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Cetintas SC, Akyol S, Alizada O, Akgun MY, Tahmazoglu B, Hanci M, Isler C. The Relationship Between Inflammatory Processes and Apoptosis in Lumbar Disc Degeneration. World Neurosurg 2024; 186:e261-e272. [PMID: 38548052 DOI: 10.1016/j.wneu.2024.03.121] [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: 01/12/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE Degenerative Disc Disease (DDD) is a common health problem in the population. There are recent studies focusing on relationship between DDD and immunological factors. However, there is still a lack of data on the role of apoptosis in DDD pathophysiology. Therefore, we aimed to investigate the relationship between Modic-type changes and the apoptosis in DDD. MATERIALS AND METHODS Ninety adult male patients who presented with low back and/or radicular pain and were operated on due to lumbar disc herniation were included. Three groups were formed based on Modic type degeneration observed on magnetic resonance imaging. Specific parameters involved in the intrinsic and extrinsic pathways of apoptosis were assessed in excised disc materials using the enzyme-linked immunosorbent assay method. RESULTS All three groups formed according to Modic degeneration types were homogenous in all variances. Cytochrome-C was significantly decreased only in the Modic type-3 group, whereas Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand Receptor-1, B-Cell Lymphoma-2 (Bcl-2) Homologous Antagonist Killer-1, Direct Inhibitor of Apoptosis-Binding Protein with Low Pi, and Bcl-2 Associated X Apoptosis Regulator levels were significantly different in both Modic type-2 and -3 groups. However, BH3 interacting domain death agonist and Bcl-2 levels were similar across all groups. CONCLUSIONS In conclusion, this study suggests that Direct Inhibitor of Apoptosis-Binding Protein with Low Pi, cytochrome - c, Bcl-2 Associated X Apoptosis Regulator, Bcl-2 Homologous Antagonist Killer-1, and Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand Receptor-1proteins play important roles in the development and progression of DDD and are correlated with Modic types. Further studies are needed to explore the potential therapeutic role of inhibiting these apoptotic proteins in DDD.
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Affiliation(s)
- Semih Can Cetintas
- Department of Neurosurgery, Turkish Ministry of Health, Bitlis State Hospital, Bitlis, Turkey
| | - Sibel Akyol
- Department of Physiology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Orkhan Alizada
- Department of Neurosurgery, Baskent University, School of Medicine, Istanbul, Turkey
| | | | - Burak Tahmazoglu
- Department of Neurosurgery, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Murat Hanci
- Department of Neurosurgery, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Cihan Isler
- Department of Neurosurgery, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey.
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Compte R, Freidin MB, Granville Smith I, Le Maitre CL, Vaitkute D, Nessa A, Lachance G, Williams FMK. No evidence of association between either Modic change or disc degeneration and five circulating inflammatory proteins. JOR Spine 2024; 7:e1323. [PMID: 38529326 PMCID: PMC10961713 DOI: 10.1002/jsp2.1323] [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: 08/14/2023] [Revised: 01/31/2024] [Accepted: 03/02/2024] [Indexed: 03/27/2024] Open
Abstract
Introduction Intervertebral disc degeneration and Modic change are the main spinal structural changes associated with chronic low back pain (LBP). Both conditions are thought to manifest local inflammation and if inflammatory proteins translocate to the blood circulation could be detected systemically. The work here assesses whether the presence of disc degeneration is associated with detectable blood level changes of five inflammatory markers and whether chronic LBP is associated with these changes. Materials and Methods Two hundred and forty TwinsUK cohort participants with both MRI disc degeneration grade and Modic change extent, and IL-6, IL-8, IL-8 TNF, and CX3CL1 protein blood concentration measurements were included in this work. Linear mixed effects models were used to test the association of blood cytokine concentration with disc degeneration score and Modic change volumetric score. Association of chronic LBP status from questionnaires with disc degeneration, Modic change, and cytokine blood concentration was also tested. Results No statistically significant association between disc degeneration or Modic change with cytokine blood concentration was found. Instead, regression analysis pointed strong association between cytokine blood concentration with body mass index for IL-6 and with age for IL-6 and TNF. Mild association was found between IL-8 blood concentration and body mass index. Additionally, LBP status was associated with Modic change volumetric score but not associated with any cytokine concentration. Conclusions We found no evidence that Modic change and disc degeneration are able to produce changes in tested blood cytokine concentration. However, age and body mass index have strong influence on cytokine concentration and both are associated with the conditions studied which may confound associations found in the literature. It is then unlikely that cytokines produced in the disc or vertebral bone marrow induce chronic LBP.
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Affiliation(s)
- Roger Compte
- Department of Twin Research and Genetic EpidemiologyKing's College LondonLondonUK
| | - Maxim B. Freidin
- Department of Biology, School of Biological and Behavioural SciencesQueen Mary University of LondonLondonUK
| | | | - Christine L. Le Maitre
- Division of Clinical Medicine, School of Medicine and Population HealthUniversity of SheffieldSheffieldUK
| | - Dovile Vaitkute
- Department of Twin Research and Genetic EpidemiologyKing's College LondonLondonUK
| | - Ayrun Nessa
- Department of Twin Research and Genetic EpidemiologyKing's College LondonLondonUK
| | - Genevieve Lachance
- Department of Twin Research and Genetic EpidemiologyKing's College LondonLondonUK
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Liu Y, Chen Q, Wang Y, He J. The area ratio of Modic changes has predictive value for postoperative surgical site infection in lumbar spine surgery: a retrospective study. BMC Musculoskelet Disord 2024; 25:137. [PMID: 38347482 PMCID: PMC10863181 DOI: 10.1186/s12891-024-07257-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/04/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Increasing evidence suggests an association between Modic changes (MC) and subclinical infection and inflammatory reactions. However, the relationship between preoperative MC and surgical site infection (SSI) has not been fully explored. This study aims to investigate the correlation between MC and SSI. METHODS A retrospective analysis was conducted on patients (n = 646) who underwent single-level lumbar spine surgery for lower back pain in our hospital between 2018 and 2023. According to the Centers for Disease Control and Prevention (CDC) criteria, the patients were divided into an SSI group (n = 40) and a Non-SSI group (n = 606). Univariate analysis was performed to determine the statistical differences in variables between the two groups, and the variables with significant differences were included in a multivariable logistic regression analysis to identify independent risk factors for SSI. Receiver operating characteristic (ROC) curve analysis was performed on the independent risk factors. RESULTS The SSI group and the Non-SSI group exhibited significant differences in diabetes prevalence, MC prevalence, Total endplate score (TEPS) and area ratio of MC (P < 0.05). Age, gender, American Society of Anesthesiologists(ASA)score, hypertension, coronary heart disease (CHD), chronic obstructive pulmonary disease (COPD), MC classification, and the location of MC in the endplate showed no significant differences (P > 0.05). Multivariate binary logistic regression analysis was performed on the variables with significant differences, and the results indicated a significant correlation between TEPS (P = 0.009) and the area ratio of MC changes (P = 0.001) with SSI. ROC curve analysis was performed on the TEPS and area ratio of MC changes, and the results showed that the diagnostic value of TEPS (AUC: 0.641; CI: 0.522-0.759) is lower than the area ratio of MC (AUC: 0.722; CI: 0.621-0.824), and the combined diagnosis did not significantly improve the diagnostic value (AUC: 0.747; CI: 0.653-0.842). The area ratio of MC had moderate diagnostic value for SSI (AUC: 0.722; CI: 0.621-0.824), with a cut-off value of 24.62% determined by the Youden index (sensitivity: 69.2%; specificity: 73.1%), and for every 1% increase in the area ratio of MC changes, the risk of SSI in MC patients increased by 10.3% (OR = 1.103; CI: 1.044-1.167). CONCLUSION The area ratio MC and the TEPS are independent risk factors for SSI after lumbar spine surgery. The predictive value of the area ratio of MC is greater than TEPS, and when the two are combined, the predictive value is not significantly improved. When the rate of MC exceeds 24.62%, caution should be exercised regarding the occurrence of SSI.
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Affiliation(s)
- Yanhang Liu
- Department of Orthopedics, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637500, Sichuan, China
| | - Qian Chen
- Department of Orthopedics, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637500, Sichuan, China
| | - Yueran Wang
- Department of Orthopedics, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637500, Sichuan, China
| | - Jiangtao He
- Department of Orthopedics, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637500, Sichuan, China.
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Li H, Yu L, Gao X, Yuan S, Tian Y, Wang L, Liu X. Novel Modic grading scoring system and its clinical validation: a preliminary investigation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:84-92. [PMID: 37955751 DOI: 10.1007/s00586-023-08003-w] [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: 05/21/2023] [Revised: 10/01/2023] [Accepted: 10/14/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE To propose a novel Modic grading scoring system and explore the relationship between the Modic grading score and disc degeneration, disc herniation, disc height, and clinical symptom scores. METHOD In total, 194 patients were included in the study. The new Modic grading scoring system included four indicators: invaded vertebral height, invaded endplate length, endplate morphology, and grade of endplate defects. The severity of Modic changes was visually quantified by numerical scores, and the kappa value was used to verify the interobserver and intraobserver reliability. Spearman correlation analysis was used to explore the relationship between the Modic grading score and intervertebral disc degeneration, disc herniation, disc height, and clinical symptom scores. RESULTS The interobserver and intraobserver reliability showed substantial to almost perfect agreement in the new Modic grading scoring system. The Modic grading score was positively correlated with intervertebral disc degeneration (r = 0.757, p < 0.001) and negatively correlated with the intervertebral disc height index (r = - 0.231, p < 0.001). There was no significant correlation between the Modic grading scoring system and disc herniation (r = 0.369, p = 0.249). Additionally, there was no significant correlation between the Modic grading score and the Japanese Orthopaedic Association score (r = - 0.349, p = 0.25), Oswestry Disability Index score (r = 0.246, p = 0.11), or visual analogue scale score (r = 0.315, p = 0.35). CONCLUSION The new Modic grading scoring system had good interobserver and intraobserver reliability. The Modic grading score was positively correlated with intervertebral disc degeneration and negatively correlated with the intervertebral disc height.
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Affiliation(s)
- Hao Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Wenhua West Road 107#, Jinan, Shandong, 250012, People's Republic of China
- Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, People's Republic of China
| | - Liye Yu
- Department of Orthopedics, Qilu Hospital of Shandong University, Wenhua West Road 107#, Jinan, Shandong, 250012, People's Republic of China
- Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, People's Republic of China
| | - Xianlei Gao
- Department of Orthopedics, Qilu Hospital of Shandong University, Wenhua West Road 107#, Jinan, Shandong, 250012, People's Republic of China
| | - Suomao Yuan
- Department of Orthopedics, Qilu Hospital of Shandong University, Wenhua West Road 107#, Jinan, Shandong, 250012, People's Republic of China
| | - Yonghao Tian
- Department of Orthopedics, Qilu Hospital of Shandong University, Wenhua West Road 107#, Jinan, Shandong, 250012, People's Republic of China
| | - Lianlei Wang
- Department of Orthopedics, Qilu Hospital of Shandong University, Wenhua West Road 107#, Jinan, Shandong, 250012, People's Republic of China.
| | - Xinyu Liu
- Department of Orthopedics, Qilu Hospital of Shandong University, Wenhua West Road 107#, Jinan, Shandong, 250012, People's Republic of China.
- Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, People's Republic of China.
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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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Mittal RK, Le C, Ledgerwood M, Jung DK, Gandu V, Zifan A. Esophageal Symptoms and Lumbosacral Back Pain. GASTRO HEP ADVANCES 2023; 3:292-299. [PMID: 38645466 PMCID: PMC11027073 DOI: 10.1016/j.gastha.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
BACKGROUND AND AIMS Esophageal symptoms, that is, heartburn, regurgitation, dysphagia, and chest pain are common in the general population. Also common are symptoms of back pain related to pathology in the lumbosacral spine. The right crus of the diaphragm that forms the esophageal hiatus, originates from lumbar spine, may be affected by lumbar spine pathology resulting in esophageal symptoms. We studied whether there was an association between esophageal symptoms and spine symptoms. METHODS Two patient groups of 150 each were investigated: group 1 (ES); patients referred to the esophageal manometry study for assessment of esophageal symptoms, group 2 (SC); patients undergoing screening colonoscopy (control group). Both groups completed standardized questionnaires assessing esophageal and spine symptoms. RESULTS Back pain was reported by 74% of patients in the ES group as compared to 55% of patients in the SC group. Thirty percent of patients in the SC group reported one or more esophageal symptoms and these patients were regrouped with the ES group, resulting in 2 groups, ES1 and SC1, with and without esophageal symptoms, respectively. The ES1 group was 3.3 times more likely to experience back pain compared to the SC1 group (95% confidence interval: 1.95-5.46). Thoracolumbar was the most common site of pain in both groups. Pain score was greater for the group with esophageal symptoms compared to controls. Narcotic intake for most patients in the ES1 group was for back pain. CONCLUSION A strong association between esophageal symptoms and thoracolumbar back pain raises the possibility that structural and functional changes in the esophageal hiatus muscles related to thoracolumbar spine pathology lead to esophageal dysmotility and symptoms.
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Affiliation(s)
- Ravinder K Mittal
- Division of Gastroenterology, Department of Medicine University of California San Diego, San Diego, California
| | - Charlie Le
- Division of Gastroenterology, Department of Medicine University of California San Diego, San Diego, California
| | - Melissa Ledgerwood
- Division of Gastroenterology, Department of Medicine University of California San Diego, San Diego, California
| | - Da Kyung Jung
- Division of Gastroenterology, Department of Medicine University of California San Diego, San Diego, California
| | - Vignesh Gandu
- Division of Gastroenterology, Department of Medicine University of California San Diego, San Diego, California
| | - Ali Zifan
- Division of Gastroenterology, Department of Medicine University of California San Diego, San Diego, California
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Erinç S, Talmaç MA, Kemah B, Özdemir MH. The effect of Modic changes on the fusion rates of posterior interbody fusion surgery. J Neurosurg Sci 2023; 67:609-615. [PMID: 34342195 DOI: 10.23736/s0390-5616.21.05386-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Modic changes have been correlated to low back pain, spinal instability. The objective of this study was to evaluate the effect of Modic changes on the fusion rates of instrumented posterior interbody fusion surgery (PLIF). METHODS The study included patients who underwent PLIF surgery between 2015-2019.The patients were separated into four groups according to Modic changes detected in the preoperative MRI. Fusion, subsidence were evaluated with postoperative CT and X-ray. Body mass index (BMI) and bone mineral density (BMD) of the patients were also evaluated. RESULTS The study included 137 operated discs of 86 patients. There was no statistical difference between groups regarding age, gender, follow-up period, BMI, and BMD. There were 70 levels with no Modic changes (M0), 26 levels with Modic type 1 (M1), 21 levels with Modic type 2 (M2), and 16 with Modic type 3 (MC3) change. The rate of successful fusion was 92.9% in M0, 92.3% in M1, 93% in M2, and 93.7% in M3. The rate of high-grade subsidence was 28.5% in M0, 26.8% in M1, 27.5% in M2, and 24.9% in M3. There was no statistically difference between the patients regarding subsidence grade or fusion rate. CONCLUSIONS Modic changes were not observed to be directly correlated to the radiological outcomes of instrumented posterior interbody fusion. The fusion rate demonstrated homogenous distribution between the Modic groups and the subsidence rate was slightly higher in MC1 and MC2 than in MC3 and MC0.
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Affiliation(s)
- Samet Erinç
- Department of Orthopedics and Traumatology, Şişli Hamidiye Etfal Research and Training Hospital, Istanbul, Türkiye -
| | - Mahmet A Talmaç
- Department of Orthopedics and Traumatology, Şişli Hamidiye Etfal Research and Training Hospital, Istanbul, Türkiye
| | - Bahattin Kemah
- Department of Orthopedics and Traumatology, Ümraniye Research and Training Hospital, Istanbul, Türkiye
| | - Mustafa H Özdemir
- Department of Orthopedics and Traumatology, Şişli Hamidiye Etfal Research and Training Hospital, Istanbul, Türkiye
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Moser M, Adl Amini D, Albertini Sanchez L, Oezel L, Haffer H, Muellner M, Zhu J, Carrino JA, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. The association between vertebral endplate defects, subchondral bone marrow changes, and lumbar intervertebral disc degeneration: a retrospective, 3-year longitudinal study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:2350-2357. [PMID: 36773077 DOI: 10.1007/s00586-023-07544-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 10/22/2022] [Accepted: 01/13/2023] [Indexed: 02/12/2023]
Abstract
PURPOSE To investigate the influence of vertebral endplate defects and subchondral bone marrow changes on the development of lumbar intervertebral disc degeneration (DD). METHODS Patients > 18 y/o without any history of lumbar fusion who had repeat lumbar magnetic resonance imaging scans primarily for low back pain (LBP) performed at a minimum of 3 years apart at a single institution, and no spinal surgery in between scans were included. Total endplate score (TEPS), Modic changes (MC), and Pfirrmann grading (PFG) per lumbar disc level were assessed. DD was defined as PFG ≥ 4. RESULTS Three hundred and fifty-three patients (54.4% female) were included in the final analysis, comprising 1765 lumbar intervertebral discs. The patient population was 85.6% Caucasian with a median age of 60.1 years and a body mass index (BMI) of 25.8 kg/m2. A cutoff score of 5 was identified for the TEPS above which both the prevalence of DD and the odds of developing DD increased. The probability of developing DD did not differ significantly between lumbar disc levels (P = 0.419). In the multivariable analysis with adjustments for age, sex, race, body mass index (BMI), MC, TEPS cutoff > 5, and spinal level, only age (OR = 1.020; P = 0.002) was found to be an independent risk factor for developing intervertebral DD. CONCLUSION Our results suggest that TEPS does not unequivocally predict intervertebral DD in patients with LBP, since higher degrees of endplate defects might also develop secondarily to DD, and MC tend to occur late in the cascade of degeneration.
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Affiliation(s)
- Manuel Moser
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Department of Spine Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne, Switzerland
| | - Dominik Adl Amini
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Leonardo Albertini Sanchez
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10065, USA
| | - Lisa Oezel
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedic Surgery and Traumatology, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Henryk Haffer
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Maximilian Muellner
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Jiaqi Zhu
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - John A Carrino
- Department of Radiology and Imaging, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA.
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Li Z, Gao X, Ding W, Li R, Yang S. Asymmetric distribution of Modic changes in patients with lumbar disc herniation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1741-1750. [PMID: 36977942 DOI: 10.1007/s00586-023-07664-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/13/2023] [Accepted: 03/18/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE This study aims to report a new distribution pattern of Modic changes (MCs) in patients with lumbar disc herniation (LDH) and investigate the prevalence, correlative factors and clinical outcomes of asymmetric Modic changes (AMCs). METHODS The study population consisted of 289 Chinese Han patients who were diagnosed with LDH and single-segment MCs from January 2017 to December 2019. Demographic, clinical and imagological information was collected. Lumbar MRI was performed to assess MCs and intervertebral discs. The visual analogue score (VAS) and Oswestry disability index (ODI) were evaluated in patients undergoing surgery preoperatively and at the final follow-up. Correlative factors contributing to AMCs were analysed by multivariate logistic regression. RESULTS The study population included 197 patients with AMCs and 92 patients with symmetric Modic changes (SMCs). The incidence of leg pain (P < 0.001) and surgical treatment (P = 0.027) in the AMC group was higher than that in the SMC group. The VAS of low back pain was lower (P = 0.048), and the VAS of leg pain was higher (P = 0.036) in the AMC group than in the SMC group preoperatively. Multivariate logistic regression analysis revealed that leg pain (OR = 2.169, 95% CI = 1.218 ~ 3.864) and asymmetric LDH (OR = 7.342, 95% CI = 4.170 ~ 12.926) were independently associated with AMCs. The receiver operating characteristic curve showed an AUC of 0.765 (P < 0.001). CONCLUSION AMCs were a more common phenomenon than SMCs in this study. The asymmetric and symmetric distribution of MCs was closely related to LDH position. AMCs were related to leg pain and higher pain levels. Surgery can achieve satisfactory clinical improvement for asymmetric and symmetric MCs.
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Affiliation(s)
- Zhaohui Li
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Xianda Gao
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Wenyuan Ding
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, China.
| | - Ruoyu Li
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Sidong Yang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, China.
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Mertimo T, Heikkala E, Niinimäki J, Blanco Sequeiros R, Määttä J, Kankaanpää M, Oura P, Karppinen J. The role of co-occurring insomnia and mental distress in the association between lumbar disc degeneration and low back pain related disability. BMC Musculoskelet Disord 2023; 24:293. [PMID: 37060071 PMCID: PMC10103434 DOI: 10.1186/s12891-023-06365-2] [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: 10/01/2022] [Accepted: 03/24/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Lumbar disc degeneration (LDD) is associated with low back pain (LBP). Although both insomnia and mental distress appear to influence the pain experience, their role in the association between LDD and LBP is uncertain. Our objective was to investigate the role of co-occurring insomnia and mental distress in the association between LDD and LBP-related disability. METHODS A total of 1080 individuals who had experienced LBP during the previous year underwent 1.5-T lumbar magnetic resonance imaging, responded to questionnaires, and participated in a clinical examination at the age of 47. Full data was available for 843 individuals. The presence of LBP and LBP-related disability (numerical rating scale, range 0-10) were assessed using a questionnaire. LDD was assessed by a Pfirrmann-based sum score (range 0-15, higher values indicating higher LDD). The role of insomnia (according to the five-item Athens Insomnia Scale) and mental distress (according to the Hopkins Symptom Check List-25) in the association between the LDD sum score and LBP-related disability was analyzed using linear regression with adjustments for sex, smoking, body mass index, education, leisure-time physical activity, occupational physical exposure, Modic changes, and disc herniations. RESULTS A positive association between LDD and LBP-related disability was observed among those with absence of both mental distress and insomnia (adjusted B = 0.132, 95% CI = 0.028-0.236, p = 0.013), and among those with either isolated mental distress (B = 0.345 CI = 0.039-0.650, p = 0.028) or isolated insomnia (B = 0.207, CI = 0.040-0.373, p = 0.015). However, among individuals with co-occurring insomnia and mental distress, the association was not significant (B = -0.093, CI = -0.346-0.161, p = 0.470). CONCLUSIONS LDD does not associate with LBP-related disability when insomnia and mental distress co-occur. This finding may be useful when planning treatment and rehabilitation that aim to reduce disability among individuals with LDD and LBP. Future prospective research is warranted.
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Affiliation(s)
- Teija Mertimo
- Faculty of Medicine and Health Technology, Tampere University Hospital and University of Tampere, P.O. Box 607, Tampere, FI-33014, Finland.
- Research Unit of Population Health, Faculty of Medicine, University of Oulu, P.O. Box 5000, Oulu, FI- 90014, Finland.
| | - Eveliina Heikkala
- Research Unit of Population Health, Faculty of Medicine, University of Oulu, P.O. Box 5000, Oulu, FI- 90014, Finland
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
| | - Jaakko Niinimäki
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
- Research Unit of Medical Imaging, Physics and Technology, Faculty of Medicine, University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
| | - Roberto Blanco Sequeiros
- Research Unit of Medical Imaging, Physics and Technology, Faculty of Medicine, University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
- Department of Radiology, Turku University Hospital, Kiinamyllynkatu 4-8, Turku, FI-20520, Finland
| | - Juhani Määttä
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
- Research Unit of Health Sciences and Technology, Faculty of Medicine, University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
| | - Markku Kankaanpää
- Department of Rehabilitation and Psychosocial Support, Tampere University Hospital, P.O. Box 2000, Tampere, FI-33521, Finland
| | - Petteri Oura
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
- Research Unit of Health Sciences and Technology, Faculty of Medicine, University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
| | - Jaro Karppinen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
- Research Unit of Health Sciences and Technology, Faculty of Medicine, University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
- Rehabilitation Services of South Karelia Social and Health Care District, Valto Käkelän katu 3, Lappeenranta, FI- 53130, Finland
- Finnish Institute of Occupational Health, Aapistie 1, Oulu, FI-90220, Finland
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11
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Atypical patterns of spinal segment degeneration in patients with abdominal aortic aneurysms. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:8-19. [PMID: 35835893 DOI: 10.1007/s00586-022-07276-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 05/13/2022] [Accepted: 05/25/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Abdominal aortic aneurysms (AAAs) affect the vascular perfusion of the lumbar spine. The treatment of AAAs with endovascular aortic aneurysm repair (EVAR) completely occludes the direct vascular supply to the lumbar spine. We hypothesized that patients with AAA who undergo EVAR show a different pattern of spinal degeneration than individuals without AAA. METHODS In this retrospective institutional review board-approved study, 100 randomly selected patients with AAA who underwent EVAR with computed tomography (CT) scans between 2005 and 2017 were compared with age- and gender-matched controls without AAA. In addition, long-term follow-up CT images (> 6 months before EVAR, at the time of EVAR, and > 12 months after EVAR) of the patients were analysed to compare the progression of degeneration from before to after EVAR. Degeneration scores, lumbar levels with the most severe degeneration, and lumbar levels with progressive degeneration were analysed in all CT images. Fisher's exact test, Wilcoxon signed-rank test, and Mann-Whitney U test were performed for statistical analyses. RESULTS Compared with the control group (n = 94), the most severe degeneration was more commonly detected in the mid-lumbar area in the patient group (n = 100, p = 0.016), with significantly more endplate erosions being detected in the lumbar spine (p = 0.015). However, EVAR did not result in significant additional acceleration of the degenerative process in the long-term follow-up analysis (n = 51). CONCLUSION AAA is associated with atypical, more cranially located spinal degradation, particularly in the mid-lumbar segments; however, EVAR does not seem to additionally accelerate the degenerative process. This observation underlines the importance of disc and endplate vascularization in the pathomechanism of spinal degeneration. LEVEL OF EVIDENCE I Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.
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12
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Sherwood D, Haring RS, Schirmer D, Modic M. The interrater reliability of Modic changes among a potential basivertebral nerve ablation population: Why AC1 may be preferred to kappa. J Orthop Res 2022; 41:1123-1130. [PMID: 36200411 DOI: 10.1002/jor.25449] [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: 05/30/2022] [Revised: 08/30/2022] [Accepted: 10/01/2022] [Indexed: 02/04/2023]
Abstract
Interrater reliability of Modic changes is subject to variables which affect consistency in reporting. Given the importance of Modic change identification for basivertebral nerve ablation (BVNA) candidacy, interrater reliability for this specific cohort has not yet been reported. Twenty lumbar magnetic resonance images of potential basivertebral nerve candidates were independently reviewed by two neuroradiologists and two interventional spine physiatrists for the presence and characterization of Modic changes. The kappa value of their agreement on the presence of Modic changes was 0.52 (95% confidence interval [CI] 0.37-0.67), whereas agreement on the type of Modic change was 0.51 (95% CI 0.37-0.65). Using an alternative methodology for measuring interrater reliability (Gwet's AC1) yielded the identification of the presence of Modic changes at AC1 0.51 (95% CI 0.36-0.66), whereas agreement on the type of Modic change was AC1 0.75 (95% CI 0.66-0.83). While less common, AC1 may be preferred in the appropriate cohort to kappa as it mitigates some of the pitfalls to which kappa values may be victim. Ultimately, our results are in-line with previous reports of interrater reliability results for Modic changes in other cohorts and should serve to caution those who perform BVNA regarding interrater agreement of the imaging crux of the procedure.
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Affiliation(s)
- David Sherwood
- Department of Orthopedics, University Health Lakewood Medical Center, Kansas City, Missouri, USA
| | - Richard Sterling Haring
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Derek Schirmer
- Stanford University Medical Center, Physical Medicine and Rehabilitation Division, Redwood City, California, USA
| | - Michael Modic
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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13
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Anderson B, Ordaz A, Zlomislic V, Allen RT, Garfin SR, Schuepbach R, Farshad M, Schenk S, Ward SR, Shahidi B. Paraspinal Muscle Health is Related to Fibrogenic, Adipogenic, and Myogenic Gene Expression in Patients with Lumbar Spine Pathology. BMC Musculoskelet Disord 2022; 23:608. [PMID: 35739523 PMCID: PMC9229083 DOI: 10.1186/s12891-022-05572-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/14/2022] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Lumbar spine pathology is a common feature of lower back and/or lower extremity pain and is associated with observable degenerative changes in the lumbar paraspinal muscles that are associated with poor clinical prognosis. Despite the commonly observed phenotype of muscle degeneration in this patient population, its underlying molecular mechanisms are not well understood. The aim of this study was to investigate the relationships between groups of genes within the atrophic, myogenic, fibrogenic, adipogenic, and inflammatory pathways and multifidus muscle health in individuals undergoing surgery for lumbar spine pathology. METHODS Multifidus muscle biopsies were obtained from patients (n = 59) undergoing surgery for lumbar spine pathology to analyze 42 genes from relevant adipogenic/metabolic, atrophic, fibrogenic, inflammatory, and myogenic gene pathways using quantitative polymerase chain reaction. Multifidus muscle morphology was examined preoperatively in these patients at the level and side of biopsy using T2-weighted magnetic resonance imaging to determine whole muscle compartment area, lean muscle area, fat cross-sectional areas, and proportion of fat within the muscle compartment. These measures were used to investigate the relationships between gene expression patterns and muscle size and quality. RESULTS Relationships between gene expression and imaging revealed significant associations between decreased expression of adipogenic/metabolic gene (PPARD), increased expression of fibrogenic gene (COL3A1), and lower fat fraction on MRI (r = -0.346, p = 0.018, and r = 0.386, p = 0.047 respectively). Decreased expression of myogenic gene (mTOR) was related to greater lean muscle cross-sectional area (r = 0.388, p = 0.045). CONCLUSION Fibrogenic and adipogenic/metabolic genes were related to pre-operative muscle quality, and myogenic genes were related to pre-operative muscle size. These findings provide insight into molecular pathways associated with muscle health in the presence of lumbar spine pathology, establishing a foundation for future research that addresses how these changes impact outcomes in this patient population.
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Affiliation(s)
- Brad Anderson
- Department of Orthopaedic Surgery, University of California San Diego, 350 Dickinson Street, Suite 121, Mail Code 8894, San Diego, CA, 92103-8894, USA
| | - Angel Ordaz
- Department of Orthopaedic Surgery, University of California San Diego, 350 Dickinson Street, Suite 121, Mail Code 8894, San Diego, CA, 92103-8894, USA.
| | - Vinko Zlomislic
- Department of Orthopaedic Surgery, University of California San Diego, 350 Dickinson Street, Suite 121, Mail Code 8894, San Diego, CA, 92103-8894, USA
| | - R Todd Allen
- Department of Orthopaedic Surgery, University of California San Diego, 350 Dickinson Street, Suite 121, Mail Code 8894, San Diego, CA, 92103-8894, USA
| | - Steven R Garfin
- Department of Orthopaedic Surgery, University of California San Diego, 350 Dickinson Street, Suite 121, Mail Code 8894, San Diego, CA, 92103-8894, USA
| | - Regula Schuepbach
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Simon Schenk
- Department of Orthopaedic Surgery, University of California San Diego, 350 Dickinson Street, Suite 121, Mail Code 8894, San Diego, CA, 92103-8894, USA
| | - Samuel R Ward
- Department of Orthopaedic Surgery, University of California San Diego, 350 Dickinson Street, Suite 121, Mail Code 8894, San Diego, CA, 92103-8894, USA
| | - Bahar Shahidi
- Department of Orthopaedic Surgery, University of California San Diego, 350 Dickinson Street, Suite 121, Mail Code 8894, San Diego, CA, 92103-8894, USA
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14
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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] [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 Imaging University of California, San Francisco San Francisco California USA
- Department of Bioengineering University of California Berkeley–University of California San Francisco Graduate Program in Bioengineering Berkeley California USA
| | - Radhika Tibrewala
- Department of Radiology and Biomedical Imaging University of California, San Francisco San Francisco California USA
| | - Madeline Hess
- Department of Radiology and Biomedical Imaging University of California, San Francisco San Francisco California USA
| | - Upasana U. Bharadwaj
- Department of Radiology and Biomedical Imaging University of California, San Francisco San Francisco California USA
| | - Gaurav Inamdar
- Department of Radiology and Biomedical Imaging 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
| | - Cynthia T. Chin
- Department of Radiology and Biomedical Imaging University of California, San Francisco San Francisco California USA
| | - Valentina Pedoia
- Department of Radiology and Biomedical Imaging University of California, San Francisco San Francisco California USA
| | - Sharmila Majumdar
- Department of Radiology and Biomedical Imaging University of California, San Francisco San Francisco California USA
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15
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Theodorou DJ, Theodorou SJ, Gelalis ID, Kakitsubata Y. Lumbar Intervertebral Disc and Discovertebral Segment, Part 1: An Imaging Review of Normal Anatomy. Cureus 2022; 14:e25558. [PMID: 35784982 PMCID: PMC9249043 DOI: 10.7759/cureus.25558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 12/03/2022] Open
Abstract
The intervertebral disc is designated the most important cartilaginous articulation of the vertebral column that functions to withstand compressive biomechanical forces and confer strength and flexibility to the spine. A thorough study of the complex fine structure and anatomic relationships of the intervertebral disc is essential for the characterization of the integrity of each individual structure in the discovertebral segment. This elaborate work in human cadavers explores the sophisticated internal structure of the normal intervertebral disc and the discovertebral segment, providing detailed data derived from the dissection of specimens through imaging and close anatomic-histologic correlation. Familiarity with the normal appearances and basic functional properties of the lumbar intervertebral disc and discovertebral segment is fundamental for the recognition of aberrations that may have important clinical implications in patients with low back pain. In Part I of this article, the anatomic structure and features of the discovertebral complex in adults will be described.
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Mertimo T, Karppinen J, Niinimäki J, Blanco R, Määttä J, Kankaanpää M, Oura P. Association of lumbar disc degeneration with low back pain in middle age in the Northern Finland Birth Cohort 1966. BMC Musculoskelet Disord 2022; 23:359. [PMID: 35428226 PMCID: PMC9011971 DOI: 10.1186/s12891-022-05302-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/30/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Although it has been suggested that lumbar disc degeneration (LDD) is a significant risk factor for low back pain (LBP), its role remains uncertain. Our objective was to clarify the association between LDD and LBP and whether mental distress modifies the association.
Methods
Participants of a birth cohort underwent 1.5-T lumbar magnetic resonance imaging at the age of 47. The association between the sum score of LDD (Pfirrmann classification, range 0–15) and LBP (categorized into “no pain”, “mild-to-moderate pain”, “bothersome-and-frequent pain”) was assessed using logistic regression analysis, with sex, smoking, body mass index, physical activity, occupational exposure, education, and presence of Modic changes and disc herniations as confounders. The modifying role of mental distress (according to the Hopkins Symptom Check List-25 [HSCL-25], the Beck Depression Inventory and the Generalized Anxiety Disorder Scale) in the association was analyzed using linear regression.
Results
Of the study population (n = 1505), 15.2% had bothersome and frequent LBP, and 29.0% had no LBP. A higher LDD sum score increased the odds of belonging to the “mild-to-moderate pain” category (adjusted OR corresponding to an increase of one point in the LDD sum score 1.11, 95% CI 1.04–1.18, P = 0.003) and the “bothersome-and-frequent pain” category (adjusted OR 1.20, 95% CI 1.10–1.31, P < 0.001), relative to the “no pain” category. Mental distress significantly modified the association between LDD and LBP, as a linear positive association was consistently observed among individuals without mental distress according to HSCL-25 (adjusted B 0.16, 95% CI 0.07–0.26, P < 0.001), but not among individuals with higher mental distress.
Conclusions
LDD was significantly associated with both mild-to-moderate and bothersome-and-frequent LBP. However, the co-occurrence of mental distress diminished the association between LDD and LBP bothersomeness. Our results strongly suggest that mental symptoms affect the pain experience.
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Sneath RJS, Khan A, Hutchinson C. An Objective Assessment of Lumbar Spine Degeneration/Ageing Seen on MRI Using An Ensemble Method-A Novel Approach to Lumbar MRI Reporting. Spine (Phila Pa 1976) 2022; 47:E187-E195. [PMID: 34224512 DOI: 10.1097/brs.0000000000004159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective, randomized, radiographic study assessing age-related changes (ARCs) on lumbar magnetic resonance imaging (MRI) using an ensemble method. OBJECTIVES This study proposed to develop a novel reporting method to calculate a predicted "age estimate" for the ARC seen on lumbar MRI. SUMMARY OF BACKGROUND DATA Lumbar MRI reports include pathological findings but usually not the prevalence data of common findings which has been shown to decrease the need for narcotics in the management of non-specific lower back pain (NSLBP). Comparing the normal age estimation for lumbar spine degenerative changes/ARC on MRI and comparing this to the patient's real age may improve patient outcome in the management of NSLBP. METHODS A total of 60 lumbar MRI were taken from patients aged between 0 and 100 years. Lumbar MRI features reported as associated with age on review of the literature were measured on each MRI and statistically evaluated for correlation with age. Factors found to be associated were then entered into an ensemble model consisting of several machine learning techniques. The resulting ensemble model was then tested to predict age for a further 10 random lumbar MRI scans. One further lumbar MRI was then assessed for observer variability. RESULTS Features that correlated with age were disc signal intensity, the appearance of paravertebral and psoas muscle, disc height, facet joint size, ligamentum flavum thickness, Schmorl nodes, Modic changes, vertebral osteophytes, and high-intensity zones. With the ensemble model, 80% of estimated spinal age were within 11 years of the subjects' physical age. CONCLUSION It would appear that the intervertebral discs, and many other structures that are subjected to loading in and around the lumbar spine change their lumbar MRI appearance in a predictable way with increasing age. ARC on lumbar MRI can be assessed to predict an "expected age" for the subject.Level of Evidence: 2.
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Liu C, Abdel Shaheed C, Braten LC, Hancock MJ, Underwood M, Jarvik JG, Elliott J, Maher CG, Buchbinder R, Lin CWC. Antibiotic treatment for low back pain or radicular pain, or both. Hippokratia 2021. [DOI: 10.1002/14651858.cd014221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Chang Liu
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- School of Public Health; Faculty of Medicine and Health, The University of Sydney; Sydney Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- School of Public Health; Faculty of Medicine and Health, The University of Sydney; Sydney Australia
| | - Lars Christian Braten
- Research and Communication Unit for Musculoskeletal Health (FORMI); Oslo University Hospital; Oslo Norway
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
| | - Mark J Hancock
- Faculty of Medicine, Health and Human Sciences; Macquarie University; Sydney Australia
| | - Martin Underwood
- Warwick Clinical Trials Unit; University of Warwick; Coventry UK
| | - Jeffrey G Jarvik
- Radiology and Neurological Surgery, Clinical Learning, Evidence And Research (CLEAR) Center; University of Washington School of Medicine; Seattle USA
| | - Julian Elliott
- Cochrane Australia; School of Public Health & Preventive Medicine; Melbourne Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- School of Public Health; Faculty of Medicine and Health, The University of Sydney; Sydney Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- School of Public Health; Faculty of Medicine and Health, The University of Sydney; Sydney Australia
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Din RU, Cheng X, Yang H. Diagnostic Role of Magnetic Resonance Imaging in Low Back Pain Caused by Vertebral Endplate Degeneration. J Magn Reson Imaging 2021; 55:755-771. [PMID: 34309129 DOI: 10.1002/jmri.27858] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 12/25/2022] Open
Abstract
Low back pain (LBP) is a common health issue worldwide with a huge economic burden on healthcare systems. In the United States alone, the cost is estimated to be $100 billion each year. Intervertebral disc degeneration is considered one of the primary causes of LBP. Moreover, the critical role of the vertebral endplates in disc degeneration and LBP is becoming apparent. Endplate abnormalities are closely correlated with disc degeneration and pain in the lumbar spine. Imaging modalities such as plain film radiography, computed tomography, and fluoroscopy are helpful but not very effective in detecting the causes behind LBP. Magnetic resonance imaging (MRI) can be used to acquire high-quality three-dimensional images of the lumbar spine without using ionizing radiation. Therefore, it is increasingly being used to diagnose spinal disorders. However, according to the American College of Radiology, current referral and justification guidelines for MRI are not sufficiently clear to guide clinical practice. This review aimed to evaluate the role of MRI in diagnosing LBP by considering the correlative contributions of vertebral endplates. The findings of the review indicate that MRI allows for fine evaluations of endplate morphology, endplate defects, diffusion and perfusion properties of the endplate, and Modic changes. Changes in these characteristics of the endplate were found to be closely correlated with disc degeneration and LBP. The collective evidence from the literature suggests that MRI may be the imaging modality of choice for patients suffering from LBP. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 3.
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Affiliation(s)
- Rahman Ud Din
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | | | - Haisheng Yang
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
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Manniche C, Hall GM. Chronic low back pain, Modic changes and low-grade virulent infection: efficacy of antibiotic treatment. Future Sci OA 2021; 7:FSO703. [PMID: 34046205 PMCID: PMC8147823 DOI: 10.2144/fsoa-2021-0026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Chronic low back pain (CLBP) has consistently been associated with the longest number of years lived with a disability in global studies, while commonly used treatments for CLBP are largely ineffective. In 2013 a randomized, double-blind, controlled study demonstrated significant improvements in CLBP patients demonstrating Modic changes type 1 on their MRI scans and undergoing long-term oral antibiotic treatment (100 days). Much of the ensuing debate has focused on whether this was a true infection or contamination. Newer and more advanced technologies clearly point to an ongoing low-grade infection. We have reviewed all of the clinical trials published in the recent past and conclude that there is compelling evidence for the effect of long-term oral antibiotic treatment for this patient group. Long-term oral antibiotic therapy has been shown to be effective for a subgroup of patients experiencing chronic low back pain and with Modic changes seen on their MRI scans. Newer and more sophisticated analyses have demonstrated that these Modic changes are often due to an ongoing low-grade infection. We provide an update of treatment results from the published literature and conclude that the evidence for the effectiveness of this new therapy is compelling and that further studies should focus on identifying which patients are best suited to undergo this form of treatment.
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Affiliation(s)
- Claus Manniche
- Department of Occupational & Environmental Medicine, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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21
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Larivière C, Preuss R, Gagnon DH, Mecheri H, Henry SM. Structural remodelling of the lumbar multifidus, thoracolumbar fascia and lateral abdominal wall perimuscular connective tissues: A cross-sectional and comparative ultrasound study. J Bodyw Mov Ther 2020; 24:293-302. [DOI: 10.1016/j.jbmt.2020.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 04/07/2020] [Accepted: 07/19/2020] [Indexed: 02/07/2023]
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Association Between Modic Changes and Low Back Pain in Middle Age: A Northern Finland Birth Cohort Study. Spine (Phila Pa 1976) 2020; 45:1360-1367. [PMID: 32341297 DOI: 10.1097/brs.0000000000003529] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A cross-sectional study of the Northern Finland Birth Cohort 1966 (NFBC1966). OBJECTIVE The aim of this study was to evaluate the association between the type, size, and location of lumbar Modic changes (MC), and prolonged disabling low back pain (LBP). SUMMARY OF BACKGROUND DATA LBP is the leading cause of disability worldwide and it affects all age- and socioeconomical groups. Only a small proportion of LBP patients are diagnosed with a specific cause: In most cases no single nociceptive cause for the pain can be identified. MC are visualized in magnetic resonance imaging (MRI) as a signal intensity change in vertebral bone marrow and have been proposed to represent a specific degenerative imaging phenotype associated with LBP. MC can be classified into several subtypes, of which inflammatory Type 1 (MC1) is suggested as being more likely to be associated with LBP. METHODS We assessed lumbar MRI (n = 1512) for the presence, type, and size of MC. The associations of MC characteristics with prolonged (≥30 days during the past year) and disabling (bothersomeness of LBP at least 6 on a 0-10 Numeric Rating Scale) LBP, evaluated at the time of imaging at 47 years, were analyzed using binary logistic regression, adjusted for sex, BMI, smoking, educational status, lumbar disc degeneration, and disc herniations. RESULTS Any MC and MC1 were associated with prolonged disabling LBP (odds ratio [OR] after full adjustments 1.50 [95% confidence interval, CI 1.05-2.15] and 1.50 [95% CI 1.10-2.05], respectively). Furthermore, MC covering the whole anterior-posterior direction or the whole endplate, as well as the height of MC, were significantly associated with prolonged disabling LBP (OR after full adjustments 1.59 [95% CI 1.14-2.20], 1.67 [95% CI 1.13-2.46] and 1.26 [95% CI 1.13-1.42], respectively). CONCLUSION Our study showed a significant and independent association between MC and clinically relevant LBP. LEVEL OF EVIDENCE 3.
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Ziegler DS, Jensen RK, Thomsen GF, Carreon L, Andersen MO. Returning to Work Within Two Years After First-Time, Single-Level, Simple Lumbar Discectomy: A Multifactorial, Predictive Model. JOURNAL OF OCCUPATIONAL REHABILITATION 2020; 30:274-287. [PMID: 31872381 DOI: 10.1007/s10926-019-09870-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Purpose Continued inability to work has societal and individual consequences. Thus, the factors associated with sustained return to work after lumbar discectomy should be identified. Prior studies of the biopsychosocial factors associated with sustained RTW were primarily based on patient-reported outcome data and have shown conflicting results because of small study samples. In patients undergoing first-time, single-level, simple lumbar discectomy, we describe the time to sustained return to work within 2 years after surgery using outcome data from a national database and identify the pre- and peri-operative factors associated with sustained return to work within 2 years by developing and validating a predictive multivariable model. Methods The time to a sustained return to work within the study period was described using a Kaplan-Meier plot. A temporal validated Cox proportional hazards model examined associations between biopsychosocial factors and return to work. Results In the derivation cohort made up by 351 operated patients who were on sick-leave for more than 3 weeks around the time of surgery, 62% returned to work (median 15 weeks). The probability of sustained return to work was associated with a high education level, positive expectations towards future labor market attachment, pre-operative stable labor market attachment, pre-operative higher physical quality of life, and less disability. Conclusions Through the development and validation of a predictive model, this study identifies a number of patient-related factors associated with sustained return to work after lumbar discectomy, while revealing that most disease-related clinical findings were not associated with the outcome.
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Affiliation(s)
- Dorthe Schoeler Ziegler
- Spine Surgery and Research, Spine Center of Southern Denmark - part of Lillebaelt Hospital, Oestre Hougvej 55, 5500, Middelfart, Denmark.
- Department of Regional Health Research, University of Southern Denmark, J.B. Winsloews Vej 19, 3, 5000, Odense C, Denmark.
| | - Rikke Krüger Jensen
- Nordic Institute of Chiropractic and Clinical Biomechanics, Campusvej 55, 5230, Odense M, Denmark
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark
| | - Gert Frank Thomsen
- Department of Occupational Medicine, Hospital of Southwest Jutland, Oestergade 81 - 83, 6700, Esbjerg, Denmark
| | - Leah Carreon
- Spine Surgery and Research, Spine Center of Southern Denmark - part of Lillebaelt Hospital, Oestre Hougvej 55, 5500, Middelfart, Denmark
- Department of Regional Health Research, University of Southern Denmark, J.B. Winsloews Vej 19, 3, 5000, Odense C, Denmark
| | - Mikkel Oesterheden Andersen
- Spine Surgery and Research, Spine Center of Southern Denmark - part of Lillebaelt Hospital, Oestre Hougvej 55, 5500, Middelfart, Denmark
- Department of Regional Health Research, University of Southern Denmark, J.B. Winsloews Vej 19, 3, 5000, Odense C, Denmark
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Ulrich NH, Burgstaller JM, Gravestock I, Winklhofer S, Porchet F, Pichierri G, Wertli MM, Steurer J, Farshad M. The influence of endplate (Modic) changes on clinical outcomes in lumbar spinal stenosis surgery: a Swiss prospective multicenter cohort study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:2205-2214. [PMID: 32157388 DOI: 10.1007/s00586-020-06364-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/26/2020] [Accepted: 03/03/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE To investigate if the presence or absence of preoperative endplate Modic changes (MC) is predictive for clinical outcomes in degenerative lumbar spinal stenosis (DLSS) patients undergoing decompression-alone or decompression with instrumented fusion surgery. METHODS Two hundred five patients were included and categorized into four groups; 102 patients into the decompression-alone group with MCs, 41 patients into the fusion group with MCs, 46 patients into the decompression-alone group without MCs, and 16 patients into the fusion group without MCs. Clinical outcome was quantified with changes in spinal stenosis measure (SSM) symptoms, SSM function, NRS pain, and EQ-5D-3L sum score over time (measured at baseline, 12-, 24-, and 36-month follow-up) and minimal clinically important difference (MCID) in SSM symptoms, SSM function, and NRS pain from baseline to 36-month follow-up. To investigate if possible effects of MCs had been modified or hidden by confounding variables, we used the group LASSO method to search for good prognostic models. RESULTS There were no obvious differences in any of the clinical outcome measures between groups at baseline. At 12 months, most patients have improved in all outcomes and maintained improved conditions over time (no significant group differences). Between 70 and 90 percent of the patients maintained a clinically important improvement up to 36 months. CONCLUSIONS Endplate MCs have no significant influence on clinical outcome parameters in patients with lumbar spinal stenosis compared to patients without MCs, independent of the chosen surgical strategy. All patients benefitted from surgical therapy up to 36-month follow-up. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Nils H Ulrich
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland. .,University Spine Centre Zurich, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
| | - Jakob M Burgstaller
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Isaac Gravestock
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Sebastian Winklhofer
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - François Porchet
- Department of Orthopedics and Neurosurgery, Spine Center, Schulthess Clinic, Zurich, Switzerland
| | - Giuseppe Pichierri
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Maria M Wertli
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland.,Division of General Internal Medicine, Bern University Hospital, Bern University, Bern, Switzerland
| | - Johann Steurer
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- University Spine Centre Zurich, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Ristolainen L, Kettunen JA, Danielson H, Heliövaara M, Schlenzka D. Magnetic resonance imaging findings of the lumbar spine, back symptoms and physical function among male adult patients with Scheuermann's disease. J Orthop 2020; 21:69-74. [PMID: 32139999 DOI: 10.1016/j.jor.2020.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/02/2020] [Indexed: 10/25/2022] Open
Abstract
Background There are only a few studies on untreated Scheuermann's disease and magnetic resonance imaging (MRI) findings in the lumbar spine. The primary aim of this study was to clarify lumbar MRI findings in patients with Scheuermann's disease and to compare with subjects without diagnosed spine disease. Methods Twenty-two male adult Scheuermann's patients (mean age 64.7 years (Standard Deviation [SD] 6.4) and 26 males (mean age 59.7 years [SD 7.4]) from a national health survey were included in this study. From MR images, the dimensions of the vertebral bodies, intervertebral discs and the dural sac were measured. Spondylolisthesis, Modic changes (MC), high intensity zone values (HIZ), and Schmorl's nodes were registered from both groups as well as self-reported data concerning general health, quality of life, and back pain symptoms. Results Significantly more patients with Scheuermann's disease had at least one MC compared to the controls at the level L1/L2 (Odds Ratio [OR] 21.11, 95% Confidence Interval [95% CI] 2.31-192.96), at the level L3/L4 (OR 13.62, 95% CI 1.41-131.26), and at the level L5/S1 (OR 6.11, 95% CI 1.50-24.83). Patients had significantly more Schmorl's nodes compared to the controls (64% vs. 8%, p < 0.001). The area of the dura sac (L3/L4) was larger (mean 201 mm2 vs. 152 mm2, p = 0.017) in the patients compared to controls. At level L1/L2 patients had higher disc than controls (mean 7.9 mm vs. 6.8 mm, p = 0.038). After adjusting for age patients had more commonly constant back pain (OR 9.4, 95% CI 1.56-56.97), and difficulties in walking up one floor without resting (OR 9.8, 95% CI 1.01-95.34) than controls. Conclusions Schmorl's nodes and Modic changes on lumbar MRI, back pain and physical function restrictions seem to be more prevalent among patients with Scheuermann's disease than in the general population.
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Affiliation(s)
- Leena Ristolainen
- Orton Orthopaedic Hospital, Helsinki, Finland, Tenholantie 10, PL 29, 00281, Helsinki, Finland
| | - Jyrki A Kettunen
- Arcada, University of Applied Sciences, Jan-Magnus Janssonin aukio 1, 00560, Helsinki, Finland
| | - Heidi Danielson
- Orton Orthopaedic Hospital, Helsinki, Finland, Tenholantie 10, PL 29, 00281, Helsinki, Finland
| | - Markku Heliövaara
- National Institute for Health and Welfare, Helsinki, Finland, Mannerheimintie 166, PL 30, 00271, Helsinki, Finland
| | - Dietrich Schlenzka
- Research Institute Orton, Helsinki, Finland, Tenholantie 10, PL 29, 00281, Helsinki, Finland
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Jensen RK, Jensen TS, Koes B, Hartvigsen J. Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:2143-2163. [PMID: 32095908 DOI: 10.1007/s00586-020-06339-1] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/27/2020] [Accepted: 02/09/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To estimate the prevalence of degenerative lumbar spinal stenosis (LSS) in adults, identified by clinical symptoms and/or radiological criteria. METHODS Systematic review of the literature. Pooled prevalence estimates by care setting and clinical or radiological diagnostic criteria were calculated and plotted [PROSPERO ID: CRD42018109640]. RESULTS In total, 41 papers reporting on 55 study samples were included. The overall risk of bias was considered high in two-thirds of the papers. The mean prevalence, based on a clinical diagnosis of LSS in the general population, was 11% (95% CI 4-18%), 25% (95% CI 19-32%) in patients from primary care, 29% (95% CI 22-36%) in patients from secondary care and 39% (95% CI 39-39%) in patients from mixed primary and secondary care. Evaluating the presence of LSS based on radiological diagnosis, the pooled prevalence was 11% (95% CI 5-18%) in the asymptomatic population, 38% (95% CI - 10 to 85%) in the general population, 15% (95% CI 13-18%) in patients from primary care, 32% (95% CI 22-41%) in patients from secondary care and 21% (95% CI 16-26%) in a mixed population from primary and secondary care. CONCLUSIONS The mean prevalence estimates based on clinical diagnoses vary between 11 and 39%, and the estimates based on radiological diagnoses similarly vary between 11 and 38%. The results are based on studies with high risk of bias, and the pooled prevalence estimates should therefore be interpreted with caution. With an growing elderly population, there is a need for future low risk-of-bias research clarifying clinical and radiological diagnostic criteria of lumbar spinal stenosis. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Rikke Krüger Jensen
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark. .,Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark.
| | - Tue Secher Jensen
- Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark.,Department of Diagnostic Imaging, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Bart Koes
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark.,Department of General Practice, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Jan Hartvigsen
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark.,Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark
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Hyperbaric oxygen treatment: A complementary treatment modality of Modic changes? Med Hypotheses 2020; 138:109617. [PMID: 32065934 DOI: 10.1016/j.mehy.2020.109617] [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: 12/08/2019] [Revised: 02/05/2020] [Accepted: 02/09/2020] [Indexed: 11/23/2022]
Abstract
Modic changes (MCs) have attracted great interest in recent years. The complex process of MC development and progression seems to involve interplay between mechanical, infective, inflammatory, and degenerative processes that cannot be clearly differentiated. Based on signal intensity on T1- and T2-weighted MRI scans, MCs can be divided three types: Type 1, Type 2, and Type 3. Predominantly Type 1 MCs are commonly associated with chronic low back pain that is unresponsive to classic treatment options. Infection with low-virulent anaerobic microorganisms, most commonly Propionibacterium acnes, has been implicated in MC development following a disc herniation when a tear enables bacteria to enter the disc. Recent studies in patients with chronic low back pain following a lumbar disc herniation associated with Type 1 MCs have reported promising results following prolonged systemic antibiotic treatment with amoxicillin-clavulanate. Hyperbaric oxygen therapy, as primary or adjuvant treatment in association combination with systemic antibiotics or anti-inflammatory therapy, could offer important advantages in treating patients with suspected low-virulent disc infections due to anaerobic microorganisms associated with Type 1 MCs. We believe that hyperbaric oxygenation could contribute to faster resolution of Type 1 MCs and associated pain through multiple effects-including direct antimicrobial effects through formation of reactive oxygen species (ROS), altering the favorable low oxygen tension milieu such that it becomes unfavorable for bacterial growth and survival, and anti-biofilm effects. Additionally, hyperbaric oxygenation could contribute to faster pain resolution via direct and indirect anti-inflammatory effects. As an adjuvant treatment administered in combination with systemic antibiotics, HBOT could increase the sensitivity of Propionibacterium acnes to antimicrobial drugs under hyperoxic conditions, resulting in faster MC resolution. Overall, the faster infection resolution, diminished bacterial load, and anti-inflammatory effects due to reduced cytokine expression and levels of infectious by-products could lead to faster pain resolution following HBOT, and a significant improvement of quality of life in these patients.
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Okano I, Salzmann SN, Jones C, Ortiz Miller C, Shirahata T, Rentenberger C, Shue J, Carrino JA, Sama AA, Cammisa FP, Girardi FP, Hughes AP. The impact of degenerative disc disease on regional volumetric bone mineral density (vBMD) measured by quantitative computed tomography. Spine J 2020; 20:181-190. [PMID: 31125693 DOI: 10.1016/j.spinee.2019.02.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/31/2019] [Accepted: 02/06/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT It has been reported that degenerative disc disease (DDD) is associated with higher spinal bone mineral density (BMD) based on previous studies that used dual X-ray absorptiometry (DXA). However, DDD is often associated with proliferative bone changes and can lead to an overestimation of BMD measured with DXA. Trabecular volumetric BMD (vBMD) in the vertebral body measured with quantitative computed tomography (QCT) is less affected by those changes and can be a favorable alternative to DXA for patients with degenerative spinal changes. PURPOSE The purpose of this study is to investigate the effect of DDD on regional trabecular vBMDs in the vertebral body measured by QCT. STUDY DESIGN/SETTING Cross-sectional observational study at a single academic institution. PATIENTS SAMPLE Consecutive patients undergoing posterior lumbar spinal fusion between 2014 and 2017 who had a routine preoperative CT scan and magnetic resonance imaging (MRI) within a 90-day interval. OUTCOME MEASURES Regional trabecular vBMDs in the vertebral body by QCT. METHODS QCT measurements were conducted in L1-S1 vertebral trabecular bone. Any apparent sclerotic lesions that might affect vBMD values were excluded from the region of interest. The vBMDs of each level were defined as the average vBMD of the upper and lower vertebrae. To evaluate DDD, Pfirrmann grade, Modic grade, total end plate score, and vacuum phenomenon were documented. Univariate regression analysis and multivariate analyses with a linear mixed model adjusted with individual variability of segmental vBMDs were conducted with vBMD as the response variable. RESULTS Of 143 patients and 715 disc levels, 125 patients and 596 discs met our inclusion criteria. Mean vBMD (±standard deviation [SD]) of all levels was 119.0±39.6 mg/cm3. After adjusting for all covariates, Pfirrmann grade was not an independent contributor to vBMD, but the presence of any Modic change (type 1, β=6.8, p≤.001; type 2, β=6.7, p<.001; type 3, β=43.6, p<.001), high TEPS (score 10-12, β=14.2, p<.001), or vacuum phenomenon (β=9.0, p<.001) was shown to be independent contributors to vBMD. CONCLUSIONS Our results showed that the presence of certain end plate lesions (Modic changes and high TEPS) on MRI was significantly associated with increased regional QCT-vBMDs in the vertebral body, but no significant association was observed with disc nucleus pathology, unless it was associated with a vacuum phenomenon. When end plate lesions with Modic changes and high TEPS are present at the measuring level, care must be taken to interpret vBMD values, which might be overestimations even if the trabecular area appears normal.
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Affiliation(s)
- Ichiro Okano
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Stephan N Salzmann
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Conor Jones
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Courtney Ortiz Miller
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Toshiyuki Shirahata
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA; Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Colleen Rentenberger
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - John A Carrino
- Department of Radiology and Imaging, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA.
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Viswanathan VK, Shetty AP, Rajasekaran S. Modic changes - An evidence-based, narrative review on its patho-physiology, clinical significance and role in chronic low back pain. J Clin Orthop Trauma 2020; 11:761-769. [PMID: 32879563 PMCID: PMC7452231 DOI: 10.1016/j.jcot.2020.06.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Lumbar degenerative spinal ailments are the most important causes for chronic low back pain. Modic changes (MC) are vertebral bone marrow signal intensity changes seen on MRI, commonly in association with degenerative disc disease (DDD). Despite being widely studied, majority of issues concerning MC are still controversial. The current narrative, evidence-based review comprehensively discusses the various aspects related to MC. LITERATURE SEARCH An elaborate search was made using keywords "Modic changes", "lumbar Modic changes", "Modic changes in lumbar spine", and "vertebral Endplate Spinal Changes", on pubmed and google (scholar.google.com) databases on the 3rd of March 2020. We identified crucial questions regarding Modic changes and included relevant articles pertaining to these topics for this narrative review. RESULTS The initial search using the keywords "Modic changes", "lumbar Modic changes", "Modic changes in lumbar spine", and "vertebral Endplate Spinal Changes" on pubmed yielded a total of 568, 412, 394 and 216 articles on "pubmed" database, respectively. A similar search using the aforementioned keywords yielded a total of 3650, 3548, 3726 and 21570 articles on "google scholar" database. The initial screening involved exclusion of duplicate articles, articles unrelated to MC, animal or other non-clinical studies, and articles in non-English literature based on abstracts or the titles of articles. This initial screening resulted in the identification of 405 articles. Full manuscripts were obtained for all these selected articles and thoroughly scrutinised at the second stage of article selection. All articles not concerning Modic changes, not pertaining to concerned questions, articles concerning other degenerative phenomena, articles discussing cervical or thoracic MC, case reports or animal studies, articles in non-English language and duplicate articles were excluded. Review articles, randomised controlled trials and level 1 studies were given preference. Overall, 69 articles were included in this review. CONCLUSION Modic change (MC) is a dynamic phenomenon and its true etiology is still not definitely known. Disc/end plate injury, occult discitis and autoimmune reactions seem to trigger an inflammatory cascade, which leads to their development. Male sex, older age, diabetes mellitus, genetic factors, smoking, obesity, spinal deformities, higher occupational loads and DDD are known risk factors. There is no conclusive evidence on the causative role of MC in chronic low back pain (LBP) or any influence on the long term outcome in patients with LBP or lumbar disc herniations (LDH). Patients with MC have been reported to have less satisfactory outcome following conservative treatment or discectomy, although the evidence is still unclear.
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Affiliation(s)
| | - Ajoy Prasad Shetty
- Department of Spine Surgery, Ganga Medical Center and Hospitals, Coimbatore, India,Corresponding author.
| | - S. Rajasekaran
- Department of Spine Surgery, Ganga Medical Center and Hospitals, Coimbatore, India,Department of Orthopedics, Ganga Medical Center and Hospitals, Coimbatore, India
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Where do patients with MRI-confirmed single-level radiculopathy experience pain, and what is the clinical interpretability of these pain patterns? A cross-sectional diagnostic accuracy study. Chiropr Man Therap 2019; 27:50. [PMID: 31608144 PMCID: PMC6778979 DOI: 10.1186/s12998-019-0273-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 07/18/2019] [Indexed: 11/10/2022] Open
Abstract
Background Clinicians nominate the distribution of leg pain as being important in diagnosing nerve root involvement. This study aimed to identify: (i) common unisegmental radicular pain patterns and whether they were dermatomal, and (ii) whether these radicular pain patterns assisted clinician discrimination of the nerve root level involved. Methods A cross-sectional diagnostic accuracy study of adult patients with radicular leg pain at a hospital in Denmark. All patients had positive neurological signs (average 2.8 signs - hypoalgesia, diminished reflexes, muscle weakness, positive Straight Leg Raise test).Part 1 (pain patterns) was a secondary analysis of baseline pain pattern data collected during a clinical trial. The pain charts of 93 patients with an MRI and clinically confirmed single-level disc herniation with nerve root compression were digitised and layered to form a composite picture of the radicular patterns for the L5 and S1 nerve roots, which were then compared to published dermatomes.In Part 2 (clinical utility) we prospectively measured the discriminative ability of the identified pain patterns. The accuracy was calculated of three groups of six clinicians at classifying the nerve root affected in a randomized sequence of 53 patients, when not shown, briefly shown or continuously shown the composite pain patterns. In each group were two chiropractors, two medical doctors and two physiotherapists. Results There was a wide overlap in pain patterns from compromised L5 and S1 nerve roots but some distinguishing features. These pain patterns had approximately 50 to 80% overlap with published dermatomes. Clinicians were unable to determine with any accuracy above chance whether an individual pain drawing was from a person with a compromised L5 or S1 nerve root, and use of the composite pain drawings did not improve that accuracy. Conclusions While pain distribution may be an indication of radiculopathy, pain patterns from L5 or S1 nerve root compression only approximated those of sensory dermatomes, and level-specific knowledge about radicular pain patterns did not assist clinicians' diagnostic accuracy of the nerve root impinged. These results indicate that, on their own, pain patterns provide very limited additional diagnostic information about which individual nerve root is affected.
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Jensen OK, Andersen MH, Østgård RD, Andersen NT, Rolving N. Probiotics for chronic low back pain with type 1 Modic changes: a randomized double-blind, placebo-controlled trial with 1-year follow-up using Lactobacillus Rhamnosis GG. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:2478-2486. [DOI: 10.1007/s00586-019-06046-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/14/2019] [Accepted: 06/20/2019] [Indexed: 02/02/2023]
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The Association Between Preoperative MRI Findings and Surgical Revision Within Three Years After Surgery for Lumbar Disc Herniation. Spine (Phila Pa 1976) 2019; 44:818-825. [PMID: 31095073 DOI: 10.1097/brs.0000000000002947] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This cohort study was an analysis of prospectively collected data in the DaneSpine Database. OBJECTIVE The objective was to determine whether preoperative magnetic resonance imaging (MRI) findings were associated with the frequency of surgical revision due to recurrent lumbar disc herniation (LDH) within 3 years after first-time, single-level, simple lumbar discectomy. SUMMARY OF BACKGROUND DATA Because of a risk of poorer outcome in patients receiving revision surgery compared with first-time discectomy, there is a need to identify patients with LDH in risk of surgical revision prior to the primary discectomy. The association between preoperative MRI findings and revision surgery in patients with LDH has not been thoroughly studied. METHODS Following an interobserver reliability study preoperative MRIs were evaluated. Potential predictive variables for surgical revision were evaluated using univariate and multivariate logistic regression analysis. Also, a sum-score of the number of MRI findings at the involved level was assessed. RESULTS In a study population of 451 operated patients, those who had surgical revision were significantly younger and were significantly less likely to have vertebral endplate signal changes Type 2 (OR 0.36 (95% CI 0.15-0.88)) or more than five MRI findings (OR 0.45 (95% CI 0.21-0.95)) at the involved level than the patients not undergoing surgical revision. Surgical revision was not significantly associated with any other MRI findings. CONCLUSIONS In general, preoperative MRI findings have a limited explanatory value in predicting surgical revision within 3 years after first-time, single-level, simple lumbar discectomy. Both the single variable VESC Type 2 and a sum-score > 5 MRI findings at the operated level were found to be negatively associated with patients undergoing surgical revision. LEVEL OF EVIDENCE 3.
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Ravindra VM, Senglaub SS, Rattani A, Dewan MC, Härtl R, Bisson E, Park KB, Shrime MG. Degenerative Lumbar Spine Disease: Estimating Global Incidence and Worldwide Volume. Global Spine J 2018; 8:784-794. [PMID: 30560029 PMCID: PMC6293435 DOI: 10.1177/2192568218770769] [Citation(s) in RCA: 227] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
STUDY DESIGN Meta-analysis-based calculation. OBJECTIVES Lumbar degenerative spine disease (DSD) is a common cause of disability, yet a reliable measure of its global burden does not exist. We sought to quantify the incidence of lumbar DSD to determine the overall worldwide burden of symptomatic lumbar DSD across World Health Organization regions and World Bank income groups. METHODS We used a meta-analysis to create a single proportion of cases of DSD in patients with low back pain (LBP). Using this information in conjunction with LBP incidence rates, we calculated the global incidence of individuals who have DSD and LBP (ie, their DSD has neurosurgical relevance) based on the Global Burden of Disease 2015 database. RESULTS We found that 266 million individuals (3.63%) worldwide have DSD and LBP each year; the highest and lowest estimated incidences were found in Europe (5.7%) and Africa (2.4%), respectively. Based on population sizes, low- and middle-income countries have 4 times as many cases as high-income countries. Thirty-nine million individuals (0.53%) worldwide were found to have spondylolisthesis, 403 million (5.5%) individuals worldwide with symptomatic disc degeneration, and 103 million (1.41%) individuals worldwide with spinal stenosis annually. CONCLUSIONS A total of 266 million individuals (3.63%) worldwide were found to have DSD and LBP annually. Significantly, data quality is higher in high-income countries, making overall quantification in low- and middle-income countries less complete. A global effort to address degenerative conditions of the lumbar spine in regions with high demand is important to reduce disability.
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Affiliation(s)
| | | | - Abbas Rattani
- Harvard Medical School, Boston, MA, USA
- Meharry Medical College, Nashville, TN, USA
| | - Michael C. Dewan
- Harvard Medical School, Boston, MA, USA
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Roger Härtl
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY,
USA
| | | | | | - Mark G. Shrime
- Harvard Medical School, Boston, MA, USA
- Massachusetts Eye and Ear Infirmary, Boston, MA, USA
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Zhou J, Li L, Li T, Xue Y. Preoperative Modic changes are related to axial symptoms after anterior cervical discectomy and fusion. J Pain Res 2018; 11:2617-2623. [PMID: 30464580 PMCID: PMC6209067 DOI: 10.2147/jpr.s172953] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The objective of this study was to compare the clinical and radiological outcomes between patients with or without axial symptoms (AS) and investigate the risk factors associated with AS by multivariate regression analysis in anterior cervical discectomy and fusion (ACDF). Materials and methods The records of 117 patients who underwent ACDF were reviewed for clinical and radiological outcomes. These outcomes were evaluated before and after surgery and at the last follow-up. Preoperative Modic changes (MCs) adjacent to the treated disc were identified. Risk factors for AS were detected through logistic regression analysis. Results The patients were divided into two groups: one with AS (AS group, n=35) and the other without (NAS group, n=82). Visual Analog Scale values after the operation (P=0.013) and at final follow-up (P<0.001) and preoperative segmental angle (P=0.031) were significantly different between the two groups. There were no significant differences with respect to other clinical and radiographic outcomes between the two groups (P>0.05). Logistic regression analysis revealed that preoperative segmental kyphosis (OR =2.912, P=0.035) and MCs (odds ratio =3.268, P=0.015) were the risk factors for the occurrence of AS. Conclusion AS do not correlate with recovery of neural function in patients treated by ACDF. In addition, preoperative segmental kyphosis and MCs at the fusion segment were found to affect the incidence of AS after ACDF.
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Affiliation(s)
- Jiaming Zhou
- Department of Orthopedics Surgery, Tianjin Medical University General Hospital, Heping District, Tianjin 300052, People's Republic of China,
| | - Liandong Li
- Department of Orthopedics Surgery, Tianjin Medical University General Hospital, Heping District, Tianjin 300052, People's Republic of China,
| | - Tengshuai Li
- Department of Orthopedics Surgery, Tianjin Hospital, Hexi District, Tianjin 300211, People's Republic of China
| | - Yuan Xue
- Department of Orthopedics Surgery, Tianjin Medical University General Hospital, Heping District, Tianjin 300052, People's Republic of China,
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Wu JP, Wang QB, Feng XJ, Wang Q, Cheng MH. Relationship Between Modic Changes and Sagittal Balance Parameters in the Cervical Spine. Med Sci Monit 2018; 24:6102-6106. [PMID: 30173243 PMCID: PMC6131981 DOI: 10.12659/msm.909773] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background We explored the possible relationship between Modic changes (MCs) and sagittal parameters of the cervical spine. Material/Methods We enrolled 150 patients with cervical MC on the magnetic resonance imaging (MRI) scans in the MC (+) group and divided them into 3 sub-groups with 50 patients each: the MC1 sub-group, the MC2 sub-group, and the MC3 sub-group. Another 150 healthy subjects receiving routine health examinations were also enrolled in the study as the MC (−) group. The sagittal parameters in the cervical spine were measured and compared and multiple logistic regression analysis was performed to analyze the risk factor for the occurrence of MC. Results Four cervical sagittal parameters were measured and compared between all the enrolled groups, including neck tilt (NT), T1 slope (T1s), thoracic inlet angle (TIA), and Cobb C2–C7. The results confirmed that the parameter of Cobb C2–C7 was much smaller in the MC(+) group when compared with that in the MC(−) group (P<0.05), while no significant differences were detected between the MC(+) and MC(−) groups for the parameters of NT, T1 T1s, and TIA (P>0.05). Multiple logistic regression analysis showed that Cobb C2–C7 (less than 8.5°) could be regarded as the risk factor for the occurrence of MC, and the receiver operating characteristic (ROC) curve showed that moderate diagnostic significance was obtained with an area under curve (AUC) of 0.82. Conclusions The present study demonstrated that Cobb C2–C7 (less than 8.5°) is a potential risk factor for the development of MC.
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Affiliation(s)
- Jian-Ping Wu
- Department of Orthopaedics, People's Hospital of Yixing, Yixin, Jiangsu, China (mainland)
| | - Quan-Bin Wang
- Department of Orthopedics, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, China (mainland)
| | - Xiao-Jun Feng
- People's Hospital of Xishan District, Wux, Jiangsu, China (mainland)
| | - Qiang Wang
- Department of Orthopaedics, People's Hospital of Yixing, Yixin, Jiangsu, China (mainland)
| | - Mao-Hua Cheng
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow, Suzhou, Jiangsu, China (mainland)
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Zhou J, Li T, Li L, Xue Y. Clinical efficacy of calcitonin compared to diclofenac sodium in chronic nonspecific low back pain with type I Modic changes: a retrospective study. J Pain Res 2018; 11:1335-1342. [PMID: 30046250 PMCID: PMC6054296 DOI: 10.2147/jpr.s158718] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background The objective of this study was to compare the efficacy of calcitonin with diclofenac sodium in the treatment of patients with nonspecific low back pain (LBP) and type I Modic changes (MC1). Patients and methods The study was a retrospective observational study with 109 patients who had nonspecific LBP and MC1 that appeared as bone marrow lesions on magnetic resonance imaging (MRI). Between October 2013 and March 2016, 62 patients were injected intramuscularly with calcitonin 50 IU once daily and 47 patients were treated with diclofenac 75 mg once per day for 4 weeks for the treatment of LBP associated with MC1 on MRI. Visual analog scale (VAS) (0–10) and Oswestry Disability Index (ODI) (0–100) questionnaires were acquired from clinical records to evaluate LBP perception and degree of disability. Imaging data were also collected before and after treatment. Results Significant improvements were found in VAS and ODI at posttreatment compared with baseline in both groups (P < 0.05). Meanwhile, there was a significant difference between calcitonin group and diclofenac group at both 4 weeks and 3 months of follow-up (4 weeks: VAS 4.46 ± 1.58 vs 5.08 ± 1.50, ODI 20.32 ± 9.64 vs 24.35 ± 7.95; 3 months: VAS 3.70 ± 1.74 vs 4.51 ± 1.67, ODI 16.67 ± 9.04 vs 21.18 ± 9.56; P < 0.05 for all). Moreover, the proportion of patients with a significant change in LBP scales was higher in the calcitonin group (4 weeks: VAS 50.00% vs 23.40%, ODI 54.83% vs 25.53%; 3 months: VAS 58.06% vs 38.29%, ODI 59.67% vs 38.29%; P < 0.05 for all). According to MRI, 43.54% patients in the calcitonin group showed improvement compared with 21.27% patients in the diclofenac group (P < 0.05). Conclusion There was greater short-term efficacy of calcitonin compared with diclofenac in patients with LBP and MC1 on MRI.
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Affiliation(s)
- Jiaming Zhou
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China, .,Graduate School, Tianjin Medical University, Tianjin, People's Republic of China
| | - Tengshuai Li
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China,
| | - Liandong Li
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China,
| | - Yuan Xue
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China,
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Predictive value of Modic type II changes in the choice of surgical treatment of lumbar disc herniation. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018. [DOI: 10.1016/j.recote.2017.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Predictive value of Modic type II changes in the choice of surgical treatment of lumbar disc herniation. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018; 62:297-301. [PMID: 29426732 DOI: 10.1016/j.recot.2017.11.001] [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: 08/21/2017] [Revised: 11/01/2017] [Accepted: 11/07/2017] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the predictive value of Modic typeII changes on nuclear magnetic resonance (NMR) prior to intervention by discectomy for lumbar disc herniation in patients with radicular symptoms. MATERIAL AND METHOD Retrospective descriptive study of 190 patients (58.2% men and 41.8% women) with a mean age of 43.5 years, treated between December 2005 and January 2013. They were divided into group 1, single disc herniation (n=85), and group 2, with disc herniation and changes Modic typeII (n=80). Variables studied: weight, height, handedness, level of injury, previous neurological deficit, postoperative complications, persistent pain and need for posterior lumbar fusion, with a mean of 67 months (group 1: 68.1; group 2: 66.8). RESULTS In group 1 there were four hernia recurrences requiring revision surgery and six patients needed lumbar fusion. In group 2, four recurrences were also revised and eight cases requiring arthrodesis were observed. No statistically significant differences were found when comparing the occurrence of relapse (P=.903), the need for subsequent fusion (P=.572) or in the remaining variables. DISCUSSION The data obtained and the characteristics of our study, we cannot say that Modic typeII changes were a predictive sign of the result of lumbar discectomy in our study population.
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Shahidi B, Hubbard JC, Gibbons MC, Ruoss S, Zlomislic V, Allen RT, Garfin SR, Ward SR. Lumbar multifidus muscle degenerates in individuals with chronic degenerative lumbar spine pathology. J Orthop Res 2017; 35:2700-2706. [PMID: 28480978 PMCID: PMC5677570 DOI: 10.1002/jor.23597] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 05/03/2017] [Indexed: 02/04/2023]
Abstract
Histological and cell-level changes in the lumbar musculature in individuals with chronic lumbar spine degenerative conditions are not well characterized. Although prior literature supports evidence of changes in fiber type and size, little information exists describing the tissue quality and biology of pathological features of muscle in this population. The purpose of this study was to quantify multifidus tissue composition and structure, inflammation, vascularity, and degeneration in individuals with chronic degenerative lumbar spine pathology. Human multifidus biopsies were acquired from 22 consecutive patients undergoing surgery for chronic degenerative lumbar spine pathology. Relative fractions of muscle, adipose, and extracellular matrix were quantified along with muscle fiber type and cross-sectional area (CSA) and markers of inflammation, vascularity, satellite cell density, and muscle degeneration. On average, multifidus biopsies contained 48.5% muscle, 11.7% adipose tissue, and 26.1% collagen tissue. Elevated inflammatory cell counts (48.5 ± 30.0 macrophages/mm2 ) and decreased vascularity (275.6 ± 69.4 vessels/mm2 ) were also observed compared to normative values. Satellite cell densities were on average 13 ± 9 cells per every 100 muscle fibers. Large fiber CSA (3,996.0 ± 1,909.2 µm2 ) and a predominance of type I fibers (61.8 ± 18.0%) were observed in addition to evidence of pathological degeneration-regeneration cycling (18.8 ± 9.4% centrally nucleated fibers, and 55.2 ± 24.2% of muscle regions containing degeneration). High levels of muscle degeneration, inflammation, and decreased vascularity were commonly seen in human multifidus biopsies of individuals with lumbar spine pathology in comparison to normative data. Evidence of active muscle degeneration suggests that changes in muscle tissue are more complex than simple atrophy. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2700-2706, 2017.
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Affiliation(s)
- Bahar Shahidi
- University of California San Diego Department of Radiology, San Diego USA,University of California San Diego Department of Orthopaedic Surgery, San Diego, USA
| | - James C Hubbard
- University of California San Diego Department of Orthopaedic Surgery, San Diego, USA
| | - Michael C Gibbons
- University of California San Diego Department of Bioengineering, San Diego USA
| | - Severin Ruoss
- University of Zurich Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
| | - Vinko Zlomislic
- University of California San Diego Department of Orthopaedic Surgery, San Diego, USA
| | - R. Todd Allen
- University of California San Diego Department of Orthopaedic Surgery, San Diego, USA
| | - Steven R Garfin
- University of California San Diego Department of Orthopaedic Surgery, San Diego, USA
| | - Samuel R Ward
- University of California San Diego Department of Radiology, San Diego USA,University of California San Diego Department of Orthopaedic Surgery, San Diego, USA,University of California San Diego Department of Bioengineering, San Diego USA
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Abstract
UNLABELLED : Imaging is important in the evaluation of patients with degenerative disease and infectious processes. There are numerous conditions that can manifest as low back pain (LBP) or neck pain in a patient, and in many cases, the cause may be multifactorial. Clinical history and physical examination are key components in the evaluation of such patients; however, physical examination has variable sensitivity and specificity. Although studies have demonstrated that uncomplicated acute LBP and/or radiculopathy are self-limited conditions that do not warrant any imaging, neuroimaging can provide clear anatomic delineation of potential causes of the patient's clinical presentation. Various professional organizations have recommendations for imaging of LBP, which generally agree that an imaging study is not indicated for patients with uncomplicated LBP or radiculopathy without a red flag (eg, neurological deficit such as major weakness or numbness in lower extremities, bowel or bladder dysfunction, saddle anesthesia, fever, history of cancer, intravenous drug use, immunosuppression, trauma, or worsening symptoms). Different imaging modalities have a complementary role in the diagnosis of pathologies affecting the spine. In this review, we discuss the standard nomenclature for lumbar disk pathology and the utility of various clinical imaging techniques in the evaluation of LBP/neck pain for potential neurosurgical management. The imaging appearance of spinal infections and potential mimics also is reviewed. Finally, we discuss advanced neuroradiological techniques that offer greater microstructural and functional information. ABBREVIATIONS ADC, apparent diffusion coefficientDTI, diffusion tensor imagingDWI, diffusion-weighted imagingDOM, diskitis-osteomyelitisLBP, low back painMRM, magnetic resonance myelographySNA, spinal neuroarthropathySPECT, single-positron emission computed tomographySTIR, short tau inversion recovery.
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Affiliation(s)
- Lubdha M Shah
- Departments of *Radiology and Imaging Sciences and ‡Neurosurgery, University of Utah, Salt Lake City, Utah; §Department of Radiology, Mayo Clinic Arizona, Scottsdale, Arizona
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Zandwijk P, van Koppen B, van Mameren H, Winkens B, de Bie R. Physical activity preferences of patients experiencing non-specific low back pain. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2017. [DOI: 10.1080/21679169.2017.1357753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Pim Zandwijk
- Centre for Physical Therapy, Papendrecht, The Netherlands
| | | | - Henk van Mameren
- Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University/CAPHRI School for Public Health and Primary Care, Maastricht, The Netherlands
| | - Rob de Bie
- Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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An Y, Li J, Li Y, Shen Y. Characteristics of Modic changes in cervical kyphosis and their association with axial neck pain. J Pain Res 2017; 10:1657-1661. [PMID: 28769586 PMCID: PMC5529086 DOI: 10.2147/jpr.s138361] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate characteristics of Modic changes in cervical kyphosis (CK) and their association with axial neck pain. METHODS Study participants included 286 asymptomatic or symptomatic patients with CK (mean age = 54.2 ± 12.2 years) who were consecutively enrolled from March 2009 to October 2015. Clinical and radiographic evaluations were performed at a university outpatient department. CK was classified as global type, reverse sigmoid type, or sigmoid type. RESULTS There were 138 participants with global type CK, 103 with reverse sigmoid type CK, and 45 with sigmoid type CK. Of the 286 participants, 102 had Modic changes (Modic-1 in 38 segments and Modic-2 in 75 segments). Spinal cord compression grade and disc degeneration occurred more frequently in the group with axial neck pain compared to the group without pain. Angular motion was decreased in those with axial neck pain (mean ± standard deviation [SD] 7.8°±4.6°) compared to those who were asymptomatic (mean ± SD 8.9°±5.1°; P<0.001). In multivariate logistic regression analysis, Modic changes were associated with axial neck pain (odds ratio =5.356; 95% confidence interval =1.314-12.800; P<0.001). CONCLUSION Modic changes occur most commonly in association with CK global type and less commonly with reverse sigmoid type and sigmoid type. Modic changes are associated with axial neck pain in patients with CK.
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Affiliation(s)
- Yonghui An
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China.,The Key Laboratory of Orthopedic Biomechanics of Hebei Province, The Third Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China
| | - Jia Li
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China.,The Key Laboratory of Orthopedic Biomechanics of Hebei Province, The Third Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China
| | - Yongqian Li
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China.,The Key Laboratory of Orthopedic Biomechanics of Hebei Province, The Third Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China
| | - Yong Shen
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China.,The Key Laboratory of Orthopedic Biomechanics of Hebei Province, The Third Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China
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Are Modic Changes Able to Help Us in Our Clinical Practice? A Study of the Modic Changes in Young Adults During Working Age. Clin Spine Surg 2017. [PMID: 28632548 DOI: 10.1097/bsd.0000000000000195] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Modic changes [vertebral endplate spinal changes (VESC)] have been related to degenerative disk disease, and in past decades it was thought that their presence justified the surgical treatment, in particular spinal fusion. OBJECTIVE The aim of the present study is to investigate its prevalence and features in a population of young workers suffering from low back pain, and explore the eventual relationship with the treatment applied in each case. BACKGROUND DATA We conducted a retrospectively review of 450 magnetic resonance images from our hospital, in patients with low back pain or sciatica and age below 40. MATERIALS AND METHODS Age, sex, symptoms predominance, concurrence with other spine disease, VESC type, evolution, level/s of involvement and placement, affected disk location and extent of the disease, disk height, and status of the endplate were recorded. The applied treatment was divided in groups according to the degree of invasiveness of the procedure. RESULTS Prevalence of VESC was 13.05% predominant in patients over 30 years, and 100% associated to disk degenerative changes. Most frequent features were: type I (54%), lower lumbar region (98%), along with a decreased disk height (68%), and distortion of the disk endplates (98%, P<0.01). The patients with VESC presented a favorable outcome with conservative treatment, but were more frequently associated with invasive treatment, compared with non-VESC patients (P<0.024). CONCLUSIONS VESC prevalence increases with age, underlying the degenerative causative etiology. Surgical indication should not be stated on the basis of the VESC findings alone, the main factor for indicating surgery depends more on other associated degenerative spinal changes.
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Abstract
STUDY DESIGN Retrospective chart analysis of 199 individuals aged 18 to 80 years scheduled for lumbar spine surgery. OBJECTIVE The purpose of this study was to quantify changes in muscle cross-sectional area (CSA) and fat signal fraction (FSF) with age in men and women with lumbar spine pathology and compare them to published normative data. SUMMARY OF BACKGROUND DATA Pathological changes in lumbar paraspinal muscle are often confounded by age-related decline in muscle size (CSA) and quality (fatty infiltration). Individuals with pathology have been shown to have decreased CSA and fatty infiltration of both the multifidus and erector spinae muscles, but the magnitude of these changes in the context of normal aging is unknown. METHODS Individuals aged 18 to 80 years who were scheduled for lumbar surgery for diagnoses associated with lumbar spine pain or pathology were included. Muscle CSA and FSF of the multifidus and erector spinae were measured from preoperative T2-weighted magnetic resonance images at the L4 level. Univariate and multiple linear regression analyses were performed for each outcome using age and sex as predictor variables. Statistical comparisons of univariate regression parameters (slope and intercept) to published normative data were also performed. RESULTS There was no change in CSA with age in either sex (P > 0.05), but women had lower CSAs than men in both muscles (P < 0.0001). There was an increase in FSF with age in erector spinae and multifidus muscles in both sexes (P < 0.0001). Multifidus FSF values were higher in women with lumbar spine pathology than published values for healthy controls (P = 0.03), and slopes tended to be steeper with pathology for both muscles in women (P < 0.08) but not in men (P > 0.31). CONCLUSION Lumbar muscle fat content, but not CSA, changes with age in individuals with pathology. In women, this increase is more profound than age-related increases in healthy individuals. LEVEL OF EVIDENCE 3.
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Hybrid Bone Single Photon Emission Computed Tomography Imaging in Evaluation of Chronic Low Back Pain: Correlation with Modic Changes and Degenerative Disc Disease. World Neurosurg 2017; 104:816-823. [PMID: 28377243 DOI: 10.1016/j.wneu.2017.03.107] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 03/22/2017] [Accepted: 03/23/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Multiple radiologic modalities are used in the evaluation of patients with low back pain (LBP). Only limited evidence currently exists to support the use of bone hydroxydiphosphonate single photon emission computed tomography (SPECT/CT) in patients with Modic changes (MCs) and degenerative disc disease. The aim of this study was to assess the value of the hybrid bone SPECT/CT imaging in patients with chronic LBP. We evaluate the correlation of hybrid bone SPECT/CT imaging patterns with MCs and disc abnormalities on magnetic resonance imaging (MRI). METHODS This was a prospective study. Ninety-nine consecutive patients with LBP from a single center. The degree of lumbar intervertebral disc and endplate degeneration on MRI and osteoblastic activity was shown on SPECT/CT. These 99 consecutive patients with LBP were prospectively evaluated. Patients with contemporary lumbosacral spine MRI and bone SPECT/CT were included. Patients with known or suspected malignancy, trauma, infectious processes, and previous surgery were excluded. The effect of LBP on the daily quality of life was assessed using Oswestry disability index. We analyzed the correlation between the degenerative changes at the intervertebral disc spaces and endplates on MRI and bone SPECT/CT findings using receiver operating characteristic curve analysis and Kappa statistics. The Pfirrmann grading system was used to score the severity of disc space degeneration on MRI scans. RESULTS A total of 99 patients were included in the study (58 women, 41 men; mean age, 56.2 years). Mean Oswestry disability index score was 38.5% (range, 8%-72%). The L2-3 through to L5-S1 levels were studied. MCs were found in 54% of patients. Of the 396 levels examined 85 were found to have MCs (21.5%). The most affected levels were L4-5 (31.3%) and L5-S1 (40.9%). Pfirrmann grade 5 disc space (72.9%) was associated with MC (Pp<0.001). MC (70.6%) and Pfirrmann grade 5 disc spaces (73%) resulted in scintigraphically active endplate/disc space on SPECT/CT (P< 0.001). Bone SPECT/CT showed high metabolic activity in 96.1% of endplates with MC type I, 56% with MC type II, and 77.8% with MC type III. CONCLUSIONS In this study we found a high agreement between MCs and increased metabolic activity on bone SPECT/CT imaging. MC type 1 and Pfirrmann grade 5 were the best binary predictors for positivity on bone SPECT/CT and had equivalent correlations. Lower vertebral levels in the lumbar spine were associated with higher degree of disc degeneration, high frequency of MCs, and positivity on bone SPECT/CT.
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Do MRI Findings Change Over a Period of Up to 1 Year in Patients With Low Back Pain and/or Sciatica?: A Systematic Review. Spine (Phila Pa 1976) 2017; 42:504-512. [PMID: 27428391 DOI: 10.1097/brs.0000000000001790] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review OBJECTIVE.: The aim of the study was to investigate whether magnetic resonance imaging (MRI) findings change over a relatively short period of time (<1 yr) in people with low back pain (LBP) or sciatica. We also investigated whether there was an association between any change in MRI findings and change in clinical outcomes. SUMMARY OF BACKGROUND DATA MRI offers the potential to identify possible pathoanatomic sources of LBP and/or sciatica; however, the clinical importance of MRI findings remains unclear. Little is known about whether lumbar MRI findings change over the short term and if so whether these changes are associated with changes in clinical outcomes. METHODS Medline, EMBASE, and CINAHL databases were searched. Included were cohort studies that performed repeat MRI scans within 12 months in patients with LBP and/or sciatica. Data on study characteristics and change in MRI findings were extracted from included studies. Any data describing associations between change in MRI findings and change in clinical outcomes were also extracted. RESULTS A total of 12 studies met the inclusion criteria and were included in the review. Pooling was not possible due to heterogeneity of studies and findings. Seven studies reported on changes in disc herniation and reported 15% to 93% of herniations reduced or disappeared in size. Two studies reported on changes in nerve root compression and reported 17% to 91% reduced or disappeared. Only one study reported on the association between change in MRI findings and change in clinical outcomes within 1 year, and found no association. CONCLUSION This review found moderate evidence that the natural course of herniations and nerve root compression is favorable over a 1-year period in people with sciatica or LBP. There is a lack of evidence on whether other MRI findings change, and whether changes in MRI findings are associated with changes in clinical outcomes. LEVEL OF EVIDENCE 1.
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Dudli S, Fields AJ, Samartzis D, Karppinen J, Lotz JC. Pathobiology of Modic changes. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:3723-3734. [PMID: 26914098 PMCID: PMC5477843 DOI: 10.1007/s00586-016-4459-7] [Citation(s) in RCA: 228] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 02/06/2016] [Accepted: 02/07/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE Low back pain (LBP) is the most disabling condition worldwide. Although LBP relates to different spinal pathologies, vertebral bone marrow lesions visualized as Modic changes on MRI have a high specificity for discogenic LBP. This review summarizes the pathobiology of Modic changes and suggests a disease model. METHODS Non-systematic literature review. RESULTS Chemical and mechanical stimulation of nociceptors adjacent to damaged endplates are likely a source of pain. Modic changes are adjacent to a degenerated intervertebral disc and have three generally interconvertible types suggesting that the different Modic change types represent different stages of the same pathological process, which is characterized by inflammation, high bone turnover, and fibrosis. A disease model is suggested where disc/endplate damage and the persistence of an inflammatory stimulus (i.e., occult discitis or autoimmune response against disc material) create predisposing conditions. The risk to develop Modic changes likely depends on the inflammatory potential of the disc and the capacity of the bone marrow to respond to it. Bone marrow lesions in osteoarthritic knee joints share many characteristics with Modic changes adjacent to degenerated discs and suggest that damage-associated molecular patterns and marrow fat metabolism are important pathogenetic factors. There is no consensus on the ideal therapy. Non-surgical treatment approaches including intradiscal steroid injections, anti-TNF-α antibody, antibiotics, and bisphosphonates have some demonstrated efficacy in mostly non-replicated clinical studies in reducing Modic changes in the short term, but with unknown long-term benefits. New diagnostic tools and animal models are required to improve painful Modic change identification and classification, and to clarify the pathogenesis. CONCLUSION Modic changes are likely to be more than just a coincidental imaging finding in LBP patients and rather represent an underlying pathology that should be a target for therapy.
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Affiliation(s)
- Stefan Dudli
- Department of Orthopaedic Surgery, University of California San Francisco, 513 Parnassus Ave, S-1164, San Francisco, CA, 94143-0514, USA.
| | - Aaron J Fields
- Department of Orthopaedic Surgery, University of California San Francisco, 513 Parnassus Ave, S-1164, San Francisco, CA, 94143-0514, USA
| | - Dino Samartzis
- Department of Orthopaedics and Traumatology, University of Hong Kong, Hong Kong, China
| | - Jaro Karppinen
- Department of Physical and Rehabilitation Medicine, Medical Research Center Oulu, Finnish Institute of Occupational Health, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Jeffrey C Lotz
- Department of Orthopaedic Surgery, University of California San Francisco, 513 Parnassus Ave, S-1164, San Francisco, CA, 94143-0514, USA
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Farshad-Amacker NA, Hughes A, Herzog RJ, Seifert B, Farshad M. The intervertebral disc, the endplates and the vertebral bone marrow as a unit in the process of degeneration. Eur Radiol 2016; 27:2507-2520. [DOI: 10.1007/s00330-016-4584-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 08/10/2016] [Accepted: 08/26/2016] [Indexed: 01/04/2023]
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Mattei TA, Rehman AA, Teles AR, Aldag JC, Dinh DH, McCall TD. The ‘Lumbar Fusion Outcome Score’ (LUFOS): a new practical and surgically oriented grading system for preoperative prediction of surgical outcomes after lumbar spinal fusion in patients with degenerative disc disease and refractory chronic axial low back pain. Neurosurg Rev 2016; 40:67-81. [DOI: 10.1007/s10143-016-0751-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 03/06/2016] [Accepted: 04/09/2016] [Indexed: 10/21/2022]
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Laustsen AF, Bech-Azeddine R. Do Modic changes have an impact on clinical outcome in lumbar spine surgery? A systematic literature review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:3735-3745. [DOI: 10.1007/s00586-016-4609-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 05/08/2016] [Accepted: 05/08/2016] [Indexed: 11/25/2022]
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