Modic Endplate Changes Research Articles

Analysis of Factors Associated with Lumbar Degenerative Disease Complicated by Baastrup's Disease

ObjectiveTo investigate the factors associated with the occurrence of Baastrup's disease in patients with lumbar degenerative diseases. MethodsA retrospective analysis was conducted on 168 patients with lumbar degenerative diseases (including lumbar disc herniation, lumbar spinal stenosis, and lumbar spondylolisthesis) who were treated at our hospital from January 2020 to January 2023, comprising 95 males and 73 females, aged 48-84 years.Patients were divided into two groups based on the presence of Baastrup's disease: those with Baastrup's disease (Group A) and those without Baastrup's disease (Group B).Relevant patient factors were extracted, including age, gender, occupation, smoking history, alcohol consumption history, body mass index (BMI), bone density, presence of internal diseases (diabetes, hypertension), lumbar lordosis angle, endplate Modic changes, degree of intervertebral disc degeneration (Pfirrmann grading), and facet joint degeneration (Weishaupt grading).Statistical analysis was performed using SPSS 26.0 software to compare the differences in these factors between the two groups, and statistically significant results were included in a multivariate logistic regression analysis. ResultsUnivariate analysis indicated that there were no statistically significant differences between the two groups in terms of gender, smoking history, alcohol consumption history, bone density, presence of internal diseases (diabetes, hypertension), lumbar lordosis angle, and endplate Modic changes (P>0.05),whereas age, occupation, body mass index (BMI), degree of intervertebral disc degeneration, and degree of facet joint degeneration showed statistically significant differences (P<0.05).Multivariate logistic regression analysis revealed that age, degree of intervertebral disc degeneration, and degree of facet joint degeneration were independent risk factors for the occurrence of Baastrup's disease in patients with lumbar degenerative diseases (P<0.05). ConclusionBaastrup's disease is relatively common in patients with lumbar degenerative diseases, and advanced age, severe intervertebral disc degeneration, and facet joint degeneration are its independent risk factors.

Intervertebral disc degeneration and vertebral end plate damage in acute lumbar disc herniation

Abstract Background: Although microtrauma, gene polymorphisms, or subclinical infection could initiate lumbar disc herniation (LDH), the final pathway culminating in herniation can involve two possible trajectories—degeneration of nucleus pulposus or vertebral end plate (EP) damage. We performed a retrospective case–control study to understand the relative role played by disc degeneration (DD) and EP changes in acute LDH. Materials and Methods: MRI of 300 consecutive patients with acute LDH (&lt;6 weeks) was evaluated for the type of LDH, severity of DD by Pfirrmann’s grading, and EP Modic changes (MC) for its type, distribution, and location in EPs. Among the1500 discs evaluated in 300 patients, 308 had disc herniation (cases) and 1192 acted as controls. Results: 98.8% of LDH had grade ≥3 DD (P &lt; 0.001). The mean DD was higher in herniated discs (P &lt; 0.05). From a mean 1.98 in normal discs, it increased to 3.31 in disc bulges, 3.73 in disc protrusions/extrusions, and 3.83 in sequestrations. Herniated discs had more MCs than normal discs (38.3%, 118/308) (P &lt; 0.001). Although in normal discs, only 7.7% had MC, herniated disc subtypes showed a progressive increase in the incidence of MC (26.2% in disc bulges, 37.5% in disc protrusion/extrusions, and 58.3% in sequestrations). MC on both EP was strongly associated with LDH (odds ratio = 9.76). Posterior corner MC had a significant association with LDH (72.72%, P &lt; 0.001). Conclusion: DD seems to be a common thread in all patients (98.8%) with LDH, whereas EP damage seems to be specific pathway in a subset (38.3%). The study showed a significant degeneration of nucleus pulposus in most (98.8%) herniated discs. Compared with nonherniated discs, vertebral MC had a higher incidence in herniated discs (38%), and interestingly these were of subacute fatty type 2.

Relationship between vertebral endplate degeneration (Modic changes, Schmorl nodes, endplate irregularities) and Bone Mineral Density

ObjectiveThe end plate plays an important role in maintaining the structural integrity, balancing biomechanical and supplying nutrition, how dose it changes with the reduced bone mineral density (BMD) remains unknown. The objective of this study is to investigate the relationship between lumbar end plate degeneration and normal BMD, osteopenia and osteoporosis. MethodsA retrospective analysis of 362 patients equal or over 55 years old who underwent both lumbar MRI and dual-energy x-ray absorptiometry(DXA) examinations due to lumbar discomfort or a healthy physical examination. Two Radiologists reported the Modic changes, Schmorl node, and end plate irregularities of 11 end plates from L1 to S1. Data were separated by sex, and then the summed results were grouped in age matching. ResultsIn women, with the decrease of hip BMD, the positive rate and severity of Modic changes and the severity of end plate irregularities showed an increasing trend; Among men, the number of Modic changes and end plate irregularities increased in osteoporosis subjects and osteopenia subjects compared with normal BMD subjects. While the positive rate of Schmorl nodes incremental trend was not obvious in female and male subjects. ConclusionsOsteoporosis in the elderly will aggravate the degeneration of the lumbar end plate Modic changes and end plate irregularities.

Placebo-controlled Trial of Oral Vitamin D and Alendronate Efficacy for Pain and Modic Changes in Lumbar Fusion Surgery

Background and Aim: Modic changes are alterations in the spine endplates and subchondral bone shock absorption, seen by magnetic resonance imaging (MRI). No studies have investigated the effect of vitamin D and alendronate as oral drugs on reducing and modifying Modic changes after degenerative spine fusion surgery. This study aimed to evaluate the efficacy of oral vitamin D and alendronate administration in patients with low back pain, and Modic changes undergoing lumbar fusion surgery. Methods and Materials/Patients: A total of 81 middle age women with a normal range of serum vitamin d were enrolled in three groups who underwent lumbar fusion surgery according to neurosurgical criteria. Group 1 (n=27) received additional oral alendronate, group 2 (n=27) received oral vitamin D for six months postoperatively, and group 3 (n=27) received no drug (except simple analgesics and antibiotics). The patients were followed up with a visual analog scale (VAS) and Oswestry disability index (ODI). MRI was done before and six months after surgery. Results: There was no significant difference between the three groups in VAS and ODI scores (P=0.416, P=0.601, respectively), but the mean VAS and ODI in all three groups decreased over six months, which was statistically significant (P&lt;0.001). Modic changes in all three groups changed significantly over 6 months (P&lt;0.01). In the vitamin D and alendronate groups, Modic type 3 increased significantly, but Modic type 2 and Modic type 1 decreased significantly in the vitamin d and no medication groups, respectively. Conclusion: Oral vitamin D administration has a desirable effect not only on clinical outcomes after lumbar spinal fusion surgery because of degenerative surgery but also on vertebral endplate Modic changes compared to oral bisphosphonate.

Is a history of episodic low back pain an indicator of Modic changes?

BackgroundPrior work demonstrated that a history of episodic low back pain was highly indicative of discogenic pain. Recently, there has been more focus on vertebrogenic pain, however little is known about the clinical features of this condition. PurposeTo determine if a history of severe episodic low back pain correlates with Modic endplate changes on lumbar spine magnetic resonance imaging (MRI), presumed to be a marker of vertebrogenic pain. Study design/setting: Retrospective, observational, in vivo study of consecutive patients at outpatient Physical Medicine & Rehabilitation clinics at a single academic spine center. Patient sampleConsecutive patients who received a lumbar spine MRI between January 1, 2020, and December 31, 2020. MethodsA retrospective chart review identified patients who received a lumbar spine MRI in 2020. Chart review then determined if patients had a history of episodes of low back pain lasting at least 2 days, or if they had non-episodic low back pain (pain beginning with a gradual onset or after a specific event with continuous symptoms for >3 months). Patients were excluded if they had prior lumbar spine surgery, radicular leg pain without low back pain, indeterminate presentations based on chart review, acute spine fractures, or metastatic spine lesions. For the primary analysis, the MRIs were reviewed and were dichotomized into positive (having for either type 1 or type 2 Modic changes at any level) or negative (no Modic changes at any level). ResultsA total of 111 patients were analyzed. Inter-rater reliability for determining whether a patient's low back pain was episodic was strong (kappa ​= ​0.83), as was inter-rater reliability for determining if a patient had any levels with type 1 or type 2 Modic changes (kappa ​= ​0.81). Seventy-one out of 111 patients had type 1 and/or type 2 Modic changes at one or more spinal levels. The sensitivity of the test (episodic vs non-episodic low back pain) in finding patients with Modic changes was 20% and the specificity was 70%. The diagnostic confidence odds were 1.2, with a diagnostic confidence of 55%. Subgroup analyses for type 1 Modic changes, and for type 2 Modic changes, showed similar values. ConclusionsA history of episodic low back pain is not a strong indicator for a vertebrogenic etiology.

Success Rate of Advancing from Medial Branch Blocks to Radiofrequency Ablation in Patients with Modic Endplate Changes

Success Rate of Advancing from Medial Branch Blocks to Radiofrequency Ablation in Patients with Modic Endplate Changes

MRI grading of spinal stenosis is not associated with the severity of low back pain in patients with lumbar spinal stenosis

BackgroundAlthough lumbar spinal stenosis (LSS) often coexists with other degenerative conditions, few studies have fully assessed possible contributing factors for low back pain (LBP) in patients with LSS. The purpose of this study was to identify factors associated with the severity of LBP in patients with LSS.MethodsThe patients with neurogenic claudication caused by LSS, which was confirmed by magnetic resonance imaging (MRI) were included in this cross-sectional study. Data included ratings 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 lumbopelvic alignment and slippage. The severity of LSS, endplate defects, Modic endplate changes, intervertebral disc degeneration, and facet joint osteoarthritis were evaluated on MRI. Spearman correlation and multivariate linear regression analyses were used to examine the factors associated with the severity of LBP (NRS score).ResultsA total of 293 patients (135 male and 158 female, average age 72.6 years) were analyzed. LBP was moderately correlated with buttock and leg pain, and buttock and leg numbness. Significant but weak correlations were observed between LBP and body mass index, appendicular and trunk muscle mass, all domains of SF-36, pelvic tilt, total number of endplate defects and Modic endplate changes, and summary score of disc degeneration grading, but not severity or number of spinal stenoses. In the multivariate regression analysis, age, female sex, trunk muscle mass, diabetes, NRS buttock and leg pain, NRS buttock and leg numbness, SF-36 vitality, pelvic tilt, and total number of endplate defects were associated with the severity of LBP.ConclusionsTrunk muscle mass, lumbopelvic alignment, and endplate defects, but not severity of stenosis are partly associated with severity of LBP, but buttock and leg pain and buttock and leg numbness have strongest relationships with LBP in patients with LSS.

What's New in Spine Surgery.

What's New in Spine Surgery.

Better Functional Outcome and Pain Relief in the Far-Lateral-Outside-in Percutaneous Endoscopic Transforaminal Discectomy.

BackgroundEven though percutaneous endoscopic transforaminal discectomy (PETD) has been widely used for the surgical treatment of lumbar herniated disc, there are only a few studies directly comparing the clinical outcomes between microdiscectomy (MD) and PETD. Therefore, further studies are needed in order to compare the clinical outcomes between PETD and MD on a single level more thoroughly.MethodsWe proposed a far-lateral-outside-in technique for PETD to get an entry point without complex planning and facet violation. From September 2017 to September 2019, a total of 155 patients (69 with PETD and 86 with MD) were enrolled for this retrospective study, with the inclusion criteria: single level between L2 and S1, clinical sciatica for at least 6 weeks, and failed attempts with non-surgical treatments. Patients were excluded due to cauda equina syndrome, progressive neurologic deficits, history of lumbar spinal surgery, endplate modic changes, severe disc degeneration and less than 24 months of follow-up.ResultsPETD showed significantly shorter surgery time and less intraoperative blood loss compared to MD. The difference between PETD and MD in VAS back pain (but not VAS leg pain) at follow-up time was significant. The ODI improvement in the follow-up time of 6 months between the 2 groups showed a significant difference (PETD: 31.23±6.59, MD: 39.85±7.81, p < 0.001). MD had a significantly higher chance of postoperative wound infection and poor healing, while PETD was more likely to have recurrence of the herniated disc.ConclusionMD has been the gold standard procedure for LDH. However, with the advanced endoscopic technology and surgical technique, PETD has emerged as an alternative method due to higher functional outcome and less wound problems.

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.

CORRELATION OF MAGNETIC RESONANCE IMAGING CHANGES OF MULTIFIDUS MUSCLE WITH OTHER DEGENERATIVE CHANGES AT LUMBOSACRAL SPINE IN PATIENTS WITH LOW BACK PAIN

Background: Multifidus muscle (MF) in the back of the vertebral column plays an important role in spinal stability. MF morphology and fatty infiltration can be influenced by factors affecting low back pain (LBP) and evaluated using MRI, CT and US, however MRI provides a higher resolution and allows for better detection of soft tissues.Objective: We proposed a new method to assess the degree of MF degeneration. Methods: The multifidus score was calculated by summation of degree of MF degeneration, with minimum score of 0 and maximum of 6. In cases of disproportion affection of MF on each side, we chose the higher degree of MF affection. Score of 6 means that MF degeneration is graded 2 in either side. We mentioned the influence of other vertebral degenerative pathologies including facet arthropathies, neural canal stenosis and Modic end plate changes. We defined disc pathology as disc bulge, herniation. The main factors affecting MF degeneration are age, body mass index (BMI), duration of compliant in years, presence of sciatica and VAS visual analogue scale (VAS) score.Results: VAS scores were statistically significantly correlated with degree of MF degeneration, with p value < 0.001. The degree of MF degeneration was significantly correlated with number of disc pathologies. Conclusion: Our study concluded a significant relation between MF degeneration and each of VAS and duration of pain, although this relation was not related to the measurement of proportionate changes between each side and different degrees of MF degeneration.

Comparison of lumbar degenerative disc disease using conventional fast spin echo T 2W MRI and T 2 fast spin echo dixon sequences

To compare the grading of lumbar degenerative disc disease (DDD), Modic end-plate changes (MEPC) and identification of high intensity zones (HIZ) on a combination of sagittal T1weighted turbo spin echo (T1W TSE), T2weighted fast spin echo (T2W FSE) and short tau inversion recovery (STIR) sequences (routine protocol) with a single sagittal T2W FSE Dixon MRI sequence which provides in-phase, opposed-phase, water only and fat only images in a single acquisition (Dixon protocol). 50 patients underwent lumbar spine MRI using the routine protocol with the addition of a T2W FSE Dixon sequence. DDD grade, MEPC and HIZ for each disc level were assessed on the routine and Dixon protocols. Each protocol was reviewed independently by three readers (consultant musculoskeletal radiologists with 26-, 8- and 4 years' experience), allowing assessment of inter-reader agreement and inter protocol agreement for each assessed variable. The study included 17 males and 33 females (mean age 51 years; range 8-82 years). Inter-reader agreement for DDD grade on the routine protocol was 0.57 and for the Dixon protocol was 0.63 (p = 0.08). Inter-reader agreement for MEPC on the routine protocol was 0.45 and for the Dixon protocol was 0.53 (p = 0.02), and inter-reader agreement for identification of the HIZ on the routine protocol was 0.52 and for the Dixon protocol was 0.46 (p = 0.27). Intersequence agreement for DDD grade ranged from 0.61 to 0.97, for MEPC 0.46-0.62 and for HIZ 0.39-0.5. A single sagittal T2W FSE Dixon MRI sequence could potentially replace the routine three sagittal sequence protocol for assessment of lumbar DDD, MEPC and HIZ resulting in ~60% time saving. Grading of lumbar DDD, presence of Modic changes and high intensity zones were compared on sagittal T1W TSE, T2W FSE and STIR sequences with a T2W FSE Dixon sequence, with fair-to-good correlation suggesting that three conventional sequences could be replaced by a single Dixon sequence.

Lumbar Disc Herniation and Preoperative Modic Changes: A Prospective Analysis of the Clinical Outcomes After Microdiscectomy.

Study design:Prospective comparative cohort study.Objectives:The study aims to elucidate the relationship between Modic endplate changes and clinical outcomes after a lumbar microdiscectomy.Methods:Consecutive patients undergoing microdiscectomy for lumbar disc herniation (LDH) were prospectively studied. Pre-operative clinical and radiological parameters were recorded. The pain was assessed by Numeric pain rating scale (NPRS), and functional assessment by Oswestry Disability Index (ODI). Minimal clinically important difference (MCID) in outcome was calculated for both the groups. Complications related to surgery were studied. Follow-up was done at 6 weeks, 3 months, 6 months and 1 year. Mac Nab criteria were used to assess patient satisfaction at 1 year.Results:Out of 309 patients, 86 had Modic changes, and 223 had no Modic changes. Both groups had similar back pain (p-value: 0.07) and functional scores (p-value: 0.85) pre-operatively. Postoperatively patients with Modic changes had poorer back pain and ODI scores in the third month, sixth month and 1 year (p-value: 0.001). However, MCID between the groups were not significant (p-value: 0.18 for back pain and 0.58 for ODI scores). Mac Nab criteria at 1 year were worse in Modic patients (p-value: 0.001). No difference was noted among Modic types in the pre-operative and postoperative pain and functional outcomes. Four patients in Modic group (4.7%) and one patient in the non-Modic group (0.5%) developed postoperative discitis (p-value: 0.009).Conclusions:Preoperative Modic changes in lumbar disc herniation is associated with less favorable back pain, functional scores and patient satisfaction in patients undergoing microdiscectomy.

MRI spectrum and prevalence of lumbar spinal degenerative disease in patients with non-traumatic low back pain

Background: Low back pain (LBP) is a frequent cause of global disability and activity limitation. In the majority of cases, LBP is nonspecific, yet diagnostic confirmation is required to rule out serious underlying pathologies such as infection, tumour, fracture or degenerative disease. It can be done by a number of imaging techniques. Of all available techniques, MRI is currently the imaging modality of choice owing to lack of radiation, multiplanar reformation capabilities and high contrast resolution. Objectives: To determine various MRI patterns and the common sites of spinal degenerative lesions among patients with LBP. Method: This study was conducted on 622 patients suffering from non-traumatic LBP, referred for MRI of the lumbar spine. MRI database of the study population were analysed using axial T2-weighted, sagittal STIR, T1and T2-weighted and coronal STIR images. After excluding patients with h/o prior surgery and MR findings suggesting infective or neoplastic etiologies, 598 patients constituted the sample size of our study. Results: A review of 598 patients with LBP revealed that degenerative changes in intervertebral disc were the most common abnormality detected. Among these, Disc bulge was the most common abnormality followed by disc desiccation, protrusion, extrusion, HIZ/annular tear, reduced IVD space and Schmorl’s nodes. Other non- disc degenerative findings were Modic endplate changes, facet joint arthropathy, osteophytes, Spinal canal stenosis and Ligamentum Flavum hypertrophy. Conclusions: Results reported the common occurrence of lumbar disc degenerative disease in patients with low backache. Research efforts should attempt to trim down risk factors and perk up the quality of life.

Magnetic resonance imaging spectrum of degenerative disease of the lumbosacral spine: a single institution retrospective cross-sectional observational study

Background: Degenerative Disease of the Lumbosacral spine is a leading cause of back ache and radiculopathy with significant medical and socioeconomic importance. Its pathogenesis represents a biomechanically related continuum of temporally evolving alterations which are identifiable on various imaging modalities. Due to its excellent soft tissue contrast, multiplanar capabilities and non-ionizing nature MRI is indispensable for detailed morphological evaluation of all components of the Functional Spinal Unit (FSU). It facilitates optimal assessment of the burden of disease thereby guiding prognostication as well as subsequent therapy and rehabilitation. Results: The mean age of the study participants was 51 years ± 14 years with Male: Female ratio of 1.9:1. The L4-L5 intervertebral disc was the most frequently as well as most severely involved level irrespective of age and gender of the study subjects. Disc degeneration was the commonest manifestation seen (100%) followed by nerve root compression (74%), spinal canal stenosis (67%), disc herniation (64%), facetal arthropathy (41%), bulging discs (38%), ligamentum flavum hypertrophy (34%) and Modic endplate degenerative changes (31%) in decreasing order of frequency.

The influence of endplate (Modic) changes on clinical outcomes in lumbar spinal stenosis surgery: a Swiss prospective multicenter cohort study.

To investigate if the presence or absence of preoperative endplate Modic changes (MC) is predictive for clinical outcomes in degenerative lumbar spinal stenosis (DLSS) patients undergoing decompression-alone or decompression with instrumented fusion surgery. Two hundred five patients were included and categorized into four groups; 102 patients into the decompression-alone group with MCs, 41 patients into the fusion group with MCs, 46 patients into the decompression-alone group without MCs, and 16 patients into the fusion group without MCs. Clinical outcome was quantified with changes in spinal stenosis measure (SSM) symptoms, SSM function, NRS pain, and EQ-5D-3L sum score over time (measured at baseline, 12-, 24-, and 36-month follow-up) and minimal clinically important difference (MCID) in SSM symptoms, SSM function, and NRS pain from baseline to 36-month follow-up. To investigate if possible effects of MCs had been modified or hidden by confounding variables, we used the group LASSO method to search for good prognostic models. There were no obvious differences in any of the clinical outcome measures between groups at baseline. At 12months, most patients have improved in all outcomes and maintained improved conditions over time (no significant group differences). Between 70 and 90 percent of the patients maintained a clinically important improvement up to 36months. Endplate MCs have no significant influence on clinical outcome parameters in patients with lumbar spinal stenosis compared to patients without MCs, independent of the chosen surgical strategy. All patients benefitted from surgical therapy up to 36-month follow-up. These slides can be retrieved under Electronic Supplementary Material.

Cutibacterium acnes in Spine Pathology: Pathophysiology, Diagnosis, and Management.

Cutibacterium acnes, long thought to be skin flora of pathological insignificance, has seen a surge in interest for its role in spine pathology. C acnes has been identified as a pathogen in native spine infection and osteomyelitis, which has implications in the management compared with more commonly recognized pathogens. In addition, It has also been recognized as a pathogen in postoperative and implant-associated infections. Some evidence exists pointing to C acnes as an unrecognized source of otherwise aseptic pseudarthrosis. Recently, it is hypothesized that low virulent organisms, in particular C acnes, may play a role in degenerative disk disease and the development of Modic end plate changes found in MRI. To this end, controversial implications exist in terms of the use of antibiotics to treat certain patients in the setting of degenerative disk disease. C acnes continues to remain an expanding area of interest in spine pathology, with important implications for the treating spine surgeon.

Modic I changes size increase from supine to standing MRI correlates with increase in pain intensity in standing position: uncovering the \u201cbiomechanical stress\u201d and \u201cactive discopathy\u201d theories in low back pain

PurposeTo evaluate the relationship between degenerative disc, endplate Modic changes (MC) type I, and pain during upright weight-bearing MRI scan of the lumbar spine in a cohort of patients with non-specific low back pain.Materials and methodsWe evaluated 38 patients with non-specific low back pain and MRI evidence of Modic I vertebral changes. The patients were evaluated in a standard and upright weight-bearing position using a dedicated MR unit. The extent of endplate MC type I, intervertebral disc height at the involved level, and degree of degeneration in the same intervertebral disc were compared. Pain was assessed through the VAS questionnaire.ResultsIn the upright position, the area of Modic I changes increased in 26 patients (68.4%, p ≤ 0.001) compared to the supine position. In the upright position, reduction in the disc height was found in 35 patients (92.1%). Correlation analysis showed moderate negative correlation (ρ = − 0.45) between intervertebral disc height and increase in the area of Modic I changes, and weak positive correlation (ρ = 0.12) between Pfirrmann grade and increase in the area of Modic I changes. At clinical evaluation, 30 patients (78.9%) reported worsening of low back pain standing in the upright position. Increase in VAS values on the upright position correlated significantly (ρ = 0.34) with an increase in the area of Modic I changes.ConclusionsOur results showed the modifications of Modic I changes under loading, with MRI evidence of increased MC area extent in the upright position and correlation between Modic changes extension increase and increase in pain in the standing position. Weight-bearing MRI scans represent a valuable complement to standard sequences since they provide the radiologist with additional diagnostic information about low back pain.Graphical abstractThese slides can be retrieved from Electronic Supplementary Material.

Expression of Matrix Metalloproteinases, Tissue Inhibitors of Metalloproteinases, and Interleukins in Vertebral Cartilage Endplate.

Turnover of cartilage endplate extracellular matrix (ECM) may play an important role in disc degeneration and low back pain (LBP). However, the expression pattern of pro-inflammatory factors, matrix metalloproteinases (MMP), and tissue inhibitors of metalloproteinases (TIMP) in the cartilage endplates (CEP) of intervertebral discs (IVD) is not understood. We aimed to examine the transcriptional levels of MMP, TIMP, and interleukins (IL), and the correlations between them. Thirty degenerated cartilage endplate samples from patients with LBP who underwent lumbar fusion surgery were included in the degenerated group. Ten patients without LBP history who underwent lumbar surgery because of vertebral burst fractures were included in the control group. The degenerative severity of the samples was evaluated by MRI, and hematoxylin-eosin and safranin O-fast green (SO-FG) staining. Real-time polymerase chain reaction (RT-PCR) was used to detect the mRNA levels of MMP-1, MMP-3, MMP-9, MMP-13, TIMP-1, TIMP-2, TIMP-3, IL-1α, IL-1β, and IL-6. The correlations between the levels of these genes were tested using Spearman's rho test. Hematoxylin-eosin and SO-FG staining confirmed a decrease in cell number and proteoglycans in the degenerated cartilage endplate. MRI showed significant signal changes in degenerated cartilage endplates. Patients in the degenerated group showed a higher rate of endplate Modic changes when compared with the control group. MMP-3, MMP-9, TIMP-3, IL-1α, and IL-1β were elevated with statistical significance, while MMP-1, MMP-13, TIMP-1, TIMP-2, and IL-6 were changed without statistical significance or remained unchanged. Expression of MMP-3 was positively correlated with IL-1α (Spearman coefficient, 0.486; P < 0.05); expression of TIMP-3 was positively correlated with MMP-9, IL-1α, and IL-1β (Spearman coefficient, 0.577, 0.407, and 0.571, respectively; P < 0.05). MMP-3, MMP-9, TIMP-3, IL-1α, and IL-1β may play a role in the process of cartilage endplate degeneration. MMP-3 may be regulated by IL-1α, and TIMP-3 might be associated with MMP-9 and regulated by IL-1α and IL-1β.

Low virulence bacterial infections in cervical intervertebral discs: a prospective case series.

A prospective cross-sectional case series study. To investigate the prevalence of low virulence disc infection and its associations with characteristics of patients or discs in the cervical spine. Low virulence bacterial infections could be a possible cause of intervertebral disc degeneration and/or back pain. Controversies are continuing over whether these bacteria, predominantly Propionibacterium acnes (P. acnes), represent infection or contamination. However, the current studies mainly focus on the lumbar spine, with very limited data on the cervical spine. Thirty-two patients (20 men and 12 women) who underwent anterior cervical fusion for degenerative cervical spondylosis or traumatic cervical cord injury were enrolled. Radiological assessments included X-ray, CT, and MRI of the cervical spine. Endplate Modic changes, intervertebral range of motion, and disc herniation type were evaluated. Disc and muscle tissues were collected under strict sterile conditions. Samples were enriched in tryptone soy broth and subcultured under anaerobic conditions, followed by identification of the resulting colonies by the PCR method. Sixty-six intervertebral discs were excised from thirty-two patients. Positive disc cultures were noted in eight patients (25%) and in nine discs (13.6%). The muscle biopsy (control) cultures were negative in 28 patients and positive in 4 patients (12.5%); three of whom had a negative disc culture. Seven discs (10.6%) were positive for coagulase-negative Staphylococci (CNS) and two discs were positive for P. acnes (3.0%). A younger patient age and the extrusion or sequestration type of disc herniation, which represented a complete annulus fibrous failure, were associated with positive disc culture. Our data show that CNS is more prevalent than P. acnes in degenerative cervical discs. The infection route in cervical discs may be predominantly through an annulus fissure. Correlation between these infections and clinical symptoms is uncertain; therefore, their clinical significance needs to be investigated in the future. These slides can be retrieved under Electronic Supplementary Material.