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Lawan A, Leung A, Leung S, Faul J, Umoh JU, Holdsworth DW, Bryant DM, Battié MC. Detection and Characterization of Endplate Structural Defects on CT: A Diagnostic Accuracy Study. Spine (Phila Pa 1976) 2024; 49:1219-1226. [PMID: 38282481 DOI: 10.1097/brs.0000000000004936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/15/2024] [Indexed: 01/30/2024]
Abstract
STUDY DESIGN Diagnostic test study. OBJECTIVE To determine the reliability and validity or diagnostic accuracy of two previously described endplate structural defect (EPSD) assessment methods. SUMMARY OF BACKGROUND DATA Studies of EPSD may further the understanding of pathoanatomic mechanisms underlying back pain. However, clinical imaging methods used to document EPSD have not been validated, leaving uncertainty about what the observations represent. MATERIALS AND METHODS Using an evaluation manual, 418 endplates on CT sagittal slices obtained from 19 embalmed cadavers (9 men and 10 women, aged 62-91 yr) were independently assessed by two experienced radiologists and a novice for EPSD using the two methods. The corresponding micro-CT (µCT) from the harvested T7-S1 spines were assessed by another independent rater with excellent intra-rater reliability (k=0.96). RESULTS Inter-rater reliability was good for the presence (k=0.60-0.69) and fair for specific phenotypes (k=0.43-0.58) of EPSD. Erosion, for which the Brayda-Bruno classification lacked a category, was mainly (82.8%) classified as wavy/irregular, while many notched defects (n=15, 46.9%) and Schmorl's nodes (n=45, 79%) were recorded as focal defects using Feng's classification. When compared to µCT, endplate fractures (n=53) and corner defects (n=28) were routinely missed on CT. Endplates classified as wavy/irregular on CT corresponded to erosion (n=29, 21.2%), jagged defects (n=21, 15.3%), calcification (n=19, 13.9%), and other phenotypes on µCT. Some focal defects on CT represented endplate fractures (n=21, 27.6%) on µCT. Overall, with respect to the presence of an EPSD, there was a sensitivity of 70.9% and a specificity of 79.1% using Feng's method, and 79.5% and 57.5% using Brayda-Bruno's method. Poor to fair inter-rater reliability (k=0.26-0.47) was observed for defect dimensions. CONCLUSION There was good inter-rater reliability and evidence of criterion validity supporting assessments of EPSD presence using both methods. However, neither method contained all needed EPSD phenotypes for optimal sensitivity, and specific phenotypes were often misclassified.
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Affiliation(s)
- Aliyu Lawan
- Faculty of Health Sciences, School of Physical Therapy, and Western's Bone and Joint Institute, Western University, London, ON, Canada
| | - Andrew Leung
- Department of Medical Imaging, Victoria Hospital, London Health Sciences Centre, London, ON, Canada
| | - Stephanie Leung
- Department of Medical Imaging, Victoria Hospital, London Health Sciences Centre, London, ON, Canada
| | - James Faul
- Department of Anatomy and Cell Biology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Joseph U Umoh
- Preclinical Imaging Research Centre, Robarts Research Institute, Western University, London, ON, Canada
| | - David W Holdsworth
- Preclinical Imaging Research Centre, Robarts Research Institute, Western University, London, ON, Canada
- Departments of Medical Biophysics and Surgery, Western University, London, ON, Canada
| | - Dianne M Bryant
- Faculty of Health Sciences, School of Physical Therapy, and Western's Bone and Joint Institute, Western University, London, ON, Canada
| | - Michele C Battié
- Faculty of Health Sciences, School of Physical Therapy, and Western's Bone and Joint Institute, Western University, London, ON, Canada
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Crane J, Zhang W, Otte A, Barik S, Wan M, Cao X. Slit3 by PTH-Induced Osteoblast Secretion Repels Sensory Innervation in Spine Porous Endplates to Relieve Low Back Pain. RESEARCH SQUARE 2024:rs.3.rs-4823095. [PMID: 39257984 PMCID: PMC11384799 DOI: 10.21203/rs.3.rs-4823095/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2024]
Abstract
During aging, the spine undergoes degenerative changes, particularly with vertebral endplate bone expansion and sclerosis, that is associated with nonspecific low back pain (LBP). We reported that parathyroid hormone (PTH) treatment could reduce vertebral endplate sclerosis and improve pain behaviors in aging, SM/J and young lumbar spine instability (LSI) mice. Aberrant innervation noted in the vertebral body and endplate during spinal degeneration was reduced with PTH treatment in aging and LSI mice as quantified by PGP9.5 + and CGRP + nerve fibers, as well as CGRP expression in dorsal root ganglia (DRG). The neuronal repulsion factor Slit3 significantly increased in response to PTH treatment mediated by transcriptional factor FoxA2. PTH type1 receptor (PPR) and Slit3 deletion in osteoblasts prevented PTH-reduction of endplate porosity and improvement in behavior tests, whereas PPR deletion in chondrocytes continued to respond to PTH. Altogether, PTH stimulates Slit3 to repel sensory nerve innervation and provides symptomatic relief of LBP associated with spinal degeneration.
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Chen H, Zhou Q, Pu X, Wang N, Wang S, Feng Z, Wang B, Zhu Z, Qiu Y, Sun X. Association between vertebral endplate defects and patient-reported symptoms: an immunohistochemical study investigating the COX-2/PGE-2/EP-4 axis. Spine J 2024; 24:1407-1415. [PMID: 38631491 DOI: 10.1016/j.spinee.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 04/07/2024] [Accepted: 04/07/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND CONTEXT Vertebral endplate defects are often implicated in degenerative disc disorders, yet their connection to patient-reported symptoms remains unclear. COX-2 and PGE-2 are known for their roles in inflammation and pain, with EP-4 receptor involvement in pain signaling. Examining their expression in vertebral endplate tissues may provide insights into pathomechanism of low back pain. PURPOSE To investigate the association between endplate defects and patient-reported symptoms and to further clarify the role of the COX-2/PGE-2/EP-4 axis in the pathogenesis of chronic low back pain. STUDY DESIGN/SETTING Retrospective study. PATIENT SAMPLE A total of 71 patients who had undergone single-level L4/5 or L5/S1 modified laminectomy decompression preserving proximal upper laminae and transforaminal lumbar interbody fusion surgery were included in this study, including 18 patients diagnosed with lumbar disc herniation, 19 with lumbar disc herniation accompanied by degenerative lumbar spinal stenosis, and 34 with degenerative spondylolisthesis. OUTCOME MEASURES Demographic data, Pfirrmann grade, Modic changes, endplate defect score, visual analog scale (VAS) for back and leg pain, and Oswestry Disability Index (ODI) before surgery, 3-month and 6-month follow-up, and the percentage of immune-positive cells (COX-2, PGE-2, and EP-4) in endplate tissue sections. METHODS Patients were divided into defect and nondefect groups according to endplate morphology on lumbar MR. All intraoperative endplate specimens were immediately fixed in 10% formaldehyde, and then embedded in paraffin 3 days later for tissue sections. The outcome measures were compared between the defect group and nondefect group. Data were analyzed using independent t-tests and χ² tests. Pearson's rank correlation test was used to assess correlations between patient-reported symptoms and the percentage of immune-positive cells in the groups. Multivariable logistic regression models using the forward stepwise likelihood ratio method were used to identify the factors that were independently associated with endplate defects. RESULTS The age of Defect group was significantly higher than that of nondefect group (52.5±7.7 vs 57.2±9.1. p=.024). There were no significant differences in gender, diagnosis, BMI, comorbidities, or surgical level between the two groups. Modic changes (Type Ⅱ/Type Ⅲ) were more common in patients of Defect group than nondefect group (38.5% vs 11.1%, p<.001), and so was disc degeneration (Pfirrmann grade Ⅳ/Ⅴ) (69.2% vs 33.3%, p<.001). Defect group had significantly higher VAS-Back (6.5±2.0 vs 4.9±1.6, p<.001) and ODI scores (62.9±10.7 vs 45.2±14.8, p<.001) than nondefect group, while there was no significant differences between the two groups during the 3 and 6-month follow-up after surgery. Histologically, Defect group was characterized by upregulation of COX-2, PGE-2, and EP-4 in endplate tissue sections. Both in defect and nondefect groups, VAS-Back showed moderate positive correlations with the expressions of COX-2 (r=0.643; r=0.558, p both<.001), PGE-2 (r=0.611; r=0.640, p both<.001), and EP-4 (r=0.643; r=0.563, p both<.001). Multivariate regression analyses reveled that percentage of COX-2-positive cells was associated with endplate defects (OR=1.509, 95%CI [1.048-2.171], p=.027), as well as percentage of PGE-2-positive (OR=1.291, 95%CI [1.106-1.508], p=.001) and EP-4-positive cells (OR=1.284, 95%CI [1.048∼2.171], p=.003). CONCLUSIONS Patients with endplate defects had worse quality of life, more severe disc degeneration and Modic changes, and up-regulated COX-2/PGE-2/EP-4 axis expression in cartilage endplates in patients with defected endplates. Inflammatory factors may significantly contribute to the onset and progression of chronic low back pain in patients with endplate defects, consequently impacting patient-reported symptoms.
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Affiliation(s)
- Haojie Chen
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Qingshuang Zhou
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital Clinical College of Jiangsu University, Nanjing, China
| | - Xiaojiang Pu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Nannan Wang
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, China
| | - Sinian Wang
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zhenhua Feng
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Bin Wang
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zezhang Zhu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yong Qiu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xu Sun
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
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Farley T, Stokke J, Goyal K, DeMicco R. Chronic Low Back Pain: History, Symptoms, Pain Mechanisms, and Treatment. Life (Basel) 2024; 14:812. [PMID: 39063567 PMCID: PMC11278085 DOI: 10.3390/life14070812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/20/2024] [Accepted: 06/24/2024] [Indexed: 07/28/2024] Open
Abstract
Chronic low back pain (cLBP) is the most frequently reported cause of years lived with disability. Identifying the anatomical structures or dysfunction contributing to patients' symptoms is critical to guiding treatment. The etiology of back pain and differential diagnosis is often broad, ranging from non-degenerative cLBP (trauma, tumor, inflammation, infection, etc.) to degenerative (also described as nonspecific) cLBP. After eliminating suspicion for more insidious causes of cLBP, a thorough investigation can be conducted in an attempt to identify a source of degenerative cLBP. Degenerative cLBP can originate from many sources, and a detailed understanding of the structures potentially involved is invaluable for an accurate diagnosis. This review article aims to provide a broad overview of the utility of clinical history, physical exam findings, imaging findings, and diagnostic procedures in identifying the cause of patients' cLBP. We provide a framework to help guide clinicians by dividing the structures into groups as follows: anterior vertebral column, posterior vertebral column, and extra-vertebral pain. For each condition listed, we touch on the treatment options that can be considered.
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Affiliation(s)
- Tyler Farley
- Center for Spine Health, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; (J.S.); (K.G.); (R.D.)
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Pan D, Benkato KG, Han X, Zheng J, Kumar V, Wan M, Zheng J, Cao X. Senescence of endplate osteoclasts induces sensory innervation and spinal pain. eLife 2024; 12:RP92889. [PMID: 38896465 PMCID: PMC11186630 DOI: 10.7554/elife.92889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
Spinal pain affects individuals of all ages and is the most common musculoskeletal problem globally. Its clinical management remains a challenge as the underlying mechanisms leading to it are still unclear. Here, we report that significantly increased numbers of senescent osteoclasts (SnOCs) are observed in mouse models of spinal hypersensitivity, like lumbar spine instability (LSI) or aging, compared to controls. The larger population of SnOCs is associated with induced sensory nerve innervation, as well as the growth of H-type vessels, in the porous endplate. We show that deletion of senescent cells by administration of the senolytic drug Navitoclax (ABT263) results in significantly less spinal hypersensitivity, spinal degeneration, porosity of the endplate, sensory nerve innervation, and H-type vessel growth in the endplate. We also show that there is significantly increased SnOC-mediated secretion of Netrin-1 and NGF, two well-established sensory nerve growth factors, compared to non-senescent OCs. These findings suggest that pharmacological elimination of SnOCs may be a potent therapy to treat spinal pain.
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Affiliation(s)
- Dayu Pan
- Department of Orthopedic Surgery and Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Kheiria Gamal Benkato
- Department of Orthopedic Surgery and Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Xuequan Han
- Department of Orthopedic Surgery and Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Jinjian Zheng
- Department of Orthopedic Surgery and Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Vijay Kumar
- Department of Orthopedic Surgery and Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Mei Wan
- Department of Orthopedic Surgery and Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Junying Zheng
- Department of Orthopedic Surgery and Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Xu Cao
- Department of Orthopedic Surgery and Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, United States
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Athertya JS, Statum S, Chen X, Du K, Shin SH, Jerban S, Chung CB, Chang EY, Ma Y. Evaluation of spine disorders using high contrast imaging of the cartilaginous endplate. Front Physiol 2024; 15:1394189. [PMID: 38860112 PMCID: PMC11163041 DOI: 10.3389/fphys.2024.1394189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/13/2024] [Indexed: 06/12/2024] Open
Abstract
Introduction: Many spine disorders are caused by disc degeneration or endplate defects. Because nutrients entering the avascular disc are channeled through the cartilaginous endplate (CEP), structural and compositional changes in the CEP may block this solute channel, thereby hindering disc cell function. Therefore, imaging the CEP region is important to improve the diagnostic accuracy of spine disorders. Methods: A clinically available T1-weighted and fat-suppressed spoiled gradient recalled-echo (FS-SPGR) sequence was optimized for high-contrast CEP imaging, which utilizes the short T1 property of the CEP. The FS-SPGR scans with and without breath-hold were performed for comparison on healthy subjects. Then, the FS-SPGR sequence which produced optimal image quality was employed for patient scans. In this study, seven asymptomatic volunteers and eight patients with lower back pain were recruited and scanned on a 3T whole-body MRI scanner. Clinical T2-weighted fast spin-echo (T2w-FSE) and T1-weighted FSE (T1w-FSE) sequences were also scanned for comparison. Results: For the asymptomatic volunteers, the FS-SPGR scans under free breathing conditions with NEX = 4 showed much higher contrast-to-noise ratio values between the CEP and bone marrow fat (BMF) (CNRCEP-BMF) (i.e., 7.8 ± 1.6) and between the CEP and nucleus pulposus (NP) (CNRCEP-NP) (i.e., 6.1 ± 1.2) compared to free breathing with NEX = 1 (CNRCEP-BMF: 4.0 ± 1.1 and CNRCEP-NP: 2.5 ± 0.9) and breath-hold condition with NEX = 1 (CNRCEP-BMF: 4.2 ± 1.3 and CNRCEP-NP: 2.8 ± 1.3). The CEP regions showed bright linear signals with high contrast in the T1-weighted FS-SPGR images in the controls, while irregularities of the CEP were found in the patients. Discussion: We have developed a T1-weighted 3D FS-SPGR sequence to image the CEP that is readily translatable to clinical settings. The proposed sequence can be used to highlight the CEP region and shows promise for the detection of intervertebral disc abnormalities.
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Affiliation(s)
- Jiyo S. Athertya
- Department of Radiology, University of California, San Diego, San Diego, CA, United States
| | - Sheronda Statum
- Department of Radiology, University of California, San Diego, San Diego, CA, United States
| | - Xiaojun Chen
- Department of Radiology, University of California, San Diego, San Diego, CA, United States
| | - Kevin Du
- Department of Radiology, University of California, San Diego, San Diego, CA, United States
| | - Soo Hyun Shin
- Department of Radiology, University of California, San Diego, San Diego, CA, United States
| | - Saeed Jerban
- Department of Radiology, University of California, San Diego, San Diego, CA, United States
| | - Christine B. Chung
- Department of Radiology, University of California, San Diego, San Diego, CA, United States
- Radiology Service, VA San Diego Healthcare System, San Diego, CA, United States
| | - Eric Y. Chang
- Department of Radiology, University of California, San Diego, San Diego, CA, United States
- Radiology Service, VA San Diego Healthcare System, San Diego, CA, United States
| | - Yajun Ma
- Department of Radiology, University of California, San Diego, San Diego, CA, United States
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Hirsch JA, Sahr DM, Brook AL, Chandra RV, Manfre L, Marcia S, Milburn J, Muto M. Basivertebral nerve ablation meets neurointervention-déjà vu? J Neurointerv Surg 2024:jnis-2024-021484. [PMID: 38653523 DOI: 10.1136/jnis-2024-021484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Diane M Sahr
- Perceive Medical LLC, Minneapolits, Minnesota, USA
| | - Allan L Brook
- Director of Interventional Neuroradiology, Montefiore Medical Center, Bronx, New York, USA
| | - Ronil V Chandra
- Interventional Neuroradiology, Monash Medical Center and Monash University, Clayton, Victoria, Australia
| | - Luigi Manfre
- ESNR Secretary of State, Department Head Minimally Invasive Spine, IOM Mediterranean Oncology Institute, Viagrande-Cantania, Sicily, Italy
| | - Stefano Marcia
- Departmento dei servizi, Radiologia Area Ospedaliera ASL Cagliari, SS Trinita Hospital, Cagliari, Sardinia, Italy
| | - James Milburn
- Department of Radiology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Mario Muto
- Chairman Diagnostic and Interventional Radiology, Cardarelli Hospital, Naples, Italy
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Couasnay G, Garcia H, Elefteriou F. A comparative analysis of TonEBP conditional knockout mouse models reveals inter-dependency between compartments of the intervertebral disc. Development 2024; 151:dev202354. [PMID: 38421307 PMCID: PMC11006390 DOI: 10.1242/dev.202354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/20/2024] [Indexed: 03/02/2024]
Abstract
Interactions between notochord and sclerotome are required for normal embryonic spine patterning, but whether the postnatal derivatives of these tissues also require interactions for postnatal intervertebral disc (IVD) growth and maintenance is less established. We report here the comparative analysis of four conditional knockout mice deficient for TonEBP, a transcription factor known to allow cells to adapt to changes in extracellular osmotic pressure, in specific compartments of the IVD. We show that TonEBP deletion in nucleus pulposus (NP) cells does not affect their survival or aggrecan expression, but promoted cell proliferation in the NP and in adjacent vertebral growth plates (GPs). In cartilage end plates/GPs, TonEBP deletion induced cell death, but also structural alterations in the adjacent NP cells and vertebral bodies. Embryonic or postnatal TonEBP loss generated similar IVD changes. In addition to demonstrating the requirement of TonEBP in the different compartments of the IVD, this comparative analysis uncovers the in vivo interdependency of the different IVD compartments during the growth of the postnatal IVD-vertebral units.
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Affiliation(s)
- Greig Couasnay
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Haley Garcia
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Florent Elefteriou
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030, USA
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Kawabata S, Nagai S, Ito K, Takeda H, Ikeda D, Kawano Y, Kaneko S, Shiraishi Y, Sano Y, Ohno Y, Fujita N. Intradiscal administration of autologous platelet-rich plasma in patients with Modic type 1 associated low back pain: A prospective pilot study. JOR Spine 2024; 7:e1320. [PMID: 38500785 PMCID: PMC10945308 DOI: 10.1002/jsp2.1320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 01/06/2024] [Accepted: 02/25/2024] [Indexed: 03/20/2024] Open
Abstract
Background Various treatments for chronic low back pain (LBP) have been reported; among them, platelet-rich plasma (PRP) as a regenerative medicine has attracted much attention. Although Modic type 1 change (MC1) is associated with LBP, no treatment has been established so far. In addition, no studies have administered PRP to intervertebral discs (IVDs) in patients with LBP, targeting MC1 only. Thus, the purpose of this study was to determine the safety and efficacy of PRP administration to the IVDs in patients with MC1 experiencing LBP. Methods PRP was injected intradiscally to 10 patients with MC1 experiencing LBP. Patients were followed prospectively for up to 24 weeks after primary administration. Physical condition, laboratory data, and lumbar x-ray images were evaluated for safety assessment. Furthermore, to evaluate the effectiveness of PRP, patient-reported outcomes were considered. In addition, changes in MC1 were assessed using magnetic resonance imaging (MRI). Results There were no adverse events in the laboratory data or lumbar X-ray images after administration. The mean visual analog scale, which was 70.0 ± 13.3 before the treatment, significantly decreased 1 week after PRP administration and was 39.0 ± 28.8 at the last observation. Oswestry disability index and Roland Morris disability questionnaire scores promptly improved after treatment, and both improved significantly 24 weeks after PRP administration. Follow-up MRI 24 weeks after treatment showed a significant decrease in the mean high-signal intensity of fat-suppressed T2-weighted imaging from 10.1 to 7.90 mm2 compared with that before PRP administration. Conclusions The safety and efficacy of PRP administration to the IVDs of patients with MC1 experiencing LBP were identified. Post-treatment MRI suggested improvement in inflammation, speculating that PRP suppressed inflammation and consequently relieved the patient's symptoms. Despite the small number of patients, this treatment is promising for patients with MC1 experiencing LBP. The study protocol has been reviewed and approved by the Certified Committee for Regenerative Medicine and the Japanese Ministry of Health, Labor and Welfare (Japan Registry of Clinical Trials [jRCT] No. jRCTb042210159).
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Affiliation(s)
- Soya Kawabata
- Department of Orthopaedic Surgery, School of MedicineFujita Health UniversityToyoakeAichiJapan
| | - Sota Nagai
- Department of Orthopaedic Surgery, School of MedicineFujita Health UniversityToyoakeAichiJapan
| | - Kei Ito
- Department of Orthopaedic Surgery, School of MedicineFujita Health UniversityToyoakeAichiJapan
| | - Hiroki Takeda
- Department of Spine and Spinal Cord Surgery, School of MedicineFujita Health UniversityToyoakeAichiJapan
| | - Daiki Ikeda
- Department of Orthopaedic Surgery, School of MedicineFujita Health UniversityToyoakeAichiJapan
| | - Yusuke Kawano
- Department of Orthopaedic Surgery, School of MedicineFujita Health UniversityToyoakeAichiJapan
| | - Shinjiro Kaneko
- Department of Spine and Spinal Cord Surgery, School of MedicineFujita Health UniversityToyoakeAichiJapan
| | | | - Yuichiro Sano
- Canon Medical Systems CorporationOtawaraTochigiJapan
| | - Yoshiharu Ohno
- Department of Diagnostic Radiology, School of MedicineFujita Health UniversityToyoakeAichiJapan
- Joint Research Laboratory of Advanced Medical Imaging, School of MedicineFujita Health UniversityToyoakeAichiJapan
| | - Nobuyuki Fujita
- Department of Orthopaedic Surgery, School of MedicineFujita Health UniversityToyoakeAichiJapan
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Heggli I, Mengis T, Laux C, Opitz L, Herger N, Menghini D, Schuepbach R, Farshad-Amacker N, Brunner F, Fields A, Farshad M, Distler O, Dudli S. Low back pain patients with Modic type 1 changes exhibit distinct bacterial and non-bacterial subtypes. OSTEOARTHRITIS AND CARTILAGE OPEN 2024; 6:100434. [PMID: 38322145 PMCID: PMC10844677 DOI: 10.1016/j.ocarto.2024.100434] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/13/2023] [Accepted: 01/08/2024] [Indexed: 02/08/2024] Open
Abstract
Objectives Modic type 1 changes (MC1) are vertebral endplate bone marrow (BM) lesions observed on magnetic resonance images in sub-populations of chronic low back pain (CLBP) patients. The etiopathogenesis remains unknown and treatments that modify the underlying pathomechanisms do not exist. We hypothesized that two biological MC1 subtypes exist: a bacterial and a non-bacterial. This would have important implications for developing treatments targeting the underlying pathomechanisms. Methods Intervertebral disc (IVD) samples adjacent to MC1 (n = 34) and control (n = 11) vertebrae were collected from patients undergoing spinal fusion. Cutibacterium acnes (C.acnes) genome copy numbers (GCNs) were quantified in IVD tissues with 16S qPCR, transcriptomic signatures and cytokine profiles were determined in MC1 and control BM by RNA sequencing and immunoassay. Finally, we assessed if C.acnes GCNs are associated with blood plasma cytokines. Results IVD tissues from control levels had <870 C.acnes GCNs/gram IVD. MC1-adjacent IVDs had either "low" (<870) or "high" (>870) C.acnes GCNs. MC1 patients with "high" C.acnes GCNs had upregulated innate immune cell signatures (neutrophil, macrophage/monocyte) and pro-inflammatory cytokines related to neutrophil and macrophage/monocyte function in the BM, consistent with a host defense against bacterium. MC1 patients with "low" C.acnes GCNs had increased adaptive immune cell signatures (T-and B-cell) in the BM and elevated IL-13 blood plasma levels. Conclusion Our study provides the first evidence for the existence of bacterial (C.acnes "high") and non-bacterial (C.acnes "low") subtypes in MC1 patients with CLBP. This supports the need for different treatment strategies.
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Affiliation(s)
- I. Heggli
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - T. Mengis
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - C.J. Laux
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - L. Opitz
- Functional Genomics Center Zurich, University and ETH Zurich, Zurich, Zurich, Switzerland
| | - N. Herger
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - D. Menghini
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - R. Schuepbach
- Unit of Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - N.A. Farshad-Amacker
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - F. Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - A.J. Fields
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - M. Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - O. Distler
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - S. Dudli
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
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11
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Heggli I, Teixeira GQ, Iatridis JC, Neidlinger‐Wilke C, Dudli S. The role of the complement system in disc degeneration and Modic changes. JOR Spine 2024; 7:e1312. [PMID: 38312949 PMCID: PMC10835744 DOI: 10.1002/jsp2.1312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 12/15/2023] [Accepted: 01/04/2024] [Indexed: 02/06/2024] Open
Abstract
Disc degeneration and vertebral endplate bone marrow lesions called Modic changes are prevalent spinal pathologies found in chronic low back pain patients. Their pathomechanisms are complex and not fully understood. Recent studies have revealed that complement system proteins and interactors are dysregulated in disc degeneration and Modic changes. The complement system is part of the innate immune system and plays a critical role in tissue homeostasis. However, its dysregulation has also been associated with various pathological conditions such as rheumatoid arthritis and osteoarthritis. Here, we review the evidence for the involvement of the complement system in intervertebral disc degeneration and Modic changes. We found that only a handful of studies reported on complement factors in Modic changes and disc degeneration. Therefore, the level of evidence for the involvement of the complement system is currently low. Nevertheless, the complement system is tightly intertwined with processes known to occur during disc degeneration and Modic changes, such as increased cell death, autoantibody production, bacterial defense processes, neutrophil activation, and osteoclast formation, indicating a contribution of the complement system to these spinal pathologies. Based on these mechanisms, we propose a model how the complement system could contribute to the vicious cycle of tissue damage and chronic inflammation in disc degeneration and Modic changes. With this review, we aim to highlight a currently understudied but potentially important inflammatory pathomechanism of disc degeneration and Modic changes that may be a novel therapeutic target.
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Affiliation(s)
- Irina Heggli
- Center of Experimental Rheumatology, Department of RheumatologyUniversity Hospital Zurich, University of ZurichZurichSwitzerland
- Department of Physical Medicine and RheumatologyBalgrist University Hospital, Balgrist Campus, University of ZurichZurichSwitzerland
- Leni and Peter W. May Department of OrthopaedicsIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Graciosa Q. Teixeira
- Institute of Orthopedic Research and Biomechanics, Trauma Research Centre, Ulm UniversityUlmGermany
| | - James C. Iatridis
- Leni and Peter W. May Department of OrthopaedicsIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | | | - Stefan Dudli
- Center of Experimental Rheumatology, Department of RheumatologyUniversity Hospital Zurich, University of ZurichZurichSwitzerland
- Department of Physical Medicine and RheumatologyBalgrist University Hospital, Balgrist Campus, University of ZurichZurichSwitzerland
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12
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Zehr JD, Quadrilatero J, Callaghan JP. Indentation mechanics and native collagen content in the cartilaginous endplate: A comparison between porcine cervical and human lumbar spines. J Mech Behav Biomed Mater 2024; 150:106334. [PMID: 38163418 DOI: 10.1016/j.jmbbm.2023.106334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/15/2023] [Accepted: 12/16/2023] [Indexed: 01/03/2024]
Abstract
This study characterized the regional indentation mechanics and native collagen content in cartilaginous endplates (CEPs) from the porcine cervical spine, young human lumbar spine, and aged human lumbar spine. Seventeen endplates were included in this study: six porcine cervical, nine young human lumbar, and two aged human lumbar. Width and depth measurements were obtained using a digital caliper and used to size-normalize and identify the central, anterior, posterior, and lateral regions. Regional microindentation tests were performed using a serial robot, where surface locations were loaded/unloaded at 0.1 mm/s and held at a constant 10 N force for 30 s. Loading stiffness and creep displacement were obtained from force-displacement data. Immunofluorescence staining for type I and type II collagen was subsequently performed on sagittal sections of all endplate regions. 255 images were obtained from which fluorescence intensity, sub-surface void area, and cartilage thickness were measured. CEPs from the young human lumbar spine were, on average, 27% more compliant, 0.891 mm thicker, had a lower fluorescence intensity for native collagen proteins within the cartilage (-58%) and subchondral bone (-24%), and had a sub-surface void area that was 19.7 times greater than porcine cervical CEPs. Compared to aged human lumbar CEPs, young human lumbar CEPs were 57% stiffer, 0.568 mm thicker, had a higher fluorescence intensity for native collagen proteins within the cartilage (+30%) and subchondral bone (+46%), and had a sub-surface void area that was 10.6 times smaller. Although not a perfect mechanical and structural surrogate, porcine cervical CEPs provided initial conditions that may be more representative of the young and healthy human lumbar spine compared to aged human cadaveric specimens. The indentation properties presented may have further applications to finite element models of the human lumbar spine.
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Affiliation(s)
- Jackie D Zehr
- Human Performance Lab, University of Calgary, Calgary, AB, Canada
| | - Joe Quadrilatero
- Department of Kinesiology & Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Jack P Callaghan
- Department of Kinesiology & Health Sciences, University of Waterloo, Waterloo, ON, Canada.
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13
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McCormick ZL, Curtis T, Cooper A, Wheatley M, Smuck M. Low back pain-related healthcare utilization following intraosseous basivertebral nerve radiofrequency ablation: a pooled analysis from three prospective clinical trials. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:20-32. [PMID: 37643639 PMCID: PMC10765157 DOI: 10.1093/pm/pnad114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND The effectiveness and safety of intraosseous basivertebral nerve ablation (BVNA) for treating vertebrogenic pain is established, but low back pain-related healthcare utilization (LBPr-HU) following BVNA continues to be defined. METHODS LBPr-HU data were pooled from 3 prospective studies. LBPr-HU categories of interest included non-invasive conservative care, opioid utilization, lumbosacral spinal injection (LSI), lumbosacral radiofrequency ablation (LRFA), and lumbosacral spinal surgery. Pre- and post-BVNA LBPr-HU were compared at both 1- and 5-years using McNemar's test for proportions and paired t-tests for means. RESULTS Two hundred forty-seven patients received BVNA and had 1-year follow-up; 205 had long-term follow-up (mean of 5.3 ± 1.33 years). Twenty-seven percent fewer participants initiated conservative care in the year post-BVNA compared to the year preceding BVNA (P < .001; 95% CI 19.8-34.5). Of 77/247 participants taking opioids at baseline, 40.3% and 61.7% fewer were taking them at one-year and 5.3 ± 1.33 years post-BVNA, respectively (P < .001). Of participants receiving LSIs in the year preceding BVNA, 81.2% fewer received LSI(s) in the year post-BVNA (P < .001; 95% CI 70.7-90.7); a 76.4% reduction in LSIs was maintained through a mean of 5.3 ± 1.33 years post-BVNA. LRFA rates were 1.6% at 1-year post-BVNA and 8.3% at 5.3 ± 1.33 years post-BVNA. Lumbar fusion surgery was 0.8% at 1-year post-BVNA and 6.5% at 5.3 ± 1.33 years post-BVNA. CONCLUSIONS In this aggregate analysis of patients with vertebrogenic pain, utilization of conservative care, opioids, LSIs, and LRFA were substantially reduced through 5 years post-BVNA compared to baseline. Lumbar fusion rates were less than half the published value at 5 years in similar populations.
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Affiliation(s)
- Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Timothy Curtis
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Amanda Cooper
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Margo Wheatley
- Health Economist, Technomics Research, LLC, Medina, MN 55356, United States
| | - Matthew Smuck
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA 94063, United States
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14
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Miller S, Caragea M, Carson D, McFarland MM, Teramoto M, Cushman DM, Cooper AN, Burnham T, McCormick ZL, Conger A. The effectiveness of intradiscal corticosteroid injection for the treatment of chronic discovertebral low back pain: a systematic review. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:33-46. [PMID: 37740319 DOI: 10.1093/pm/pnad127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/03/2023] [Accepted: 08/21/2023] [Indexed: 09/24/2023]
Abstract
OBJECTIVE Determine the effectiveness of intradiscal corticosteroid injection (IDCI) for the treatment of discovertebral low back pain. DESIGN Systematic review. POPULATION Adults with chronic low back pain attributed to disc or vertebral end plate pain, as evidenced by positive provocation discography or Modic 1 or 2 changes on magnetic resonance imaging. INTERVENTION Fluoroscopically guided or computed tomography-guided IDCI. COMPARISON Sham/placebo procedure including intradiscal saline, anesthetic, discography alone, or other active treatment. OUTCOMES Reduction in chronic low back pain reported on a visual analog scale or numeric rating scale and reduction in disability reported by a validated scale such as the Oswestry Disability Index. METHODS Four reviewers independently assessed articles published before January 31, 2023, in Medline, Embase, CENTRAL, and CINAHL. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The risk of bias in randomized trials was evaluated with the Cochrane Risk of Bias tool (version 2). RESULTS Of the 7806 unique records screened, 6 randomized controlled trials featuring 603 total participants ultimately met the inclusion criteria. In multiple randomized controlled trials, IDCI was found to reduce pain and disability for 1-6 months in those with Modic 1 and 2 changes but not in those selected by provocation discography. CONCLUSION According to GRADE, there is low-quality evidence that IDCI reduces pain and disability for up to 6 months in individuals with chronic discovertebral low back pain as evidenced by Modic 1 and 2 changes but not in individuals selected by provocation discography. STUDY REGISTRATION PROSPERO (CRD42021287421).
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Affiliation(s)
- Scott Miller
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Marc Caragea
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Dan Carson
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Mary M McFarland
- Eccles Health Sciences Library, University of Utah, Salt Lake City, UT 84112, United States
| | - Masaru Teramoto
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Daniel M Cushman
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Amanda N Cooper
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Taylor Burnham
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Aaron Conger
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
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15
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Crump KB, Alminnawi A, Bermudez‐Lekerika P, Compte R, Gualdi F, McSweeney T, Muñoz‐Moya E, Nüesch A, Geris L, Dudli S, Karppinen J, Noailly J, Le Maitre C, Gantenbein B. Cartilaginous endplates: A comprehensive review on a neglected structure in intervertebral disc research. JOR Spine 2023; 6:e1294. [PMID: 38156054 PMCID: PMC10751983 DOI: 10.1002/jsp2.1294] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 09/15/2023] [Accepted: 09/26/2023] [Indexed: 12/30/2023] Open
Abstract
The cartilaginous endplates (CEP) are key components of the intervertebral disc (IVD) necessary for sustaining the nutrition of the disc while distributing mechanical loads and preventing the disc from bulging into the adjacent vertebral body. The size, shape, and composition of the CEP are essential in maintaining its function, and degeneration of the CEP is considered a contributor to early IVD degeneration. In addition, the CEP is implicated in Modic changes, which are often associated with low back pain. This review aims to tackle the current knowledge of the CEP regarding its structure, composition, permeability, and mechanical role in a healthy disc, how they change with degeneration, and how they connect to IVD degeneration and low back pain. Additionally, the authors suggest a standardized naming convention regarding the CEP and bony endplate and suggest avoiding the term vertebral endplate. Currently, there is limited data on the CEP itself as reported data is often a combination of CEP and bony endplate, or the CEP is considered as articular cartilage. However, it is clear the CEP is a unique tissue type that differs from articular cartilage, bony endplate, and other IVD tissues. Thus, future research should investigate the CEP separately to fully understand its role in healthy and degenerated IVDs. Further, most IVD regeneration therapies in development failed to address, or even considered the CEP, despite its key role in nutrition and mechanical stability within the IVD. Thus, the CEP should be considered and potentially targeted for future sustainable treatments.
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Affiliation(s)
- Katherine B. Crump
- Tissue Engineering for Orthopaedics & Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical FacultyUniversity of BernBernSwitzerland
- Department of Orthopaedic Surgery and Traumatology, InselspitalBern University Hospital, Medical Faculty, University of BernBernSwitzerland
- Graduate School for Cellular and Biomedical Sciences (GCB)University of BernBernSwitzerland
| | - Ahmad Alminnawi
- GIGA In Silico MedicineUniversity of LiègeLiègeBelgium
- Skeletal Biology and Engineering Research Center, KU LeuvenLeuvenBelgium
- Biomechanics Research Unit, KU LeuvenLeuvenBelgium
| | - Paola Bermudez‐Lekerika
- Tissue Engineering for Orthopaedics & Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical FacultyUniversity of BernBernSwitzerland
- Department of Orthopaedic Surgery and Traumatology, InselspitalBern University Hospital, Medical Faculty, University of BernBernSwitzerland
- Graduate School for Cellular and Biomedical Sciences (GCB)University of BernBernSwitzerland
| | - Roger Compte
- Twin Research & Genetic EpidemiologySt. Thomas' Hospital, King's College LondonLondonUK
| | - Francesco Gualdi
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM)BarcelonaSpain
| | - Terence McSweeney
- Research Unit of Health Sciences and TechnologyUniversity of OuluOuluFinland
| | - Estefano Muñoz‐Moya
- BCN MedTech, Department of Information and Communication TechnologiesUniversitat Pompeu FabraBarcelonaSpain
| | - Andrea Nüesch
- Division of Clinical Medicine, School of Medicine and Population HealthUniversity of SheffieldSheffieldUK
| | - Liesbet Geris
- GIGA In Silico MedicineUniversity of LiègeLiègeBelgium
- Skeletal Biology and Engineering Research Center, KU LeuvenLeuvenBelgium
- Biomechanics Research Unit, KU LeuvenLeuvenBelgium
| | - Stefan Dudli
- Center of Experimental RheumatologyDepartment of Rheumatology, University Hospital Zurich, University of ZurichZurichSwitzerland
- Department of Physical Medicine and RheumatologyBalgrist University Hospital, Balgrist Campus, University of ZurichZurichSwitzerland
| | - Jaro Karppinen
- Research Unit of Health Sciences and TechnologyUniversity of OuluOuluFinland
- Finnish Institute of Occupational HealthOuluFinland
- Rehabilitation Services of South Karelia Social and Health Care DistrictLappeenrantaFinland
| | - Jérôme Noailly
- BCN MedTech, Department of Information and Communication TechnologiesUniversitat Pompeu FabraBarcelonaSpain
| | - Christine Le Maitre
- Division of Clinical Medicine, School of Medicine and Population HealthUniversity of SheffieldSheffieldUK
| | - Benjamin Gantenbein
- Tissue Engineering for Orthopaedics & Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical FacultyUniversity of BernBernSwitzerland
- Department of Orthopaedic Surgery and Traumatology, InselspitalBern University Hospital, Medical Faculty, University of BernBernSwitzerland
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16
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Schönnagel L, Zhu J, Guven AE, Camino-Willhuber G, Tani S, Caffard T, Haffer H, Muellner M, Chiapparelli E, Amoroso K, Arzani A, Moser M, Shue J, Tan ET, Carrino JA, Jöns T, Sama AA, Girardi FP, Cammisa FP, Hughes AP. Understanding the Interplay Between Paraspinal Muscle Atrophy and Lumbar Endplate Degeneration: A 3-Year Longitudinal Study. Spine (Phila Pa 1976) 2023; 48:1627-1634. [PMID: 37698271 DOI: 10.1097/brs.0000000000004826] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/04/2023] [Indexed: 09/13/2023]
Abstract
STUDY DESIGN Retrospective analysis of longitudinal data. OBJECTIVE To assess the association between the paraspinal musculature (PM) and lumbar endplate degeneration. BACKGROUND The PM is essential for spinal stability, while the vertebral endplate is pivotal for nutrient transport and force distribution. The clinical importance of both has been highlighted in recent literature, though little is known about their interaction. METHODS We identified patients with lumbar MRI scans due to low back pain, with a 3-year interval between MRI scans. Endplate damage was assessed by the total endplate score (TEPS) at each lumbar level. The PM was evaluated for its functional cross-sectional area and fatty infiltration (FI) at the L4 level. We used a generalized mixed model to analyze the association between PM parameters and TEPS at timepoint one, adjusting for age, sex, BMI, diabetes, hypertension, and smoking status. The association with the progression of endplate damage was analyzed through an ordinal regression model, additionally adjusted for TEPS at baseline. RESULTS In all, 329 patients were included, with a median follow-up time of 3.4 years. Participants had a median age of 59 and a BMI of 25.8 kg/m 2 . In the univariate analysis, FI of the posterior PM was significantly associated with TEPS at baseline (β: 0.08, P <0.001) and progression of TEPS [Odds Ratio (OR): 1.03, P =0.020] after adjustment for confounders. The β and OR in this analysis are per percent of FI. In a binary analysis, patients with FI≥40% had an OR of 1.92 ( P =0.006) for the progression of TEPS. CONCLUSIONS This is the first longitudinal study assessing the relationship between PM and endplate degeneration, demonstrating the association between PM atrophy and the progression of endplate degeneration. This insight may aid in identifying patients at risk for degenerative lumbar conditions and guide research into preventive measures.
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Affiliation(s)
- Lukas Schönnagel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY
| | - Ali E Guven
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gaston Camino-Willhuber
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Soji Tani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Thomas Caffard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Henryk Haffer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Muellner
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Krizia Amoroso
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Artine Arzani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Manuel Moser
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Department of Neurosurgery, Cantonal Hospital Graubünden, Loëstrasse, Chur, Switzerland
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY
| | - John A Carrino
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY
| | - Thomas Jöns
- Berlin Simulation & Training Center, Department of Anatomy Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
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17
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Ling Z, Crane J, Hu H, Chen Y, Wan M, Ni S, Demehri S, Mohajer B, Peng X, Zou X, Cao X. Parathyroid hormone treatment partially reverses endplate remodeling and attenuates low back pain in animal models of spine degeneration. Sci Transl Med 2023; 15:eadg8982. [PMID: 37967203 DOI: 10.1126/scitranslmed.adg8982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 10/23/2023] [Indexed: 11/17/2023]
Abstract
Low back pain (LBP) is one of the most prevalent diseases affecting quality of life, with no disease-modifying therapy. During aging and spinal degeneration, the balance between the normal endplate (EP) bilayers of cartilage and bone shifts to more bone. The aged/degenerated bony EP has increased porosity because of osteoclastic remodeling activity and may be a source of LBP due to aberrant sensory innervation within the pores. We used two mouse models of spinal degeneration to show that parathyroid hormone (PTH) treatment induced osteogenesis and angiogenesis and reduced the porosity of bony EPs. PTH increased the cartilaginous volume and improved the mechanical properties of EPs, which was accompanied by a reduction of the inflammatory factors cyclooxygenase-2 and prostaglandin E2. PTH treatment furthermore partially reversed the innervation of porous EPs and reversed LBP-related behaviors. Conditional knockout of PTH 1 receptors in the nucleus pulposus (NP) did not abolish the treatment effects of PTH, suggesting that the NP is not the primary source of LBP in our mouse models. Last, we showed that aged rhesus macaques with spontaneous spinal degeneration also had decreased EP porosity and sensory innervation when treated with PTH, demonstrating a similar mechanism of PTH action on EP sclerosis between mice and macaques. In summary, our results suggest that PTH treatment could partially reverse EP restructuring during spinal regeneration and support further investigation into this potentially disease-modifying treatment strategy for LBP.
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Affiliation(s)
- Zemin Ling
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, Department of Spinal Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 51008, P. R. China
| | - Janet Crane
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Hao Hu
- Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, Department of Spinal Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 51008, P. R. China
| | - Yan Chen
- Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, Department of Spinal Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 51008, P. R. China
| | - Mei Wan
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Shuangfei Ni
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Shadpour Demehri
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Bahram Mohajer
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Xinsheng Peng
- Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, Department of Spinal Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 51008, P. R. China
| | - Xuenong Zou
- Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, Department of Spinal Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 51008, P. R. China
| | - Xu Cao
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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18
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Mengis T, Herger N, Heggli I, Devan J, Spirig JM, Laux CJ, Brunner F, Farshad M, Distler O, Dudli S. Bone marrow stromal cells in Modic type 1 changes promote neurite outgrowth. Front Cell Dev Biol 2023; 11:1286280. [PMID: 37965581 PMCID: PMC10641389 DOI: 10.3389/fcell.2023.1286280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/10/2023] [Indexed: 11/16/2023] Open
Abstract
The pain in patients with Modic type 1 changes (MC1) is often due to vertebral body endplate pain, which is linked to abnormal neurite outgrowth in the vertebral body and adjacent endplate. The aim of this study was to understand the role of MC1 bone marrow stromal cells (BMSCs) in neurite outgrowth. BMSCs can produce neurotrophic factors, which have been shown to be pro-fibrotic in MC1, and expand in the perivascular space where sensory vertebral nerves are located. The study involved the exploration of the BMSC transcriptome in MC1, co-culture of MC1 BMSCs with the neuroblastoma cell line SH-SY5Y, analysis of supernatant cytokines, and analysis of gene expression changes in co-cultured SH-SY5Y. Transcriptomic analysis revealed upregulated brain-derived neurotrophic factor (BDNF) signaling-related pathways. Co-cultures of MC1 BMSCs with SH-SY5Y cells resulted in increased neurite sprouting compared to co-cultures with control BMSCs. The concentration of BDNF and other cytokines supporting neuron growth was increased in MC1 vs. control BMSC co-culture supernatants. Taken together, these findings show that MC1 BMSCs provide strong pro-neurotrophic cues to nearby neurons and could be a relevant disease-modifying treatment target.
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Affiliation(s)
- Tamara Mengis
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Nick Herger
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Irina Heggli
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Jan Devan
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - José Miguel Spirig
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Christoph J. Laux
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Florian Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Oliver Distler
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Stefan Dudli
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
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19
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Peng Y, Chen X, Rao Z, Wu W, Zuo H, Chen K, Li K, Lin H, Liu S, Xiao Y, Wang B, Quan D, Qing X, Bai Y, Shao Z. Multifunctional annulus fibrosus matrix prevents disc-related pain via inhibiting neuroinflammation and sensitization. Acta Biomater 2023; 170:288-302. [PMID: 37598791 DOI: 10.1016/j.actbio.2023.08.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 07/25/2023] [Accepted: 08/15/2023] [Indexed: 08/22/2023]
Abstract
Chronic low back pain mainly attributed to intervertebral disc (IVD) degeneration. Endogenous damage-associated molecular patterns (DAMPs) in the injured IVD, particularly mitochondria-derived nucleic acid molecules (CpG DNA), play a primary role in the inflammatory responses in macrophages. M1-type macrophages form a chronic inflammatory microenvironment by releasing pro-inflammatory factors and nerve growth factor (NGF) that induce nerve growth into the inner annulus fibrosus, resulting in persistent hyperalgesia. We fabricated an amphiphilic polycarbonate that naturally forms cationic nanoparticles (cNP) in aqueous solutions, with the hydrophobic core loaded with TrkA-IN-1, an antagonist against the NGF receptor (TrkA). The drug delivery nanoparticles were denoted as TI-cNP. TrkA-IN-1 and TI-cNP were added to the decellularized annulus fibrosus matrix (DAF) hydrogel to form hybrid hydrogels, denoted as TI-DAF and TI-cNP-DAF, respectively. As a result, TrkA-IN-1 showed a delayed release profile both in TI-DAF and TI-cNP-DAF. Each mole of cNP could bind approximately 3 mol of CpG DNA to inhibit inflammation. cNP-DAF and TI-cNP-DAF significantly inhibited the M1 phenotype induced by CpG DNA. TI-DAF and TI-cNP-DAF reduced neurite branching and axon length, and inhibited the expression of neurogenic mediators (CGRP and substance P) in the presence of NGF. Besides, TI-cNP-DAF relieved mechanical hyperalgesia, reduced CGRP and substance P expression in the dorsal root ganglion, and downregulated GFAP and c-FOS signaling in the spinal cord in the rat disc herniation model. Summarily, TI-cNP-DAF, a novel composite IVD hydrogel, efficiently mediated the inflammatory environment, inhibited nerve ingrowth and sensitization, and could be clinically applied for treating discogenic pain. STATEMENT OF SIGNIFICANCE: Discogenic lower back pain, related to intervertebral disc degeneration (IDD), imposes a tremendous health and economic burden globally. M1-type macrophages release pro-inflammatory factors and nerve growth factor (NGF) that induce nerve growth into the inner annulus fibrosus, resulting in persistent hyperalgesia and discogenic pain. Reconstructing matrix integrity and modulating the inflammatory microenvironment are promising strategies for preventing the ingrowth and activation of neurites. The TI-cNP-DAF hydrogel recovers tissue integrity, alleviates inflammation, and delivers the TrkA antagonist to inhibit the activity of NGF, thus restraining hyperinnervation and nociceptive input. Due to its simple production process, injectability, and acellular strategy, the hydrogel is operable and holds great potential for treating discogenic lower back pain.
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Affiliation(s)
- Yizhong Peng
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Xuanzuo Chen
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Zilong Rao
- School of Materials Science and Engineering, Sun Yat-sen University, Guangzhou 510127, China
| | - Wei Wu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Huiying Zuo
- School of Materials Science and Engineering, Sun Yat-sen University, Guangzhou 510127, China
| | - Kaibin Chen
- School of Materials Science and Engineering, Sun Yat-sen University, Guangzhou 510127, China
| | - Kanglu Li
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Hui Lin
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Sheng Liu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yan Xiao
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - BaiChuan Wang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Daping Quan
- School of Materials Science and Engineering, Sun Yat-sen University, Guangzhou 510127, China
| | - Xiangcheng Qing
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - Ying Bai
- School of Materials Science and Engineering, Sun Yat-sen University, Guangzhou 510127, China.
| | - Zengwu Shao
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
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20
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Waldenberg C, Brisby H, Hebelka H, Lagerstrand KM. Associations between Vertebral Localized Contrast Changes and Adjacent Annular Fissures in Patients with Low Back Pain: A Radiomics Approach. J Clin Med 2023; 12:4891. [PMID: 37568293 PMCID: PMC10420134 DOI: 10.3390/jcm12154891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 07/21/2023] [Accepted: 07/22/2023] [Indexed: 08/13/2023] Open
Abstract
Low back pain (LBP) is multifactorial and associated with various spinal tissue changes, including intervertebral disc fissures, vertebral pathology, and damaged endplates. However, current radiological markers lack specificity and individualized diagnostic capability, and the interactions between the various markers are not fully clear. Radiomics, a data-driven analysis of radiological images, offers a promising approach to improve evaluation and deepen the understanding of spinal changes related to LBP. This study investigated possible associations between vertebral changes and annular fissures using radiomics. A dataset of 61 LBP patients who underwent conventional magnetic resonance imaging followed by discography was analyzed. Radiomics features were extracted from segmented vertebrae and carefully reduced to identify the most relevant features associated with annular fissures. The results revealed three important texture features that display concentrated high-intensity gray levels, extensive regions with elevated gray levels, and localized areas with reduced gray levels within the vertebrae. These features highlight patterns within vertebrae that conventional classification systems cannot reflect on distinguishing between vertebrae adjacent to an intervertebral disc with or without an annular fissure. As such, the present study reveals associations that contribute to the understanding of pathophysiology and may provide improved diagnostics of LBP.
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Affiliation(s)
- Christian Waldenberg
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45 Gothenburg, Sweden;
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (H.B.); (H.H.)
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - Helena Brisby
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (H.B.); (H.H.)
- Department of Orthopaedics, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - Hanna Hebelka
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (H.B.); (H.H.)
- Department of Radiology, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - Kerstin Magdalena Lagerstrand
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45 Gothenburg, Sweden;
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (H.B.); (H.H.)
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
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21
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Mayoral Rojals V, Amescua Garcia C, Denegri P, Narvaez Tamayo MA, Varrassi G. The Invasive Management of Pain: Diagnosis and New Treatment Options. Cureus 2023; 15:e42717. [PMID: 37654942 PMCID: PMC10466260 DOI: 10.7759/cureus.42717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 07/31/2023] [Indexed: 09/02/2023] Open
Abstract
Both the diagnosis and treatment of pain are evolving, especially in interventional approaches. Diagnosis of low back pain combines old and new methodologies, in particular, it involves an expanded role for ultrasound. While low back pain is a common complaint, there are many etiologies to the condition which must be explored before a final diagnosis can be made and treatment planned. Tumors and infections are rarely involved in low back pain but should be ruled out in the initial phase itself since failing to address them early can have devastating consequences. Some invasive treatments seem promising in the management of low back pain. Treating musculoskeletal pain with regenerative medicine, such as platelet-rich plasma, holds great promise. Autologous blood products are safe and may help stimulate the body's own responses for regeneration. The so-called "orthobiologics" play a role in sports medicine and the treatment of musculoskeletal pain. Neuromodulation, especially spinal cord stimulation, is undergoing a renaissance with new waveforms, devices, and a greater albeit incomplete understanding of its mechanisms of action. Spinal cord stimulation is not a first-line therapy and not all patients or all back problems respond to this treatment. Nevertheless, the therapy can be safe, effective, and cost-effective with appropriate patient selection. Radiofrequency ablation of nerves in the form of neurotomy can be effective in reducing the pain of osteoarthritis. These procedures, including the newer cooled radiofrequency neurotomy, can restore function, reduce pain, and may potentially have an opioid-sparing effect. Technical expertise in nerve and anatomy is needed for the use of this technique. This review article aims to provide updated information on some invasive intervention techniques in pain management.
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Affiliation(s)
| | | | - Pasquale Denegri
- Anesthesia, Intensive Care, and Pain Medicine, Sant'Anna and San Sebastiano Hospital, Caserta, ITA
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22
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Shi Z, Li P, Wu W, Jiang Y, Wang Y. Analysis of the Efficacy of Percutaneous Endoscopic Interlaminar Discectomy for Lumbar Disc Herniation with Different Types/Grades of Modic Changes. J Pain Res 2023; 16:1927-1940. [PMID: 37303694 PMCID: PMC10257467 DOI: 10.2147/jpr.s403266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/27/2023] [Indexed: 06/13/2023] Open
Abstract
Background Percutaneous endoscopic interlaminar discectomy (PEID), one of the main techniques of spinal endoscopy, has achieved excellent results in treating lumbar disc herniation (LDH). However, its efficacy has not been systematically described in patients with LDH accompanied by Modic changes (MC). Purpose The purpose of this study was to observe the clinical efficacy of PEID treatment of LDH accompanied by MC. Patients and Methods A total of 207 patients who underwent PEID surgery for LDH were selected. According to the existence and type of MC on preoperative lumbar magnetic resonance images (MRI), they were divided into normal group (no MC, n=117), M1 group (MC I, n=23), and M2 group (MC II, n=67). According to the severity of MC, they were divided into MA group (grade A, n=45) and MBC group (grade B and C, n=45). The visual analog scale (VAS) score, Oswestry disability index (ODI) score, Disc height index (DHI), Lumbar lordosis angle (LL) and modified Macnab criteria were used to assess clinical outcomes. Results Postoperative back pain and leg pain VAS scores and ODI scores were significantly improved in all groups compared with preoperative scores. Patients with MC showed a deterioration in postoperative back pain VAS scores and ODI scores as time went by, and postoperative DHI decreased significantly compared with preoperative. Postoperative LL did not change significantly in each group. There was no significant difference in complications, recurrence rate and excellent rate between the groups. Conclusion Whether accompanied by MC or not, the efficacy of PEID for LDH was significant. However, postoperative back pain and functional status of patients with MC tend to deteriorate as time went by, especially those with type I or severe MC.
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Affiliation(s)
- Zhen Shi
- Department of Orthopedics, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, People’s Republic of China
| | - Pengfei Li
- Department of Orthopedics, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, People’s Republic of China
| | - Wentao Wu
- Department of Orthopedics, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, People’s Republic of China
| | - Yunduo Jiang
- Department of Orthopedics, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, People’s Republic of China
| | - Yansong Wang
- Department of Orthopedics, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, People’s Republic of China
- NHC Key Laboratory of Cell Transplantation, Harbin Medical University, Harbin, Heilongjiang Province, People’s Republic of China
- Heilongjiang Provincial Key Laboratory of Hard Tissue Development and Regeneration, Harbin Medical University, Harbin, Heilongjiang Province, People’s Republic of China
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23
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Smuck M, Truumees E, Macadaeg K, Jaini AM, Chatterjee S, Levin J. Intraosseous basivertebral nerve ablation: Pooled long-term outcomes from two prospective clinical trials. INTERVENTIONAL PAIN MEDICINE 2023; 2:100256. [PMID: 39238665 PMCID: PMC11373002 DOI: 10.1016/j.inpm.2023.100256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 09/07/2024]
Abstract
Background Vertebrogenic pain is an established source of anterior column chronic low back pain (CLBP) resulting from damaged vertebral endplates with pain signals transmitted by the basivertebral nerve (BVN). Type 1 or Type 2 Modic changes on magnetic resonance imaging (MRI) are objective biomarkers for vertebrogenic pain. Radiofrequency ablation of the BVN (BVNA) has demonstrated both efficacy and effectiveness for the treatment of vertebrogenic pain in two randomized trials. Here, we report 3-year aggregate results from two prospective studies of BVNA-treated patients. Methods Pooled results at 3 years post-BVNA are reported for two studies with similar inclusion/exclusion criteria and outcomes measurements: 1) a prospective, open label, single-arm follow-up of the treatment arm of a randomized controlled trial (RCT) comparing BVNA to standard care (INTRACEPT Trial), and 2) a prospective, open label, single cohort long-term follow-up study of BVNA-treated patients. Paired datasets (baseline and 3-years) for mean changes in Oswestry disability index (ODI) and numeric pain scores (NPS) were analyzed using a two-sided t-test with a 0.05 level of significance. Results There were 95/113 (84%) BVNA patients who completed a 3-year visit across 22 study sites. At baseline, 71% of patients reported back pain for ≥5 years, 28% were taking opioids, 34% had spinal injections in the prior 12 months, and 14% had prior low back surgery. Pain and functional improvements were significant at 3 years with a mean reduction in NPS of 4.3 points from 6.7 at baseline (95% CI 3.8, 4.8; p<0.0001) and a mean reduction in ODI of 31.2 points from 46.1 at baseline (95% CI 28.4, 34.0; p<0.0001). Responder rates, using minimal clinically important differences of ≥15-points for ODI and ≥50% reduction in NPS from baseline to three years, were 85.3% and 72.6%, respectively (combined response 69.5%), with 26.3% of patients reporting 100% pain relief at 3 years. There was a 74% reduction in the use of opioids and 84% reduction in the use of therapeutic spinal interventions from baseline to 3 years. There were no serious device or device-procedure related adverse events reported through three years. Conclusion Intraosseous BVNA demonstrates statistically significant, clinically meaningful, and durable improvements in pain and function through 3 years in patients with primary vertebrogenic low back pain. BVNA-treated patients significantly reduced opioid use and interventions for low back pain.
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Affiliation(s)
- Matthew Smuck
- Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, 430 Broadway Street, Pavilion C 4th For, Redwood City, CA, 94063, USA
| | - Eeric Truumees
- Ascension Texas Spine & Scoliosis, 1004 W 32nd St Suite 200, TX, 78705, USA
| | - Kevin Macadaeg
- Indiana Spine Group, 13225 N Meridian St, Carmel, IN, 46032, USA
| | - Ashwin M Jaini
- Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, 430 Broadway Street, Pavilion C 4th For, Redwood City, CA, 94063, USA
| | - Susmita Chatterjee
- Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, 430 Broadway Street, Pavilion C 4th For, Redwood City, CA, 94063, USA
| | - Joshua Levin
- Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, 430 Broadway Street, Pavilion C 4th For, Redwood City, CA, 94063, USA
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24
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Lorio MP, Beall DP, Calodney AK, Lewandrowski KU, Block JE, Mekhail N. Defining the Patient with Lumbar Discogenic Pain: Real-World Implications for Diagnosis and Effective Clinical Management. J Pers Med 2023; 13:jpm13050821. [PMID: 37240991 DOI: 10.3390/jpm13050821] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
There is an enormous body of literature that has identified the intervertebral disc as a potent pain generator. However, with regard to lumbar degenerative disc disease, the specific diagnostic criteria lack clarity and fail to capture the primary components which include axial midline low back pain with or without non-radicular/non-sciatic referred leg pain in a sclerotomal distribution. In fact, there is no specific ICD-10-CM diagnostic code to classify and define discogenic pain as a unique source of pain distinct from other recognized sources of chronic low back pain including facetogenic, neurocompressive including herniation and/or stenosis, sacroiliac, vertebrogenic, and psychogenic. All of these other sources have well-defined ICD-10-CM codes. Corresponding codes for discogenic pain remain absent from the diagnostic coding vernacular. The International Society for the Advancement of Spine Surgery (ISASS) has proposed a modernization of ICD-10-CM codes to specifically define pain associated with lumbar and lumbosacral degenerative disc disease. The proposed codes would also allow the pain to be characterized by location: lumbar region only, leg only, or both. Successful implementation of these codes would benefit both physicians and payers in distinguishing, tracking, and improving algorithms and treatments for discogenic pain associated with intervertebral disc degeneration.
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Affiliation(s)
- Morgan P Lorio
- Advanced Orthopedics, 499 E. Central Pkwy., Ste. 130, Altamonte Springs, FL 32701, USA
| | - Douglas P Beall
- Clinical Radiology of Oklahoma, 1800 S. Renaissance Blvd., Ste. 110, Edmond, OK 73013, USA
| | | | - Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, 4787 E. Camp Lowell Drive, Tucson, AZ 85712, USA
| | - Jon E Block
- Independent Consultant, 2210 Jackson Street, Ste. 401, San Francisco, CA 94115, USA
| | - Nagy Mekhail
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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25
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Wáng YXJ, Wang XR, Leung JCS, Yu BWM, Griffith JF, Kwok TCY. Schmorl's nodes are associated with prevalent osteoporotic vertebral fracture and low bone mineral density: a population-based thoracic spine MRI study in older men and women. Quant Imaging Med Surg 2023; 13:1914-1926. [PMID: 36915321 PMCID: PMC10006149 DOI: 10.21037/qims-22-1410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 01/05/2023] [Indexed: 02/25/2023]
Abstract
Background Schmorl's node (SN) corresponds to nucleus pulposus herniation into the vertebral spongy bone with thickened trabeculae around the formed node. We hypothesize that a pathway may exist that: osteoporosis → weakened endplate → SN development ↔ endplate fracture of an osteoporotic vertebra. Methods For osteoporotic fractures in men (MrOS) and in women (MsOS) Hong Kong studies, at 14-year follow-up, thoracic spine magnetic resonance imaging (MRI) was sampled in 270 males (mean: 82.9±3.7 years) and 150 females (mean: 81.5±4.3 years). SN and Modic change were assessed as existed or not existed. For posterior disc protrusion, ligamentum flavum ossification, and spinal canal stenosis, semi-quantitative gradings were applied. For each vertebra in women, a score of 0, 0.5, 1, 1.5, 2, 2.5, 3 was assigned for no osteoporotic vertebral fracture (OVF) or OVF of <1/5, ≥1/5-1/4, ≥1/4-1/3, ≥1/3-2/5, ≥2/5-2/3, and ≥2/3 vertebral height loss, respectively, and a summed score was calculated by summing up the scores of vertebrae T1 to T12. For men, those of minimal grade were not considered as OVF and assigned a '0' score. Results SN prevalence in women (55.5%) almost doubled that in men (25.9%). SN was statistically significantly correlated with lower bone mineral density (BMD) derived femoral neck T-score, while the other four spine degeneration changes were not statistically significantly correlated with the T-score. SN were statistically significantly correlated with OVF score. Subjects with SN were more likely to have OVF, with odds ratio for men of 4.32 [95% confidence interval (CI): 1.70-11.00, P=0.002] and odds ratio for women of 3.28 (95% CI: 1.23-8.74, P=0.018). Conclusions Among older population, many features of SN parallel those of OVF.
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Affiliation(s)
- Yì Xiáng J Wáng
- Department of Imaging and Interventional Radiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Xiao-Rong Wang
- Department of Imaging and Interventional Radiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China.,Department of Radiology, Ningbo First Hospital, Ningbo, China
| | - Jason C S Leung
- JC Centre for Osteoporosis Care and Control, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Blanche W M Yu
- JC Centre for Osteoporosis Care and Control, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - James F Griffith
- Department of Imaging and Interventional Radiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Timothy C Y Kwok
- JC Centre for Osteoporosis Care and Control, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China.,Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
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26
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Fine N, Lively S, Séguin CA, Perruccio AV, Kapoor M, Rampersaud R. Intervertebral disc degeneration and osteoarthritis: a common molecular disease spectrum. Nat Rev Rheumatol 2023; 19:136-152. [PMID: 36702892 DOI: 10.1038/s41584-022-00888-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 01/27/2023]
Abstract
Intervertebral disc degeneration (IDD) and osteoarthritis (OA) affecting the facet joint of the spine are biomechanically interdependent, typically occur in tandem, and have considerable epidemiological and pathophysiological overlap. Historically, the distinctions between these degenerative diseases have been emphasized. Therefore, research in the two fields often occurs independently without adequate consideration of the co-dependence of the two sites, which reside within the same functional spinal unit. Emerging evidence from animal models of spine degeneration highlight the interdependence of IDD and facet joint OA, warranting a review of the parallels between these two degenerative phenomena for the benefit of both clinicians and research scientists. This Review discusses the pathophysiological aspects of IDD and OA, with an emphasis on tissue, cellular and molecular pathways of degeneration. Although the intervertebral disc and synovial facet joint are biologically distinct structures that are amenable to reductive scientific consideration, substantial overlap exists between the molecular pathways and processes of degeneration (including cartilage destruction, extracellular matrix degeneration and osteophyte formation) that occur at these sites. Thus, researchers, clinicians, advocates and policy-makers should consider viewing the burden and management of spinal degeneration holistically as part of the OA disease continuum.
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Affiliation(s)
- Noah Fine
- Osteoarthritis Research Program, Division of Orthopaedics, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada.,Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Starlee Lively
- Osteoarthritis Research Program, Division of Orthopaedics, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada.,Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Cheryle Ann Séguin
- Department of Physiology & Pharmacology, Schulich School of Medicine & Dentistry, Bone and Joint Institute, University of Western Ontario London, London, Ontario, Canada
| | - Anthony V Perruccio
- Osteoarthritis Research Program, Division of Orthopaedics, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada.,Krembil Research Institute, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mohit Kapoor
- Osteoarthritis Research Program, Division of Orthopaedics, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada.,Krembil Research Institute, University Health Network, Toronto, Ontario, Canada.,Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Raja Rampersaud
- Osteoarthritis Research Program, Division of Orthopaedics, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada. .,Krembil Research Institute, University Health Network, Toronto, Ontario, Canada. .,Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Levin J, Schirmer D, Garcia R, Levi D. Is a history of episodic low back pain an indicator of Modic changes? INTERVENTIONAL PAIN MEDICINE 2023; 2:100239. [PMID: 39239605 PMCID: PMC11372870 DOI: 10.1016/j.inpm.2023.100239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 09/07/2024]
Abstract
Background Prior 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. Purpose To 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 sample Consecutive patients who received a lumbar spine MRI between January 1, 2020, and December 31, 2020. Methods A 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). Results A 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. Conclusions A history of episodic low back pain is not a strong indicator for a vertebrogenic etiology.
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Affiliation(s)
- Josh Levin
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway St., Pavilion C, 4 Floor, MC 6342, Redwood City, CA, 94063, USA
- Department of Neurosurgery, Stanford University, USA
| | - Derek Schirmer
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway St., Pavilion C, 4 Floor, MC 6342, Redwood City, CA, 94063, USA
| | - Roxana Garcia
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway St., Pavilion C, 4 Floor, MC 6342, Redwood City, CA, 94063, USA
| | - David Levi
- Jordan Young Institute, Virginia Beach, VA, 5716 Cleveland St., Suite 200, Virginia Beach, VA, 23462, USA
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Lai A, Iliff D, Zaheer K, Wang D, Gansau J, Laudier DM, Zachariou V, Iatridis JC. Spinal Cord Sensitization and Spinal Inflammation from an In Vivo Rat Endplate Injury Associated with Painful Intervertebral Disc Degeneration. Int J Mol Sci 2023; 24:3425. [PMID: 36834838 PMCID: PMC9964286 DOI: 10.3390/ijms24043425] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/11/2023] Open
Abstract
Intervertebral disc (IVD) degeneration with Modic-like changes is strongly associated with pain. Lack of effective disease-modifying treatments for IVDs with endplate (EP) defects means there is a need for an animal model to improve understanding of how EP-driven IVD degeneration can lead to spinal cord sensitization. This rat in vivo study determined whether EP injury results in spinal dorsal horn sensitization (substance P, SubP), microglia (Iba1) and astrocytes (GFAP), and evaluated their relationship with pain-related behaviors, IVD degeneration, and spinal macrophages (CD68). Fifteen male Sprague Dawley rats were assigned into sham or EP injury groups. At chronic time points, 8 weeks after injury, lumbar spines and spinal cords were isolated for immunohistochemical analyses of SubP, Iba1, GFAP, and CD68. EP injury most significantly increased SubP, demonstrating spinal cord sensitization. Spinal cord SubP-, Iba1- and GFAP-immunoreactivity were positively correlated with pain-related behaviors, indicating spinal cord sensitization and neuroinflammation play roles in pain responses. EP injury increased CD68 macrophages in the EP and vertebrae, and spinal cord SubP-, Iba1- and GFAP-ir were positively correlated with IVD degeneration and CD68-ir EP and vertebrae. We conclude that EP injuries result in broad spinal inflammation with crosstalk between spinal cord, vertebrae and IVD, suggesting that therapies must address neural pathologies, IVD degeneration, and chronic spinal inflammation.
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Affiliation(s)
- Alon Lai
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Denise Iliff
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Kashaf Zaheer
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Dalin Wang
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Orthopaedics, Nanjing First Hospital, Nanjing Medical University, Nanjing 211166, China
- Department of Orthopedic Surgery, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| | - Jennifer Gansau
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Damien M. Laudier
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Venetia Zachariou
- Nash Family Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - James C. Iatridis
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Heggli I, Laux CJ, Mengis T, Karol A, Cornaz F, Herger N, Aradi‐Vegh B, Widmer J, Burkhard MD, Farshad‐Amacker NA, Pfammatter S, Wolski WE, Brunner F, Distler O, Farshad M, Dudli S. Modic type 2 changes are fibroinflammatory changes with complement system involvement adjacent to degenerated vertebral endplates. JOR Spine 2022; 6:e1237. [PMID: 36994463 PMCID: PMC10041382 DOI: 10.1002/jsp2.1237] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 11/04/2022] [Accepted: 12/02/2022] [Indexed: 12/25/2022] Open
Abstract
Background Vertebral endplate signal intensity changes visualized by magnetic resonance imaging termed Modic changes (MC) are highly prevalent in low back pain patients. Interconvertibility between the three MC subtypes (MC1, MC2, MC3) suggests different pathological stages. Histologically, granulation tissue, fibrosis, and bone marrow edema are signs of inflammation in MC1 and MC2. However, different inflammatory infiltrates and amount of fatty marrow suggest distinct inflammatory processes in MC2. Aims The aims of this study were to investigate (i) the degree of bony (BEP) and cartilage endplate (CEP) degeneration in MC2, (ii) to identify inflammatory MC2 pathomechanisms, and (iii) to show that these marrow changes correlate with severity of endplate degeneration. Methods Pairs of axial biopsies (n = 58) spanning the entire vertebral body including both CEPs were collected from human cadaveric vertebrae with MC2. From one biopsy, the bone marrow directly adjacent to the CEP was analyzed with mass spectrometry. Differentially expressed proteins (DEPs) between MC2 and control were identified and bioinformatic enrichment analysis was performed. The other biopsy was processed for paraffin histology and BEP/CEP degenerations were scored. Endplate scores were correlated with DEPs. Results Endplates from MC2 were significantly more degenerated. Proteomic analysis revealed an activated complement system, increased expression of extracellular matrix proteins, angiogenic, and neurogenic factors in MC2 marrow. Endplate scores correlated with upregulated complement and neurogenic proteins. Discussion The inflammatory pathomechanisms in MC2 comprises activation of the complement system. Concurrent inflammation, fibrosis, angiogenesis, and neurogenesis indicate that MC2 is a chronic inflammation. Correlation of endplate damage with complement and neurogenic proteins suggest that complement system activation and neoinnervation may be linked to endplate damage. The endplate-near marrow is the pathomechanistic site, because MC2 occur at locations with more endplate degeneration. Conclusion MC2 are fibroinflammatory changes with complement system involvement which occur adjacent to damaged endplates.
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Affiliation(s)
- Irina Heggli
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of Zurich Zurich Switzerland
| | - Christoph J. Laux
- Department of Orthopedics, Balgrist University Hospital University of Zurich Zurich Switzerland
| | - Tamara Mengis
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of Zurich Zurich Switzerland
| | - Agnieszka Karol
- Department of Molecular Mechanisms of Disease University of Zurich Zurich Switzerland
| | - Frédéric Cornaz
- Department of Orthopedics, Balgrist University Hospital University of Zurich Zurich Switzerland
| | - Nick Herger
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of Zurich Zurich Switzerland
| | - Borbala Aradi‐Vegh
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of Zurich Zurich Switzerland
| | - Jonas Widmer
- Department of Orthopedics, Balgrist University Hospital University of Zurich Zurich Switzerland
| | - Marco D. Burkhard
- Department of Orthopedics, Balgrist University Hospital University of Zurich Zurich Switzerland
| | | | - Sibylle Pfammatter
- Functional Genomics Center Zurich, University and ETH Zurich Zurich Switzerland
| | - Witold E. Wolski
- Functional Genomics Center Zurich, University and ETH Zurich Zurich Switzerland
- Swiss Institute of Bioinformatics Lausanne Switzerland
| | - Florian Brunner
- Department of Physical Medicine and Rheumatology Balgrist University Hospital, University of Zurich Zurich Switzerland
| | - Oliver Distler
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of Zurich Zurich Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital University of Zurich Zurich Switzerland
| | - Stefan Dudli
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of Zurich Zurich Switzerland
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Lv X, Gao F, Cao X. Skeletal interoception in bone homeostasis and pain. Cell Metab 2022; 34:1914-1931. [PMID: 36257317 PMCID: PMC9742337 DOI: 10.1016/j.cmet.2022.09.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/07/2022] [Accepted: 09/26/2022] [Indexed: 01/24/2023]
Abstract
Accumulating evidence indicates that interoception maintains proper physiological status and orchestrates metabolic homeostasis by regulating feeding behaviors, glucose balance, and lipid metabolism. Continuous skeletal remodeling consumes a tremendous amount of energy to provide skeletal scaffolding, support muscle movement, store vital minerals, and maintain a niche for hematopoiesis, which are processes that also contribute to overall metabolic balance. Although skeletal innervation has been described for centuries, recent work has shown that skeletal metabolism is tightly regulated by the nervous system and that skeletal interoception regulates bone homeostasis. Here, we provide a general discussion of interoception and its effects on the skeleton and whole-body metabolism. We also discuss skeletal interoception-mediated regulation in the context of pathological conditions and skeletal pain as well as future challenges to our understanding of these process and how they can be leveraged for more effective therapy.
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Affiliation(s)
- Xiao Lv
- Center for Musculoskeletal Research, Department of Orthopaedic Surgery and Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, MD 21205, USA
| | - Feng Gao
- Center for Musculoskeletal Research, Department of Orthopaedic Surgery and Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, MD 21205, USA
| | - Xu Cao
- Center for Musculoskeletal Research, Department of Orthopaedic Surgery and Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, MD 21205, USA.
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31
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Korhonen T, Järvinen J, Pesälä J, Haapea M, Niinimäki J. Modic changes associated with greater pain relief following anesthetization of the adjacent lumbar intervertebral disc: A retrospective study of chronic low back pain patients. Eur J Radiol 2022; 157:110589. [DOI: 10.1016/j.ejrad.2022.110589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
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Sun K, Jiang J, Wang Y, Sun X, Zhu J, Xu X, Sun J, Shi J. The role of nerve fibers and their neurotransmitters in regulating intervertebral disc degeneration. Ageing Res Rev 2022; 81:101733. [PMID: 36113765 DOI: 10.1016/j.arr.2022.101733] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/11/2022] [Accepted: 09/11/2022] [Indexed: 01/31/2023]
Abstract
Intervertebral disc degeneration (IVDD) has been the major contributor to chronic lower back pain (LBP). Abnormal apoptosis, senescence, and pyroptosis of IVD cells, extracellular matrix (ECM) degradation, and infiltration of immune cells are the major molecular alternations during IVDD. Changes at tissue level frequently occur at advanced IVD tissue. Ectopic ingrowth of nerves within inner annulus fibrosus (AF) and nucleus pulposus (NP) tissue has been considered as the primary cause for LBP. Innervation at IVD tissue mainly included sensory and sympathetic nerves, and many markers for these two types of nerves have been detected since 1940. In fact, in osteoarthritis (OA), beyond pain transmission, the direct regulation of neuropeptides on functions of chondrocytes have attracted researchers' great attention recently. Many physical and pathological similarities between joint and IVD have shed us the light on the neurogenic mechanism involved in IVDD. Here, an overview of the advances in the nervous system within IVD tissue will be performed, with a discussion on in the role of nerve fibers and their neurotransmitters in regulating IVDD. We hope this review can attract more research interest to address neuromodulation and IVDD itself, which will enhance our understanding of the contribution of neuromodulation to the structural changes within IVD tissue and inflammatory responses and will help identify novel therapeutic targets and enable the effective treatment of IVDD disease.
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Affiliation(s)
- Kaiqiang Sun
- Department of Orthopedic Surgery, Changzheng Hospital, Navy Medical University, No.415 Fengyang Road, Shanghai 200003, China; Department of Orthopedics, Naval Medical Center of PLA, China
| | - Jialin Jiang
- Department of Orthopedic Surgery, Changzheng Hospital, Navy Medical University, No.415 Fengyang Road, Shanghai 200003, China
| | - Yuan Wang
- Department of Orthopedic Surgery, Changzheng Hospital, Navy Medical University, No.415 Fengyang Road, Shanghai 200003, China
| | - Xiaofei Sun
- Department of Orthopedic Surgery, Changzheng Hospital, Navy Medical University, No.415 Fengyang Road, Shanghai 200003, China
| | - Jian Zhu
- Department of Orthopedic Surgery, Changzheng Hospital, Navy Medical University, No.415 Fengyang Road, Shanghai 200003, China
| | - Ximing Xu
- Department of Orthopedic Surgery, Changzheng Hospital, Navy Medical University, No.415 Fengyang Road, Shanghai 200003, China
| | - Jingchuan Sun
- Department of Orthopedic Surgery, Changzheng Hospital, Navy Medical University, No.415 Fengyang Road, Shanghai 200003, China.
| | - Jiangang Shi
- Department of Orthopedic Surgery, Changzheng Hospital, Navy Medical University, No.415 Fengyang Road, Shanghai 200003, China.
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Sollmann N, Bonnheim NB, Joseph GB, Chachad R, Zhou J, Akkaya Z, Pirmoazen AM, Bailey JF, Guo X, Lazar AA, Link TM, Fields AJ, Krug R. Paraspinal Muscle in Chronic Low Back Pain: Comparison Between Standard Parameters and Chemical Shift Encoding-Based Water-Fat MRI. J Magn Reson Imaging 2022; 56:1600-1608. [PMID: 35285561 PMCID: PMC9470775 DOI: 10.1002/jmri.28145] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Paraspinal musculature (PSM) is increasingly recognized as a contributor to low back pain (LBP), but with conventional MRI sequences, assessment is limited. Chemical shift encoding-based water-fat MRI (CSE-MRI) enables the measurement of PSM fat fraction (FF), which may assist investigations of chronic LBP. PURPOSE To investigate associations between PSM parameters from conventional MRI and CSE-MRI and between PSM parameters and pain. STUDY TYPE Prospective, cross-sectional. POPULATION Eighty-four adults with chronic LBP (44.6 ± 13.4 years; 48 males). FIELD STRENGTH/SEQUENCE 3-T, T1-weighted fast spin-echo and iterative decomposition of water and fat with echo asymmetry and least squares estimation sequences. ASSESSMENT T1-weighted images for Goutallier classification (GC), muscle volume, lumbar indentation value, and muscle-fat index, CSE-MRI for FF extraction (L1/2-L5/S1). Pain was self-reported using a visual analogue scale (VAS). Intra- and/or interreader agreement was assessed for MRI-derived parameters. STATISTICAL TESTS Mixed-effects and linear regression models to 1) assess relationships between PSM parameters (entire cohort and subgroup with GC grades 0 and 1; statistical significance α = 0.0025) and 2) evaluate associations of PSM parameters with pain (α = 0.05). Intraclass correlation coefficients (ICCs) for intra- and/or interreader agreement. RESULTS The FF showed excellent intra- and interreader agreement (ICC range: 0.97-0.99) and was significantly associated with GC at all spinal levels. Subgroup analysis suggested that early/subtle changes in PSM are detectable with FF but not with GC, given the absence of significant associations between FF and GC (P-value range: 0.036 at L5/S1 to 0.784 at L2/L3). Averaged over all spinal levels, FF and GC were significantly associated with VAS scores. DATA CONCLUSION In the absence of FF, GC may be the best surrogate for PSM quality. Given the ability of CSE-MRI to detect muscle alterations at early stages of PSM degeneration, this technique may have potential for further investigations of the role of PSM in chronic LBP. LEVEL OF EVIDENCE 2 TECHNICAL EFFICACY STAGE: 2.
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Affiliation(s)
- Nico Sollmann
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Noah B. Bonnheim
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Gabby B. Joseph
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Ravi Chachad
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Jiamin Zhou
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Zehra Akkaya
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Amir M. Pirmoazen
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Jeannie F. Bailey
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Xiaojie Guo
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ann A. Lazar
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Thomas M. Link
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Aaron J. Fields
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Roland Krug
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
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Lorio M, Clerk-Lamalice O, Rivera M, Lewandrowski KU. ISASS Policy Statement 2022: Literature Review of Intraosseous Basivertebral Nerve Ablation. Int J Spine Surg 2022; 16:1084-1094. [PMID: 36266051 PMCID: PMC9807041 DOI: 10.14444/8362] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The index 2020 ISASS Guideline Statement "Intraosseous Ablation of the Basivertebral Nerve for the Relief of Chronic Low Back Pain" was generated in response to growing requests for background, supporting literature, evidence, as well as proper coding for intraosseous basivertebral nerve ablation. Since the guideline was published, the American Medical Association has added Current Procedural Terminology category I codes for basivertebral nerve ablation: 64628 and 64629. Additionally, the has recognized a need for greater specificity in differentiating various types of low back pain and has designatedthe International Classification of Diseases, 10th revision, Clinical Modification code M54.51, vertebrogenic low back pain, to ensure correct diagnosis. The timing of these additions provides an opportunity to refresh the ISASS Guideline to ensure proper diagnosis and procedural coding and to update the supporting literature and evidence.
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Affiliation(s)
- Morgan Lorio
- Advanced Orthopedics, Altamonte Springs, Florida, USA, Morgan Lorio, Advanced Orthopedics, 499 E Central Parkway, Altamonte Springs, FL 32701, USA;
| | | | - Milaris Rivera
- Universidad Autónoma de Guadalajara, School of Medicine, Zapopan, Jalisco, USA
| | - Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, Surgical Institute of Tucson, Tucson, AZ, USA
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35
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Sayed D, Naidu RK, Patel KV, Strand NH, Mehta P, Lam CM, Tieppo Francio V, Sheth S, Giuffrida A, Durkin B, Khatri N, Vodapally S, James CO, Westerhaus BD, Rupp A, Abdullah NM, Amirdelfan K, Petersen EA, Beall DP, Deer TR. Best Practice Guidelines on the Diagnosis and Treatment of Vertebrogenic Pain with Basivertebral Nerve Ablation from the American Society of Pain and Neuroscience. J Pain Res 2022; 15:2801-2819. [PMID: 36128549 PMCID: PMC9482788 DOI: 10.2147/jpr.s378544] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/26/2022] [Indexed: 12/05/2022] Open
Abstract
Chronic low back pain is a worldwide leading cause of pain and disability. Degenerative disc disease has been the presumptive etiology in the majority of cases of chronic low back pain (CLBP). More recent study and treatments have discovered that the vertebral endplates play a large role in CLBP in a term defined as vertebrogenic back pain. As the vertebral endplates are highly innervated via the basivertebral nerve (BVN), this has resulted in a reliable target in treating patients suffering from vertebrogenic low back pain (VLBP). The application of BVN ablation for patients suffering from VLBP is still in its early stages of adoption and integration into spine care pathways. BVN ablation is grounded in a solid foundation of both pre-clinical and clinical evidence. With the emergence of this therapeutic option, the American Society of Pain and Neuroscience (ASPN) identified the need for formal evidence-based guidelines for the proper identification and selection of patients for BVN ablation in patients with VLBP. ASPN formed a multidisciplinary work group tasked to examine the available literature and form best practice guidelines on this subject. Based on the United States Preventative Task Force (USPSTF) criteria for grading evidence, gives BVN ablation Level A grade evidence with high certainty that the net benefit is substantial in appropriately selected individuals.
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Affiliation(s)
- Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Ramana K Naidu
- Anesthesiology, California Orthopedics & Spine, Marin, CA, USA.,Pain Management, MarinHealth Medical Center, Marin, CA, USA
| | - Kiran V Patel
- Interventional Pain Management/ Anesthesiology, The Spine & Pain Institute of New York, New York City, NY, USA
| | - Natalie H Strand
- Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA
| | - Pankaj Mehta
- Clinical Research, Pain Specialists of Austin, Austin, TX, USA
| | - Christopher M Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Samir Sheth
- Interventional Pain Management, Sutter Health, Roseville, CA, USA
| | - Anthony Giuffrida
- Cantor Spine Center, Paley Orthopedic and Spine Institute, Fort Lauderdale, FL, USA
| | - Brian Durkin
- Pain Institute of Long Island, Port Jefferson, NY, USA
| | - Nasir Khatri
- Interventional Pain Medicine, Novant Health, Charlotte, NC, USA
| | - Shashank Vodapally
- Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA
| | - Christopher O James
- Department of Physical Medicine and Rehabilitation, University of Kentucky, Lexington, KY, USA
| | | | - Adam Rupp
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Newaj M Abdullah
- Pain Medicine and Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Kasra Amirdelfan
- Clinical Research, IPM Medical Group, Inc, Walnut Creek, CA, USA
| | - Erika A Petersen
- Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, AR, USA
| | | | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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36
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McCormick ZL, Sperry BP, Boody BS, Hirsch JA, Conger A, Harper K, Lotz JC, Burnham TR. Pain Location and Exacerbating Activities Associated with Treatment Success Following Basivertebral Nerve Ablation: An Aggregated Cohort Study of Multicenter Prospective Clinical Trial Data. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S14-S33. [PMID: 35856332 PMCID: PMC9297150 DOI: 10.1093/pm/pnac069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/25/2022] [Accepted: 04/11/2022] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Develop pain location "maps" and investigate the relationship between low back pain (LBP)-exacerbating activities and treatment response to basivertebral nerve radiofrequency ablation (BVN RFA) in patients with clinically suspected vertebral endplate pain (VEP). DESIGN Aggregated cohort study of 296 patients treated with BVN RFA at 33 centers in three prospective trials. METHODS Participant demographics, pain diagrams, and LBP-exacerbating activities were analyzed for predictors using stepwise logistic regression. Treatment success definitions were: (1) ≥50% LBP visual analog scale (VAS), (2) ≥15-point Oswestry Disability Index (ODI), and (3) ≥50% VAS or ≥15-point ODI improvements at 3 months post-BVN RFA. RESULTS Midline LBP correlated with BVN RFA treatment success in individuals with clinically-suspected VEP. Duration of pain ≥5 years (OR 2.366), lack of epidural steroid injection within 6 months before BVN RFA (OR 1.800), lack of baseline opioid use (OR 1.965), LBP exacerbation with activity (OR 2.099), and a lack of LBP with spinal extension (OR 1.845) were factors associated with increased odds of treatment success. Regressions areas under the curve (AUCs) were under 70%, indicative of low predictive value. CONCLUSIONS This study demonstrates that midline LBP correlates with BVN RFA treatment success in individuals with VEP. While none of the regression models demonstrated strong predictive value, the pain location and exacerbating factors identified in this analysis may aid clinicians in identifying patients where VEP should be more strongly suspected. The use of objective imaging biomarkers (Type 1 and/or 2 Modic changes) and a correlating presentation of anterior spinal element pain remain the most useful patient selection factors for BVN RFA.
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Affiliation(s)
- Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Beau P Sperry
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | | | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron Conger
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Jeffrey C Lotz
- Department of Orthopaedics, University of California San Francisco, San Francisco, California, USA
| | - Taylor R Burnham
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Conger A, Burnham TR, Clark T, Teramoto M, McCormick ZL. The Effectiveness of Intraosseous Basivertebral Nerve Radiofrequency Ablation for the Treatment of Vertebrogenic Low Back Pain: An Updated Systematic Review with Single-Arm Meta-analysis. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S50-S62. [PMID: 35856331 PMCID: PMC9297160 DOI: 10.1093/pm/pnac070] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To provide an estimate of the effectiveness of basivertebral nerve (BVN) radiofrequency ablation (RFA) to treat vertebrogenic low back pain (LBP). DESIGN Systematic review with single-arm meta-analysis. POPULATION Persons ≥18 years of age with chronic LBP associated with type 1 or 2 Modic changes. INTERVENTION Intraosseous BVN RFA. COMPARISON Sham, placebo procedure, active standard care treatment, or none. OUTCOMES The proportion of patients treated with BVN RFA who reported ≥50% pain score improvement on a visual analog scale or numeric rating scale. The main secondary outcome was ≥15-point improvement in Oswestry Disability Index score. METHODS Three reviewers independently assessed articles published before December 6, 2021, in MEDLINE and Embase. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was used to evaluate the overall quality of evidence. RESULTS Of the 856 unique records screened, 12 publications met the inclusion criteria, representing six unique study populations, with 414 participants allocated to receive BVN RFA. Single-arm meta-analysis showed a success rate of 65% (95% confidence interval [CI] 51-78%) and 64% (95% CI 43-82%) for ≥50% pain relief at 6 and 12 months, respectively. Rates of ≥15-point Oswestry Disability Index score improvement were 75% (95% CI 63-86%) and 75% (95% CI 63-85%) at 6 and 12 months, respectively. CONCLUSION According to GRADE, there is moderate-quality evidence that BVN RFA effectively reduces pain and disability in most patients with vertebrogenic LBP. Further high-quality studies will likely improve our understanding of the effectiveness of this procedure.
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Affiliation(s)
- Aaron Conger
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Taylor R Burnham
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Tyler Clark
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Masaru Teramoto
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
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Conger A, Smuck M, Truumees E, Lotz JC, DePalma MJ, McCormick ZL. Vertebrogenic Pain: A Paradigm Shift in Diagnosis and Treatment of Axial Low Back Pain. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S63-S71. [PMID: 35856329 PMCID: PMC9297155 DOI: 10.1093/pm/pnac081] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/22/2022] [Accepted: 05/01/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Aaron Conger
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA
| | - Matthew Smuck
- Department of Orthopaedics, Stanford University, Redwood City, CA, USA
| | - Eeric Truumees
- The University of Texas Dell Medical School, Ascension Texas Spine and Scoliosis, Austin, TX, USA
| | - Jeffrey C Lotz
- Department of Orthopaedics, University of California San Francisco, San Francisco, CA, USA
| | | | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA
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Lan W, Wang X, Tu X, Hu X, Lu H. Different phylotypes of Cutibacterium acnes cause different modic changes in intervertebral disc degeneration. PLoS One 2022; 17:e0270982. [PMID: 35819943 PMCID: PMC9275720 DOI: 10.1371/journal.pone.0270982] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 06/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background The contribution of Cutibacterium acnes (C. acnes) infection to intervertebral disc degeneration (IDD) and the antibiotic therapy has evoked several controversies in recent years. While some microbiology studies report bacterial disc infection within IDD patients, others attribute the positive results to contamination during prolonged cultures. In addition to the clinical controversy, little was known about the mechanism of C. acnes-caused Modic changes (MCs) if C. acnes was the pathogenic factor. Objectives This study aimed to investigate the inflammatory mechanism of MCs induced by different phylotypes of C. acnes in patients with IDD. Methods Specimens from sixty patients undergoing microdiscectomy for disc herniation were included, C. acnes were identified by anaerobic culture, followed by biochemical and PCR-based methods. The identified species of C. acnes were respectively inoculated into the intervertebral discs of rabbits. MRI and histological change were observed. Additionally, we detected MMP expression in the rabbit model using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Results Of the 60 cases, 18 (30%) specimens were positive for C. acnes, and we identified 4 of 6 defined phylogroups: IA, IB, II and III. The rabbits that received Type IB or II strains of C. acnes showed significantly decreased T1WI and higher T2WI at eighth weeks, while strain III C. acnes resulted in hypointense signals on both T1WI and T2WI. Histological examination results showed that all of the three types of C. acnes could cause disc degeneration and endplates rupture. Moreover, endplate degeneration induced by type IB or II strains of C. acnes is related with MMP13 expression. Meanwhile, strain III C. acnes might upregulated the level of MMP3. Conclusion This study suggested that C. acnes is widespread in herniated disc tissues. Different types of C. acnes could induce different MCs by increasing MMP expression.
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Affiliation(s)
- Weibin Lan
- Department of Spinal Surgery, Affiliated Longyan First Hospital of Fujian Medical University, Longyan City, Fujian Province, China
| | - Xiaomeng Wang
- Department of Spinal Surgery, Affiliated Longyan First Hospital of Fujian Medical University, Longyan City, Fujian Province, China
| | - Xuezhao Tu
- Department of Spinal Surgery, Affiliated Longyan First Hospital of Fujian Medical University, Longyan City, Fujian Province, China
| | - Xiunian Hu
- Department of Radiology, Affiliated Longyan First Hospital of Fujian Medical University, Longyan City, Fujian Province, China
| | - Haichuan Lu
- Department of Spinal Surgery, Affiliated Longyan First Hospital of Fujian Medical University, Longyan City, Fujian Province, China
- * E-mail:
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Gao KT, Tibrewala R, Hess M, Bharadwaj UU, Inamdar G, Link TM, Chin CT, Pedoia V, Majumdar S. Automatic detection and voxel-wise mapping of lumbar spine Modic changes with deep learning. JOR Spine 2022; 5:e1204. [PMID: 35783915 PMCID: PMC9238279 DOI: 10.1002/jsp2.1204] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/01/2022] [Accepted: 05/05/2022] [Indexed: 11/14/2022] Open
Abstract
Background Modic changes (MCs) are the most prevalent classification system for describing magnetic resonance imaging (MRI) signal intensity changes in the vertebrae. However, there is a growing need for novel quantitative and standardized methods of characterizing these anomalies, particularly for lesions of transitional or mixed nature, due to the lack of conclusive evidence of their associations with low back pain. This retrospective imaging study aims to develop an interpretable deep learning-based detection tool for voxel-wise mapping of MCs. Methods Seventy-five lumbar spine MRI exams that presented with acute-to-chronic low back pain, radiculopathy, and other symptoms of the lumbar spine were enrolled. The pipeline consists of two deep convolutional neural networks to generate an interpretable voxel-wise Modic map. First, an autoencoder was trained to segment vertebral bodies from T1-weighted sagittal lumbar spine images. Next, two radiologists segmented and labeled MCs from a combined T1- and T2-weighted assessment to serve as ground truth for training a second autoencoder that performs segmentation of MCs. The voxels in the detected regions were then categorized to the appropriate Modic type using a rule-based signal intensity algorithm. Post hoc, three radiologists independently graded a second dataset with the aid of the model predictions in an artificial (AI)-assisted experiment. Results The model successfully identified the presence of changes in 85.7% of samples in the unseen test set with a sensitivity of 0.71 (±0.072), specificity of 0.95 (±0.022), and Cohen's kappa score of 0.63. In the AI-assisted experiment, the agreement between the junior radiologist and the senior neuroradiologist significantly improved from Cohen's kappa score of 0.52 to 0.58 (p < 0.05). Conclusions This deep learning-based approach demonstrates substantial agreement with radiologists and may serve as a tool to improve inter-rater reliability in the assessment of MCs.
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Affiliation(s)
- Kenneth T. Gao
- Department of Radiology and Biomedical ImagingUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
- Department of BioengineeringUniversity of California Berkeley–University of California San Francisco Graduate Program in BioengineeringBerkeleyCaliforniaUSA
| | - Radhika Tibrewala
- Department of Radiology and Biomedical ImagingUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Madeline Hess
- Department of Radiology and Biomedical ImagingUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Upasana U. Bharadwaj
- Department of Radiology and Biomedical ImagingUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Gaurav Inamdar
- Department of Radiology and Biomedical ImagingUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Thomas M. Link
- Department of Radiology and Biomedical ImagingUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Cynthia T. Chin
- Department of Radiology and Biomedical ImagingUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Valentina Pedoia
- Department of Radiology and Biomedical ImagingUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Sharmila Majumdar
- Department of Radiology and Biomedical ImagingUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
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Azzouzi H, Ichchou L. Schmorl's nodes: demystification road of endplate defects-a critical review. Spine Deform 2022; 10:489-499. [PMID: 34825353 DOI: 10.1007/s43390-021-00445-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/11/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Schmorl's nodes (SN) were the first vertebral endplate defects described. Debate continues about their epidemiology, physiopathology, and clinical significance. The purpose of this work was to summarize and discuss available literature about SN. METHODS We have searched for relevant papers about SN until April 2020, with 104 articles have been reviewed. RESULTS More than half of the available literature described the epidemiological aspects of SN or reported rare clinical presentations and treatment options. The lack of a consensual definition of SN, among other endplate defects, contributed to difficulties in literature results' interpretation. Summing up, SN is a frequent vertebral defect at the thoracolumbar juncture, with ethnic and gender influence. Lumbar Schmorl's nodes were frequently associated with disc degenerative disease and back pain. Their physiopathology remains unknown. However, strain energy changes in the spine along with morphological aspects of the vertebra, the genetic background, and the osteoimmunology may constitute possible clues. New SN could be confused in malignancy context with bone metastasis. The literature describes some imaging techniques to differentiate them, avoiding invasive approaches. Treatment options for rare painful presentations remain few with low evidence. Further studies are needed to establish a consensual definition for SN, understand clinical aspects, and provide adequate therapeutic strategies.
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Affiliation(s)
- Hamida Azzouzi
- Department of Rheumatology, Faculty of Medicine, Mohammed VI University Hospital of Oujda, Université Mohammed Premier, Oujda, Morocco.
| | - Linda Ichchou
- Department of Rheumatology, Faculty of Medicine, Mohammed VI University Hospital of Oujda, Université Mohammed Premier, Oujda, Morocco
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Schmorl's nodes could be associated with intervertebral disc degeneration at upper lumbar levels and end-plate disease at lower lumbar level in patients with low back pain. J Clin Neurosci 2022; 100:66-74. [PMID: 35427987 DOI: 10.1016/j.jocn.2022.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/03/2022] [Accepted: 04/06/2022] [Indexed: 01/01/2023]
Abstract
Schmorl's nodes (SNs) have increasingly been recognized on vertebral end-plates using advanced imaging techniques. Even though vertebral end-plates are the closest structures to discs, their pathologies are underestimated in the etiology of low back pain (LBP). We aimed to detect the prevalence of SNs and other end-plate defects in subjects with/without LBP and to understand whether SNs were associated with LBP and spinal degeneration. Subjects were evaluated in terms of end-plate defects, intervertebral disc degeneration (IVDD), and vertebral end-plate changes (Modic changes) at all lumbar levels on lumbar spine magnetic resonance imagings (MRI). Control subjects were compared to patients with LBP. Higher Pfirrmann scores (OR: 2.696) and higher SN scores (OR: 8.076) were significantly associated with Modic changes at L4-L5 disc level. Patients with higher SN scores at L1-L2 or L2-L3 levels had approximately 7-fold increased risk of severe IVDD at the corresponding levels. The most significant factor associated with presence of SNs was body weight of the patients (OR: 1.417). The most significant factor associated with intensity of LBP was severe IVDD at L5-S1 level (OR: 3.670). Having higher total SN score had an OR of 1.230 (95% CI: 1.003-1.509; p = 0.047) for predicting LBP. Schmorl's nodes were seen in 33.1% of patients and 11.5% of asymptomatic subjects. Body weight was the most significant factor associated with SNs. The most significant factor associated with LBP was severe IVDD at L5-S1 level.
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McDonnell EE, Buckley CT. Consolidating and re-evaluating the human disc nutrient microenvironment. JOR Spine 2022; 5:e1192. [PMID: 35386756 PMCID: PMC8966889 DOI: 10.1002/jsp2.1192] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 12/14/2021] [Accepted: 01/07/2022] [Indexed: 12/19/2022] Open
Abstract
Background Despite exciting advances in regenerative medicine, cell-based strategies for treating degenerative disc disease remain in their infancy. To maximize the potential for successful clinical translation, a more thorough understanding of the in vivo microenvironment is needed to better determine and predict how cell therapies will respond when administered in vivo. Aims This work aims to reflect on the in vivo nutrient microenvironment of the degenerating IVD through consolidating what has already been measured together with investigative in silico models. Materials and Methods This work uses in silico modeling, underpinned by more recent experimentally determined parameters of degeneration and nutrient transport from the literature, to re-evaluate the current knowledge in terms of grade-specific stages of degeneration. Results Through modeling only the metabolically active cell population, this work predicts slightly higher glucose concentrations compared to previous in silico models, while the predicted results show good agreement with previous intradiscal pH and oxygen measurements. Increasing calcification with degeneration limits nutrient transport into the IVD and initiates a build-up of acidity; however, its effect is compensated somewhat by a reduction in diffusional distance due to decreasing disc height. Discussion This work advances in silico modeling through a strong foundation of experimentally determined grade-specific input parameters. Taken together, pre-existing measurements and predicted results suggest that metabolite concentrations may not be as critically low as commonly believed, with calcification not appearing to have a detrimental effect at stages of degeneration when cell therapies are an appropriate intervention. Conclusion Overall, our initiative is to provoke greater deliberation and consideration of the nutrient microenvironment when performing in vitro cell culture and cell therapy development. This work highlights urgency for robust experimental glucose measurements in healthy and degenerating IVDs, not only to validate in silico models but to significantly advance the field in fully elucidating the nutrient microenvironment and refining in vitro techniques to accelerate clinical translation.
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Affiliation(s)
- Emily E. McDonnell
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College DublinThe University of DublinDublinIreland
- Discipline of Mechanical, Manufacturing and Biomedical Engineering, School of Engineering, Trinity College DublinThe University of DublinDublinIreland
| | - Conor T. Buckley
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College DublinThe University of DublinDublinIreland
- Discipline of Mechanical, Manufacturing and Biomedical Engineering, School of Engineering, Trinity College DublinThe University of DublinDublinIreland
- Advanced Materials and Bioengineering Research (AMBER) Centre, Royal College of Surgeons in Ireland & Trinity College DublinThe University of DublinDublinIreland
- Tissue Engineering Research Group, Department of Anatomy and Regenerative MedicineRoyal College of Surgeons in IrelandDublinIreland
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Ye F, Lyu F, Wang H, Zheng Z. The involvement of immune system in intervertebral disc herniation and degeneration. JOR Spine 2022; 5:e1196. [PMID: 35386754 PMCID: PMC8966871 DOI: 10.1002/jsp2.1196] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 02/06/2022] [Accepted: 02/25/2022] [Indexed: 02/06/2023] Open
Abstract
Intervertebral disc (IVD) herniation and degeneration contributes significantly to low back pain (LBP), of which the molecular pathogenesis is not fully understood. Disc herniation may cause LBP and radicular pain, but not all LBP patients have disc herniation. Degenerated discs could be the source of pain, but not all degenerated discs are symptomatic. We previously found that disc degeneration and herniation accompanied by inflammation. We further found that anti-inflammatory molecules blocked immune responses, alleviated IVD degeneration and pain. Based on our recent findings and the work of others, we hypothesize that immune system may play a prominent role in the production of disc herniation or disc degeneration associated pain. While the nucleus pulposus (NP) is an immune-privileged organ, the damage of the physical barrier between NP and systemic circulation, or the innervation and vascularization of the degenerated NP, on one hand exposes NP as a foreign antigen to immune system, and on the other hand presents compression on the nerve root or dorsal root ganglion (DRG), which both elicit immune responses induced by immune cells and their mediators. The inflammation can remain for a long time at remote distance, with various types of cytokines and immune cells involved in this pain-inducing process. In this review, we aim to revisit the autoimmunity of the NP, immune cell infiltration after break of physical barrier, the inflammatory activities in the DRG and the generation of pain. We also summarize the involvement of immune system, including immune cells and cytokines, in degenerated or herniated IVDs and affected DRG.
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Affiliation(s)
- Fubiao Ye
- Department of Spine Surgery, The First Affiliated HospitalSun Yat‐Sen UniversityGuangzhouChina
- Department of Orthopaedics, Fujian Provincial HospitalProvincial Clinical Medical College of Fujian Medical UniversityFuzhouFujianChina
| | - Feng‐Juan Lyu
- Joint Center for Regenerative Medicine Research of South China University of Technology and The University of Western Australia, School of MedicineSouth China University of TechnologyGuangzhouChina
| | - Hua Wang
- Department of Spine Surgery, The First Affiliated HospitalSun Yat‐Sen UniversityGuangzhouChina
| | - Zhaomin Zheng
- Department of Spine Surgery, The First Affiliated HospitalSun Yat‐Sen UniversityGuangzhouChina
- Pain Research CenterSun Yat‐sen UniversityGuangzhouChina
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Herger N, Bermudez-Lekerika P, Farshad M, Albers CE, Distler O, Gantenbein B, Dudli S. Should Degenerated Intervertebral Discs of Patients with Modic Type 1 Changes Be Treated with Mesenchymal Stem Cells? Int J Mol Sci 2022; 23:ijms23052721. [PMID: 35269863 PMCID: PMC8910866 DOI: 10.3390/ijms23052721] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 12/16/2022] Open
Abstract
Low back pain (LBP) has been among the leading causes of disability for the past 30 years. This highlights the need for improvement in LBP management. Many clinical trials focus on developing treatments against degenerative disc disease (DDD). The multifactorial etiology of DDD and associated risk factors lead to a heterogeneous patient population. It comes as no surprise that the outcomes of clinical trials on intradiscal mesenchymal stem cell (MSC) injections for patients with DDD are inconsistent. Intradiscal MSC injections have demonstrated substantial pain relief and significant disability-related improvements, yet they have failed to regenerate the intervertebral disc (IVD). Increasing evidence suggests that the positive outcomes in clinical trials might be attributed to the immunomodulatory potential of MSCs rather than to their regenerative properties. Therefore, patient stratification for inflammatory DDD phenotypes may (i) better serve the mechanisms of action of MSCs and (ii) increase the treatment effect. Modic type 1 changes—pathologic inflammatory, fibrotic changes in the vertebral bone marrow—are frequently observed adjacent to degenerated IVDs in chronic LBP patients and represent a clinically distinct subpopulation of patients with DDD. This review discusses whether degenerated IVDs of patients with Modic type 1 changes should be treated with an intradiscal MSC injection.
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Affiliation(s)
- Nick Herger
- Center of Experimental Rheumatology, University Hospital Zurich and Balgrist University Hospital, University of Zurich, CH-8008 Zurich, Switzerland; (N.H.); (O.D.)
| | - Paola Bermudez-Lekerika
- Tissue Engineering for Orthopaedics and Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical Faculty, University of Bern, CH-3008 Bern, Switzerland; (P.B.-L.); (B.G.)
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Medical Faculty, University of Bern, CH-3010 Bern, Switzerland;
| | - Mazda Farshad
- Department of Orthopaedics, Balgrist University Hospital, CH-8008 Zurich, Switzerland;
| | - Christoph E. Albers
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Medical Faculty, University of Bern, CH-3010 Bern, Switzerland;
| | - Oliver Distler
- Center of Experimental Rheumatology, University Hospital Zurich and Balgrist University Hospital, University of Zurich, CH-8008 Zurich, Switzerland; (N.H.); (O.D.)
| | - Benjamin Gantenbein
- Tissue Engineering for Orthopaedics and Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical Faculty, University of Bern, CH-3008 Bern, Switzerland; (P.B.-L.); (B.G.)
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Medical Faculty, University of Bern, CH-3010 Bern, Switzerland;
| | - Stefan Dudli
- Center of Experimental Rheumatology, University Hospital Zurich and Balgrist University Hospital, University of Zurich, CH-8008 Zurich, Switzerland; (N.H.); (O.D.)
- Correspondence: ; Tel.: +41-4451-07511
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Udby PM, Samartzis D, Carreon LY, Andersen MØ, Karppinen J, Modic M. A definition and clinical grading of Modic changes. J Orthop Res 2022; 40:301-307. [PMID: 34910328 DOI: 10.1002/jor.25240] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/14/2021] [Accepted: 12/11/2021] [Indexed: 02/04/2023]
Abstract
To provide an up-to-date description of knowledge and pitfalls related to the classification, definition and grading of Modic changes (MC) visualized on magnetic resonance imaging (MRI). State-of-the-art review of current knowledge regarding the definition and grading of MC on MRI. MC on MRI have been reported to be associated with low back pain and disability. However, previous studies have shown heterogeneous results in regards to the impact of MC and its clinical relevance in patients with back pain. MC is a term used with considerable variation in the literature. No strict definition has been provided previously, this has contributed to varying diagnostic inclusion criteria, heterogeneous study populations, and discrepancy in results. A definition of MC and a proposal for grading is provided in this state-of-the-art review. MC are important, clinically relevant findings. However, issues with the nomenclature, definition and grading of these changes need to be addressed. Our current review highlights relevant issues related to MC, and provides a definition and grading score for the term MC that includes the Modic type and the extent of vertebral body involvement. Future studies should seek to validate the MC grading score in clinically relevant populations.
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Affiliation(s)
- Peter M Udby
- Spine Unit, Department of Orthopedic Surgery, Zealand University Hospital, Roskilde, Denmark.,Spine Surgery and Research, Spine Center of Southern Denmark, Lillebaelt Hospital, Middelfart, Denmark
| | - Dino Samartzis
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA.,International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, Illinois, USA
| | - Leah Y Carreon
- Spine Surgery and Research, Spine Center of Southern Denmark, Lillebaelt Hospital, Middelfart, Denmark
| | | | - Jaro Karppinen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.,Rehabilitation Services of South Karelia Social and Health Care District, Lappeenranta, Finland
| | - Michael Modic
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Koreckij T, Kreiner S, Khalil JG, Smuck M, Markman J, Garfin S. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 24-Month treatment arm results. NORTH AMERICAN SPINE SOCIETY JOURNAL 2021; 8:100089. [PMID: 35141653 PMCID: PMC8820067 DOI: 10.1016/j.xnsj.2021.100089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Vertebral endplates, innervated by the basivertebral nerve, can be a source of vertebrogenic low back pain when damaged with inflammation, visible as types 1 or 2 Modic changes. A randomized controlled trial (RCT) compared basivertebral nerve ablation (BVNA) to standard care (SC) showed significant differences between arms at 3 and 6-months. At 12-months, significant improvements were sustained for BVNA. We report results of the BVNA arm at 24-months. METHODS Prospective, open label, single-arm follow-up of the BVNA treatment arm of a RCT in 20 US sites with visits at 6-weeks, and 3, 6, 9, 12 and 24-months. Paired comparisons to baseline were made for the BVNA arm at each timepoint for Oswestry Disability Index (ODI), Visual Analog Scale (VAS), Short Form Health Survey (SF-36), EQ-5D-5L, and responder rates. RESULTS 140 patients were randomized, 66 to BVNA. In the 58 BVNA patients completing a 24-month visit, 67% had back pain for >5 years, 36% were actively taking opioids at baseline, 50% had prior epidural steroid injections, and 12% had prior low back surgery. Improvements in ODI, VAS, SF-36 PCS, and EQ-5D-5L were statistically significant at all timepoints through 2 years. At 24 months, ODI and VAS improved 28.5±16.2 points (from baseline 44.5; p < 0.001) and 4.1±2.7 cm (from baseline 6.6; p < 0.001), respectively. A combined responder rate of ODI≥15 and VAS≥2 was 73.7%. A ≥50% reduction in pain was reported in 72.4% of patients and 31.0% were pain-free at 2 years. At 24 months, only 3(5%) of patients had BVNA-level steroid injections, and 62% fewer patients were actively taking opioids. There were no serious device or device-procedure related adverse events reported through 24 months. CONCLUSION Intraosseous BVNA demonstrates an excellent safety profile and significant improvements in pain, function, and quality of life that are sustained through 24 months in patients with chronic vertebrogenic low back pain.
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Key Words
- AE, Adverse Events
- ANCOVA, Analysis of Covariance
- BVN, Basivertebral Nerve
- BVNA, Basivertebral Nerve Ablation
- Basivertebral nerve
- Basivertebral nerve ablation
- CLBP, Chronic Low Back Pain
- Chronic low back pain
- DMC, Data Management Committee
- ESI, Epidural Steroid Injection
- LS, Least Squares
- MCID, Minimal Clinically Important Difference
- Modic
- ODI, Oswestry Disability Index
- QOL, Quality of Life
- RCT, Randomized Controlled Trial
- RDQ, Roland-Morris Disability Questionnaire
- Radiofrequency ablation
- SC, Standard Care
- VAS, Visual Analog Scale
- Vertebrogenic pain
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Affiliation(s)
- Theodore Koreckij
- Department of Orthopedic Surgery, Kansas City Othropedic Alliance, Kansas City, MO, USA
| | - Scott Kreiner
- Department of Interventional Spine and Sports, Barrow Brain and Spine, Phoenix, AZ, USA
| | - Jad G Khalil
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI, USA
| | - M Smuck
- Physical Medicine & Rehabilitation Division, Stanford University, Redwood City, CA, USA
| | - J Markman
- Department of Neurosurgery, Translational Pain Research Program, University of Rochester School of Medicine, Rochester, NY, USA
| | - Steven Garfin
- Department of Orthopaedic Surgery, University of California-San Diego, La Jolla, CA, USA
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Barcellona MN, Speer JE, Jing L, Patil DS, Gupta MC, Buchowski JM, Setton LA. Bioactive in situ crosslinkable polymer-peptide hydrogel for cell delivery to the intervertebral disc in a rat model. Acta Biomater 2021; 131:117-127. [PMID: 34229105 PMCID: PMC9157564 DOI: 10.1016/j.actbio.2021.06.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/29/2021] [Accepted: 06/29/2021] [Indexed: 12/11/2022]
Abstract
Degeneration of the intervertebral disc (IVD) is associated with
significant biochemical and morphological changes that include a loss of disc
height, decreased water content and decreased cellularity. Cell delivery has
been widely explored as a strategy to supplement the nucleus pulposus (NP)
region of the degenerated IVD in both pre-clinical and clinical trials, using
progenitor or primary cell sources. We previously demonstrated an ability for a
polymer-peptide hydrogel, serving as a culture substrate, to promote adult NP
cells to undergo a shift from a degenerative fibroblast-like state to a
juvenile-like NP phenotype. In the current study, we evaluate the ability for
this peptide-functionalized hydrogel to serve as a bioactive system for cell
delivery, retention and preservation of a biosynthetic phenotype for primary IVD
cells delivered to the rat caudal disc in an anular puncture degeneration model.
Our data suggest that encapsulation of adult degenerative human NP cells in a
stiff formulation of the hydrogel functionalized with laminin-mimetic peptides
IKVAV and AG73 can promote cell viability and increased biosynthetic activity
for this population in 3D culture in vitro. Delivery of the
peptide-functionalized biomaterial with primary rat cells to the degenerated IVD
supported NP cell retention and NP-specific protein expression in
vivo, and promoted improved disc height index (DHI) values and
endplate organization compared to untreated degenerated controls. The results of
this study suggest the physical cues of this peptide-functionalized hydrogel can
serve as a supportive carrier for cell delivery to the IVD.
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Affiliation(s)
- Marcos N Barcellona
- Department of Biomedical Engineering, Washington University in St. Louis, United States
| | - Julie E Speer
- Department of Biomedical Engineering, Washington University in St. Louis, United States
| | - Liufang Jing
- Department of Biomedical Engineering, Washington University in St. Louis, United States
| | - Deepanjali S Patil
- Department of Biomedical Engineering, Washington University in St. Louis, United States
| | - Munish C Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, United States
| | - Jacob M Buchowski
- Department of Orthopedic Surgery, Washington University School of Medicine, United States
| | - Lori A Setton
- Department of Biomedical Engineering, Washington University in St. Louis, United States; Department of Orthopedic Surgery, Washington University School of Medicine, United States.
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Liu S, Wang Q, Li Z, Ma L, Li T, Li Y, Wang N, Liu C, Xue P, Wang C. TRPV1 Channel Activated by the PGE2/EP4 Pathway Mediates Spinal Hypersensitivity in a Mouse Model of Vertebral Endplate Degeneration. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:9965737. [PMID: 34471470 PMCID: PMC8405310 DOI: 10.1155/2021/9965737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/04/2021] [Indexed: 11/25/2022]
Abstract
Low back pain (LBP) is the primary cause of disability globally. There is a close relationship between Modic changes or endplate defects and LBP. Endplates undergo ossification and become highly porous during intervertebral disc (IVD) degeneration. In our study, we used a mouse model of vertebral endplate degeneration by lumbar spine instability (LSI) surgery. Safranin O and fast green staining and μCT scan showed that LSI surgery led to endplate ossification and porosity, but the endplates in the sham group were cartilaginous and homogenous. Immunofluorescent staining demonstrated the innervation of calcitonin gene-related peptide- (CGRP-) positive nerve fibers in the porous endplate of LSI mice. Behavior test experiments showed an increased spinal hypersensitivity in LSI mice. Moreover, we found an increased cyclooxygenase 2 (COX2) expression and an elevated prostaglandin E2 (PGE2) concentration in the porous endplate of LSI mice. Immunofluorescent staining showed the colocalization of E-prostanoid 4 (EP4)/transient receptor potential vanilloid 1 (TRPV1) and CGRP in the nerve endings in the endplate and in the dorsal root ganglion (DRG) neurons, and western blotting analysis demonstrated that EP4 and TRPV1 expression significantly increased in the LSI group. Our patch clamp study further showed that LSI surgery significantly enhanced the current density of the TRPV1 channel in small-size DRG neurons. A selective EP4 receptor antagonist, L161982, reduced the spinal hypersensitivity of LSI mice by blocking the PGE2/EP4 pathway. In addition, TRPV1 current and neuronal excitability in DRG neurons were also significantly decreased by L161982 treatment. In summary, the PGE2/EP4 pathway in the porous endplate could activate the TRPV1 channel in DRG neurons to cause spinal hypersensitivity in LSI mice. L161982, a selective EP4 receptor antagonist, could turn down the TRPV1 current and decrease the neuronal excitability of DRG neurons to reduce spinal pain.
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Affiliation(s)
- Sijing Liu
- Editorial Department of Hebei Medical University, Hebei Medical University, Shijiazhuang, Hebei 050017, China
| | - Qiong Wang
- Department of Pharmacology, Hebei Medical University, Shijiazhuang, Hebei 050017, China
| | - Ziyi Li
- Department of Endocrinology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
- Key Orthopaedic Biomechanics Laboratory of Hebei Province, Shijiazhuang, Hebei 050051, China
| | - Lei Ma
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Ting Li
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300020, China
| | - Yukun Li
- Department of Endocrinology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
- Key Orthopaedic Biomechanics Laboratory of Hebei Province, Shijiazhuang, Hebei 050051, China
| | - Na Wang
- Department of Endocrinology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
- Key Orthopaedic Biomechanics Laboratory of Hebei Province, Shijiazhuang, Hebei 050051, China
| | - Chang Liu
- Department of Endocrinology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
- Key Orthopaedic Biomechanics Laboratory of Hebei Province, Shijiazhuang, Hebei 050051, China
| | - Peng Xue
- Department of Endocrinology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
- Key Orthopaedic Biomechanics Laboratory of Hebei Province, Shijiazhuang, Hebei 050051, China
| | - Chuan Wang
- Department of Pharmacology, Hebei Medical University, Shijiazhuang, Hebei 050017, China
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Michalik A, Conger A, Smuck M, Maus TP, McCormick ZL. Intraosseous Basivertebral Nerve Radiofrequency Ablation for the Treatment of Vertebral Body Endplate Low Back Pain: Current Evidence and Future Directions. PAIN MEDICINE 2021; 22:S24-S30. [PMID: 34308955 DOI: 10.1093/pm/pnab117] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Recently, basivertebral nerve (BVN) radiofrequency ablation has been developed for the treatment of chronic low back pain (CLBP) thought to arise from the vertebral body endplates (VEPs). This review describes the relevant neuroanatomy and pathobiology of VEP degeneration and injury, imaging correlates of presumed VEP pain, randomized controlled trials performed, appropriate patient selection, and safety. Anatomic, histological, and clinical evidence supports the concept of the VEP as a source of CLBP and the nociceptive role of the BVN. BVN radiofrequency ablation appears to be an effective treatment for a subset of patients with CLBP and evidence of Modic change types 1 and 2 in the L3 to S1 VEPs who have failed to respond to conservative treatment. However, all studies performed to date have been industry sponsored, and future non-industry-funded trials will be needed to confirm these results.
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Affiliation(s)
- Adam Michalik
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Aaron Conger
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Matthew Smuck
- Division of Physical Medicine & Rehabilitation, Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Timothy P Maus
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
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