Lumbar subcutaneous edema and degenerative spinal disease in patients with low back pain: a retrospective MRI study

The importance of psoas muscle on low back pain: a single-center study on lumbar spine MRI

Background

Low back pain (LBP) is the most frequent indication to magnetic resonance imaging (MRI) examinations of the lumbosacral spine. The individual role of soft tissues, including muscles, on LBP is not fully understood and the contribution of each MRI-derived parameter of soft tissues status on the intensity of LBP has not been investigated in detail.

Methods

The study design was observational retrospective, single center carried out at a University Hospital. Images were acquired using a using a 1.5 Tesla scanner. Patients completed a symptom questionnaire and rated their pain intensity using the Visual Analogue Scale (VAS). The VAS scores ​​were categorized as mild, moderate, and severe using cutoff values of 3.8 and 5.7, based on the literature. Biometric data, including weight and height, were also recorded to calculate the body mass index (BMI). The ratios between intramuscular fat infiltration and net muscle area were also calculated. Patient sample included 94 patients with LBP underwent MRI of the lumbosacral spine.

Results

The stepwise analysis revealed that increasing psoas net area was associated with lower VAS levels (odds ratio [OR]: 0.94: 95% confidence interval [CI]: 0.90-0.98; p=.005), and an increase of one square centimeter of total psoas area resulted in a greater probability of reporting a mild (+1.21%; 95% CI: 0.37, 2.05%) or a moderate VAS (+0.40%; 95% CI: -0.02, 0.82%), Furthermore, a more severe VAS was associated with a higher BMI (OR: 1.13; 95% CI: 1.00-1.27).

Conclusion

Our study demonstrates a relationship between LBP and MRI parameters of paravertebral and psoas muscles status. The psoas muscle is extremely important for spine stabilization and is linked to clinical symptoms of patients affected by LBP. These findings could contribute to future studies and improve treatment options in patients with LBP, possibly reducing the impact on disability, quality of life and socioeconomical burden.

Visceral adiposity in patients with lipomatous hypertrophy of the interatrial septum

Lipomatous hypertrophy of the interatrial septum (LHIS) is a benign cardiac mass determined by abnormal deposition of adipose tissue in the interatrial septum. The quantitative relationship between LHIS and visceral adiposity has not been explored to date.In this retrospective study, three groups of consecutive patients undergoing CT imaging were enrolled: L + with LHIS, L- without LHIS, and LO- without both LHIS and history of malignancies. Areas of total adipose tissue (TAT), visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT) and LHIS areas were calculated on CT images. The relationship between LHIS and abdominal fat distribution was investigated with linear regression models. Bonferroni correction was applied to account for multiple testing. Statistical significance was set at 5%. In this study we enrolled a total of 175 subjects: 58 (33.14%) with LHIS (L +), 51(29.14%) without LHIS (L-) and 66 (37.71%) without both LHIS and medical history of malignancies (LO-). VAT (coeff: 105.82; 95% CI 59.37-152.27), SAT (coeff: 74.59; 95% CI 31.63-117.54), and TAT (coeff: 190.37; 95% CI 115.02-265.72), were significantly higher in L + patients. Moreover, VAT (coeff: 24.95; 95% CI 6.94-42.96) and TAT (coeff: 36.58; 95% CI 8.75-64.41) were statistically significant linear predictors for LHIS area. Here, we report a novel association between LHIS and visceral adiposity using a quantitative CT-based imaging approach. The results are of great importance also because they might drive early identification of subjects with LHIS at risk for visceral obesity, and trigger lifestyle interventions aimed at weight loss.

Innovative quantitative magnetic resonance tools to detect early intervertebral disc degeneration changes: a systematic review

BACKGROUND CONTEXT

Low back pain (LBP) is the leading cause of disability worldwide, with a tremendous socioeconomic burden. It is mainly caused by intervertebral disc degeneration (IDD), a progressive and age-related process. Due to its ability to accurately characterize intervertebral disc morphology, magnetic resonance imaging (MRI) has been established as one of the most valuable tools in diagnosing IDD. Innovative quantitative MRI (qMRI) techniques able to detect the earliest signs of IDD have been increasingly reported.

PURPOSE

To systematically review available reports on the application of novel qMRI techniques to detect early IDD changes.

STUDY DESIGN

Systematic literature review.

METHODS

A systematic search of PubMed/MEDLINE, Scopus, CINAHL, EMBASE, CENTRAL and Cochrane databases was performed through January 21, 2023. Randomized and nonrandomized studies on innovative qMRI tools able to diagnose early biochemical and architectural IDD changes in patients with or without discogenic LBP were searched. Data on study population, follow-up time (when applicable) and MRI sequence used were recorded. The QUADAS-2 tool was utilized to assess the risk of bias of included studies.

RESULTS

A total of 39 articles published between 2005 and 2022 resulted from the search. All novel qMRI techniques showed an increased capacity to detect early IDD changes thanks to the ability to assess subtle alterations of water content, proteoglycan and glycosaminoglycan concentration, and increased levels of catabolic biomarkers compared to conventional MRI.

CONCLUSIONS

Innovative qMRI techniques have proven effective in identifying premature IDD changes. Further studies are needed to validate their application in wider populations and confirm their applicability in the clinical setting.

Adverse Effects of Immune-Checkpoint Inhibitors: A Comprehensive Imaging-Oriented Review

Immune-checkpoint inhibitors (ICIs) are immunomodulatory monoclonal antibodies, which increase antitumor immunity of the host and facilitate T-cell-mediated actions against tumors. These medications have been used in recent years as a weapon against advanced stage malignancies, such as melanoma, renal cell carcinoma, lymphoma, small or non-small cell lung cancer, and colorectal cancer. Unfortunately, they are not free from possible adverse effects (immune-related adverse events-irAEs) that mainly affect skin, gastrointestinal, hepatic, and endocrine systems. Early diagnosis of irAEs is essential to correctly and rapidly manage patients, with ICIs suspension and therapies administration. Deep knowledge of the imaging and clinical patterns of irAEs is the key to promptly rule out other diagnoses. Here, we performed a review of the radiological signs and differential diagnosis, based on the organ involved. The aim of this review is to provide guidance to recognize the most significant radiological findings of the main irAEs, based on incidence, severity, and the role of imaging.

Brain functional connectivity differences between responders and non-responders to sleeve gastrectomy

PURPOSE

To compare resting-state functional connectivity (RSFC) of obese patients responders or non-responders to sleeve gastrectomy (SG) with a group of obese patients with no past medical history of metabolic or bariatric surgery.

METHODS

MR images were acquired at 1.5 Tesla. Resting-state fMRI data were analyzed with statistical significance threshold set at p < 0.05, family-wise error (FWE) corrected.

RESULTS

Sixty-two subjects were enrolled: 20 controls (age range 25-64; 14 females), 24 responders (excess weight loss > 50%; age range 23-68; 17 females), and 18 non-responders to sleeve gastrectomy (SG) (excess weight loss < 50%; age range 23-67; 13 females). About within-network RSFC, responders showed significantly lower RSFC with respect to both controls and non-responders in the default mode and frontoparietal networks, positively correlating with psychological scores. Non-responders showed significantly higher (p < 0.05, family-wise error (few) corrected) RSFC in regions of the lateral visual network as compared to controls. Regarding between-network RSFC, responders showed significantly higher anti-correlation between executive control and salience networks (p < 0.05, FWE corrected) with respect to both controls and non-responders. Significant positive correlation (Spearman rho = 0.48, p = 0.0012) was found between % of excess weight loss and executive control-salience network RSFC.

CONCLUSION

There are differences in brain functional connectivity in either responders or non-responders patients to SG. The present results offer new insights into the neural correlates of outcome in patients who undergo SG and expand knowledge about neural mechanisms which may be related to surgical response.

Advanced MR Imaging for Knee Osteoarthritis: A Review on Local and Brain Effects

Knee osteoarthritis is one of the leading causes of chronic disability worldwide and is a significant social and economic burden on healthcare systems; hence it has become essential to develop methods to identify patients at risk for developing knee osteoarthritis at an early stage. Standard morphological MRI sequences are focused mostly on alterations seen in advanced stages of osteoarthritis. However, they possess low sensitivity for early, subtle, and potentially reversible changes of the degenerative process. In this review, we have summarized the state of the art with regard to innovative quantitative MRI techniques that exploit objective and quantifiable biomarkers to identify subtle alterations that occur in early stages of osteoarthritis in knee cartilage before any morphological alteration occurs and to capture potential effects on the brain. These novel MRI imaging tools are believed to have great potential for improving the current standard of care, but further research is needed to address limitations before these compositional techniques can be robustly applied in research and clinical settings.

The origin of lumbar subcutaneous edema: two case reports

Since magnetic resonance imaging (MRI) is widely used to evaluate complaints of low back pain, there have been many reports of lumbar subcutaneous edema (LSE). However, the mechanism underlying its development is unknown. We herein report 2 cases that showed the reduction of LSE. These cases suggest details concerning the mechanism underlying the development of LSE. The first case was an obese 70-year-old woman with a history of chronic back pain due to lumbar canal stenosis. MRI revealed LSE extending from the level of the L2 vertebral body to the sacrum. However, LSE was reduced following weight loss due to a stomach ulcer. This case clearly indicated obesity as the cause of LSE. The second case was a nonobese 31-year-old woman with acute excruciating low back pain due to thoracolumbar fascia strain. LSE was observed at the level of the L3-L4 vertebral body. Two weeks later, her low back pain and LSE were reduced. This case suggests that the origin of LSE was impairment of the thoracolumbar fascia due to strain. We hypothesize that the mechanism underlying the development of LSE may be lymphatic or interstitial fluid pooling due to disturbance of the lumbar fascia.

Novel Magnetic Resonance Imaging Tools for the Diagnosis of Degenerative Disc Disease: A Narrative Review

Low back pain (LBP) is one of the leading causes of disability worldwide, with a significant socioeconomic burden on healthcare systems. It is mainly caused by degenerative disc disease (DDD), a progressive, chronic, and age-related process. With its capacity to accurately characterize intervertebral disc (IVD) and spinal morphology, magnetic resonance imaging (MRI) has been established as one of the most valuable tools in diagnosing DDD. However, existing technology cannot detect subtle changes in IVD tissue composition and cell metabolism. In this review, we summarized the state of the art regarding innovative quantitative MRI modalities that have shown the capacity to discriminate and quantify changes in matrix composition and integrity, as well as biomechanical changes in the early stages of DDD. Validation and implementation of this new technology in the clinical setting will allow for an early diagnosis of DDD and ideally guide conservative and regenerative treatments that may prevent the progression of the degenerative process rather than intervene at the latest stages of the disease.

Subcutaneous edema on back detected by MRI in hospitalized patients with osteoporotic vertebral compression fracture

Objectives

Almost all hospitalized patients with osteoporotic vertebral compression fracture are given an MRI. At that time, subcutaneous edema on their back is often identified. It is empirically known that patients with subcutaneous edema on their back have a history of compression fracture and vertebral kyphotic deformity. In this study, we examined whether there were any differences between patients who had subcutaneous edema on their back and those who did not; those with a history of compression fractures would be especially assessed.

Materials and methods

The observation period was between January 1, 2009, and December 31, 2020. All patients were on the ward, and there were a total of 375 patients (male: 114; female: 261) aged 66-98 years old (mean: 81.1 years).Patients who had subcutaneous edema on their back and those who did not were compared in terms of sex, age, osteoporosis diagnosis by DEXA and X-ray imaging, body mass index (BMI), serum total protein and albumin, Japanese senile independence score, presence of decubitus, history of vertebral compression fracture and incidents of compression fracture during the observation period.

Results

Significant differences were not observed for sex, osteoporosis diagnosis by DEXA, BMI, blood serum total protein and albumin, or the presence of decubitus. However, age, osteoporosis diagnosis by X-ray imaging, Japanese senile independence score, history of vertebral compression fracture, and incidents of another vertebral compression fracture during the observation period were significantly different between those with and without edema.

Conclusion

It has been suggested that hospitalized patients with subcutaneous edema on their back often have a history of vertebral compression fracture and experience another vertebral compression fracture during the observation period. Hospitalized patients with subcutaneous edema on their back should have their osteoporosis treated more carefully.

Axial Spondyloarthritis: Mimics and Pitfalls of Imaging Assessment

Axial spondyloarthritis (axSpA) is a chronic inflammatory disorder that predominantly involves the axial skeleton. Imaging findings of axSpA can be divided into active changes, which include bone marrow edema, synovitis, enthesitis, capsulitis, and intra-articular effusion, and structural changes, which include erosions, sclerosis, bone fatty infiltration, fat deposition in an erosion cavity, and bone bridging or ankylosis. The ability to distinguish between imaging lesions suggestive of axSpA and artifacts or lesions suggestive of other disorders is critical for the accurate diagnosis of axSpA. Diagnosis may be challenging, particularly in early-stage disease and magnetic resonance imaging (MRI) plays a key role in the detection of subtle or inflammatory changes. MRI also allows the detection of structural changes in the subchondral bone marrow that are not visible on conventional radiography and is of prognostic and monitoring value. However, bone structural changes are more accurately depicted using computed tomography. Conventional radiography, on the other hand, has limitations, but it is easily accessible and may provide insight on gross changes as well as rule out other pathological features of the axial skeleton. This review outlines the imaging evaluation of axSpA with a focus on imaging mimics and potential pitfalls when assessing the axial skeleton.

Posterior lumbar subcutaneous edema as the rare sign of IgA vasculitis (Henoch-Schönlein purpura): A case of a child

Posterior lumbar subcutaneous edema (PLSE) is often found on MRI in adults with obesity or various lumbar conditions. We report a case of a 6-year-old boy with IgA vasculitis (Henoch-Schönlein purpura) along with PSLE observed on CT and MRI. The finding is markedly rare in patients with IgA vasculitis, with only limited cases previously reported in the literature. The edema was symmetrically localized along the erector spine muscle with a smooth margin. These findings differed from the irregularly accumulated edema observed in some adult cases. PLSE should not be overlooked as a nonspecific finding. When symmetrical and circumscribed PLSE is found in children, IgA vasculitis should be added to differential diagnosis in PLSE.

When an incidental MRI finding becomes a clinical issue : Posterior lumbar subcutaneous edema in degenerative, inflammatory, and infectious conditions of the lumbar spine

Background

On magnetic resonance imaging (MRI), posterior lumbar subcutaneous edema (PLSE) is a frequent incidental, yet unclear finding within the deep subcutaneous perifascial tissue. This study aimed to investigate PLSE in various pathological lumbar conditions.

Methods

This retrospective study included the MR images of the lumbar spine of 279 patients (age range 18–82 years) without cardiovascular, renal or hepatic diseases, 79 of whom had low-grade disc degeneration, 101 combined endplate and facet joint degeneration, 53 axial spondyloarthritis and 46 infectious spondylodiscitis. There were 232 patients with a body mass index (BMI) <30, and 47 with a BMI ≥30 (obese). For each group, the relationship between PLSE and BMI was analyzed using multiple logistic regression, and between PLSE extension and BMI using ordinal regression.

Results

A PLSE was found in 11/79 (13.9%) patients with disc degeneration, 37/101 (36.6%) with endplate and facet joint degeneration, 7/53 (13.2%) with spondyloarthritis, and 28/46 (60.9%) with spondylodiscitis. For each group, a statistically significant relationship was demonstrated between PLSE and BMI (P = 0.000–P = 0.031), except for spondylodiscitis (P = 0.054), as well as between PLSE extension and BMI (P = 0.000–P = 0.049). A PLSE was found in 21.1% of nonobese and 72.3% of obese patients (P = 0.000).

Conclusion

The presence of PLSE seems to be associated with various lumbar conditions, particularly in obese patients. Its perifascial location may suggest a potential fascial origin; however, PLSE should not to be confused with posttraumatic, postsurgical or infectious edema or edema associated with internal diseases.

What is the clinical evidence on regenerative medicine in intervertebral disc degeneration?

PURPOSE

This review aims to explore and summarize the current clinical evidence about the use of regenerative medicine such as mesenchymal stem cells or platelet-rich plasma in intervertebral disc regeneration, in order to clarify the state of art of these novel approaches.

MATERIALS AND METHODS

We performed a research of the available literature about regenerative medicine strategies aiming to prevent intervertebral disc degeneration. All preclinical trials and in vitro studies were excluded. Only clinical trials were critically analysed.

RESULTS

The manuscript selection produced a total of 7 articles concerning the use of regenerative therapies in intervertebral disc degeneration, covering the period between 2010 and 2016. Articles selected were 4 about the injection of mesenchymal stem cells-related results and 3 using platelet-rich plasma. The total population of patients treated with regenerative medicine strategies were 104 patients.

CONCLUSIONS

Regenerative medicine, such as the use of mesenchymal stem cells or platelet-rich plasma, in intradiscal disc degeneration has shown preclinical and clinical positive results. Randomized clinical trials studying the potential of MSCs intradiscal injection have not been conducted, and PRP effect has been studied only preliminarily. Additional more powered high-quality studies are needed to really appreciate the long-term safety and efficacy of regenerative medicine approaches in IDD.

Metastatic epidural spinal cord compression

INTRODUCTION

Metastatic epidural spinal cord compression (MESSC) is a frequent event in patients affected by solid tumor metastases. Current available approaches for MESCC include corticosteroids, radiotherapy and surgery. In the last few years, surgery has evolved from decompression by laminectomy alone, with the introduction of instrumentation systems by metalware (screws and hooks), and this has been associated to an improvement of clinical results compared to radiotherapy alone. Areas covered: In this narrative review, we outline the phases of management of cancer patients affected by MESSC, and discuss the timing of treatments, their impact on the Quality of life (QoL), and the relative benefits and harms of surgery and radiotherapy. Expert commentary: Despite the fact that clinical and surgical trials will be required to determine the most appropriate surgical technique and timing of surgery, we do expect a newer and more important role for radiotherapy in the management of MESCC patients in the next future. In particular, the implementation of radiotactic stereosurgery as adjuvant to decompressive surgery is expected to increase in the next few years, above all in those patients that can be candidate to the so called separation surgery.

Surgical management of spinal fractures and neurological involvement in patients with myeloma

INTRODUCTION

Multiple Myeloma (MM) typically involves the spine and causes bone pain, pathological fractures and spinal cord compression with possible consequent neurological deficits. This retrospective study reports the results of surgery on a selected population of patients who underwent surgery for symptomatic spinal myeloma.

MATERIALS AND METHODS

A total of 26 patients who underwent surgery for spinal myeloma with neurological involvement were studied retrospectively. Neurological evaluation was performed according to the Frankel grade. Characteristics of this population, reconstructive techniques and surgery-related complications were reviewed.

RESULTS

The tumours involved the thoracic spine in 13 patients, the lumbar spine in 10 patients, and the cervical spine in three patients. The most common approach was a posterior-only approach (70%), followed by a staged, combined approach (20%), and an anterior-only approach (10%). The mean postoperative survival time was 43 months (range: 8-60 months). A significant improvement in neurological function was observed in the study population after surgery (p=0.001). There were seven early postoperative complications, two late complications and five surgery-related complications.

DISCUSSION

Surgery in selected patients affected by spinal myeloma with neurological involvement is associated with good clinical outcomes and neurological recovery and an acceptable rate of complications. Neurological deficit and segmental instability can be treated sufficiently in most cases by the implementation of a posterior-only approach; however, the final treatment should, when possible, include adjuvant chemotherapy and radiotherapy and rigorous bracing.