International Journal of Epidemiology Vol. 4, No.

3
© Oxford Unrvernty Press 1975 Printed in Great Britain

An Epidemiological Study of the Relationship

Between Occupations and Acute Herniated
Lumbar Intervene bra I Discs*
JENNIFER L. KELSEY1

Kelsey, J. (Dept. Epidemiology and Public Heattn, Yale University School of Medicine, 60 College Street, New
Haven, Connecticut 06510, U.S.A.). An epidemiological study of the relationship between occupations and

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acute herniated lumbar intervertebral discs. Int. J. Epid. 1975, 4:197-205.
A case-control study of the epidemiology of acute herniated lumbar intervertebral discs in the New Haven,
Connecticut, area indicates that sedentary occupations increase the risk for herniated lumbar discs, particularly
among those aged 35 years and older who have had sedentary jobs for several years. People in occupations
requiring prolonged driving of motor vehicles, such as truck drivers, appear to be at particularly high risk. The
results of this study provide no evidence that people whose jobs involve heavy manual labour are at greater risk
for acute herniated lumbar disc than others of their age and sex.

INTRODUCTION
There has been much discussion of the role that
occupations play in the aetiology of herniated
lumbar intervertebral discs. Some surgeons (1-3)
have felt that jobs involving heavy physical labour
predispose to herniated lumbar discs, while others
(4-5) have suggested that sedentary occupations
increase the risk. Despite these diverse opinions,
which are based primarily on clinical.impression,
to our knowledge no epidemiological studies have
previously been undertaken of the relationship
between occupations and herniated lumbar discs.
Using data from an epidemiological study in the
New Haven, Connecticut, area (6), this paper
examines the risk for acute herniated lumbar
intervertebral discs among people in different types
of occupations.
METHODS
The general approach in this study involved com-
paring characteristics of people with recent her-
• Supported by USPHS Grant 5-RO1-AM-15397 from tne
National Institute of Arthritis, Metabolism and Digestive
Diseases.
1
Department of Epidemiology and Public Health, Yale
University School of Medicine, 60 College Street, New Haven,
Connecticut 06510, U.S.A.
t Supported by Career Development Award 1-KO4-NS-70502
from the National Institute of Neurological Diseases and Stroke.
This paper was presented at the Rheumatic Complaints session
of the Seventh International Scientific Meeting of the Inter-
national Epidemiological Association, held at the University of
Sussex, England, August 1974.
197
niated lumbar intervertebral discs to characteristics
of two groups of people of the same sex and similar
age without herniated lumbar discs.
Cases were ascertained from people in the age
group 20-64 years residing in the New Haven
Standard Metropolitan Statistical Area who had
lumbar X-rays taken during the period June 1971
to May 1973 at the three hospitals in this area and
at the office of two of the private radiologists in
New Haven. Lumbar X-rays alone are of course of
limited value in diagnosing herniated discs, but the
assumption was made that most people with severe
low back or sciatic pain would have lumbar X-rays
taken, so that many with herniated lumbar disc
could be ascertained from among these patients.
In order to determine which of them were in fact
likely to have herniated discs, they were inter-
viewed within a few weeks of the time they were
X-rayed and their medical records were reviewed.
During the interview, in addition to being asked
about demographic characteristics, occupational
history, and exposure to other possible risk factors,
they were asked about symptoms and were given a
few simple diagnostic tests by the interviewers.
On the basis of the symptoms and signs noted
during the interview, the radiologist's report
(which could be used to exclude people with other
conditions which could be bringing about the same
symptoms and signs), and the surgeon's observa-
tions (in cases in which surgery was performed), the
people having low back X-rays were divided into
 198 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
those who might have herniated lumbar discs and
those who probably did not.
Among those considered likely to have herniated
lumbar disc, the following diagnostic criteria were
applied:
1. Surgical cases were those in which all of the
following three criteria were fulfilled: (a) the
surgeon stated on the hospital chart that he saw
the herniated disc during surgery;* (b) the patient
gave evidence in his answers to the questionnaire
that his pain was distributed along the sciatic
nerve; and (c) the patient had a positive straight
leg raising test and/or the symptoms of increased
pain in the low back or along the sciatic nerve
when stretching or extending his leg from a sitting
position and/or the symptom of increased pain
along the sciatic nerve when coughing or sneezing.
2. Probable cases were similar to the surgical
except that the herniation need not have been
observed at surgery. Included were cases in which
the sciatic pain was felt in both the thigh and lower
leg and cases in which there was sciatic pain in part
of the leg and numbness in another part.
3. Possible cases differed from the probable in
that the sciatic pain was only in the thigh or the
lower leg but not in both. Also, if the leg was
numb so that the distribution of pain was unknown
but the symptoms and signs were otherwise con-
sistent with a herniated disc, the person was
classified as a possible case.
Only those who had developed symptoms within
the previous year were included in the case-control
comparison, since it was desired to find out about
exposure to possible risk factors prior to the
onset of the disc problem rather than subsequent
to it.
Two control groups of people without known
herniated discs were also interviewed so that their
occupational histories and exposure to other risk
factors could be compared to those of the cases.
The first group was a matched control group.
Each surgical, probable, and possible case was
matched to the next person of the same sex and
about the same age who was admitted to the same
hospital service or to the same radiologist's office
for a condition not related to the spine. Ages of
patients admitted to the emergency room were
matched within two years in two hospitals and
• The descriptions 'ruptured', 'free fragments', 'herniated',
'prolapsed', 'bulging', and 'extruded' are included, but not disc
degeneration without evidence of nerve root involvement. The
one patient whose medical record indicated that the herniated
disc was seen at surgery but who did not have symptoms con-
sistent with a herniated disc is not included as a case.
within three years in the other hospital; the ages of
all other patients were matched within ten years.
No one who would have been classified as a
surgical, probable, or possible case or who had
previously had a herniated lumbar disc or chronic
low back pain could serve as a control. In addition,
the controls had to have sought medical care for a
condition which they had had for no more than
one year, so that, like the cases, they had recently
acquired their disease. When a potential control did
not meet these criteria, another person of the appro-
priate age and sex admitted to the same service
was chosen.
The second control group was composed of
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people who had low back X-rays taken and were
thus interviewed in the course of ascertaining cases,
but who were not classified as surgical, probable,
or possible cases and who had not had their
symptoms for more than one year. Because of the
different characteristics of people going to various
hospital services, comparisons of these cases and
controls were made in seven separate groups for
males and six groups for females according to the
hospital service. The separate four-fold tables
resulting from these comparisons were then com-
bined by the Mantel-Haenzel procedure (7) in
order to test for overall statistical significance and
to estimate relative risk. The age distributions of
cases and controls in each group were similar, so
they did not have to be compared in separate age
groups.
The same questionnaire and diagnostic tests
were administered by carefully trained non-
medical interviewers to all cases and controls.
Most interviewing was done in the homes of the
subjects, but when it was possible to interview them
in the hospital this was done. The overall response
rate was 79 per cent for those having low back
X-rays and 77 per cent for matched controls.
Information was obtained on all jobs which the
respondent had held for at least a year since he
left school. Questions were asked about what the
specific occupation was; how many years he had
been employed in it; how many hours per week he
usually worked; whether he sat none of the time,
a little of the time, about half of the time, most of
the time, or all the time; if he sat half the time or
more, what kind of chair he usually sat in; whether
he did any lifting, pushing, pulling, or carrying;
and if he lifted, about how many times a day he
did this and what was the approximate weight of
the objects he usually lifted.
A total of 217 pairs was obtained (89 females,
128 males) for the comparison of cases and matched
 RELATIONSHIP BETWEEN OCCUPATIONS A N D ACUTE HERNIATED LUMBAR INTERVERTEBRAL DISCS
controls. For the analysis of cases and unmatched
controls, there were 223 cases* (91 females and
132 males) and 494 controls (225 females and 269
males). A detailed description of the demographic
characteristics of the cases is given elsewhere (6).
The highest incidence of new cases was in the age
group 30-39 years, although there were some cases
throughout the 20-64 year age range of the study.
There were about twice as many males as females
among the surgical cases, but only slightly more
males than females among the non-surgical cases.
Twenty-two per cent of the cases were non-white,
and 63 per cent had graduated from high school.
199
than pairs in which the case sat less than half the
time and the control sat half the time or more.
With the sexes combined, the relative risk is esti-
mated to be 1-58.
In Table II, the pairs are divided into those in
which the case was 35 years of age or older and
those in which the case was younger than 35. It may
be seen that the association between sedentary
occupations and herniated lumbar discs is seen
only among those in the older age group, in which
the estimate of relative risk is 2-40.
The proportions of cases and unmatched controls
who sat half or more of the time on the job are
compared in Table i n . In most of the groups, the

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RESULTS
Table I compares cases and matched controls
according to whether they spent half or more of
their time sitting while at the job they had at the
time they developed their symptoms. It can be seen
that among both males and females there were
more pairs in which the case sat half of the time
or more and the control sat less than half the time
• Matched controls could not be obtained for six of the cases
seen by private radiologists because of problems related to
confidentiality of names of people seeking medical care from
private physicians.
proportion of cases is higher than the proportion
of controls; when the individual groups are com-
bined by the Mantel-Haenzel procedure, the
estimate of relative risk, 1 -70, is very close to that
for the cases and matched controls. When this was
examined by age group (data are not shown here)
it was again found that the trend was stronger
in those age 35 and over. Thus, both comparisons
suggest that sedentary occupations are conducive
to the development of herniated lumbar discs,
especially among those aged 35 years and older,
and that, more specifically, those who sit half of
the time or more on their jobs have about a 60-70

TABLE I
Cases and matched controls according to whether they sat half the time or more on their job ( > i ) or sat less than half the
time on their job ( < i ) , by sex and type of case*
Number of pairs
Relative
Type of case Case >\ Case > i Case <i Case <i risk
Control > i Control •< i Control >i Control < i

Males
Surgical 11 14 9 19
Probable 3 9 4 17
Possible 4 7 6 6
Total 18 30 19 42 1 58 204

Females
Surgical 3 6 4 6
Probable 6 10 6 7
Possible 2 3 2 1

Total 11 19 12 14 1-58 116

Total, both sexes 29 49 31 56 1-58 3-61t

* Includes only pairs in which both members were employed during the year in which the symptoms began.
t p - 006.
j x1 values are for paired observations (8). These were calculated from the number of pairs in which the case was exposed
to the risk factor and the control was not and the number of pairs in which the control was exposed to the risk factor and the
case was not.
200 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

TABIJEH
Cases and matched controls according to whether they sat half the time or more on their job (> i) or sat less than half the
time on their job ( < J) by sex and age of cast*
Number of pairs
Sex and age Relative
of case Case >i Case >i Case <t Case < i risk
Control > i Control < i Control > i Control <l

Males
<35 years 6 8 9 23 0-89
>35 years 12 22 10 19 2-20 2-38

Females
<35 years 4 5 7 10 0-71 008
>35 years 7 14 5 4 2-80 3-37

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Both sexes
<35 years 10 13 16 33 0-81 014
2s35 years 19 36 15 23 2-40 7-84f

• Includes only pairs in which both members were employed during the year in which the symptoms began.
t P < 01.
t X1 values are for paired observations (8).

TABLE m
Proportion of cases and unmatched controls who sat half the time or more on their job, by sex and hospital service*

Cases Controls
Hospital service Number Proportion Number Proportion
in who sat in who sat
group \ time group i time
Males
I. Yale-New Haven in-patients 52 0-423 25 0-240
II. St. Raphael in-patients 20 0-650 21 0-381
HI. Yale-New Haven emergency room patients 16 0-437 72 0-278
IV. St. Raphael emergency room patients 13 0-385 66 0-379
V. Other Yale and St. Raphael patients 4 0-250 10 0-600
VI. Private radiologists' patients 4 0-750 13 0-462
VIL Veterans Administration patients 13 0-230 27 0185

Females
I. Yale-New Haven in-patients 15 0-667 6 0
II. St. Raphael in-patients 17 0-471 10 0-500
m . Yale-New Haven emergency room patients 12 0-417 50 0-460
IV. St. Raphael emergency room patients 11 0-727 60 0-450
V. Other Yale and St. Raphael patients 9 0-333 29 0-241
VI. Private radiologists' patients 3 0-333 9 0-667

X*i Test of association by Mantel-Haenzel procedure:

Males only: x* = 4-53, p — -03, estimate of relative risk = 1-74.
Females only: x1 =• 2- 33, p > • 10, estimate of relative risk = 1-63.
Males and females: x1 — 6-83, p < 01, estimate of relative risk — 1-70.
• Includes only those who were employed during year in which the symptoms began.

per cent increased risk compared to those who sit
less than half the time.
Persons who sat half or more of the time on their
job were asked about the type of chair they usually
sat in. Among males there was a large excess of
cases who had jobs in which they sat driving a
motor vehicle. Table IV shows that there were
many more pairs in which the case sat driving a
motor vehicle and. the- control did not than pairs
in which the control sat driving a motor vehicle
 RELATIONSHIP BETWEEN OCCUPATIONS AND ACUTE HERNIATED LUMBAR INTERVERTEBRAL DISCS 201

TABLE IV
Male cases and matched controls according to whether they had a job in which they sat half the time or more in a motor
vehicle (MV) or did not have a job in which they sat half the time or more in a motor vehicle (NMV) by type of case
Number of pairs

Type of case CaseMV CaseMV Case NMV Case NMV Total

Control MV Control NMV Control MV Control NMV

Surgical 0 6 4 52 62
Probable 0 8 2 29 39
Possible 0 8 2 17 27

Al] cases 0 22 8 98 128

Relative risk — 2-75

X1, - 5-63, p = 02

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X1 value is for paired observations (8).

and the cases did not, leading to an estimate of
relative risk of 2 • 75. If the data are subdivided by
age (not shown here), the difference is seen both in
those aged 35 years and older and those under 35.
Among truck drivers Table V indicates that the
relative risk is even higher, 4-67. The data for male
cases and unmatched controls, although not pre-
sented here, also show differences between the
proportion of cases and of controls whose jobs
involve sitting while driving motor vehicles and
who were truck drivers, with estimates of relative
risk of 3 • 14 and 2-26, respectively. Thus, not only
are people with sedentary occupations at increased
risk for herniated lumbar disc, but those who sit
while driving motor vehicles are at especially high
risk, In fact, if persons who sit half or more of the
time in motor vehicles are removed from the
analysis, the overall association with sitting is
reduced.
Next, consideration is given to the role of
lifting in the aetiology of herniated lumbar discs.
It should be mentioned that when the respondents
were asked what they were doing when their symp-
toms started, lifting was the most common answer
given by males, accounting for 16 per cent of the
responses, and the fifth most common answer from
the females, making up 9 per cent of the answers.
However, since most people can do ordinary lifting
without experiencing a disc herniation, this says
little about the role of lifting as a predisposing or
underlying factor.
Of more relevance is a comparison of lifting done
on the job by cases and controls. Table VI shows the
numbers of cases and matched controls according
to whether they did any lifting or no lifting on their
job. It can be seen that among the males, cases and
controls were equally likely to lift; among the
females, cases were somewhat more likely to lift
than controls, but this did not reach statistical
significance. Comparisons of the proportions of
cases and unmatched controls who did any lifting
on the job may be seen in Table VII. There is no

TABLE V
Male cases and matched controls according to whether their occupation was truck driver (TD) or not truck driver (NTD),
by type of case
Number of pairs
Type of case CaseTD CaseTD Control NTD Case NTD Total
Control TD Control NTD CaseTD Control NTD
Surgical 1 8 1 52 62
Probable 0 2 1 36 39
Possible 0 4 1 22 27

Total 1 14 3 110 128

Relative risk = 4-67

X « 1 - 5 - 8 8 , p < 02
X* value is for paired observations (8).
202 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
TABLE VI
Cases and matched controls according to whether they did any lifting (L) or did not do any lifting (NL) on their job, by sex
and type of case*

Number of pairs
Relative
Type of case CaseL Case L CaseNL CaseNL risk xt
Control L Control NL Control L Control NL

Males
:
Surgical 29 9 9 7 100
Probable 17 7 4 5 1-75
Possible 12 5 5 1 100

Total 58 21 18 13 117 010

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Females
Surgical 5 9 3 3
Probable 8 7 7 7
Possible 0 3 1 4

Total 13 19 11 14 1-73 1-63

Total, both sexes 71 40 29 27 1-38 1-45

• Includes only pairs in which both members were employed during the year in which the symptoms began.
t x* values are for paired observations (8).

indication that male cases did any more lifting DISCUSSION

than the controls, and just a suggestion that female
cases were less likely than controls to have jobs in
which they lifted.
The cases and controls who did any lifting on
their jobs were asked about the weight of what they
usually lifted, in five broad categories ranging from
less than 5 pounds to 50 pounds or more, and
about the frequency with which they usually lifted
it, again in five broad categories ranging from less
than once a day to 20 or more times per day.
Among both males and females and in comparisons
of cases with both matched and unmatched con-
trols, there was no tendency for cases to lift heavier
objects than controls or to lift more frequently than
the controls. Table VIII, for instance, shows the
comparison of male cases and matched controls
according to the weight of what was lifted; it can
be seen that there are about as many pairs in which
the case lifted heavier objects than the control as
pairs in which the control lifted heavier objects
than the case.
Respondents were also asked whether they did
any pushing, pulling or carrying on their jobs.
Comparisons of cases with the two control groups
gave no indication that jobs requiring pushing,
pulling, or carrying either increased or decreased
the risk for herniated lumbar discs.
In interpreting the results of this study, it must be
kept in mind that these cases were not a probability
sample of persons with herniated lumbar inter-
vertebral discs since this study population is
weighted towards people who were hospitalized
for their disc problems. The controls were also
people who sought medical care for various
conditions, and it would be impossible to describe
the population from which either control group
came. However, it is felt that with so little known
about the epidemiology of herniated lumbar
intervertebral discs, it was reasonable to under-
take an exploratory study such as this based on
people seeking medical care rather than on a more
general population. In any event, it is hoped that
the cases and controls are subject to similar selective
factors and that differences between these cases and
controls are indicative of differences between people
with and without herniated lumbar discs in a more
general population.
In addition, it should be stressed that a large
number of individual occupations and many
possible risk factors besides those relating to
occupations were examined in this study. When this
many variables are considered, it is likely that some
associations will occur by chance, so further investi-
 RELATIONSHIP BETWEEN OCCUPATIONS AND ACUTE HERNIATED LUMBAR INTERVERTEBRAL DISCS 203

TABLE VII
Proportion of cases and unmatched controls who did any lifting on their Job, by sex and hospital service*

Cases Controls
Hospital service Number proportion Number proportion
in group who lift in group who lift
Males
I. Yale-New Haven in-patients 52 0-731 25 0-761
n . St. Raphael in-patients 20 0-700 21 0-571
IH. Yale-New Haven emergency room patients 16 0-813 72 0-722
IV. St. Raphael emergency room patients 13 0-846 67 0-716
V. Other Yale and St. Raphael patients 4 0-500 11 0-545
VI. Private radiologists' patients 4 0-500 13 0-692
VII. Veterans Administration patients 13 0-769 27 0-815

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Females
I. Yale-New Haven in-patients 16 0-500 6 0-833
IL St. Raphael in-patients 17 0-647 10 0-600
IIL Yale-New Haven emergency room patients 12 0-500 50 0-540
IV. St. Raphael emergency room patients 11 0-364 60 0-583
V. Other Yale and St. Raphael patients 9 0-667 29 0-724
VI. Private radiologists' patients 3 0-333 9 0-222

X* tests of association calculated by Mantel-Haenzel procedure:

Males only, x* = 0-403, p > 10, estimate of relative risk « 1-20.
Females only, *• — 0-922, p > -10, estimate of relative risk = 0-67.
Males and females, *• = 0-017, p > -10, estimate of relative risk — 0-94.
* Includes those who were employed during the year in which the symptoms began.

TABLE v m
Male cases and matched controls according to weight of what was lifted on the job*

Controls
0 5 1b. 5-9 lb. 10-24 lb. 25-49 lb. >501b. Total

0 12 0 0 5 2 10 29
Cases <5 1b. 2 0 0 1 1 2 6
5-9 lb. 3 0 0 1 0 1 5
10-24 lb. 5 0 0 0 2 4 11
25-49 lb. 6 0 1 6 3 8 24
>501b. 4 2 3 4 4 14 31

Total 32 2 4 17 12 39 106

Z — 0-119 by Wilcoxon matched-pairs signed-ranks test.

* Includes pairs in which both members were employed during the year in which the symptoms began.

gations are clearly needed to confirm or refute the
leads provided in this study.
The association between sedentary occupations,
especially those which involve driving motor
vehicles, and herniated lumbar discs would appear
to be real since it was seen in both sexes and in
comparison between cases and both control
groups. The strength of this association in those
aged 35 and older and the lack of association in
those who are under that age suggest that a
certain amount of time in sedentary occupations is
necessary for an effect to be seen. In fact, a com-
parison (not shown here) of the number of years
cases and controls have had jobs in which they
spend half or more of the time sitting confirms this
suggestion, for the increased risk is seen only
among those who have had sedentary occupations
for about five years or more, and appears to become
greater with increasing number of years at a
sedentary job. Further evidence of an aetiological
204 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
role for too much sitting comes from another part
of this study, in which it was found that the length
of time males reported that they usually sat on
weekends was also associated with herniated lumbar
discs.
The reason for the association with sedentary
occupations cannot be ascertained from this type
of study. However, two possible explanations are
apparent: one that prolonged sitting has an adverse
effect, and the other that physical activity is bene-
ficial. It is known that sitting puts more pressure
on the discs than either standing or lying down
(9-11), and it would seem reasonable that pro-
longed stress from sitting for long periods of time
would increase the probability of a disc herniation.
A beneficial effect of physical activity is also
plausible, since it would presumably improve the
general condition of the muscles and ligaments of
spine and thus provide more support for the discs.
There was little evidence from this study that
physical activity at or away from work decreased
the risk for lumbar disc herniations, but this could
be attributable to the difficulty of assessing physical
activity, especially away from work. In any event,
the relative importance of prolonged' sitting com-
pared to lack of exercise remains unknown.
The additional risk associated with jobs in-
volving driving motor vehicles was not anticipated
when the study began, but can be clearly seen in
the comparisons of occupations of cases and
controls. In fact, the one single occupation which
stood out as having a particularly high risk for
herniated lumbar discs in this relatively small study
was that of truck driver. Again, the exact reason for
this association remains unknown; however, driving
for long periods of time requires prolonged sitting
in a seat with insufficient support for the low back,
with legs extended, in a position subject to the
vibration from the road and to mechanical stress
from starting and stopping, so it is not surprising
that it is associated with an increased risk for disc
herniation. In addition, respondents were asked in
another part of the questionnaire whether they
drove a car; significantly more cases than controls
answered affirmatively, thus providing further
support for the role of driving in the aetiology of
herniated lumbar discs (12).
This study gave no evidence of an increased risk
for herniated lumbar discs among males who did
lifting on their jobs, and little indication of this
among the females. The slight positive association
between lifting and herniated lumbar discs when
female cases were compared to matched controls
should be noted, although it is most likely attri-
butable to chance. Other considerations which
decrease the likelihood that the association is real
are that if the comparison is limited to pairs in
which both the case and control worked 20 hours
per week or more, the relative risk was estimated
to be only about 1-25, and that there were no
associations between the weight of what was lifted
or the frequency with which it was lifted and the
development of herniated lumbar discs. Further-
more, the female cases were somewhat less likely
to have jobs involving lifting than the unmatched
controls. Thus, although the possibility of a
relationship between lifting and herniated lumbar
discs in females cannot be ruled out, the present
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study provides little evidence of such an association
in either sex.
It is also possible that the rough indicators of
lifting used in this study were not sensitive enough
to detect a difference between cases and controls,
and, indeed, this is an additional reason for further
more detailed study. It would seem, nevertheless,
that if lifting on the job were an important factor,
some association would have been found. Hult
(13) and Friberg and Hirsch (14) also concluded
that heavy work is not a fundamental cause,
although they were concerned with the 'lumbago-
sciatica syndrome* and with disc degeneration in
patients seen at a clinic for back problems, respec-
tively, rather than specifically with herniated lumbar
intervertebral discs. This is not to imply that lifting
might not play a role in certain other types of back
problems, such as muscle strain, but heavy manual
labour would not appear to be an important
underlying factor in the aetiology of herniated
lumbar intervertebral discs.
Finally, it should again be emphasized that since
this study is apparently the first of its kind, and
since it had certain limitations in the study popula-
tion used, the response rate, the types of questions
asked, and the large number of associations
examined, it will be important to have' these
findings tested in other epidemiological investiga-
tions.
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(1) Goodsell, J. O.: Correlation of ruptured lumbar disc
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(2) Howorth, M. B.: A Textbook of Orthopedics. Phila-
delphia: Saunders, 1953.
(3) Spurting, R. G.: Lesions of the Lumbar Intervertebral
Disc. Springfield: Thomas, 1953.
(4) Semmes, R. E.: Ruptures of the Lumbar Intervertebral
Disc. Springfield: Thomas, 1964.
 RELATIONSHIP BETWEEN OCCUPATIONS A N D ACUTE HERNIATED LUMBAR INTERVERTEBRAL DISCS
(5) Coventry, M. B.: Introduction of Symposium, including
anatomy, physiology, and epidemiology. / . Bone Jt.
Surg. [Amer.] 50: 167, 1968.
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