. The calculation includes frequency and duration of all
handlings. A cumulative lifetime dose for the compressive force on the disc L5/S1in kNhwas
computed as a relevant indicator of the situational lumbar load.
Quantification of lumbosacral compressive force was based on biomechanical calculations

applying the formerly developed 3-D-dynamic simulation tool “The Dortmunder”(15).
Lumbar-disc compressive force is weighted linearly or over proportionally (power 2 to 4) in
relation to the respective duration of material handling or intensive-load posture. Ingeneral,
only exposures prior to the date of first diagnosis were considered.
Confounders and statistical analyses
All continuous variables were categorised in tertiles (low, moderate, high exposure) based on
the distribution of the exposed control subjects. Cumulative dose values were calculated
separately for each study participant. If less than 20% of the control subjects were “non-
exposed”, the reference category combined non-exposed subjects and subjects in the first
exposure tertile. If the highest category covered more than 10% of the control subjects
anadditional “high dose category”was formed. Odds ratios and 95% confidence intervals
were calculated using unconditional logistic regression analysis. All statistical analyses were
adjusted for age and study region.
The following variables were checked with respect to their potential confounder status: body
mass index, history of tobacco use, born children, sports, competitive spine
diseasesi.e.Scheuermann’s disease, accidents, psychosocial workload anddistress by critical
life events. Only distress by unemployment as a major life event (for case group 1) and
psychosocial workload (for case groups 2 and 4) fulfilled the mentioned conditions.
Adjustment for the consequences of a disease (or its precedents) was assumed to distort the
risk estimates. As such,the present analysis adjustedsolely for age, unemployment, work
stress and study region.We calculated odds ratios (OR) for the cumulative lumbar load
through manual material handling and intensive-load postures; furthermore, we calculated
OR separately for the cumulative lumbar load through manual material handling and for
trunk inclination >20°, adjusting for each. As very few women were exposed to whole-body
vibrations (WBV), we restricted our analysis of WBV to men (threshold aw(8)=0.63 m/s2).
Comprehensive analyses were performedto identify the “best” dose model in terms of
goodness of fit (estimated by the Akaike information criterion AIC), specificity, simplicity,
and clarity of the dose-response-relationship.
3. Results
We compared the original case groups (symptomatic prolapse and disc narrowing) with the
new “low-back pain free” control subjects. Second, as a new casegroup (Control subjects
with low back pain leading to medical consultation), we compared subjects with low-back
pain with “low-back pain free” control subjects.
Among men, there was a positive dose-response relationship between the cumulative lumbar
load and low back pain leading to medical consultation. For a high cumulative exposure
(>21.51*106Nh)the LBP risk was elevated to OR 1.9 (CI 1.0-3.5; Table 3). In separate
analyses of manual material handling and trunk inclination we found non-significantly
elevated risks with an OR of 2.2 (95% CI 0.9-5.3) for the highest category of cumulative
exposure to high-intensity load postures. For a high dose of total whole-body vibrations
(WBV), the LBP risk is elevated to 4.3 (95% CI 0.7-24.9). In patients with lumbar disc
herniation (case group 1), we find a remarkably steeper dose-response relationship than inthe
original analysis with control subjects regardlessof LBP.The OR is significantly elevated to
1.9 (95% CI 1.1-3.0) in the moderate category of cumulative lumbar load and to 3.7 (95% CI
2.3-6.0) in the highest category. Bothmanual material handling and intensive-load postures,
but not whole-body vibrations, are associated with lumbar disc herniation. Considering
lumbar disc narrowing with symptoms, we again founda remarkably steep dose-response
relationship: the OR issignificantly elevated to 1.9 (95% CI 1.0-3.7) for a moderate exposure
and to 4.1 (95% CI 2.2-7.6) in the highest category. In contrast to lumbar disc herniation,
lumbar disc narrowing with symptomswas more likely associated with whole-body
vibrations: for a high dose of total WBV, the risk of lumbar disc narrowing is elevated to 6.3
(95% CI 1.3-30.8).
Among women (Table 4), we did not find a clearly increased LBP risk for persons exposed to
manual material handling and/or to intensive-load postures; however, numbers of exposed
women are considerably lower than numbers of exposed men. In contrast, also among women
the OR for lumbar disc herniation is significantly increased (OR in the highest exposure
category3.5; 95% CI 2.0-5.9). The lumbar disc herniation risk is remarkably higher among
women exposed to intensive-load postures than among women exposed to manual material
handling. Considering lumbar disc narrowing, we again found significantly elevated risks for
women exposed to a high cumulative lumbar load (OR in the highest exposure category3.3;
95% CI 1.8-5.9).
4. Discussion
Several key observations could be made from this study.First, we found a positive dose-
responserelationshipbetween cumulative lumbar load and low back pain among men, but not
among women. Second, a strong dose-responserelationship between cumulative lumbar load
and lumbar disc herniation as well as lumbar disc narrowing was observed among both men
and women. The absolute size of risk estimates(OR) should be interpreted cautiously, as the
choice of the control group (persons without low-back pain during the last 12 months) led to
relatively high odds ratios. Third, although cases from our original study were compared with
all population controls (independently from existing low back pain), lower OR would have
been achieved (10).The present analysis revealeda considerably stronger dose-response
relationship between cumulative lumbar load and specific lumbar disc diseases (lumbar disc
herniation as well as disc narrowing) than between cumulative lumbar load and LBP.
Together these findingspoint to potentially different aetiological pathways in the
heterogeneous disease group of LBP; Physical occupational risks for specific lumbar disc
diseases are higher than for low back pain. Therefore, results suggest that not all of the
structural disc damage arising from physical workload leads to back pain."
With regard to vibration, there was a significant relationship between the cumulative dose of
whole-body vibration and the risk of disc narrowing, but no clear association between whole-
body vibration and lumbar herniation or low back pain. Adifferent pathogenic mechanism in
the aetiology of lumbar disc herniation and lumbar disc narrowing is probably. This
hypothesis is further supported by the fact that patients with lumbar herniation were on
average 10 years younger than patients with disc narrowing. These resultssupport the
assumption that exposure to whole-body vibration inducesstructural damage leading to disc
narrowing, andlifting over a longer time is more closely related to disc herniation. In an
animal model, histologic hallmarks of degeneration in the annulus fibrosus, disruption of
collagen, and increased cell death was found following exposure of WBV (16). High
hydrostatic pressure during lifting influences matrix-protein expression (17). Apenetration of
nucleus pulposus into the endplate and annulus fibrosus in response to compressive cyclic
loading has been reported in studies involving human cadavers and animal models
(18,19,20).
To our knowledge this is the first study to compare cumulative occupational load as a risk
factor for low back pain with its risk for specific lumbar disc diseases. The strengths of our
study are the high number of participants, inclusion of men and women, expert-based detailed
exposure assessment, subsequent biomechanical analysis for each documented work place
task and adjustment for multiple potential confounders.
Many studies have reported the varied levels of lumbar disc diseases and symptoms. There is
no strong concordance between radiologic findings and clinical symptoms (21). To avoid
misclassification we includedonly patients with symptoms relatedto the herniated segment.
For patientswith disc space narrowing who hadonly pronounced movement restrictionsbut no
radicular deficits a link between low back symptoms and severe disc degeneration cannot be
implied.
The prevalence of asymptomatic lumbar disc diseases ranges from 20 to 60 percentand is
related to age (22). Therefore, the control group contains asymptomatic subjects. This
misclassification leads to an underestimation of risks for structural disc diseases due to
physical workload. Furthermore we see a potential of recall biasdue to interviews for
documentation of exposureandlow back pain.
As another potential limitation of our study, the relatively low response rate might have
introduced selection bias. To further evaluate this potential bias, we asked non-participants by
telephone about their longest held job. The non-responderanalysis showed no difference
between cases and control subjects with respect to their blue or white-collar status. As control
subjects did not receive diagnostics, the frequency of lumbar disc disease is unknown among
the population control.
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Table 1. Classification of lumbar disc herniations
Degree I (protrusion) Displacement of disc material ≤ 3 mm; displacement of disc

material > 3 to < 5 mm, if morphological criteria not fulfilled
Degree II (extrusion) Displacement of disc material ≤ 3 mm; displacement of disc

material > 3 to < 5 mm, if morphological criteria are fulfilled
Degree III (extrusion) Displacement of disc material ≥ 5 mm
Degree IV (sequestration) Sequestration of disc material
Table 2. Neurological findings in patients with lumbar disc disease
Males Females
Lumbar disc
Lumbar disc space
Lumbar disc Lumbar disc
space narrowing
herniation herniation
narrowing
N= 286 N= 278
N = 145
N= 206
Motor/sensory
157 (55%) 43 (31%) 137 (49%) 52 (25%)
radiculopathy
Sensory
128 (44%) 33 (23%) 138 (50%) 40 (19%)
radiculopathy
Radiculopathy, not
1 (1%) 1 (1%) 3 (1%) 2 (1%)
further classified
Symptoms without
- 66 (46%) - 112 (54%)
radicular pattern
Table 3. Occupational risks for low back pain and lumbar disc disease among men in comparison with “low back-pain free” men.
No low back Controls with low back pain leading to Lumbar disc herniation (original Lumbar disc narrowing (original
pain (new medical consultation (new case group) case group 1) case group 3)
control group)
N % N % Adj. ORa 95% CI N % Adj. 95% CI N % Adj. 95% CI
a a
OR OR
cumulative lumbar load through manual materials handling and/or trunk inclination>20° (Nh)
0 - <5.0*106Nh 87 39.5 30 27.8 1.0 - 54 18.9 1.0 - 27 18.6 1.0 -
5.0 – <21.51*106Nh 70 31.8 30 27.8 1.3 0.7-2.5 76 26.6 1.9 1.1-3.0 31 21.4 1.9 1.0-3.7
>21.51*106Nh 63 28.6 48 44.4 1.9 1.0-3.5 156 54.5 3.7 2.3-6.0 87 60.0 4.1 2.2-7.6
cumulative lumbar load through manual materials handling (Nh)

0 - <2.34*106Nh 94 42.7 28 25.9 1.0 - 58 20.3 1.0 - 27 18.6 1.0 -
2.34 – <8.98*106Nh 64 29.1 38 35.2 1.8 0.8-4.0 77 26.9 1.4 0.8-2.6 39 26.9 1.7 0.8-3.6
>=8.98*106Nh 62 28.2 42 38.9 1.5 0.6-3.4 151 52.8 2.2 1.2-4.1 79 54.5 2.7 1.3-5.8
cumulative lumbar load through trunk inclination>20° (Nh)

0 Nh 72 32.7 24 22.2 1.0 - 45 15.7 1.0 - 26 17.9 1.0 -
>0 - <4.85*106Nh 56 25.5 18 16.7 1.0 0.4-2.3 45 15.7 1.1 0.6-2.1 25 17.2 1.6 0.7-3.6
4.85 – 14.62 *106Nh 52 23.6 26 24.1 1.1 0.4-2.7 84 29.4 1.7 0.8-3.4 37 25.5 1.6 0.7-3.6
6
>=14.62*10 Nh 40 18.2 40 37.0 2.2 0.9-5.3 112 39.2 2.4 1.2-5.0 57 39.3 2.1 0.9-4.9
cumulative whole-body vibration dose due to vertical vibrations (m/s2)2

0 (m/s2)2 201 91.4 97 89.8 1.0 - 250 87.4 1.0 - 118 81.4 1.0 -
2 2
>0 - <364 (m/s ) 5 2.3 5 4.6 1.8 0.5-7.5 14 4.9 1.6 0.5-4.9 5 3.4 1.1 0.3-4.3
2 2
364- <1,190 (m/s ) 12 5.5 1 0.9 0.1 0.02-1.0 15 5.2 0.7 0.3-1.6 9 6.2 1.0 0.4-2.6
>=1,190 (m/s2)2 2 0.9 5 4.6 4.3 0.7-24.9 7 2.4 1.8 0.4-9.0 13 9.0 6.3 1.3-30.8
a
Adjusted for age and region; OR for manual materials handling additionally adjusted for trunk inclination and vice versa
Table 4. Occupational risks for low back pain and lumbar disc disease among women in comparison with “low back-pain free” women
No low back Controls with low back pain leading to Lumbar disc herniation (original Lumbar disc narrowing (original
pain (new medical consultation (new case group) case group 2) case group 4)
control group)
N % N % Adj. ORa 95% CI N % Adj. 95% CI N % Adj. 95% CI
a a
OR OR
Cumulative lumbar load manual materials handling and/or trunk inclination>20° (Nh)
0 Nh 95 47.0 52 41.6 1.0 - 71 25.5 1.0 - 55 26.7 1.0 -
>0 - <4.04*106Nh 40 19.8 24 19.2 1.4 0.7-2.6 55 19.8 2.2 1.3-3.8 28 13.6 1.5 0.8-3.0
4.04 - <14.47*106Nh 34 16.8 23 18.4 1.6 0.8-3.2 74 26.6 3.6 2.1-6.1 50 24.3 3.6 1.9-6.8
6
>=14.47*10 Nh 33 16.3 26 20.8 1.0 0.5-2.0 78 28.1 3.5 2.0-5.9 73 35.4 3.3 1.8-5.9
Cumulative lumbar load through manual materials handling (Nh)

0 Nh 105 52.0 60 48.0 1.0 - 92 33.1 1.0 - 61 29.6 1.0 -
6
0 - <1.58*10 Nh 34 16.8 23 18.4 0.9 0.3-2.5 46 16.5 0.8 0.4-1.8 20 9.7 1.2 0.4-3.5
6
1.58 – <9.06*10 Nh 34 16.8 17 13.6 0.7 0.2-2.2 70 25.2 1.1 0.5-2.5 62 30.1 3.0 1.1-8.1
>=9.06*106Nh 29 14.4 25 20.0 1.2 0.4-4.0 70 25.2 1.1 0.5-2.5 63 30.6 2.0 0.7-5.9
Cumulative lumbar load through trunk inclination>20° (Nh)

0 Nh 100 49.5 54 43.2 1.0 - 75 27.0 1.0 - 61 29.6 1.0 -
6
>0 - <2.77*10 Nh 34 16.8 26 20.8 2.2 0.8-6.1 52 18.7 2.7 1.2-6.3 24 11.7 1.2 0.4-3.7
2.77 – 8.83 *106Nh 36 17.8 26 20.8 1.6 0.6-4.8 66 23.7 2.6 1.2-6.0 45 21.8 1.2 0.4-3.2
6
>=8.83*10 Nh 32 15.8 19 15.2 0.7 0.2-2.3 85 30.6 3.7 1.6-8.6 76 36.9 1.6 0.6-4.5
a
Adjusted for age and region; OR for manual materials handling additionally adjusted for trunk inclination and vice versa

Bergmann 2017

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SPINE An International Journal for the study of the spine Publish Ahead of Print

Dr. Annekatrin Bergmann

Section Occupational Medicine

Acknowledgement: July 6, 2016

1st Revise: October 4, 2016

2nd Revise: November 29, 2016

3rd Revise: January 17, 2016

Accept: January 24, 2017

A multicentre population based case-control study.

Summary of Background Data

Physical workplace factors seem to play an important aetiological role.

Our analysis is based on the German multicentre case-control study EPILIFT,which

The German Spine Study EPILIFT was designed as a multicentrepopulation-based case-

Original case groups of the EPILIFT study

Lumbar herniation (case groups 1 and 2)

Disc narrowing/chrondrosis (case groups 3 and 4)

Radiologic and clinical findings

Control subjects without low back complaints

Evaluation of occupational exposure

The evaluation of cumulative physical workloadwas based on a two-stage procedure. First, in

- manual material handling of loads: lifting, carrying, pulling, pushing, throwing,

Quantification of lumbosacral compressive force was based on biomechanical calculations

Confounders and statistical analyses

Degree I (protrusion) Displacement of disc material ≤ 3 mm; displacement of disc

Degree II (extrusion) Displacement of disc material ≤ 3 mm; displacement of disc

Degree III (extrusion) Displacement of disc material ≥ 5 mm

Degree IV (sequestration) Sequestration of disc material

cumulative lumbar load through manual materials handling (Nh)

cumulative lumbar load through trunk inclination>20° (Nh)

cumulative whole-body vibration dose due to vertical vibrations (m/s2)2

Cumulative lumbar load through manual materials handling (Nh)

Cumulative lumbar load through trunk inclination>20° (Nh)

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