Asian Spine J. 2016 Oct;10(5):834-842. Epub 2016 Oct 17.
Zolfaghari F1, Faridmoayer A1, Soleymani B2, Taji M3, Mahabadi M4.
1Department of Neurosurgery, School of Medicine, Najafabad Branch, Islamic Azad University, Isfahan, Iran.
2Department of Health, School of Medicine, Najafabad Branch, Islamic Azad University, Isfahan, Iran.
3Young Researchers and Elite Club, Najafabad Branch, Islamic Azad University, Isfahan, Iran.
4School of Medicine, Najafabad Branch, Islamic Azad University, Isfahan, Iran.
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STUDY DESIGN: Descriptive cross-sectional study.
PURPOSE: To determine the prevalence of vitamin D deficiency in patients with degenerative diseases of the spine about to undergo spinal surgery and the relations between such deficiency and potential risk factors.
OVERVIEW OF LITERATURE: Vitamin D has a major role in musculoskeletal system health maintenance. Recently, studies on degenerative diseases of the spine have shown a high prevalence of vitamin D deficiency in patients undergoing spine surgery.
METHODS: Serum levels of 25(OH)D were determined by an electrochemiluminescence detection assay. The other variables were determined through relevant questionnaires, and the data was analyzed through analysis of variance, t-test, chi-square and multivariate logistic regression analysis.
RESULTS: A total of 110 patients were enrolled in the study. The mean serum level of 25(OH)D was 27.45±18.75 ng/mL, and 44.5% of patients showed vitamin D deficiency (25(OH)D<20 ng/mL), with an additional 17.3% of patients having a serum level of 25(OH)D that was insufficient (20=25(OH)D<30 ng/mL). The prevalence of vitamin D deficiency was significantly higher in the younger age group compared to the older age group (p<0.001) and the ones without a history of taking vitamin D supplements (p=0.013). Compared to men, women showed significantly higher levels of vitamin D (p=0.029).
CONCLUSIONS: A high prevalence of vitamin D deficiency is seen in patients with degenerative diseases of the spine. On the other hand, the conventional risk factors such as old age or female sex alone did not seem to be sufficient in determining the likelihood of deficiency. Thus, it is recommended that vitamin D deficiency prevention strategies comprise a broader spectrum of the population through which such degenerative diseases and their consequences may be prevented or delayed.
PMID: 27790310 DOI: 10.4184/asj.2016.10.5.834
Although, the degeneration of the vertebral discs is considered a part of a natural trend in aging, it can become accelerated, with the affected individual becoming symptomatic at a younger age. This degeneration can most likely be accounted for by mostly a genetic predisposition and partly by environmental factors. The environmental factors such as heavy physical activity can trigger a cascade of molecular events in disc degeneration, exacerbating the disorder in a vicious cycle. One of the factors playing a role in these molecular processes is the vitamin D system. Of note, VDRs (vitamin D receptors) are expressed in osteoblasts, chondrocytes, and annulus fibrosus and nucleus pulposus cells of the discs [3,4]. In addition, vitamin D has been demonstrated to affect the proliferation and functional regulation of these cells and their production of certain proteins and cytokines in vitro.
However, degenerative changes in bone and cartilage, either because of the natural aging or disease, can lead to fractures, spine instability and deformity, which can in turn result in chronic pain and neurological deficits. Also, a poor quality of bone affects the outcome of spine surgeries, especially instrumented ones, resulting in undesirable consequences.
In a study of 360 patients with chronic LBP, the prevalence of severe vitamin D deficiency (<9 ng/mL) was reported as 83% . Stoker et al.  studied 313 patients undergoing surgical spinal fusion and reported that the prevalence of vitamin D deficiency (<20 ng/mL) was 27% and the prevalence of insufficiency (<30 ng/mL) was 57%. Also, in a study of the prevalence of vitamin D deficiency in patients with lumbar spinal stenosis (LSS) and its relation with pain, the prevalence of hypovitaminosis D was reported as 74.3% .
In the present study, we examined the vitamin D serum level status of the patients undergoing surgery for degenerative diseases of the spine and the relationship between the serum levels of vitamin D and the factors that can act as risk factors for vitamin D deficiency for these patients. A total of 110 patients were enrolled. Of these, 49 patients (44.5%) suffered from the vitamin D deficiency; also 19 (17.3%) had insufficient levels of vitamin D; the remaining 42 patients (38.2%) had normal serum levels. As such, 61.8% suffered from hypovitaminosis D (25(OH)D<30 ng/mL), which is a considerable percentage of these patients. For the group with no history of the consumption of vitamin D supplement, the rate was 71.6%. Although the mean serum level of 25(OH)D was significantly higher in the group with a consumption history of vitamin D supplements (p=0.013), hypovitaminosis D prevalence was still 47.6%, indicating inadequate or incorrect levels of vitamin D supplementation.
For patients undergoing cervical spine surgery, they made up only a small percentage of the patients in our study (19 subjects) and although their numbers may not be representative, 17 of 19 the patients (89.5%) suffered from hypovitaminosis D and only 2 patients (10.5%) showed normal vitamin D levels. On the contrary, patients undergoing lumbosacral spine surgery (91 subjects), only 56.1% suffered from hypovitaminosis D.
In terms of age of patients, older age has been traditionally reported as a risk factor for vitamin D deficiency and various reports have stated the high prevalence of vitamin D deficiency in older people . Also, the mechanisms such as the reduced capacity of intestinal absorption and the reduced skin synthesis of vitamin D are discussed in the context of aging . However, clinical studies, particularly those for the spine, have shown that the age cannot be a good predictor of vitamin D deficiency. Moreover, studies conducted on patients with orthopedic surgery and spinal fusion have found a high prevalence of vitamin D deficiency in young adults [7,18]. Our study also revealed a significant direct correlation (p<0.001) between age and serum levels of 25(OH)D, which was independent of the effect resulting from the consumption of vitamin D supplement. The highest rate of vitamin D deficiency was seen for the 20-39-year-old age group. Considering this, care should be taken that although the aging population suffers from osteoporosis, osteomalacia, fractures and degenerative processes, young people should not be neglected. It may be that many of these pathological processes start early at youth and controlling vitamin D levels at a young age might prevent degenerative spine diseases later in life.
Females are regarded to be at risk for vitamin D deficiency and many studies have confirmed this . However, in a number of studies, there were no differences between female and male subjects for vitamin D deficiency  and even in some cases, it was shown a lower risk for hypovitaminosis D existed in females [18,21]. Also, in our study, the serum levels of 25(OH)D were significantly higher in women among the studied population (p=0.029). Moreover, vitamin D supplement consumption was considerably and significantly higher in women (p<0.001), and the higher vitamin D levels in this group may be due to the increased dietary supplementation and treatment in this group.
Research and data about vitamin D status in the general adult population in our country is very limited. In these studies [22,23] prevalence of vitamin D deficiency has been reported to be from 30% to 80%, according to population and regional differences. In the only study of adult population in our region (Isfahan, Iran) prevalence of hypovitaminosis D was reported to be about 70%  and the deficiency was more prevalent in women and youth. The main problem of this study was that about 80% of the studied population were female.
Some assumptions have been suggested for smoking and its effects on the musculoskeletal system with indications of reduced intestinal absorption of calcium and increased rate of bone loss . In this study, there was no significant difference in the serum levels of vitamin D between the smokers and non-smokers (p=0.134). The only noteworthy point was that the vitamin D supplement consumption was significantly higher in the non-smoker group (p=0.032).
What should be stated about BMI as a risk factor for vitamin D deficiency is that in obese patients, an increase in adipose tissue leads to dispersion and distribution of this fat-soluble vitamin and thus a reduction in its bioavailability . In this case, many studies suggest an inverse relationship between BMI and the serum levels of vitamin D [18,25]. However, several clinical studies have also indicated a high prevalence of vitamin D deficiency in non-obese patients . In our study, there was no significant correlation between the serum levels of 25(OH) D and BMI (p=0.458); this was similar to the results of the study by Kim et al.  where they reported on 350 patients with LSS. This was unlike the finding by Stoker et al.  in a study of 313 patients undergoing spinal fusion surgery where there was a high prevalence of vitamin D deficiency in obese individuals.
In the case of presence of pain, there have been several reports on the relationship between musculoskeletal pain and vitamin D deficiency [15,20,27], and it was demonstrated that treatment by vitamin D supplements could improve the symptoms [15,27]. In particular, in the case of the spine, both Stoker et al.  and Kim et al.  suggested an inverse correlation between the pain and the serum levels of vitamin D. Similar results have been reported for patients with chronic LBP and unsuccessful fusion surgery [15,28]. In spite of the above- mentioned studies, we did not find any significant correlation between the severity of pain and the serum levels of vitamin D (p=0.467).
It is believed that individuals who live in more northern latitude are at a higher risk of vitamin D deficiency in winter. This also includes individuals who in any way may have a limited exposure to sunlight . However, several clinical studies  showed a high prevalence of vitamin D deficiency in lower latitudes and in summer, among them in our country (Iran) where there is a good deal of sunlight and there is still a high prevalence of vitamin D deficiency. In the present study, similar to what were stated in the studies by Stoker et al.  and Kim et al. , there was not a significant difference between the serum levels of vitamin D and the different seasons (p=0.655). For our study, however, the distribution of samples was not uniform in different seasons and most of samples (85.5%) were collected in spring and winter.
In summary, according to the results from the present study and similar to other studies in this area, it can be stated that the vitamin D deficiency shows a high prevalence in patients with degenerative diseases of the spine, even in patients treated by vitamin D supplements.
Although vitamin D has attracted the attention of researchers in recent decades and its role has been studied and confirmed in various diseases, with knowledge and awareness having increased among the public and medical professionals, it has not yet been enough. Although the elderly and women are traditionally at a higher risk of vitamin D deficiency with consequences such as osteomalacia, osteoporosis, etc., there is also no safety margin for vitamin D deficiency among youths and men and they should not be ignored. On the other hand, given the diversity and differences in research results for vitamin D deficiency risk factors, they are not enough for predicting or proposing vitamin D deficiency and it is recommended that vitamin D deficiency prevention strategies comprise a broader spectrum of the population in order to prevent or delay the onset of degenerative diseases and their consequences. In addition, considering that vitamin D deficiency existed even for patients treated with supplements, attention should be paid to the correct and complete dosing after diagnosing the vitamin D deficiency.Degenerative Diseases of the Spine are related to low vitamin D levels – Oct 2016
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