The prevalence of degenerative or incidental findings in the lumbar spine of pediatric patients: a study using magnetic resonance imaging as a screening tool

Relationship of disc degeneration after pubertal growth spurt to future low back pain: a longitudinal cohort study

PURPOSE

In this longitudinal cohort study, we investigated the relationship of disc degeneration (DD) after pubertal growth spurt to future low back pain (LBP).

METHODS

A group of healthy volunteers underwent a semi-structured interview about LBP without trauma and a 1.5T lumbar MRI at ages 18 and 34. A Pfirrmann Summary Score (PSS) was calculated by adding up the Pfirrmann grades of the three lowest lumbar discs of each subject (range 3-15). The relationship of PSS at age 18 to LBP at age 34 was analyzed.

RESULTS

Forty-one participants had full data at both time points. Mean PSS at age 18 was 6.8 (SD 1.1) and 5.6 (SD 1.2) for participants with or without LBP at age 34, respectively (p = 0.009). The OR (95% CI) of PSS at age 18 for LBP at age 34 was 5.46 (1.22 to 24.47) when adjusted for sex, BMI, smoking and physical activity. All participants but one with PSS greater than 6 at age 18 reported LBP at age 34.

CONCLUSION

This is the first study to suggest that DD may be associated with future LBP and the critical time frame seems to be the pubertal growth spurt. Every 1-point increase in Pfirrmann grade at age 18 increased the risk of LBP 5.5-fold at age 34 when adjusted for sex, BMI, smoking and physical activity at age 34. All participants but one with at least one disc with Pfirrmann grade 3 or higher at age 18 reported LBP at age 34.

Lumbar degeneration and quality of life in patients with lumbar disc herniation: a case-control long-term follow-up study

BACKGROUND AND PURPOSE

Adults treated surgically for lumbar disc herniation in adolescence have a higher degree of lumbar disc degeneration than controls. We aimed to establish whether the degree of lumbar degeneration differs at diagnosis or at follow-up between surgically and non-surgically treated individuals.

METHODS

We identified individuals with a lumbar disc herniation in adolescence diagnosed with magnetic resonance imaging (MRI) and contacted them for follow-up MRI. Lumbar degeneration was assessed according to Pfirrmann, Modic, and total end plate score (TEP score). Patient-reported outcome measures at follow-up comprised the Oswestry Disability Index (ODI), EQ-5D-3-level version, 36-Item Short Form Health Survey (SF-36), and Visual Analogue Scale (VAS) for back and leg pain. Fisher's exact test, Mann-Whitney U tests, Wilcoxon tests, and logistic regression were used for statistical analysis.

RESULTS

MRIs were available at diagnosis and after a mean of 11.9 years in 17 surgically treated individuals and 14 non-surgically treated individuals. Lumbar degeneration was similar at diagnosis (P = 0.2) and at follow-up, with the exception of higher TEP scores in surgically treated individuals at levels L4-L5 and L5-S1 at follow-up (P ≤ 0.03), but this difference did not remain after adjustment for age and sex (P ≥ 0.8). There were no significant differences in patient-reported outcome measures between the groups at follow-up (all P ≥ 0.2).

CONCLUSION

Adolescents with a lumbar disc herniation have, irrespective of treatment, a similar degree of lumbar degeneration at the time of diagnosis, and similar lumbar degeneration and patient-reported outcomes at long-term follow-up.

Epidemiology of Lumbar Degenerative Phenotypes of Children and Adolescents: A Large-Scale Imaging Study

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

Recently, there has been a rise in children and adolescents developing low back pain and/or sciatica. Degenerative lumbar spine MRI phenotypes can occur in this population but reports have been sporadic and the true incidence of such spine changes remains debatable. As such, the study aimed to address the epidemiology of MRI phenotypes of the lumbar spine in this young population.

METHODS

597 children and adolescents with lumbar MRIs were included in the study. T1- and T2-weighted lumbar images from L1/2 to L5/S1 were analyzed in axial and sagittal planes. Global phenotype assessment was performed of each level and based on established nomenclature protocols.

RESULTS

The cohort consisted of 57.3% (342) boys and 42.7% (255) girls, with a mean age of 10.75 ± 5.25 years (range: 0 to 18 years). The prevalence of imaging findings of lumbar disc degeneration (LDD) and lumbar disc herniation (LDH) were 2.2% (95% CI: 0.93-3.43) and 5.8% (95%CI: 2.58-8.99), respectively. There was significant difference between each disc segment from L1/2 to L5/S1 for both LDD and LDH. Schmorl's nodes were noted in 16 cases (2.7%, youngest case as 15 years), with 11 boys (68.8%) and most frequent segment as L3/4. Modic changes and high-intensity zones were absent in this cohort.

CONCLUSIONS

LDD can emerge as early as the first decade of life with Schmorl's nodes, without additional specific phenotypes, including Modic changes and high-intensity zones. The study provides valuable information of a unique age group that is often under-represented but equally important as adults.

The prevalence of incidental findings on pelvis MRI of 8-13-year-old children

BACKGROUND

The prevalence and clinical relevance of incidental findings (IF(s)) on imaging assessing the pelvis in children has not been well documented.

METHODS

Three-thousand two-hundred thirty-one children (mean age 10.2 (range 8.6-12.9) years) were evaluated with MRI of the hips, pelvis, and lumbar spine, as part of a prospective population-based pediatric cohort study. Scans were reviewed by trained medical staff for abnormalities. IFs were categorized by clinical relevance and need for further clinical evaluation.

RESULTS

8.3% (n = 267) of children featured at least one IF. One or more musculoskeletal IFs were found in 7.9% (n = 254) of children, however, only 0.8% (n = 2) of musculoskeletal IFs required clinical evaluation. Most frequent abnormalities were simple bone cysts 6.0% (n = 195), chondroid lesions 0.6% (n = 20), and perineural cysts 0.5% (n = 15). Intra-abdominal IFs were detected in 0.5% (n = 17) of children, with over half (n = 9) of these requiring evaluation. The three most common intra-abdominal IFs were a duplex collecting system 0.09% (n = 3), significant ascites 0.06% (n = 2), and hydroureteronephrosis 0.06% (n = 2).

CONCLUSIONS

IFs on MRI of the lower abdominal and hip region are relatively common in children aged 8-13 years, most of these can be confidently categorized as clinically irrelevant without the need for additional clinical or radiologic follow up.

IMPACT

Our research contributes greatly to the knowledge of the prevalence of (asymptomatic) pathology in children. We evaluated MR images of 3231 children, covering hip joints, pelvic skeleton, lower and mid-abdomen, and lumbar and lower thoracic spine as part of a population study. One or more musculoskeletal incidental finding were found in 7.9% of children. Most of these can be confidently categorized as clinically irrelevant without the need for additional follow up. However 0.8% of musculoskeletal findings required further evaluation. Intra-abdominal incidental findings were detected in 0.5% of children, with over half of the abdominal and urogenital findings requiring further evaluation.

Intervertebral Disk Health Following Vertebral Body Tethering for Adolescent Idiopathic Scoliosis: A Preliminary Study

BACKGROUND

Interest in vertebral body tethering (VBT) as an alternative to posterior spinal fusion for adolescent idiopathic scoliosis (AIS) continues to grow. The purpose of this study was to prospectively assess intervertebral disk health on magnetic resonance imaging (MRI) at 1 year following VBT in AIS patients.

METHODS

AIS patients were enrolled in a prospective surgeon-sponsored Food and Drug Administration (FDA) Investigational Device Exemption (IDE) Study and underwent MRI at 1-year following VBT. All spanned disks and the untethered disks immediately adjacent to the upper instrumented vertebra and lowest instrumented vertebra levels were evaluated according to Pfirrmann grading criteria. Associations between patient factors and preoperative and postoperative disk health and patient-reported outcomes were evaluated.

RESULTS

Twenty-two patients were enrolled with a postoperative MRI (25 curves, 188 disks), and 7 patients (7 curves) had both preoperative and postoperative MRIs (67 disks). The mean age was 12.7 years. Most were Risser 0 (65%) and either Sanders Skeletal Maturity Score 3 (35%) or 4 (53%). In the 7 patients with preoperative and postoperative MRI, the mean Pfirrmann grade of the disks spanned by the tether was 1.88 preoperatively and 2.31 postoperatively ( P =0.0075). No statistically significant differences in preoperative versus postoperative Pfirrmann grade were identified in the disks adjacent to the upper or lower instrumented vertebrae. No association was found between patient-reported outcomes and Pfirrmann grade.

CONCLUSION

At 1 year postoperatively, increased degenerative changes in disks spanned by the tether was identifiable on MRI without evidence of adjacent segment disk disease. These changes were not associated with patient-reported outcomes.

LEVEL OF EVIDENCE

Level III.

ISSLS PRIZE in Clinical Science 2022: Epidemiology, risk factors and clinical impact of juvenile Modic changes in paediatric patients with low back pain

PURPOSE

It's a long-held belief that Modic changes (MC) occur only in adults, with advanced age, and are highly associated with pain and adverse outcomes. The following study addressed the epidemiology, risk factors and clinical relevance of MC in young paediatric patients.

METHODS

Two hundred and seven consecutive patients with no history of deformities, neoplasms, trauma, or infections were included in this ambispective study. MRIs were utilized to assess MCs and types, and other degenerative disc/endplate abnormalities. Subject demographics, duration of symptoms, clinic visits, conservative management (physical therapy, NSAIDs, opioids, injections) and surgery were noted.

RESULTS

The mean age was 16.5 years old (46.9% males), 14% had MCs and they occurred throughout the spine. Subject baseline demographics were similar between MCs and non-MCs patients (p > 0.05). Modic type 2 (50%) was the most common type (type 1:27.1%; type 3:18.8%; mixed:4.7%). Multivariate analyses noted that endplate damage (OR: 11.36), disc degeneration (OR: 5.81), disc space narrowing (OR: 5.77), Schmorl's nodes (OR: 4.30) and spondylolisthesis (OR: 3.55) to be significantly associated with MCs (p < 0.05). No significant differences in conservative management were noted between Modic and non-MCs patients (p > 0.05). Among surgery patients (n = 44), 21% also had MCs (p = 0.134). Symptom-duration was significantly greater in MC patients (p = 0.049).

CONCLUSION

Contrary to traditional dogma, robust evidence now exists noting that MCs and their types can develop in children. Our findings give credence to the "Juvenile" variant of MCs, whereby its implications throughout the lifespan need to be assessed. Juvenile MCs have prolonged symptoms and related to specific structural spine phenotypes.

Application of a targeted and quantificational foraminoplasty device in percutaneous transforaminal endoscopic discectomy for L5-S1 disc herniation: preliminary clinical outcomes

OBJECTIVE

Percutaneous transforaminal endoscopic discectomy (PTED) is minimally invasive and has been widely used to treat patients with lumbar disc herniation (LDH) due to its safety and efficiency. However, due to the unique anatomy of the L5-S1 level, the PTED procedure is often difficult to perform in the region. ZESSYS, a targeted and quantificational foraminoplasty device, may help to overcome these anatomical limitations. In this study, we assessed the efficiency and the short-term effects of PTED with ZESSYS at the L5-S1 level.

METHODS

Between January and August of 2018, fifty-six patients with lumbar disc herniation at the single level of L5-S1 and who underwent percutaneous transforaminal endoscopic discectomy were enrolled in this retrospective cohort study. They were segregated into the transforaminal endoscopic surgical system (TESSYS) group and the ZESSYS group. The puncture time, foraminoplasty time, decompression time, and fluoroscopy time were evaluated for operation efficiency. Clinical outcomes were assessed by the visual analog scale (VAS) score and Oswestry Disability Index (ODI) score. The MacNab criteria were used to evaluate patient subjective satisfaction at 12-month follow-up postoperatively.

RESULTS

The average puncture time (5.29 ± 2.05 min), foraminoplasty time (12.82 ± 2.52 min), and fluoroscopy time (26.29 ± 5.96 s) were all significantly shorter in the ZESSYS group than in the TESSYS group (average puncture time 8.07 ± 3.13 min, p < 0.01; foraminoplasty time, 17.18 ± 2.92 min, p < 0.01; fluoroscopy time, 34.73 ± 6.86 s; p < 0.01). No significant differences were observed between the 2 groups in the decompression time (p = 0.057). The VAS score of low back pain and leg pain, as well as the ODI score, improved at all time points postoperatively compared with preoperative, in both the TESSYS group and the ZESSYS group (P < 0.05). There were no significant differences in the VAS score of low back pain, VAS score of leg pain, and ODI score between the TESSYS group and the ZESSYS group at the same time points (P > 0.05). According to the MacNab criteria, the excellent and good rate at 12-month follow-up postoperatively was 85.7% in the TESSYS group and 89.3% in the ZESSYS group (P > 0.05).

CONCLUSION

The targeted and quantificational foraminoplasty device named ZESSYS was more efficient in the puncture and foraminoplasty procedures, effectively protecting the exiting nerve and minimizing the level of radiation exposure. The device is efficient and safe for PTED in treating lumbar disc herniation at the L5-S1 level.

Role of growth plate (apophyseal ring fracture) in causing modic type changes in pediatric low back pain patients

PURPOSE

We investigated the prevalence of Modic changes (MCs) and associated pathologies in pediatric patients.

METHODS

A total of 368 MRI obtained for 240 male and 128 female patients under the age of 18 years with complaints of low back/leg pain were retrospectively examined. All changes in signal intensity in the vertebral endplate and subchondral bone on MRI were defined as MCs. We investigated the relationship between MCs and underlying diseases, including lumbar spondylolysis/spondylolisthesis, and conditions of the growth plate in cases with MCs. The degree of disc degeneration in patients with MCs was evaluated using the Pfirrmann grading system.

RESULTS

MCs were identified in six patients (1.6%). In five of the six patients, the signal intensity changes were localized to the anterosuperior endplate of the affected vertebra; the MCs were associated with anterior apophyseal ring fracture and an open growth plate in all these cases. Disc degeneration was classified as Pfirrmann grade I in three patients and grade II and III in one patient each. One patient had type I changes associated with grade IV disc degeneration and herniation and no sign of an open growth plate.

CONCLUSION

The prevalence of MCs in pediatrics patients was much lower than the rates reported in adults. Most MCs were associated with an anterior apophyseal ring fracture. If Modic type changes are seen in immature vertebrae of pediatric patients, growth plate lesions such as apophyseal ring fractures should be considered.

LEVEL OF EVIDENCE

Diagnostic: individual l cross-sectional studies with consistently applied reference standard and blinding.

Intervertebral Disc and Adipokine Leptin-Loves Me, Loves Me Not

Leptin—the most famous adipose tissue-secreted hormone—in the human body is mostly observed in a negative connotation, as the hormone level increases with the accumulation of body fat. Nowadays, fatness is becoming another normal body shape. Fatness is burdened with numerous illnesses—including low back pain and degenerative disease of lumbar intervertebral disc (IVD). IVD degeneration and IVD inflammation are two indiscerptible phenomena. Irrespective of the underlying pathophysiological background (trauma, obesity, nutrient deficiency), the inflammation is crucial in triggering IVD degeneration. Leptin is usually depicted as a proinflammatory adipokine. Many studies aimed at explaining the role of leptin in IVD degeneration, though mostly in in vitro and on animal models, confirmed leptin’s “bad reputation”. However, several studies found that leptin might have protective role in IVD metabolism. This review examines the current literature on the metabolic role of different depots of adipose tissue, with focus on leptin, in pathogenesis of IVD degeneration.

Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017

Background

Low back pain (LBP) is a common musculoskeletal problem globally. Updating the prevalence and burden of LBP is important for researchers and policy makers. This paper presents, compares and contextualizes the global prevalence and years lived with disability (YLDs) of LBP by age, sex and region, from 1990 to 2017.

Methods

Data were extracted from the GBD (the Global Burden of Disease, Injuries, and Risk Factors Study) 2017 Study. Age, sex and region-specific analyses were conducted to estimate the global prevalence and YLDs of LBP, with the uncertainty intervals (UIs).

Results

The age-standardized point prevalence of LBP was 8.20% (95% UI: 7.31–9.10%) in 1990 and decreased slightly to 7.50% (95% UI: 6.75–8.27%) in 2017. The prevalent numbers of people with LBP at any one point in time in 1990 was 377.5 million, and this increased to 577.0 million in 2017. Age-standardized prevalence of LBP was higher in females than males. LBP prevalence increased with age, and peaked around the ages of 80 to 89 years, and then decreased slightly. Global YLDs were 42.5 million (95% UI: 30.2 million–57.2 million) in 1990 and increased by 52.7% to 64.9 million (95% UI: 46.5 million–87.4 million) in 2017. YLDs were also higher in females than males and increased initially with age; they peaked at 35–39 years of age in 1990, before decreasing, whereas in 2017, they peaked at 45–49 years of age, before decreasing. Western Europe had the highest number of LBP YLDs.

Conclusions

Globally, LBP is the leading global cause of YLDs. Greater attention is urgently needed to mitigate this increasing burden and the impact it is having on health and social systems.

Pediatric herniated lumbar disc: a population-based risk factor analysis

OBJECTIVE

Surgical treatment of herniated lumbar disc (HLD) remains rare in children. The purpose of this study was to evaluate for potential disease risk factors leading to surgery based on a large single-center experience.

METHODS

Data for all patients who had undergone surgical treatment for HLD between December 2008 and December 2016 at a single pediatric tertiary care referral center were collected and compared to data for a healthy control population obtained through a Youth Risk Behavior Surveillance System (YRBSS) survey in order to determine relevant disease risk factors. Univariate and multivariate logistic regression were used to determine the effect of potential risk factors.

RESULTS

Twenty-seven patients in the disease cohort and 5212 healthy controls from the general population were included in the risk factor analysis. The mean body mass index was significantly higher in the disease population (30.2 vs 24.0 kg/m2, p < 0.0001). Children who had undergone microdiscectomy were more likely to be obese (OR 7.4, 95% CI 3.46-15.8, p < 0.001). No association was found between lumbar microdiscectomy and sports participation (OR 1.0, 95% CI -0.002 to 0.005, p = 0.37).

CONCLUSIONS

Microdiscectomy remains a viable and safe option in the setting of failed conservative management for pediatric HLD. Childhood obesity is a risk factor for HLD and many other diseases, which increases its importance as a public health priority.

Short-term clinical efficacy of percutaneous transforaminal endoscopic discectomy in treating young patients with lumbar disc herniation

Background

In the last decades, full-endoscopic techniques to treat lumbar disc herniation (LDH) have gained popularity in clinical practice. However, few studies have described the safety and efficacy of percutaneous transforaminal endoscopic discectomy (PTED) in treating younger patients with LDH. This study aims to evaluate the preliminary surgical outcome and complication of PTED in treating younger patients with LDH.

Methods

Between June 2012 and June 2016, 72 young patients (< 45 years old) who underwent PTED for single-level LDH were prospectively followed up. All patients were followed up for at least 12 months (range 12–35 months). Pain was measured using visual analogue scale (VAS) scores. Patient satisfaction was evaluated using the MacNab outcome scale. Clinical outcomes were measured preoperatively, at 2 days and 6 months, and 12 months postoperatively.

Results

The mean VAS score for back pain was 5.1 ± 2.3 preoperatively and 3.1 ± 1.2, 2.1 ± 0.5, and 2.0 ± 0.7 at 2 days, 6 months, and 12 months postoperatively, respectively. The VAS score for leg pain was 7.1 ± 2.6 preoperatively and 3.0 ± 1.1, 2.1 ± 1.3, and 1.9 ± 0.8 at 2 days, 6 months, and 12 months postoperatively, respectively. These postoperative scores were all significantly different when compared with preoperative scores (P < 0.001). According to the modified MacNab outcome scale, excellent was obtained in 43 patients, good was obtained in 25 patients, and fair was obtained in 4 patients, and 94.44% of these patients had excellent and good outcomes at the final follow-up. There were no complications related to surgery, and no spinal instability was detected.

Conclusion

PTED appears to be an effective and safe intervention for younger patients with LDH. High-quality randomized controlled trials are required to further study the efficacy and safety of PTED in treating younger patients with LDH.

Asthma and early herniated intervertebral disc disease

BACKGROUND

The etiology of herniated intervertebral disc (HIVD) disease in children and adolescents is multifactorial and not merely related to disc degeneration. Therefore, in the present study, we investigated the relationship between young asthma patients and the risk of early HIVD disease in a population under 30 years of age.

METHODS

Data from the National Health Insurance Research Database (NHIRD) of Taiwan were used to conduct a retrospective longitudinal cohort study. The study cohort comprised 23,470 patients with asthma (asthma group) and 23,470 patients without asthma (non-asthma group), who were selected through frequency matching on the basis of sex, age, and the index year. The study patients were followed until HIVD disease occurrence, withdrawal from the National Health Insurance program, or 31 December 2013. Cox proportional hazards regression analysis was conducted to assess the risk of HIVD disease in the asthma group after adjustment for sex, age, and comorbidities.

RESULTS

After adjustment for sex, age, and comorbidities, the asthma group had a 1.69-fold (95% confidence interval [CI] = 1.29-2.23) higher risk of HIVD disease than did the non-asthma group. In addition, the asthma group had a higher risk of cervical and lumbar HIVD diseases than did the non-asthma group (adjusted hazard ratio [HR] = 2.38; 95% CI = 1.25-4.57 and adjusted HR = 1.56; 95% CI = 1.15-2.12, respectively).

CONCLUSIONS

Young patients with asthma are at a significantly higher risk of early cervical or lumbar HIVD disease.

Lumbar disc degeneration progression in young women in their 20's: A prospective ten-year follow up

BACKGROUND

Lumbar disc degeneration (LDD) is known to be the main cause of low back pain, although it is unclear how or when LDD progresses. The purpose of this study was to clarify the process and features of LDD progression in young women.

METHODS

We enrolled 480 nursing students and carried out a prospective cohort study in 84 nursing students. MRI of the lumbar spine was taken once during their time as a student and again at 9.8 years (7-14) after the first MRI when they were working as nurses. The grade of LDD was determined according to Schneiderman's grade. The progression of disc degeneration was evaluated by the change in the degenerative disc disease (DDD) score (the summation of DDD score at each disc level). The subjects were divided into two groups based on MRI findings: Group A, those without disc degeneration at the first MRI (n = 58) and Group B, those showing disc degeneration on the first MRI (n = 26). We evaluated the change in DDD score and assessed the particular disc levels that showed Schneiderman's grade worsening in each group.

RESULTS

At the time of the 2nd MRI, the DDD score increased from 5.6 (5-9) to 6.3 (5-11). The L5/S disc was the most frequent level showing the progression of LDD. In Group A, 18 subjects (31.0%) and in Group B, 15 subjects (57.7%) had degeneration progression (p = 0.02).

CONCLUSIONS

This study revealed that 31% of the young adult subjects already had disc degeneration in 20's (time of first MRI) and the disc degeneration rapidly progressed in these subjects.

The Pfirrmann classification of lumbar intervertebral disc degeneration: an independent inter- and intra-observer agreement assessment

PURPOSE

Grading inter-vertebral disc degeneration (IDD) is important in the evaluation of many degenerative conditions, including patients with low back pain. Magnetic resonance imaging (MRI) is considered the best imaging instrument to evaluate IDD. The Pfirrmann classification is commonly used to grade IDD; the authors describing this classification showed an adequate agreement using it; however, there has been a paucity of independent agreement studies using this grading system. The aim of this study was to perform an independent inter- and intra-observer agreement study using the Pfirrmann classification.

METHODS

T2-weighted sagittal images of 79 patients consecutively studied with lumbar spine MRI were classified using the Pfirrmann grading system by six evaluators (three spine surgeons and three radiologists). After a 6-week interval, the 79 cases were presented to the same evaluators in a random sequence for repeat evaluation. The intra-class correlation coefficient (ICC) and the weighted kappa (wκ) were used to determine the inter- and intra-observer agreement.

RESULTS

The inter-observer agreement was excellent, with an ICC = 0.94 (0.93-0.95) and wκ = 0.83 (0.74-0.91). There were no differences between spine surgeons and radiologists. Likewise, there were no differences in agreement evaluating the different lumbar discs. Most differences among observers were only of one grade. Intra-observer agreement was also excellent with ICC = 0.86 (0.83-0.89) and wκ = 0.89 (0.85-0.93).

CONCLUSIONS

In this independent study, the Pfirrmann classification demonstrated an adequate agreement among different observers and by the same observer on separate occasions. Furthermore, it allows communication between radiologists and spine surgeons.