ISSLS Prize in Clinical Science 2025: Cartilage End Plate Defects Precede and Initiate Bony End Plate Defects and Disc Degeneration- An 'Integrated Total End Plate Score' Identify Preclinical Discs at Risk for Degeneration.

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We utilized the Fast Low Angle Shot (FLASH) sequence to document the sequential changes in cartilaginous (CEP) and bony end plate (BEP) to study the influence on disc degeneration (DD). Routine MRI and FLASH sequences were used in 500 lumbar discs in 100 each of healthy volunteers (HV), low back pain patients treated conservatively (CG) and surgically (SG) to document CEP and BEP status, Pfirrmann Grade (PG) and various MRI parameters. The three groups were identical demographically but had a significantly different number of healthy discs (p < 0.01) and changes in CEP and BEP (p < 0.01), with patients having a higher severity of end plate changes and DD, even in asymptomatic discs. CEP abnormalities always appeared first, followed by a sequence of BEP defects of different severity, allowing the development of an 'Integrated Total End Plate Score' (I-TEPS). There was a good correlation between I-TEPS and PG, with a steep escalation of DD after a score of 7. A score of ≥ 7 was also associated with higher surgical incidence in patients with both degenerated and herniated discs. The most significant influencing factors for surgery was a combination of I-TEPS ≥ 7 with herniation (OR7.7;p-0.00), smoking (OR4.63;p-0.02), and an I-TEPS ≥ 7 (OR3.37;p-0.04). CEP changes identified by FLASH preceded BEP defects and DD. I-TEPS was superior to TEPS in identifying a subgroup of discs that had CEP abnormalities without BEP. An I-TEPS ≥ 7 had a significant correlation to the severity of DD, influenced variations in herniation and also surgical incidence.