Endplate Abnormalities Research Articles

Lumbar paraspinal muscle morphology is associated with spinal degeneration in patients with lumbar spinal stenosis

BACKGROUND CONTEXTLumbar spinal stenosis (LSS) has been reported to induce changes in paraspinal muscle morphology, but objective physical function and degenerative spine conditions are rarely assessed. PURPOSETo identify factors associated with paraspinal muscle morphology using objective physical and degenerative spine assessments in patients with LSS. STUDY DESIGN/SETTINGCross-sectional design. PATIENT SAMPLESeventy patients with neurogenic claudication caused by LSS, receiving outpatient physical therapy. OUTCOME MEASURESCross-sectional area (CSA) and functional CSA (FCSA) of the multifidus, erector spinae, and psoas muscles, the severity of stenosis, disc degeneration, and endplate abnormalities were evaluated by magnetic resonance imaging, as well as sagittal spinopelvic alignment by X-ray. Objective physical assessments included pedometry and claudication distance. Patient-reported outcomes included the numerical rating scale of low back pain, leg pain, and leg numbness, and the Zurich Claudication Questionnaire. METHODSTo assess the impact of LSS on paraspinal muscles, FCSA and FCSA/CSA were compared between the dominant and nondominant sides based on the patients’ neurogenic symptoms, and multivariable regression analyses adjusted for age, sex, height, and weight were performed; p<.05 was considered significant. RESULTSSeventy patients were analyzed. At one level below the maximum stenotic level, erector spinae FCSA on the dominant side was significantly lower than that on the nondominant side. In the multivariable regression analyses, at one level below the symptomatic level, disc degeneration, endplate abnormalities, and lumbar spinopelvic alignment, such as decreased lumbar lordosis and increased pelvic tilt, were negatively associated with multifidus FCSA and FCSA/CSA ratio. A significant association was observed between dural sac CSA and erector spinae FCSA. Throughout L1/2 to L5/S, disc degeneration, endplate abnormalities, and lumbar spinopelvic alignment were negatively associated with multifidus and erector spinae FCSA or FCSA/CSA. CONCLUSIONSLumbar paraspinal muscle asymmetry caused by LSS was observed only in erector spinae. Disc degeneration, endplate abnormalities, and lumbar spinopelvic alignment, rather than spinal stenosis and LSS symptoms, were more associated with paraspinal muscle atrophy or fat infiltration.

Prediction of lumbar disc herniation resorption in symptomatic patients: a prospective, multi-imaging and clinical phenotype study

Symptomatic lumbar disc herniations (LDH) are very common. LDH resorption may occur by a "self-healing" process, however this phenomenon remains poorly understood. By most guidelines, if LDH remains symptomatic after 3 months and conservative management fails, surgical intervention may be an option. The following prospective study aimed to identify determinants that may predict early versus late LDH resorption. Prospective study with patients recruited at a single center. Ninety-three consecutive patients diagnosed with acute symptomatic LDH were included in this study (n=23 early resorption and n=67 late resorption groups) with a mean age of 48.7±11.9 years. Baseline assessment of patient demographics (eg, smoking status, height, weight, etc.), herniation characteristics (eg, the initial level of herniation, the direction of herniation, prevalence of multiple herniations, etc.) and MRI phenotypes (eg, Modic changes, end plate abnormalities, disc degeneration, vertebral body dimensions, etc.) were collected for further analysis. Lumbar MRIs were performed approximately every 3 months for 1 year from time of enrollment to assess disc integrity. All patients were managed similarly. LDH resorption was classified as early (<3 months) or late (>3 months). A prediction model of pretreatment factors was constructed. No significant differences were noted between groups at any time-point (p>.05). Patients in the early resorption group experienced greater percent reduction of disc herniation between MRI-0-MRI-1 (p=.043), reduction of herniation size for total study duration (p=.007), and percent resorption per day compared to the late resorption group (p<.001). Based on multivariate modeling, greater L4 posterior vertebral height (coeff:14.58), greater sacral slope (coeff:0.12), and greater herniated volume (coeff:0.013) at baseline were found to be most predictive of early resorption (p<.05). This is the first comprehensive imaging and clinical phenotypic prospective study, to our knowledge, that has identified distinct determinants for early LDH resorption. Early resorption can occur in 24.7% of LDH patients. We developed a prediction model for early resorption which demonstrated great overall performance according to pretreatment measures of herniation size, L4 posterior body height, and sacral slope. A risk profile is proposed which may aid clinical decision-making and managing patient expectations.

Endplate abnormalities, Modic changes and their relationship to alignment parameters and surgical outcomes in the cervical spine.

Modic changes (MC) and endplate abnormalities (EA) have been shown to impact preoperative symptoms and outcomes following spinal surgery. However, little is known about how these phenotypes impact cervical alignment. This study aimed to evaluate the impact that these phenotypes have on preoperative, postoperative, and changes in cervical alignment in patients undergoing anterior cervical discectomy and fusion (ACDF). We performed a retrospective study of prospectively collected data of ACDF patients at a single institution. Preoperative magnetic resonance imagings (MRIs) were used to assess for the MC and EA. Patients were subdivided into four groups: MC-only, EA-only, the combined Modic-Endplate-Complex (MEC), and patients without either phenotype. Pre and postoperative MRIs were used to assess alignment parameters. Associations with imaging phenotypes and alignment parameters were assessed, and statistical significance was set at p < 0.5. A total of 512 patients were included, with 84 MC-only patients, 166 EA-only patients, and 71 patients with MEC. Preoperative MC (p = 0.031) and the MEC (p = 0.039) had significantly lower preoperative T1 slope compared to controls. Lower preoperative T1 slope was a risk factor for MC (p = 0.020) and MEC (p = 0.029) and presence of MC (Type II) and the MEC (Type III) was predictive of lower preoperative T1 slope. There were no differences in postoperative alignment measures or patient reported outcome measures. MC and endplate pathologies such as the MEC appear to be associated with worse cervical alignment at baseline relative to patients without these phenotypes. Poor alignment may be an adaptive response to these degenerative findings or may be a risk factor for their development.

Endplate defects, not the severity of spinal stenosis, contribute to low back pain in patients with lumbar spinal stenosis

BACKGROUND CONTEXTIt is controversial whether lumbar spinal stenosis (LSS) itself contributes to low back pain (LBP). Lower truncal skeletal muscle mass, spinopelvic malalignment, intervertebral disc degeneration, and endplate abnormalities are thought to be related to LBP. However, whether these factors cause LBP in patients with LSS is unclear. PURPOSETo identify factors associated with LBP in patients with LSS. STUDY DESIGN/SETTINGCross-sectional design. PATIENT SAMPLEA total of 260 patients (119 men and 141 women, average age 72.8 years) with neurogenic claudication caused by LSS, as confirmed by magnetic resonance imaging (MRI). OUTCOME MEASURESRatings of LBP, buttock and leg pain, and numbness on a numerical rating scale (NRS), 36-Item Short Form Survey (SF-36) scores, muscle mass measured by bioelectrical impedance analysis, and radiographic measurements including slippage and lumbopelvic alignment. The severity of LSS, endplate defects, Modic endplate changes, intervertebral disc degeneration, and facet joint osteoarthritis were assessed on MRI. METHODSThe presence of LBP was defined as an NRS score ≥3. The demographic data, patient-reported outcomes, and radiological and MRI findings were compared between patients with and without LBP. Multivariate logistic regression analysis was used to identify the factors that were independently associated with the presence of LBP. RESULTSThere were significant differences between patients with and without LBP for buttock and leg pain and numbness on the NRS, general health on the SF-36, presence of endplate defects, presence of Modic changes, disc degeneration grading, and disc height grading (all p < .05). Multivariate logistic regression analysis showed significant associations between LBP and diabetes (OR 2.43; 95% CI 1.07–5.53), buttock and leg numbness on the NRS (OR 1.34; 95% CI 1.17–1.52), general health on the SF-36 (OR 0.97; 95% CI 0.95–0.99), and the presence of erosive endplate defects (OR 3.04; 95% CI 1.51–6.11) (all p < .05). CONCLUSIONSThese results suggest that LBP in patients with LSS should be carefully assessed not only for spinal stenosis but also clinical factors and endplate defects.

Diagnostic Role of Magnetic Resonance Imaging in Low Back Pain Caused by Vertebral Endplate Degeneration.

Low back pain (LBP) is a common health issue worldwide with a huge economic burden on healthcare systems. In the United States alone, the cost is estimated to be $100 billion each year. Intervertebral disc degeneration is considered one of the primary causes of LBP. Moreover, the critical role of the vertebral endplates in disc degeneration and LBP is becoming apparent. Endplate abnormalities are closely correlated with disc degeneration and pain in the lumbar spine. Imaging modalities such as plain film radiography, computed tomography, and fluoroscopy are helpful but not very effective in detecting the causes behind LBP. Magnetic resonance imaging (MRI) can be used to acquire high-quality three-dimensional images of the lumbar spine without using ionizing radiation. Therefore, it is increasingly being used to diagnose spinal disorders. However, according to the American College of Radiology, current referral and justification guidelines for MRI are not sufficiently clear to guide clinical practice. This review aimed to evaluate the role of MRI in diagnosing LBP by considering the correlative contributions of vertebral endplates. The findings of the review indicate that MRI allows for fine evaluations of endplate morphology, endplate defects, diffusion and perfusion properties of the endplate, and Modic changes. Changes in these characteristics of the endplate were found to be closely correlated with disc degeneration and LBP. The collective evidence from the literature suggests that MRI may be the imaging modality of choice for patients suffering from LBP. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 3.

Muscle Tissue Damage and Recovery After EV71 Infection Correspond to Dynamic Macrophage Phenotypes.

Enterovirus 71 (EV71) is a positive single-stranded RNA virus from the enterovirus genus of the Picornaviridae family. Most young children infected with EV71 develop mild symptoms of hand, foot and mouth disease, but some develop severe symptoms with neurological involvement. Limb paralysis from EV71 infection is presumed to arise mainly from dysfunction of motor neurons in the spinal cord. However, EV71 also targets and damages skeletal muscle, which may also contribute to the debilitating symptoms. In this study, we have delineated the impacts of EV71 infection on skeletal muscle using a mouse model. Mouse pups infected with EV71 developed limb paralysis, starting at day 3 post-infection and peaking at day 5-7 post-infection. At later times, mice recovered gradually but not completely. Notably, severe disease was associated with high levels of myositis accompanied by muscle calcification and persistent motor end plate abnormalities. Interestingly, macrophages exhibited a dynamic change in phenotype, with inflammatory macrophages (CD45+CD11b+Ly6Chi) appearing in the early stage of infection and anti-inflammatory/restorative macrophages (CD45+CD11b+Ly6Clow/-) appearing in the late stage. The presence of inflammatory macrophages was associated with severe inflammation, while the restorative macrophages were associated with recovery. Altogether, we have demonstrated that EV71 infection causes myositis, muscle calcification and structural defects in motor end plates. Subsequent muscle regeneration is associated with a dynamic change in macrophage phenotype.

The Modic-endplate-complex phenotype in cervical spine patients: Association with symptoms and outcomes.

This study describes a novel, combined Modic changes (MC) and structural endplate abnormality phenotype of the cervical spine, which we have termed the Modic-Endplate-Complex (MEC), and its association with preoperative symptoms and outcomes in anterior cervical discectomy and fusion (ACDF) patients. This was a retrospective study of prospectively collected data at a single institution. Preoperative cervical magnetic resonance imagings were used to assess the presence of MC and endplate abnormalities. Patients were divided into four groups: MC-only, endplate abnormality-only, the MEC and controls. The MEC was defined as the presence of both a MC and endplate abnormality in the cervical spine. Phenotypes were further stratified by location and compared to controls. Associations with patient-reported outcome measures were assessed using regression controlling for baseline characteristics. A total of 628 patients were included, with 84 MC-only, 166 endplate abnormality-only, and 187 MEC patients. Both MC (p < 0.001) and endplate abnormalities (p < 0.001) were independently associated with one another. MC at the adjacent level (p = 0.018), endplate abnormalities (regardless of location) (p = 0.001), and the MEC within the fusion segment (p = 0.027) were all associated with higher Neck Disability Index scores. Both MC within the fusion segment (p = 0.008) and endplate abnormalities within the fusion segment (p = 0.017) associated with lower Veteran's Rand 12-item scores. MC and structural endplate abnormalities commonly manifest concomitantly in patients indicated for ACDF for degenerative pathology. Patients with the endplate pathology, including the MEC phenotype, reported significantly higher levels of postoperative disability following ACDF. These findings add valuable data to the prognostic assessment of degenerative cervical spine patients.

Cervical spine MRI phenotypes and prediction of pain, disability and adjacent segment degeneration/disease after ACDF.

Degenerative spine imaging findings have been extensively studied in the lumbar region and are associated with pain and adverse clinical outcomes after surgery. However, few studies have investigated the significance of these imaging "phenotypes" in the cervical spine. Patients with degenerative cervical spine pathology undergoing anterior cervical discectomy and fusion (ACDF) from 2008 to 2015 were retrospectively and prospectively assessed using preoperative MRI for disc degeneration, narrowing, and displacement, high-intensity zones, endplate abnormalities, Modic changes, and osteophyte formation from C2-T1. Points were assigned for these phenotypes to generate a novel Cervical Phenotype Index (CPI). Demographics were evaluated for association with phenotypes and the CPI using forward stepwise regression. Bootstrap sampling and multiple imputations assessed phenotypes and the CPI in association with patient-reported outcomes (Neck Disability Index [NDI], Visual Analog Scale [VAS]-neck, VAS-arm) and adjacent segment degeneration (ASDeg) and disease (ASDz). Of 861 patients, disc displacement was the most common (99.7%), followed by osteophytes (92.0%) and endplate abnormalities (57.3%). Most findings were associated with age and were identified at similar cervical vertebral levels; at C5-C7. Imaging phenotypes demonstrated both increased and decreased associations with adverse patient-reported outcomes and ASDeg/Dz. However, the CPI consistently predicted worse NDI (P = .012), VAS-neck (P = .007), and VAS-arm (P = .013) scores, in addition to higher odds of ASDeg (P = .002) and ASDz (P = .004). The CPI was significantly predictive of postoperative symptoms of pain/disability and ASDeg/Dz after ACDF, suggesting that the totality of degenerative findings may be more clinically relevant than individual phenotypes and that this tool may help prognosticate outcomes after surgery.

Cervical Spine Endplate Abnormalities and Association With Pain, Disability, and Adjacent Segment Degeneration After Anterior Cervical Discectomy and Fusion.

A retrospective study with prospectively-collected data. To determine how type, location, and size of endplate lesions on magnetic resonance imaging (MRI) may be associated with symptoms and clinical outcomes after anterior cervical discectomy and fusion (ACDF). Structural endplate abnormalities are important, yet understudied, phenomena in the cervical spine. ACDF is a common surgical treatment for degenerative disc disease; however, adjacent segment degeneration/disease (ASD) may develop. Assessed the imaging, symptoms and clinical outcomes of 861 patients who underwent ACDF at a single center. MRI and plain radiographs of the cervical spine were evaluated. Endplate abnormalities on MRI were identified and stratified by type (atypical, typical), location, relation to operative levels, presence at the adjacent level, and size. These strata were assessed for association with presenting symptoms, patient-reported, and postoperative outcomes. Of 861 patients (mean follow-up: 17.4 months), 57.3% had evidence of endplate abnormalities, 39.0% had typical abnormalities, while 18.2% had atypical abnormalities. Patients with any endplate abnormality had greater odds of myelopathy irrespective of location or size, while sensory deficits were associated with atypical lesions (P = 0.016). Typical and atypical abnormalities demonstrated differences in patient-reported outcomes based on location relative to the fused segment. Typical variants were not associated with adverse surgical outcomes, while atypical lesions were associated with ASD (irrespective of size/location; P = 0.004) and reoperations, when a large abnormality was present at the proximal adjacent level (P = 0.025). This is the first study to examine endplate abnormalities on MRI of the cervical spine, demonstrating distinct risk profiles for symptoms, patient-reported, and surgical outcomes after ACDF. Patients with typical lesions reported worsening postoperative pain/disability, while those with atypical abnormalities experienced greater rates of ASD and reoperation. This highlights the relevance of a degenerative spine phenotypic assessment, and suggests endplate abnormalities may prognosticate clinical outcomes after surgery. 3.

Endplate Changes with Polyetheretherketone Cages in Posterior Lumbar Interbody Fusion.

Study DesignA retrospective radiographic analysis.PurposeThe aim of the current study is to assess endplate changes after the use of polyetheretherketone (PEEK) cages in posterior lumbar interbody fusion (PLIF).Overview of Literature A few recent reports had revealed endplate abnormalities due to PEEK cages, which may lead to nonunions.MethodsA retrospective computed tomography (CT)-based analysis of the endplate cavities and fusion status following PLIFs with PEEK cages was conducted by two independent observers. The term “cavity” was used to describe the endplate changes. The vertebral endplate cavities were assessed according to the size, multiplicity, location, and presence or absence of sclerosis.ResultsThere were 86 fixed levels in 65 consecutive patients, with a mean age of 35.44±19.60 years. The mean follow-up was 16.5±10.1 months (range, 6–57 months). Definite fusion was seen in 56 levels (65.12%) by observer 1 versus 44 levels (51.16) by observer 2. The strength of agreement was moderate. Endplate cavities were observed in 42 levels (48.84%) by observer 1 versus 47 levels (54.65%) by observer 2, with fair agreement. The strengths of agreement for the locations, multiplicity, and size were moderate, fair, and poor, respectively. Neither age, sex, etiology, levels, nor follow-up period was significantly associated with the presence of cavities. With regard to fusions, the nonunions detected by observer 1 were significantly associated with the presence of cavities (p<0.0001). However, those detected by observer 2 were nearly significant (p=0.05).ConclusionsThere was a high rate of unfavorable radiographic findings in the form of endplate cavities in PLIF cases with PEEK cages. A more comprehensive classification for the assessment of fusions and endplate cavities should be formulated. We strongly recommend further CT-based studies with larger sample size and longer follow-up periods.

Comparative Sacral Morphology in Spondylolisthesis Patients

Study DesignRetrospective comparative case series. ObjectivesEvaluation of sacral morphology in spondylolisthesis patients compared with asymptomatic controls. Summary of Background DataPatients with spondylolisthesis are known to differ from asymptomatic controls in sagittal plane anatomy, but few studies examine the coronal and axial plane differences in these cohorts. MethodsThis is a retrospective evaluation of magnetic resonance imaging of the lumbosacral spine in 29 spondylolisthesis patients and an asymptomatic cohort (n = 154). Measurements of the linear distance and angular position of L5 and sacrum were performed in the sagittal, coronal, and axial planes. Receiver operating characteristic (ROC) curve analysis quantified these associations. High- and low-grade spondylolisthesis patients were compared with two-sample t-tests. All p-values are two-sided and considered significant when p < .05. ResultsAxial measurements showed the distance of the right to left anterior ala and the L5 body width did not differ between the cohorts. Sacroiliac (SI) joint angles in the spondylolisthesis cohort were closer to the true sagittal plane than in the controls 109° versus 121° (p < .001). In the sagittal plane, the linear measurement of the ratio of the midpoint anteroposterior width L5 to the sacral end plate was larger in the high-grade patients than the low-grade patients and controls. In addition, the kyphosis between S1–S2 and S2–S3 was larger in the spondylolisthesis cohort. ConclusionsThe SI joints in patients with spondylolisthesis were orientated closer to the sagittal plane than in the controls. An awareness of this positioning may be important in surgical implant insertion as well as rehabilitation of hip extensor weakness. The main anatomical differences found in this study were in the sagittal plane. Sacral end plate abnormalities were well visualized and consistent with radiographic findings in the literature. Level of EvidenceLevel III, diagnostic.

106. Subclinical propionibacterium acnes infection estimation in the intervertebral disc (SPInE-ID)

BACKGROUND CONTEXT Low back pain and vertebral end plate abnormalities are common conditions within the population. Subclinical infection caused by indolent pathogens can potentially lead to these findings, with differentiation between them notably challenging from a clinical perspective. Progressive infection of the intervertebral disc has been extensively associated with increasing low back pain, with Propionibacterium acnes specifically implicated with in relation to sciatica. PURPOSE To identify if the presence of an infective pathogen within the intervertebral disc is primary or is a result of intraoperative contamination, and whether this correlates to low back pain. STUDY DESIGN/SETTING Single-center prospective cohort. PATIENT SAMPLE Subjects included within the study will be between the ages of 18 and 65 years and have a diagnosis of lumbar disc herniation requiring open decompression surgery. OUTCOME MEASURES Tissue culture and pathogen identificationNRSODIEQ-5DModic changesESR, CRP, Leucogram. METHODS Excised herniated disc fragments, muscle and ligamentum flavum samples will be collected during surgery and sent to microbiology for tissue culture and pathogen identification. A disc infection is considered if only disc tissue has a positive culture growth. Score questionnaires for pain, functionality and quality of life will be given preoperatively and at 1, 3, 6 and 12 months postoperatively. An MRI will be performed 12 months after surgery for analysis of Modic changes and baseline comparison. The primary endpoint is the rate of disc infection in patients with symptomatic degenerative disease. The secondary endpoints will be performance scores, Modic incidence and size. RESULTS Ninety-five patients were enrolled and completed one-year follow-up with full data collected. Eighteen patients (18.9%) presented at least one of the 3 collected tissues with a positive culture and 4 patients (4.21%) presented only intervertebral disc positive tissue culture, which was considered disc infection, while other patients were considered contaminated. P. acnes was cultured in 2 of the 4 infected discs. NRS for low back pain and sciatica, and ODI improved from mean baseline 7, 6 and 45 to final follow-up 1.2, 2.2, and 16, respectively. Performance score improvements were not statistically related to presence of disc infection. Modic changes and increasing of size over time were not related to disc positive culture. No patients developed clinical discitis over time. CONCLUSIONS Based on a strict methodology of tissue culturing and contamination controls, subclinical infection rate of the intervertebral lumbar disc is at 4.2% and is overestimated in the current literature. Subclinical disc infection is not related to worse outcomes after lumbar microdiscectomy in patients with lumbar disc herniation, and worsening of Modic changes over time is not related to the presence of pathogens in the disc. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

The association of high-intensity zones on MRI and low back pain: a systematic review

BackgroundMagnetic resonance imaging (MRI) of the lumbar spine is commonly used to identify the source of low back pain (LBP); however, its use has been questionable. Throughout the years, numerous lumbar phenotypes (e.g., endplate abnormalities, Modic changes, black disc) have been studied as possible pain generators. High-intensity zones (HIZs) are of particular interest as they may represent annular tears. However, for over three decades, there has been heated debate as to whether these imaging biomarkers are synonymous with LBP. Therefore, the following study addressed a systematic review of the reported literature addressing the relationship of HIZs and LBP.MethodsA systematic review was conducted via MEDLINE, SCOPUS, Cochrane, PubMed, PubMed Central, EMBASE via Ovid, and Web of Science with the following search terms: “HIZ,” “high intensity zone,” or “high intensity zones” and “low back pain,” “pain,” “lumbago,” and/or “sciatica.” Specific exclusion criteria were also maintained. Two independent reviewers searched the literature, selected the studies, and extracted the data.ResultsWe identified six studies from our search strategy that met the inclusion criteria from a total of 756 possible studies. One cross-sectional population-based study and five comparison studies were identified, which provided information regarding the prevalence of HIZs. The prevalence of HIZs was 3 to 61% in subjects with LBP and 2 to 3% in subjects without LBP. Only three studies suggested a significant association between the presence of HIZ and LBP with or without sciatica.ConclusionsOur systematic review has found evidence that HIZs may be a possible risk factor for LBP; however, a mismatch of the clinical relevance of HIZs between studies still remains. The available evidence is limited by small sample size, heterogeneous study populations, and lack of standardized imaging methods for phenotyping. HIZs may be important lumbar biomarkers that demand further investigation and should be considered in the global imaging assessment of the spine, which may have immense clinical utility. Further large-scale studies with standardized imaging and classification techniques as well as the assessment of patterns of HIZs are necessary to better understand their role with LBP development.

Propionibacterium acnes Incubation in the Discs Can Result in Time-Dependent Modic Changes: A Long-Term Rabbit Model.

A case-control study of animal model of Modic changes (MCs) on rabbits. To evaluate the feasibility of inducing of MCs by injection of Propionibacterium acne (P. acnes) into the lumbar intervertebral discs of rabbits. MCs have been widely observed, and assume to be closely associated with low back pain and P. acnes, but there are few animal models showing the progression of MCs. Ten rabbits were used for the study. The L3-4 and L4-5 discs of all rabbits were injected with 100 μL P. acnes (1.6 × 10 CFU/mL) as P. acnes group, L2-3 disc were injected with 100 μL normal saline as vehicle, and L5-6 disc was untreated (blank). MCs were investigated by magnetic resonance imaging before operation and at 2 weeks, 1, 3, 4.5, 6, and 9 months postoperatively. Following sacrifice, histological analysis, blood test and micro-computed tomography were performed. Cytokine expression in nucleus and endplate tissues was quantified using real-time polymerase chain reaction. From 3 months postoperatively, the P. acnes group showed significantly decreased T1-weighted signal intensity, whereas the T2-weighted signal was significantly higher at 3 and 4.5 months, and then decreased remarkably at 6 and 9 months. Eleven of 20 inferior endplates were identified as type I MCs at 4.5 months, and 9 of 20 were identified as type II MCs at 9 months. Real-time polymerase chain reaction showed that expression of interleukin-1β, tumor necrosis factor α, interferon-γ, matrix metalloproteinase-9, and thrombospondin motifs-5 in the nucleus pulposus, and interleukin-1β, tumor necrosis factor α, and thrombospondin motifs-5 in the endplates, were significantly upregulated after injection of P. acnes. Histological slices of discs injected with P. acnes showed disc degeneration, endplate abnormalities, and inflammatory response, with micro-computed tomography confirming bone resorption. P. acnes infection of the disc can induce degeneration of the disc and an inflammatory response in the endplate region, presenting as MCs type I and II time dependently. N/A.

Subclinical Propionibacterium acnes infection estimation in the intervertebral disc (SPInE-ID): protocol for a prospective cohort

IntroductionLow back pain and vertebral endplate abnormalities are common conditions within the population. Subclinical infection caused by indolent pathogens can potentially lead to these findings, with differentiation between them notably...

Structural vertebral endplate nomenclature and etiology: a study by the ISSLS Spinal Phenotype Focus Group.

Vertebral endplate abnormalities may be associated with disc degeneration and, perhaps, pain generation. However, consensus definitions for endplate findings on spine MRI do not exist, posing a challenge to compare findings between studies and ethnic groups. The following survey was created to characterize the variability among the global spine community regarding endplate structural findings with respect to nomenclature and etiology. A working group within the International Society for the Study of the Lumbar Spine (ISSLS) Spinal Phenotype Focus Group was established to assess the endplate phenotype. A survey which consisted of 13 T2-weighted sagittal MRIs of the human lumbar spine illustrating the superior and inferior endplates was constructed based on discussion and agreement by the working group. A list of nomenclature and etiological terms with historical precedence was generated. Participants were asked to describe the endplates of each image and select from 14 possible nomenclatures and 10 etiological terms along with the option of free text response. The survey was entered into RedCap and was circulated throughout the ISSLS membership for data capture. Participants' demographics were also noted. The survey was completed by 55 participants (87% males; 85% above 45years of age, 39 clinicians, and 16 researchers). Sixty-eight percent of researchers and seventy-four percent of clinicians reported more than 16 and 20years of research and clinical experience. Considerable variation existed in selection of nomenclature, etiology, and degree of severity of the endplate structural findings (reliability coefficients for single measures in each case were 0.3, 0.08, and 0.2, respectively). Sixty-seven percent regarded Modic changes as being a structural endplate finding. Approximately 84 and 80% of clinicians and researchers, respectively, agreed that a standardized endplate nomenclature and understanding the etiology is clinically important and needed. This study found that variations exist with respect to endplate nomenclature and etiology between clinicians and basic scientists, and paves the way for a consensus process to formalize the definitions.

Modic changes in the lumbar spine and their association with body composition, fat distribution and intervertebral disc height - a 3.0 T-MRI study.

BackgroundVertebral endplate (Modic) abnormalities are important structural lesions in the spine, but their association with body composition and fat distribution have not been examined. Moreover, no study has examined whether Modic change are related to other structural features of low back pain, such as reduced intervertebral disc height.MethodsSeventy-two community-based individuals not selected for low back pain had lumbar vertebral Modic change and intervertebral disc height assessed from MRI. Dual energy x-ray absorptiometry measured body composition and fat distribution.ResultsThe predominance of Modic change was type 2. Modic change was associated with an increased fat mass index (OR 1.20, 95 % CI 1.01 to 1.43), and tended to be associated with a reduced fat-free mass index (OR 0.62, 95 % CI 0.37 to 1.03, p = 0.07). While an increased percentage of gynoid fat was associated with a reduced risk (OR 0.62, 95 % CI 0.43 to 0.89), an increased percentage of android fat was associated with an increased risk of Modic change (OR 2.11, 95 % CI 1.18 to 3.76). Modic change was also associated with reduced intervertebral disc height at L2/3, L4/5 and L5/S1 (OR range 1.4 to 1.8; all p ≤ 0.03).ConclusionModic type 2 change is associated with reduced intervertebral disc height and an increased fat mass index. Whereas gynoid fat distribution protected against Modic type 2 change, an android pattern increased the risk of this lesion. Modic type 2 change, which histologically represent fat replacement, might have a metabolic component to its aetiology.

Nuclear medicine imaging of bone infections

Osteomyelitis is a broad group of infectious diseases that involve the bone and/or bone marrow. It can arise haematogenously, via extension from a contiguous infection, or by direct inoculation during surgery or trauma. The diagnosis is not always obvious and imaging tests are frequently performed as part of the diagnostic work-up. Commonly performed radionuclide tests include technetium-99m ((99m)Tc)-diphosphonate bone scintigraphy (bone), and gallium-67 ((67)Ga) and invitro labelled leukocyte (white blood cell; WBC) imaging. Although they are useful, each of these tests has limitations. Bone scintigraphy is sensitive but not specific, especially when underlying osseous abnormalities are present. (67)Ga accumulates in tumour, trauma, and in aseptic inflammation; furthermore, there is typically an interval of 1-3 days between radiopharmaceutical injection of and imaging. Currently, this agent is used primarily for spinal infections. Except for the spine, WBC imaging is the nuclear medicine test of choice for diagnosing complicating osteomyelitis. The invitro leukocyte labelling process requires skilled personnel, is laborious, and is not always available. Complementary marrow imaging is usually required to maximise accuracy. Not surprisingly, alternative radiopharmaceuticals are continuously being investigated. Radiolabelled anti-granulocyte antibodies and antibody fragments, investigated as invivo leukocyte labelling agents, have their own limitations and are not widely available. (111)In-biotin is useful for diagnosing spinal infections. Radiolabelled synthetic fragments of ubiquicidin, a naturally occurring human antimicrobial peptide that targets bacteria, have shown promise as infection specific radiopharmaceuticals. 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET) with or without computed tomography (CT) is very useful in musculoskeletal infection. Sensitivities of more than 95% and specificities ranging from 75-99% have been reported in acute and subacute bone and soft-tissue infection. FDG is the radionuclide test of choice for spinal infection. It is sensitive, has a high negative predictive value, and can differentiate degenerative from infectious vertebral body end-plate abnormalities. Data on the accuracy of FDG for diagnosing diabetic pedal osteomyelitis and prosthetic joint infection are inconclusive and its role for these indications remains to be determined. Other PET radiopharmaceuticals that are under investigation as infection imaging agents include gallium-68 citrate ((68)Ga) and iodine-124 fialuridine ((124)I -FIAU).

Oxidative/Nitrosative Stress in Patients With Modic Changes: Preliminary Controlled Study.

Oxidative/nitrosative stress in vertebral endplates of patients with low back pain and Modic changes (MCs) (types I, II, and III) endplate changes on magnetic resonance imaging. The aim of this study was to assess the levels of oxidative/nitrosative stress biomarkers in patients with MCs. Degenerated discs and endplate abnormalities is postulated as a possible source of low back pain. Oxidative/nitrosative stress plays an important the role in various human diseases. However, the presence of oxidative/nitrosative stress has not been studied in patients with low back pain and endplate changes on magnetic resonance imaging. Patients with MCI, II, and III (n = 32) and age- and sex-matched controls subjects (n = 15) were enrolled in this study. Also, 3-nitrotyrosine (3-NT) and nitric oxide levels as nitrosative stress biomarkers were measured with enzyme-linked immunosorbent assay. Also, the activities of catalase (CAT) and superoxide dismutase (SOD), and the levels of malondialdehyde (MDA) as oxidative stress biomarkers were determined on spectrophotometer. Oxidative/nitrosative stress was confirmed by the significant elevation in nitric oxide, 3-NT, MDA and decreased of CAT and SOD activities in MCI compared with other MCs and the control group (P < 0.05). The highest CAT and SOD activities were found in patients with MCII compared with the other MCs and the control group. However, the levels of nitric oxide, 3-NT, and MDA showed moderate increase in this group (P < 0.05). In addition, the levels of nitrosative stress biomarkers in patients with MCIII were approximated to the control values (P > 0.05). However, the levels of oxidative stress biomarkers in patients with MCIII were slightly higher than that of the control group (P < 0.05). Our findings indicated that oxidative/nitrosative stress in patients with MCI may be aggravated as a result of oxidant/antioxidant imbalance and it may cause formation of the lesion in these patients. However, the increased antioxidant activities and MDA, 3-NT levels in patients with MCII and MCIII may be an adaptative response to against oxidative/nitrosative stress. 4.

Phenotype profiling of Modic changes of the lumbar spine and its association with other MRI phenotypes: a large-scale population-based study

Background contextModic changes (MC) are associated with low back pain. They represent vertebral endplate and adjacent vertebral marrow changes on magnetic resonance imaging (MRI), classified into three types. Because of small sample sizes, patient cohorts, and limited phenotype assessment, the morphology and involvement of MC and their association with other spinal phenotypes remain speculative. PurposeWe addressed and proposed a phenotypic profiling of MC and their relationship with lumbar MRI phenotypes in a large-scale population-based study. Study design/settingA cross-sectional study of the Hong Kong Disc Degeneration Cohort. Patient sampleThe study population consisted of 1,546 Southern Chinese volunteers. Outcome measuresTopographical and morphological dimensions of MC, presence of disc degeneration (DD) and displacement, and Schmorl nodes were evaluated. MethodsAxial T1-weighted and sagittal T2-weighted MRIs (3T) were assessed. ResultsFemales were 62.4% (mean age, 49 years). The overall prevalence of MC was 21.9% (6.3% Type I and 15.5% Type II). Of all MC, 76% were located at the two lowest lumbar levels. Modic changes at the two lowest lumbar levels were more commonly located laterally (p<.001), less commonly anteriorly (p<.001), and were more extensive horizontally (p=.006) but not in vertical height compared with the upper levels. Type I MC were less common in the anterior part (p=.022), larger in size (height p=.004), and affected more likely the whole horizontal plane (p=.016) than Type II MC. Modic changes were associated with disc displacement, Schmorl nodes, and DD at the affected level (all p<.001), and the strength of association increased with the size of the lesion. Type I MC were associated more strongly with disc displacement (p=.008) and DD (p=.022) than Type II MC. ConclusionsOur large-scale MRI study is the first to definitely note that MC were size- and type-dependently significantly associated with disc pathology and endplate abnormalities. Our phenotype profiling of MC may have clinical utility.