Inflammatory cytokines released from the facet joint tissue in degenerative lumbar spinal disorders

The Relationship Between Craniocervical Morphology and the Presence and Level of Cervical Facet Joint Degeneration

OBJECTIVE

To investigate the relationship between craniocervical morphology and the presence and level of cervical facet joint degeneration (FJD).

METHODS

A total of 108 consecutive female patients aged 45-55 years who had undergone neck + brain CT angiography were included in this retrospective sectional study. Only patients of a certain age and of the same gender were included in order to eliminate the differences that create a disposition to the development of spinal degeneration. The presence of facet joint (FJ) arthritis (grade ≥2 degeneration in at least one affected facet joint) and the grade of the facet joint degeneration for each patient were recorded. A total of 20 lengths and 3 angles of craniocervical morphology were measured. The differences between the individuals with and without FJ arthritis were investigated with the independent-sample t test, and the relationship between the FJD grade and craniocervical morphology was investigated using the Spearman correlation test.

RESULTS

Individuals with FJ arthritis were found to have longer Grabb-Oakes measurement, shorter FM AP length, lower ADI, lower EOP thickness, higher clivus length, higher crista gall-ATS distance, lower CCA angle, lower distance between the C1 vertebra lateral masses, and higher BAI than those without FJ arthritis (P ˂ 0.05). Besides, we found that the FJD grade increased as the Grabb-Oakes measurement increased, ADI distance decreased, FM AP length decreased, EOP thickness decreased, clivus length increased, basal angle increased, distance between the C1 vertebra lateral masses decreased, and BAI increased (P ˂ 0.05).

CONCLUSIONS

Differences in craniocervical morphology are statistically associated with degenerative processes that result in degenerative changes in the facet joint. Therefore, some morphological changes in craniocervical anatomy cause changes in the momentum and distribution of the load on the facet joints, predisposing the patient to facet arthropathy and osteoarthritis.

Facet joint involvement in the inflammatory rheumatic disease

BACKGROUND

The involvement of facet joints (FJ) in patients with inflammatory rheumatic disorders remains underexplored. This review aims to look at FJ disease from a rheumatologist's perspective, with the emphasis given to the clinical presentations and patterns of FJ engagement in axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), rheumatoid arthritis (RA), and crystal-related arthropathies, and discussion of challenges in studying FJ in rheumatic disease.

METHODS

A systematic PubMed search using the pertinent keywords was performed, relevant articles extracted, and the acquired data critically assessed, interpreted, and organized according to the authors' experience and judgment.

RESULTS

FJ involvement is common in patients with radiographic axSpA, occurs throughout the spine, but is more frequently seen in the thoracic segment. The existing data suggests that the FJ are primarily affected by the disease process, while altered spine biomechanics due to the presence of syndesmophytes at the same vertebral level contributes to the FJ fusion. Predominant involvement of FJ of the cervical spinal segment has been suggested in PsA; however, prevalence and clinical significance of FJ involvement in PsA is still markedly underexplored. RA-related FJ disease of the cervical spine in patients with poorly controlled RA is not uncommon and can be related to significant morbidity, while the burden of FJ involvement in the thoracic and lumbar spinal segments in RA is also underexplored. FJ disease is possible in the course of crystal-related arthropathies, but the high level of suspicion is a prerequisite for the timely diagnosis.

CONCLUSIONS

The involvement of FJ in the course of inflammatory rheumatic disease is not uncommon. Prospective studies are needed to understand the epidemiology and significance of FJ disease in inflammatory rheumatic conditions.

Exosomes for the Management of Low Back Pain: A Review of Current Clinical Evidence

Low back pain affects millions of people, creating an enormous financial burden on the global healthcare system. Traditional treatment modalities are short-lived and have shortcomings. Recently, orthobiologics, including extracellular vesicles or exosomes derived from mesenchymal stem cells, have markedly increased for managing musculoskeletal conditions. Here, the primary aim is to review the outcomes of clinical studies using extracellular vesicles or exosomes for treating low back pain. Numerous databases (Scopus, PubMed, Web of Science, Embase, and Google Scholar) were searched using terms for the intervention 'exosomes' and the treatment 'low back pain' for studies published in English to March 18, 2024. Articles utilizing exosomes for the management of low back pain were included. Articles not utilizing exosomes, not explicitly stating the presence of exosomes in their formulation, or not targeting low back pain were excluded. Two articles that met our pre-defined criteria were included in this review. The results showed that administering extracellular vesicles or exosomes is safe and potentially effective in patients suffering from low back pain. Yet, more sufficiently powered, multi-center, prospective, randomized, and non-randomized trials with longer follow-up are essential to assess the long-term safety and efficacy of extracellular vesicles or exosomes derived from various sources and to support its routine clinical use for managing low back pain.

Transforming Growth Factor-β Induces Interleukin-6 Secretion from Human Ligamentum Flavum-Derived Cells through Partial Activation of p38 and p44/42 Mitogen-Activated Protein Kinases

STUDY DESIGN

This experimental study was performed using human ligamentum flavum-derived cells (HFCs).

PURPOSE

To investigate the intracellular signaling mechanism of interleukin-6 (IL-6) secretion in transforming growth factor-β (TGF- β)-stimulated HFCs.

OVERVIEW OF LITERATURE

Lumbar spinal stenosis (LSS) is a prevalent disease among the elderly, characterized by debilitating pain in the lower extremities. Although the number of patients with LSS has increased in recent years, the underlying pathomechanism remains unclear. Clinical examinations typically rely on magnetic resonance imaging to diagnose patients, revealing ligamentum flavum hypertrophy. Some studies have suggested an association between ligamentum flavum hypertrophy and inflammation/fibrosis, and expression of TGF-β and IL-6 has been observed in surgically obtained ligamentum flavum samples. However, direct evidence linking TGF-β and IL-6 expression in HFCs is lacking.

METHODS

HFCs were obtained from patients with LSS who had undergone decompression surgery. The cells were stimulated with TGF-β and pretreated with either the p38 mitogen-activated protein (MAP) kinase inhibitor SB203580 or the p44/42 MAP kinase inhibitor FR180204. IL-6 secretion in the cell culture medium and IL-6 messenger RNA (mRNA) expression levels were analyzed using an enzyme-linked immunoassay and real-time polymerase chain reaction, respectively.

RESULTS

TGF-β administration resulted in a dose- and time-dependent stimulation of IL-6 release. Treatment with SB203580 and FR180204 markedly suppressed TGF-β-induced IL-6 secretion from HFCs. Moreover, these inhibitors suppressed IL-6 mRNA expression in response to TGF-β stimulation.

CONCLUSIONS

Our findings indicate that TGF-β induces IL-6 protein secretion and gene expression in HFCs through the activation of p38 or p44/42 MAP kinases. These results suggest a potential association between IL-6-mediated inflammatory response and tissue hypertrophy in LSS, and we provide insights into molecular targets for therapeutic interventions targeting LSS-related inflammation through our analysis of the MAP kinase pathway using HFCs.

Amniotic membrane and/or umbilical cord tissue for treatment of facet joint syndrome: a narrative review

Musculoskeletal spine disorders, especially low back pain, induce enormous amounts of stress and financial burden on individuals and healthcare systems throughout the world. Disorders of the facet joints in the lumbar spine are the most predominant cause of back pain, resulting in facet joint syndrome (FJS). Conventional treatments for FJS are short-lived and have limitations and side effects. Thus, safer and more effective alternatives that can reduce pain and improve patient-reported outcomes are needed. Recently, the utilization of biologics, including the ones derived from perinatal tissue such as amniotic membrane (AM) and umbilical cord (UC), has significantly increased for regenerative medicine applications. This manuscript summarizes the outcomes of preclinical and clinical studies utilizing AM and/or UC for FJS. We identified no preclinical studies and 3 retrospective studies utilizing the search terms "amniotic membrane" and/or "umbilical cord" and "facet joint syndrome". The administration of AM + UC is safe and potentially efficacious for patients with FJS. However, more preclinical studies and appropriately powered, multi-center, prospective non-randomized and randomized controlled studies with longer follow-up are warranted to further evaluate the efficacy of AM + UC to justify its clinical use.

Association between body composition and chronic low back pain in Korean adults aged over 50 years: The Korea National Health and Nutrition Examination Survey (KNHANES) 2010-2011

Background The relationship between overweight or obesity and low back pain (LBP) has previously been investigated. Several recent studies have focused on the relationship between other indicators of obesity, particularly indicators of fat and the risk of LBP. However, the results of body composition and LBP have been inconsistent. Methods All data for the present retrospective, cross-sectional study was extracted from the Korea National Health and Nutrition Examination Survey (KNHANES) versions V-1 and 2 conducted in 2010 and 2011 by the Korean Centers for Disease Control and Prevention. In KNHANES V-1 (2010) and V-2 (2011), those over 50 years of age completed the surveys on LBP, body weight, and body composition assessed using dual-energy X-ray absorptiometry (DXA) were included. The multivariable logistic regression analysis was used to examine the relationship between the presence of chronic LBP and body composition adjusting for confounders. Results We analyzed 3,579 persons who completed the question. In the multivariable analyses adjusting for age and sex, none of the variables, including fat mass and fat-free mass, remained positively or negatively associated with LBP. Additionally, when depression, smoking, alcohol intake, physical activity, diabetes mellitus, and fat or lean tissue mass were included in the multivariable logistic model, no significant associations were found between all measures of fat mass, fat-free mass, and LBP Conclusion This study is contrary to previous studies that concluded that there is a correlation between obesity and fat mass and LBP. LBP is not associated with increased levels of obesity and fat mass.

MiR-337-3p confers protective effect on facet joint osteoarthritis by targeting SKP2 to inhibit DUSP1 ubiquitination and inactivate MAPK pathway

OBJECTIVE

To probe the performance of miR-337-3p on the facet joint osteoarthritis (FJOA) and its underlying mechanism.

METHODS

qRT-PCR and Western blot were utilized to analyze the levels of miR-337-3p and DUSP1 in the synovial tissues from 36 FJOA patients and 10 healthy controls. The human synovial fibroblasts of FJOA were isolated and cultured followed by cell transfection. Then, cells were exposed to 10 ng/mL of IL-1β to induce inflammatory response of synovial fibroblasts. The alternation on cell biological function in cell models was determined. The binding of miR-337-3p and SKP2 was predicted by StarBase, TargetScan, DIANA-microT and miRmap, and further verified by RIP assay and dual-luciferase reporter assay. Co-IP experiment and ubiquitination assay were used to display the binding of SKP2 and DUSP1 as well as the ubiquitination and degradation of DUSP1. After that, the FJOA rat model was established and miR-337-3p mimic or negative control was given to rats by tail vein injection. The pathological changes of synovial tissues, synovitis score, and inflammation level in rats were assessed.

RESULTS

The low expressions of miR-337-3p and DUSP1 were noticed in the synovial tissues of FJOA patients and in IL-1β-induced synovial fibroblasts, and highly expressed p-p38 MAPK was noticed. Upregulation of miR-337-3p/DUSP1 or downregulation of SKP2 inhibited IL-1β-induced proliferation and inflammatory response of synovial fibroblasts. SKP2 was the target gene of miR-337-3p, and SKP2 induced the ubiquitination and degradation of DUSP1. MiR-337-3p exerted a protective effect on FJOA rats by alleviating damage of rat synovial tissues, promoting cell apoptosis and repressing inflammatory response.

CONCLUSION

MiR-337-3p plays a protective role in FJOA by negatively targeting SKP2 to suppress DUSP1 ubiquitination and inactivate the p38 MAPK pathway.

Ultrasound-guided axial facet joint interventions for chronic spinal pain: A narrative review

Background

Axial facet joint interventions (e.g., medial branch block and radiofrequency ablation, facet joint intra-articular injection) are commonly performed for managing chronic spinal pain. Although traditionally performed with fluoroscopy or computed tomography (CT) guidance, ultrasound-guided techniques have also been developed for these interventions.

Aims

The aim of this study is to present contemporary ultrasound-guided techniques for facet joint interventions and synthesize data addressing their accuracy, safety, and efficacy.

Methods

The PubMed, MEDLINE, CINAHL, Embase, and Cochrane Central Register of Controlled Trials databases were systematically searched for studies of ultrasound-guided facet joint interventions with human subjects from November 1, 1992, to November 1, 2022. Additional sources were drawn from reference lists and citations of relevant studies.

Results

We found 48 studies assessing ultrasound-guided facet joint interventions. Ultrasound guidance for injection of the cervical facet joints and their innervating nerves had favorable accuracy (78%-100%), with lower procedural time compared to fluoroscopy or CT guidance and comparable pain relief. Accuracy with ultrasound-guided lumbar facet joint intra-articular injection (86%-100%) was more reliable than medial branch block (72%-97%); analgesia was comparable to fluoroscopy and CT guidance. In general, these procedures were more challenging for patients with obesity, and deeper structures were more difficult to accurately target (e.g., lower cervical levels, L5 dorsal ramus).

Conclusions

Ultrasound-guided facet joint interventions continue to evolve. Some technically challenging interventions may be impractical for widespread usage or require further technical refinement. The utility of ultrasound guidance with obesity and abnormal anatomy may be reduced.

Does Facet Distraction Affect Patient Outcomes After ACDF?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study is to determine if there is a correlation between the amount of facet distraction and postoperative patient-reported outcomes after ACDF.

METHODS

A retrospective cohort analysis of patients undergoing 1 to 3 level ACDF for degenerative pathologies at a single academic center was performed. Each patient received upright, lateral cervical spine x-rays at the immediate postoperative time point from which interfacet distance (facet distraction) was measured. Patient-reported outcome measures including NDI, PCS-12, MCS-12, VAS Neck, and VAS Arm pain scores were obtained preoperatively and at short-term (<3 months) and long-term (>1 year) follow-up. Receiver operating curves were generated to evaluate the possibility of a critical interfacet distraction distance. Univariate and multivariate analysis were performed to compare outcomes between groups based on the degree of facet distraction.

RESULTS

A total of 229 patients met the inclusion criteria. Receiver operating curves failed to yield a critical interfacet distraction distance associated with worse post-operative outcomes. Patients were instead grouped based on facet distraction distance below and above the third quartile (0.8mm-2.0 mm, 2.0mm-3.7 mm), with 173 and 56 patients in each respective group. Univariate analysis did not detect any statistically significant differences in outcome measures, recovery ratio, or % MCID achievement at short- and long-term follow-up between groups. Multivariate analysis also failed to demonstrate any significant differences between the facet distraction groups.

CONCLUSION

Increased interfacet distance did not correlate with increased neck pain or disability after an ACDF.

Safety and Efficacy of Autologous Stem Cell Treatment for Facetogenic Chronic Back Pain

Background: Chronic back pain due to facet joint syndrome is a common and debilitating condition. Advances in regenerative medicine have shown that autologous unmodified adipose tissue-derived regenerative cells (ADRC) provide several beneficial effects. These regenerative cells can differentiate into various tissues and exhibit a strong anti-inflammatory potential. ADRCs can be obtained from a small amount of fatty tissue derived from the patient’s abdominal fat. Methods: We report long-term results of 37 patients (age 31–78 years, mean 62.5) suffering from “Facet Joint Syndrome” The pathology was confirmed by clinical, radiological examinations and fluoroscopically guided test injections. Then, liposuction was performed. An amount of 50–100 cc of fat was harvested. To recover stem cells from adipose tissue, we use the CE-certified Transpose RT™ system from InGeneron GmbH. The cells were then injected under fluoroscopic control in the periarticular fat. Follow-up examinations were performed at 1 week, 1 year, and 5 years. Results: Every patient reported improved VAS pain at any follow-up (1 week, 1 year, and 5 years) with ADRCs compared to the baseline. Conclusions: Our observational data indicate that facet joint syndrome patients treated with unmodified adipose tissue-derived regenerative cells experience improved the quality of life in the long term.

Mechanisms behind the Development of Chronic Low Back Pain and Its Neurodegenerative Features

Chronic back pain is complex and there is no guarantee that treating its potential causes will cause the pain to go away. Therefore, rather than attempting to "cure" chronic pain, many clinicians, caregivers and researchers aim to help educate patients about their pain and try to help them live a better quality of life despite their condition. A systematic review has demonstrated that patient education has a large effect on pain and pain related disability when done in conjunction with treatments. Therefore, understanding and updating our current state of knowledge of the pathophysiology of back pain is important in educating patients as well as guiding the development of novel therapeutics. Growing evidence suggests that back pain causes morphological changes in the central nervous system and that these changes have significant overlap with those seen in common neurodegenerative disorders. These similarities in mechanisms may explain the associations between chronic low back pain and cognitive decline and brain fog. The neurodegenerative underpinnings of chronic low back pain demonstrate a new layer of understanding for this condition, which may help inspire new strategies in pain education and management, as well as potentially improve current treatment.

Clinical Outcomes of Amniotic Membrane/Umbilical Cord Particulate in Spinal Disorders: A Retrospective Study

Background

Musculoskeletal spinal disorders significantly impact patient populations from everyday workers to military soldiers. Effective treatment is critical to minimize the time between injury and returning to work and daily activities. Injection of amniotic membrane/umbilical cord (AMUC) tissue has demonstrated great potential in reducing patients' pain and has become an increasingly popular treatment option for painful orthopedic disorders.

Methods

A single-center, retrospective study was conducted on patients diagnosed with musculoskeletal spinal disorders and subsequently treated with AMUC via epidural and facet injections. Demographics and outcomes related to pain were assessed. Pain was verbally reported by the patient on a scale of 0-10 where 0 indicated no pain and 10 indicated worst imaginable pain. Complications and adverse events were also reported.

Results

A total of 52 patients (average age 40.8 ± 9.6 years) were included in the analysis with diagnoses of spondylosis (n = 44), intervertebral disc degeneration (n = 31), radiculopathy (n = 18), stenosis (n = 2), or other conditions. The cohort's average baseline pain score was 4.9 ± 2.2 with a mean duration of symptoms for 54.2 months (range: 1-300 months). After AMUC injection, pain significantly decreased to 3.4 ± 2.3 at two weeks (p < 0.0001) and 3.5 ± 2.2 at 3-4 weeks (p = 0.0023). For the mean follow-up period of 10.6 ± 5.4 weeks, pain was reduced to 2.8 ± 2.1 (p < 0.0001 vs baseline). No significant complications or adverse events were reported.

Conclusion

Use of an injectable AMUC, such as CLARIX FLO, may alleviate pain in patients with painful spinal indications of various pathologies. This study provides further evidence of its safety and efficacy in epidural and facet injections. Further studies are warranted to verify these promising results.

Facet Joint Syndrome: Pathophysiology, Diagnosis, and Treatment

Facet joint osteoarthritis (OA) is the most frequent form of facet joint syndrome. Medical history, referred pain patterns, physical examination, and diagnostic imaging studies (standard radiographs, magnetic resonance imaging, computed tomography and single-photon emission computed tomography) may suggest but not confirm lumbar facet joint (LFJ) syndrome as a source of low back pain (LBP). However, the diagnosis and treatment of facet joint syndrome is still controversial and needs further study. It is widely acknowledged that block with local anesthetic is perhaps the most effective method to establish a diagnosis of pain from LFJ. Particularly, there are different rates of success among different populations selected for diagnostic block with various positive criteria. Currently, in addition to conservative treatments for pain such as painkillers, functional exercises, and massage, there are many other methods, including block, denervation of the nerves that innervate the joints by radiofrequency, freezing or endoscopy, and injections. Due to the limited duration of pain relief from neurolysis of medial branch, many scholars have recently turned their targets to dorsal roots and LFJ capsules. Therefore, we reviewed the latest research progress of facet joint syndrome from diagnosis to treatment.

Facet overhang: A novel parameter in the pathophysiology of multifidus muscle atrophy

The relationship between degenerative zygapophysial joint (facet) arthropathy and multifidus muscle atrophy has not been rigorously evaluated. The purpose of this study was to determine if specific morphological features of degenerative facet arthropathy are correlated with multifidus muscle atrophy. We retrospectively reviewed medical records and imaging studies of patients with lumbar spinal stenosis. Facet overhang, bridging osteophyte formation, facet effusion, and facet angles were evaluated by univariable and multivariable regression to identify independent associations with deep and superficial parts of the multifidus total cross-sectional area (tCSA), functional cross-sectional area (fnCSA), and fatty infiltration (FI). Facet overhang was classified as severe in 50 females (53.2%) versus 56 males (36.9%) (p = 0.030). Severity of facet overhang and female sex were independently associated with smaller deep part of the multifidus tCSA and fnCSA as well as higher FI, reflecting greater atrophy of the deep region compared to total muscle mass. In comparison, severe facet overhang (p < 0.001; OR = 3.47, 95% CI = 2.13-5.66) and female sex (p < 0.001; OR = 4.19, 95% CI = 2.58-6.79) were independently associated only with higher superficial part of the multifidus FI, reflecting muscle steatosis without significant lean muscle atrophy. In patients with degenerative lumbar spinal stenosis, facet overhang is an independent risk factor for deep part of the multifidus atrophy. Bridging osteophyte formation, facet effusion, and facet angles were not independently associated with deep part of the multifidus atrophy.

MRI lesions in SpA: a comparison with noninflammatory back pain using propensity score adjustment method

Background:

Magnetic resonance imaging (MRI) is important in the management of axial spondyloarthritis (SpA). However, many MRI lesions are not exclusive to axial SpA. Further characterization of these lesions may lead to better clinical decisions.

Objective:

The objective of this study was to compare the frequency of individual spinal MRI lesions between axial SpA and noninflammatory back pain. The factors associated with individual lesions in participants with axial SpA were also determined.

Design:

This was a cross-sectional observational study.

Methods:

MRI lesions in 447 participants with axial SpA and 122 participants with noninflammatory back pain were compared using the propensity score adjustment method. Individual lesions included discovertebral lesions (DVL), Modic type 1 lesions, DVL without Modic type 1 lesions, facet joint lesions, costovertebral joint lesions, corner inflammatory lesions (CIL), and fatty corner lesions (FCL). The factors associated with the lesions were determined using regression analyses.

Results:

Among participants with axial SpA, 81.9% were HLA-B27-positive, 55.0% had radiographic axial SpA, and 60.5% had radiographic features of spinal damage (mSASSS >2). Almost half (48.6% in axial SpA versus 31.1% in noninflammatory back pain) had inflammatory lesions on spinal MRI. In propensity score matching with noninflammatory back pain, axial SpA had an increased occurrence of DVL without Modic type 1 lesion (OR = 3.43, p = 0.01), costovertebral lesion (OR = 11.89, p = 0.02), number of CIL (B = 1.19, p < 0.001), and number of FCL (B = 3.33, p < 0.001). Similar associations were found in the regression models in the radiographic axial SpA subgroup: DVL without Modic type 1 lesion (OR = 2.46, p = 0.001), costovertebral lesion (OR = 3.86, p < 0.001), number of CIL (B = 1.13, p < 0.001), and FCL (B = 2.29, p < 0.01).

Conclusion:

MRI lesions including DVL without Modic type 1, costovertebral joint lesions, CIL, and FCL were more specific in axial SpA.

The retrospective analysis of platelet-rich plasma and corticosteroid injection under epiduroscopic guidance for radiculopathy in operated or unoperated patients for lumbar disc herniation

Objectives: Epiduroscopy is a treatment method that can be applied to operated or non-operated patients with lumbar disc pathology. The aim of our study was to investigate and compare the efficacy of corticosteroid and platelet-rich plasma (PRP) therapy that we have injected in epidural and foraminal spaces under the guidance of epiduroscopy in the operated or unoperated patients with radicular pain.

Patients and methods: The retrospective study was conducted with 62 patients (40 females, 22 males; mean age: 48±12.3 years; range, 20 to 75 years) between January 2014 and September 2020. Of the patients, 32 were unoperated, whereas 30 were operated. All the patients had radicular pain. All the patients were evaluated by the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) at the start, on the 10th day, and at one and six months after the procedure by polyclinic control and by a phone call for their last follow-up.

Results: The VAS and ODI scores of patients treated with corticosteroid and PRP were decreased on the 10th day, at one and six months and the last follow-up, and this decrease was statistically significant.

Conclusion: Both PRP and corticosteroid injections were effective in pain scores during short-term and long-term follow-ups owing to the contribution of epiduroscopic intervention by allowing local administration of PRP or corticosteroids and analgesic agents as well as its mechanical adhesiolysis effect.

Interleukin-18 Inhibition Protects Against Intervertebral Disc Degeneration via the Inactivation of Caspase-3/9 Dependent Apoptotic Pathways

BACKGROUND

The present study was designed to identify and understand the potential effectiveness of therapeutic target in intervertebral disc degeneration (IVDD) and its regulation mechanism.

METHODS

The role and mechanism of interleukin-18 (IL-18) in the disease were investigated. The IVDD degenerative nucleus pulposus (NP) tissues from the human and mouse models were used.A total of three groups of Male BALB/c mice were randomly made i.e control, IVDD, and IVDD+Ad-shIL-18 groups. After Ad-shIL-18 transfection, the expression of ECM synthesis related protein Aggrecan (ACAN) and Collagen II, apoptotic effector Caspases (Caspase-3, 8, 9, 12 and Cleaved-Caspase 3, 8, 9, 12), pro-apoptotic gene Bax and anti-apoptotic factors Bcl-2 in NP cells of the human were evaluated.

RESULTS

The results of our study revealed that the mRNA and protein expression levels of IL-18 were notably increased in the NP tissues of IVDD patients and mice models. In the IVDD mice model, Ad-sh-IL-18 treatment reversed the IVDD progression. The levels of Aggrecan and Collagen II, contributing to ECM degradation in NP cells, were also significantly increased. Additionally, Ad-sh-IL-18 could inhibit the NP cell's apoptosis via regulating the caspase-3/9 pathway.

CONCLUSION

The IL-18 knockdown via the caspase-3/9 pathway, might reduce the NP cell's death as well as the imbalance between catabolism and anabolism of ECM in IVDD.

Injectable amniotic membrane/umbilical cord particulate for facet joint syndrome: A retrospective, single-center study

BACKGROUND

Facet joint syndrome (FJS) pain is a significant contributor to back pain and has a high rate of opioid prescription. Unfortunately, there are a limited number of therapeutic options for these patients.

OBJECTIVE

To evaluate the safety and effectiveness of amniotic membrane/umbilical cord particulate (AM/UC) in managing FJS pain.

METHODS

A single-center, investigator-initiated, retrospective study was performed on consecutive patients with FJS pain who received intra- or peri-articular injection of AM/UC between July 1, 2018 and July 26, 2019. Primary outcome was change in Patient Global Impression of Change (PGIC) at 6 weeks, 3 months, 6 months, and 12 months to assess the self-reported percent improvement relative to baseline. Safety was assessed by AM/UC- and procedure-related complications. Paired t-tests were used to determine whether there is a statistically significant improvement of pain post-injection compared to baseline.

RESULTS

There were a total of 54 patients (69.7 ± 13.4 years; 31 female) presenting baseline pain score of 9.2 ± 1.0 despite prior treatments of activity modification (66.7%), NSAIDs (61.1%), opioids (37.0%), and physical therapy (35.2%). Mean GPIC improvement was 65.3%, 67.5%, 56.9%, and 56.7% among responders30, respectively. There were no complications.

CONCLUSION

This study supports the safety and effectiveness of AM/UC particulate injection in managing FJS pain.

Do Inflammatory Cytokines Affect Patient Outcomes After ACDF?

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

The aim was to determine the relationship between serum inflammatory mediators, preoperative cervical spine disease severity, and clinical outcomes after anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Given the role of the inflammatory cascade in spinal degenerative disease, it has been hypothesized that inflammatory markers may serve as a predictor of patient outcomes after surgery.

MATERIALS AND METHODS

All patients over age 18 who underwent ACDF for cervical spondylosis with associated radiculopathy and/or myelopathy between 2015 and 2017 from a single institution were prospectively recruited. Preoperative serum inflammatory markers including interleukin (IL)-6, IL-8, tumor necrosis factor-α, high-mobility group box-1 (HMGB1), and white blood cells were measured and correlated to patient demographics, surgical characteristics, duration of symptoms, previous opioid use, and preoperative and 1-year postoperative patient-reported outcomes measures (PROMs) including the neck disability index (NDI), visual analog scale neck pain, visual analog scale arm pain, and Physical and Mental Component Scores of the Short Form-12 (PCS and MCS, respectively) using spearman's rho coefficient.

RESULTS

A total of 77 patients were enrolled with follow-up PROMs available for 62% (n=48) of patients at a minimum of 1-year after ACDF. The absolute concentrations of IL-6 and tumor necrosis factor-α were found to be weakly correlated with one another (ρ=0.479). Preoperative symptoms lasting <1-year were weakly correlated with elevation in HMGB1 (ρ=0.421). All other patient demographics exhibited negligible correlation with the preoperative inflammatory markers. Lower preoperative PCS (ρ=0.355) and higher preoperative NDI (ρ=0.336) were weakly correlated with elevated HMGB1. Lower MCS (ρ=0.395) and higher NDI (ρ=0.317) preoperatively were weakly correlated with elevated white blood cells. Postoperative improvement in MCS (ρ=0.306) and MCS recovery ratio (ρ=0.321) exhibited a weakly positive correlation with IL-6.

CONCLUSION

Preoperative cytokine levels demonstrated minimal correlation with preoperative symptoms or clinical improvement, suggesting that profiling of patient cytokines has limited utility in predicting outcomes after ACDF.

LEVEL OF EVIDENCE

Level III.

Factors Associated with Pain Intensity and Walking Disability After Lumbar Fusion: A Longitudinal Study

STUDY DESIGN

Retrospective longitudinal study.

OBJECTIVE

To identify the preoperative factors associated with postoperative lumbar fusion recovery in back or leg pain, self-reported walking time, and gait speed over a 6-month period.

SUMMARY OF BACKGROUND DATA

The demand for lumbar fusion surgeries has significantly increased over the years. Yet, some patients report persistent postsurgical pain and poor functional outcomes. Unfortunately, the associated risk factors are not well understood.

METHODS

The study analyzed 232 subjects with mono- or bisegmental lumbar fusion surgery who underwent standardized assessment preoperatively and at 4, 12, and 24weeks postoperatively. Preoperative variables collected were demographic, clinical, and psychological variables. Back or leg pain was measured by the Numeric Pain Rating Scale. Walking disability was measured by self-reported walking time and performance-based fast gait speed. Risk factors of pain and walking disability over time were identified using ordinal and linear mixed-effects modeling.

RESULTS

At 6 months post-surgery, 17% of patients reported having moderate or severe back/leg pain and 24% were unable to walk longer than 30 minutes. Greater preoperative self-reported leg weakness frequency and body-mass-index (BMI) were strongly associated with greater pain and walking disability. Additionally, greater preoperative depression symptoms were associated with greater back/leg pain (adjusted odds ratio = 4.0) and shorter walking time (adjusted odds ratio = 2.7)-but not with slower gait speed (difference = 0.01 m/s). Old age and female gender were strongly associated with gait speed but not with self-reported walking time.

CONCLUSION

A sizable proportion of patients had poor pain and walking outcomes even at 6 months post-surgery. Preoperative leg weakness and BMI were consistent risk factors and patients with greater depression symptoms may have poorer self-reported outcomes. Although requiring validation, our study has identified potentially modifiable risk factors which may give clinicians an opportunity to provide early (preoperative) and targeted intervention strategies to optimize postoperative outcomes.

Level of Evidence: NA.

PET/CT imaging of spinal inflammation and microcalcification in patients with low back pain: A pilot study on the quantification by artificial intelligence-based segmentation

Background

Current imaging modalities are often incapable of identifying nociceptive sources of low back pain (LBP). We aimed to characterize these by means of positron emission tomography/computed tomography (PET/CT) of the lumbar spine region applying tracers ¹⁸F‐fluorodeoxyglucose (FDG) and ¹⁸F‐sodium fluoride (NaF) targeting inflammation and active microcalcification, respectively.

Methods

Using artificial intelligence (AI)‐based quantification, we compared PET findings in two sex‐ and age‐matched groups, a case group of seven males and five females, mean age 45 ± 14 years, with ongoing LBP and a similar control group of 12 pain‐free individuals. PET/CT scans were segmented into three distinct volumes of interest (VOIs): lumbar vertebral bodies, facet joints and intervertebral discs. Maximum, mean and total standardized uptake values (SUVmax, SUVmean and SUVtotal) for FDG and NaF uptake in the 3 VOIs were measured and compared between groups. Holm–Bonferroni correction was applied to adjust for multiple testing.

Results

FDG uptake was slightly higher in most locations of the LBP group including higher SUVmean in the intervertebral discs (0.96 ± 0.34 vs. 0.69 ± 0.15). All NaF uptake values were higher in cases, including higher SUVmax in the intervertebral discs (11.63 ± 3.29 vs. 9.45 ± 1.32) and facet joints (14.98 ± 6.55 vs. 10.60 ± 2.97).

Conclusion

Observed intergroup differences suggest acute inflammation and microcalcification as possible nociceptive causes of LBP. AI‐based quantification of relevant lumbar VOIs in PET/CT scans of LBP patients and controls appears to be feasible. These promising, early findings warrant further investigation and confirmation.

Analysis of Functional Outcomes and Risk Factors for Facet Joint Distraction During Anterior Cervical Discectomy and Fusion for Cervical Spondylotic Myelopathy

OBJECTIVE

This study aimed to clarify functional outcomes of facet joint distraction (FJD) and identify specific risk factors for excessive FJD during single-level anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM).

METHODS

This study retrospectively analyzed 100 patients who underwent single-level ACDF for CSM from January 2016 to May 2020. Anteroposterior and lateral radiographs were obtained before surgery and 12 months after surgery. Radiographic parameters including anterior intervertebral height (AIH), posterior intervertebral height, facet joint gap, cage posterior depth (CPD), upper vertebral length, cervical segmental Cobb angle (CSCA), C2-C7 Cobb angle, and C2-C7 sagittal vertical axis were analyzed. Functional outcomes were evaluated using the modified Japanese Orthopedic Association Score, visual analog scale (VAS), and Neck Disability Index (NDI).

RESULTS

Comparison between the appropriate FJD and excessive FJD groups showed statistically significant differences in the NDI, VAS, CPD, and ΔAIH (P < 0.05). Multivariate logistic regression analysis showed that independent factors associated with excessive FJD were as follows: a ΔAIH > 2.28 mm (odds ratio [OR] = 6.792, 95% confidence interval [CI] = 1.885-24.470, P = 0.003), CPD > 12.45 mm (OR = 5.876, 95% CI = 1.828-18.895, P = 0.003), and post-CSCA < 0° (OR = 6.251, 95% CI = 1.275-30.633, P = 0.024). Furthermore, receiver operating characteristic curve analysis for the multilevel logistic regression model produced an area under the curve of 0.783 (P < 0.001).

CONCLUSION

Patients with an FJD of >0.905 mm had worse NDI and VAS pain scores, but not a poorer modified Japanese Orthopedic Association Score recovery rate. Our findings suggested that a ΔAIH > 2.28 mm, CPD > 12.45 mm, and post-CSCA < 0° were independent risk factors for excessive FJD after single-level ACDF for CSM.

Dietary factors and the risk of lumbar spinal stenosis: A case-control analysis from the PREFACE study

BACKGROUND AND AIMS

There is a lack of knowledge on the association of dietary factors and Lumbar Spinal Stenosis (LSS). We evaluated the association of a Mediterranean diet (MD), its major food components and ultra-processed food (UPF) with the risk of LSS.

METHODS AND RESULTS

Participants were recruited from the Neurosurgery Department of the IRCCS Neuromed, Italy. The study sample consisted of 156 cases of LSS, and 312 controls matched 1:2 for sex, age (±6 months) and physical activity, without a history or clinical evidence of LSS who were identified from the general population. Adherence to MD was assessed by the Mediterranean Diet Score based on 9 food groups. UPF was defined according to NOVA classification and calculated as the ratio (%) of UPF (g/d) on total food consumed (g/d). In multivariable-adjusted analysis, a 2-point increase in the MD score was not associated with LSS risk (OR: 1.02, 95% CI: 0.72-1.46). An increment of 10 g/d of fruits and nuts, cereals or fish led to lower odds of LSS (OR: 0.97, 95% CI: 0.95-0.99; OR: 0.88, 95% CI: 0.82-0.94; OR: 0.87, 95% CI: 0.76-0.99, respectively). Additionally, 1% increment in the consumption of UPF in the diet was independently associated with higher LSS risk (OR: 1.09, 95% CI: 1.04-1.14).

CONCLUSION

A diet rich in fruits, cereals, fish is associated with lower risk of LSS while a large dietary share of UPF increases the risk of this disease. Further studies with a prospective design and larger sample sizes are warranted.

Correlation of Tumor Necrosis Factor-α Expression with Pain Level in Degenerative Lumbar Canal Stenosis Patients

Introduction: Pain in degenerative lumbar canal stenosis is caused by osteoarthritis of a facet joint and intervertebral disc degeneration. Some inflammatory mediators such as tumor necrosis factor (TNF)-α are present in degenerative lumbar canal stenosis. This study aimed to evaluate the correlation of pain and functional pre-operative scores with the expression of TNF-α in nucleus pulposus, annulus fibrosus, and facet joint. Methods: Patients diagnosed with degenerative lumbar canal stenosis and planned for surgical treatment were included in this study. Patients with history of fracture, neoplasm, and/or infection of the spine were excluded. Tissue samples were collected from the nucleus pulposus, annulus fibrosus, facet joint, flavum ligament and paraspinal muscles of the spine during the surgery. TNF-α expression was examined semi-quantitively and correlated with the axial and radicular pain that were measured using Visual Analog Score (VAS) score. The result was then statistically analyzed. Results: The expression of TNF-α in the paraspinal muscle (6.30±14.20) was significantly higher compared to other locations. TNF-α expression in the facet joint group was significantly correlated with the intensity of low back pain measured by VAS score (r=0.893, p < 0.001), and pre-operative functional outcome based on Oswestry Disability Index (ODI) (r=0.948, p < 0.001). Conclusion: TNF-α expression, especially in the facet joint, is significantly associated with the pain intensity and pre-operative ODI that allow pain reduction with less invasive treatment in lumbar canal stenosis patients.  

Serum apolipoprotein B/apolipoprotein A1 ratio in relation to intervertebral disk herniation: a cross-sectional frequency-matched case-control study

Study design

This was a cross-sectional frequency-matched case–control study.

Background and aim

The serum lipid profile of lipoprotein(a) [Lp(a)] level and apolipoprotein B/apolipoprotein A1 ratio (Apo B/Apo A1) ratio were found to be more representative for serum lipid level and were recognized as the independent risk factors for various diseases. Although the blood levels of total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) were found to be associated with symptomatic intervertebral disk herniation (IDH), no studies to date have evaluated the association of Apo AI, Apo B, Lp(a), and Apo B/Apo AI levels with symptomatic IDH. This study aimed to assess the link between blood lipid levels and symptomatic IDH.

Method

The study included 1839 Chinese patients. Of these, 918 patients were diagnosed with IDH and enrolled in the experimental group. A control group of 921 patients underwent a physical examination during the same period. The serum lipid levels of TC, TG, LDL-C, HDL-C, Lp(a), Apo B, and Apo B/Apo AI were examined and analyzed. The control group comprised randomly selected patients who met the baseline levels of the aforementioned lipid molecules.

Results

Patients with IDH exhibited significantly higher TC, TG, LDL, Apo B, and Lp(a) levels than controls. The percentage of high TC, high TG, high LDL, high Apo B, and high Lp(a) were obviously higher in the IDH group than in the control group. However, hyperlipidemia had no relationship with the degenerated segment of the IDH (P = 0.201). The odds ratio (OR) for the incidence of IDH with elevated levels of LDL-C, TC, TG, Lp(a), Apo B, and Apo B/Apo AI was 1.583, 1.74, 1.62, 1.58, 1.49, and 1.39, respectively. The correlation analysis revealed the correlation between elevated LDL-C, TC, TG, Apo B, Lp(a), and incidence of IDH was significant (R²_LDL = 0.017; R²_TC = 0.004; R²_TG = 0.015; R²_{Apo B} = 0.004; R²_Lp(a) = 0.021) (P < 0.05).

Conclusion

This study suggested that elevated levels of serum TC, TG, LDL, Apo B, Lp(a), and Apo B/Apo AI were associated with a higher risk of IDH. This study provided useful information to identify a population that might be at risk of developing IDH based on elevated lipid levels.

Clinical impact and imaging results after a modified procedure of ACDF: a prospective case-controlled study based on ninety cases with two-year follow-up

Study design

This is a prospective case-controlled study.

Background

To analyze the postoperative axial pain and cage subsidence of patients presenting with cervical spondylotic myelopathy (CSM) after a modified procedure of ACDF (mACDF).

Methods

Ninety patients with CSM were prospectively collected from 2014 to 2018. The patients were divided into spread group and non-spread group (48:42 ratio) according to the cage placement with or without releasing the Caspar cervical retractor after decompression. Spread group received conventional ACDF and non-spread group received mACDF. Patients were followed-up for at least 24 months after surgery. Radiologic data, including height of intervertebral space and Cobb Angle, were collected. Nervous system function was obtained using JOA scores, and level of pain was assessed using VAS scores.

Results

A total of 90 patients were enrolled and the patients were divided into spread group (n = 48) and none-spread group(n = 42). Cage subsidence of (spread group vs none-spread group) was (0.82 ± 0.68 vs 0.58 ± 0.81) mm, (0.64 ± 0.77 vs 0.34 ± 0.46) mm, (0.48 ± 0.43 vs 0.25 ± 0.28) mm, and (0.45 ± 0.47 vs 0.17 ± 0.32) mm at 3 months, 6 months, 12 months and 24 months, respectively. The period exhibiting the most decrease of the height of intervertebral space was 3 months postoperatively. However, there was no statistical difference in the height of intervertebral space, JOA or VAS scores at the final follow-up between the two groups.

Conclusions

The mACDF can avoid excessive distraction by releasing the Caspar Cervical retractor, restore the “natural height” of cervical vertebra, relieve immediate pain after surgery, and prevent rapid Cage subsidence and the loss of cervical curvature.

Improvements in Intractable Lumbar and LowerExtremity Symptoms after Systemic Administration of Tocilizumab, an Anti-interleukin-6 Receptor Antibody

Study Design

Prospective cohort study (open-label, single-arm, and non-blinded).

Purpose

This study aims to determine the effects of systemic administration of tocilizumab, an anti-interleukin-6 (IL-6) receptor antibody on refractory low back pain and leg symptoms.

Overview of Literature

IL-6 overexpression is associated with neuropathic pain pathogenesis, which is potentially followed by chronic low back pain, including leg pain and numbness. This finding suggest that inhibition of IL-6 at the site of pain or in the transmission pathway could provide novel therapeutic targets for chronic low back pain.

Methods

This prospective, single-arm study included 11 patients (eight men; mean age, 62.7 years) with ≥3-months’ chronic pain history due to lumbar disease. Subcutaneous TCZ injections were administered twice, at a 2-week interval. We evaluated low back pain, leg pain, and leg numbness using numeric rating scales and the Oswestry Disability Index (ODI; baseline and 6 months postinjection); serum IL-6 and tumor necrosis factor-α levels (baseline and 1 month postinjection); and clinical adverse events.

Results

Intractable symptoms reduced after TCZ administration. Low back pain improved for 6 months. Improvements in leg pain and numbness peaked at 4 and 1 month, respectively. Improvements in ODI were significant at 1 month and peaked at 4 months. Serum IL-6 was increased at 1 month. IL-6 responders (i.e., patients with IL-6 increases >10 pg/mL) showed particularly significant improvements in leg pain at 2 weeks, 1 month, and 2 months compared with nonresponders. We observed no apparent adverse events.

Conclusions

Systemic TCZ administration improved symptoms effectively for 6 months, with peak improvements at 1–4 months and no adverse events. Changing serum IL-6 levels correlated with leg pain improvements; further studies are warranted to elucidate the mechanistic connections between lumbar disorders and inflammatory cytokines.

Does cervical facet degeneration impact surgical outcomes and sagittal balance in patients with radiculopathy?

Purpose

In our present study, we aimed to investigate (1) whether cervical facet degeneration (FD) affects the clinical functional scores of patients with cervical radiculopathy after single-segment anterior cervical discectomy fusion (ACDF) and (2) whether FD affects the sagittal parameters of the cervical spine.

Methods

A total of 120 enrolled patients who underwent single-segment ACDF for radiculopathy with more than 2 years of follow-up were classified into two groups based on whether the preoperative mean FD was greater than or less than the mean FD grading score: mild FD group (mean score ≤ 2, n = 102) or severe FD group (mean score > 2, n = 48). Sagittal alignment changes and clinical functional scores were compared between the 2 groups. The relevant factors for FD were identified using multivariate logistic regression.

Results

Age, duration of symptoms, disc height and interfacet distance were independently associated with preoperative FD (age: P < 0.001; duration of symptoms: P = 0.020; disc height: P < 0.001; interfacet distance: P = 0.045). Compared with the mild FD group, the preoperative VAS (neck pain) score and NDI of the severe FD group were also higher, and the improvement of neck symptoms was better during the follow-up period. However, all clinical scores and radiographic parameters showed no significant differences during the 2-year follow-up. Additionally, no significant differences in the sagittal parameter changes were presented.

Conclusion

Patients with severe FD tended to experience more severe neck pain before surgery and greater improvement of neck symptoms at the follow-up visit. However, 2-year clinical efficacy and sagittal alignment after ACDF may not be markedly affected by preoperative FD severity. ACDF is considered to be a good choice for patients with radiculopathy, especially for patients with severe FD.

Intradural Disc Herniation in the Setting of Congenital Lumbar Spinal Stenosis

INTRODUCTION

Accounting for an estimated 1.10-1.76% of all lumbar herniations, lumbar intradural disc herniation (IDH) occurs primarily in males during the fourth to fifth decades of life. While not validated, congenital lumbar spinal stenosis (CLSS) is implicated as one precipitating factor for IDH.

CASE REPORT

We report 28-year-old Hispanic female with CLSS, severe obesity, and degenerative disk disease, with a history of minimally invasive surgical (MIS) decompression for a large paracentral L4-5 disc herniation at 25. After three years, the patient developed sudden burning dysesthesias in the L4-5 dermatomes bilaterally and temporary leg weakness. Lumbar magnetic resonance imaging exhibited severe L4-5 spinal stenosis, and the patient underwent repeat MIS decompression, which again provided her with adequate symptom resolution. However, 20 days postoperatively she developed cauda equina syndrome with anal dysfunction, and bilateral leg and foot weakness. Upon open surgical exploration we discovered a tense L4-5 dural protrusion. After a dorsal durotomy, a large IDH with a ventral dural tear was identified. Subsequent to adequate debulking of the IDH, the ventral tear was repaired, and an expansile duraplasty was performed. Overall, the patient's bladder and bowel function, pain, hypoesthesia, and motor strength all improved. Two weeks after surgery she presented with a lumbar pseudomeningocele that was managed conservatively.

CONCLUSION

This report not only highlights an atypical presentation of IDH and is the first case of CLSS linked with IDH, lending support to the hypothesis that CLSS can lead to IDH, but also provides a comprehensive review of IDHs.

The Outcome of Epidural Injections in Lumbar Radiculopathy Is Not Dependent on the Presence of Disc Herniation on Magnetic Resonance Imaging: Assessment of Short-Term and Long-Term Efficacy

OBJECTIVE

Lumbar radiculopathy is a condition with major physical, social, and economic consequences. Despite its favorable prognosis, the burden can be significant. In this study, we aimed to determine the value of magnetic resonance imaging (MRI) and the efficacy of transforaminal epidural injections (TEIs) in patients with lumbar radiculopathy secondary to lumbar disc herniation (LDH) and other causes (non-LDH).

METHODS

Patients with lumbar radiculopathy were reviewed for radiologic diagnosis based on MRI. For patients receiving TEI therapy, response after 6-8 weeks (short-term) and 16 weeks (long-term), number of injections, subsequent surgery, and patient outcome were evaluated. Treatment response was assessed by patient-reported symptom relief and numeric rating scale pain scores.

RESULTS

Overall, 66% of MRI examinations showed a clinically relevant LDH. A total of 486 of 1824 patients received TEI, of whom one third did not show LDH. Of patients, 70% reported a short-term effect with significant pain reduction and 44% reported a long-term effect. No significant differences were observed between the LDH and non-LDH groups. Of patients, 59% required multiple injections and reported similar efficacy compared with patients treated with a single injection.

CONCLUSIONS

A considerable part of MRI examinations in patients with lumbar radiculopathy do not show a clinically relevant LDH. Regardless of the radiologic diagnosis, most patients treated with TEI benefit in both the short-term and the long-term after a single-injection or multiple-injection regime. Subsequent injections are advisable if the effect from the first injection is unsatisfactory or wears off. MRI examination before TEI therapy may be redundant, which allows for expedition of this treatment.

Medical ozone therapy in facet joint syndrome: an overview of sonoanatomy, ultrasound-guided injection techniques and potential mechanism of action

Facet joint osteoarthritis is the most prevalent source of facet joint pain and represents a significant cause of low back pain. Oxygen-ozone therapy has been shown to have positive results in acute and chronic spinal degeneration diseases and it could be a safe and efficacious alternative to traditional facet joint conservative treatments. This review article explains the interventional facet joint management with ultrasound-guided oxygen-ozone therapy, providing an anatomy/sonoanatomy overview of lumbar facet joints and summarizing the potential mechanism of action of oxygen-ozone in the treatment of facet joint osteoarthritis, not yet fully understood.

Toll-like receptor involvement in adolescent scoliotic facet joint degeneration

Facet joint osteoarthritis is prevalent in young patients with adolescent idiopathic scoliosis (AIS) and might contribute to back pain. Toll-like receptors (TLR) have been linked to cartilaginous tissue degeneration but their involvement in facet joint osteoarthritis in AIS patients is still unknown. We compared baseline gene expression levels of TLRs -1, -2, -4, and -6 in scoliotic and non-scoliotic chondrocytes and found higher expression levels in scoliotic chondrocytes with significantly higher TLR2 levels. Furthermore, TLR expression correlated strongly and significantly with inflammatory and catabolic markers in scoliotic but not in non-scoliotic chondrocytes. TLR activation with a synthetic TLR2/6 agonist resulted in a robust induction and release of pro-inflammatory and catabolic factors which exacerbated proteoglycan loss in scoliotic but not in non-scoliotic cartilage. We also detected a higher abundance of alarmins including S100A8/9 and biglycan in scoliotic cartilage. Finally, the small-molecule antagonists Sparstolonin B and o-Vanillin reduced catabolism following induction with naturally occurring alarmins and the synthetic TLR2/6 agonist. The high baseline expression, robust responsiveness and strong and significant correlation with proteases and pro-inflammatory cytokines suggest that TLRs are key regulators of facet joint degeneration in AIS. Blocking their activity could therefore potentially modify disease progression.

Development of a novel rat model of lumbar facet joint osteoarthritis induced by persistent compressive injury

The aim of the present study was to develop a novel animal model of lumbar facet joint osteoarthritis induced by persistent compressive injury. An intraspinal compression spring was randomly implanted into either the L4/5 or the L5/6 spinal segments of 40 Sprague Dawley (SD) rats to induce compression. Sham-operations were used in the other segment of the same rats as the control levels. The animals were sacrificed at 7, 14, 28, 42 and 56 days after surgery, prior to the radiological confirmation of the spring location. Degeneration of the lumbar facet joints was evaluated by macroscopic observation in addition to histological and immunohistological analyses. The results of this present study revealed the absence of spring dislocation during the entire observation period. Macroscopic and Osteoarthritis Research Society International scores of the compression levels were found to be higher in the compression levels compared with those noted in the control levels (P<0.05). In addition, interleukin-1β and tumor necrosis factor-α expression in the compression levels were increased over time compared with those recorded in the control levels. In conclusion, persistent compressive injury may induce degeneration of the lumbar facet joint. This novel animal model could serve as a useful tool for further studies into the mechanisms of action and potential treatment of lumbar facet joint osteoarthritis.

Ligamentum flavum fibrosis and hypertrophy: Molecular pathways, cellular mechanisms, and future directions

Hypertrophy of ligamentum flavum (LF), along with disk protrusion and facet joints degeneration, is associated with the development of lumbar spinal canal stenosis (LSCS). Of note, LF hypertrophy is deemed as an important cause of LSCS. Histologically, fibrosis is proved to be the main pathology of LF hypertrophy. Despite the numerous studies explored the mechanisms of LF fibrosis at the molecular and cellular levels, the exact mechanism remains unknown. It is suggested that pathophysiologic stimuli such as mechanical stress, aging, obesity, and some diseases are the causative factors. Then, many cytokines and growth factors secreted by LF cells and its surrounding tissues play different roles in activating the fibrotic response. Here, we summarize the current status of detailed knowledge available regarding the causative factors, pathology, molecular and cellular mechanisms implicated in LF fibrosis and hypertrophy, also focusing on the possible avenues for anti-fibrotic strategies.

Reciprocal relationship between multifidus and psoas at L4-L5 level in women with low back pain

Background Low back pain (LBP) may originate from different sources such as intervertebral disc degeneration (IVDD), end-plate and paraspinal muscle changes. Our aim is to explore the relevance of paraspinal muscles' fat-infiltration in women with LBP and its association with IVDD and Modic changes.Methods Consecutive female patients presenting with chronic LBP to the outpatient clinics were included. Patients were evaluated in terms of IVDD, vertebral end-plate changes, and fatty infiltration in the paraspinal muscles at all lumbar levels on lumbar spine magnetic resonance imaging (MRI). Visual Analogue Scale (VAS) scores were recorded using our prospectively collected database.Results Patients with higher VAS scores were significantly more likely to have more fatty infiltration in the multifidus and less fatty infiltration in the psoas at L4-L5 level when compared to those with lower VAS scores (69.1 vs. 31.8%, p = 0.003). To predict LBP, fatty infiltration in the multifidus and psoas had odds ratio (OR) of 4 (p = 0.010), and 0.3 (p = 0.013), respectively; whereas disc degeneration had an OR of 0.5 (p = 0.028).Conclusion This is the first clinical cross-sectional study suggested that women with chronic low back pain could have less fat-infiltrated psoas to compensate more fat-infiltrated multifidus at L4-L5 disc level.

Prevalence of facet joint arthritis and its association with spinal pain in mountain population - A cross-sectional study

Introduction:

People living in the mountains are subject to tough terrain and climbing biomechanics which lead to degeneration of the spine and Facet joint arthritis (FJA).

Aims:

The goal of present study was (1) to know the prevalence of facet joint arthritis on CT scans in mountain population in regard to (a) different levels in spine (b) age (c) sex (2) to know if there is any significant association between FJA and spinal pain at that corresponding level.

Materials and Methods:

Bilateral Facet joints of 210 participants (age range, 18 to 97 years) who underwent MDCT imaging for reasons other than spinal pain, were graded and statistically analysed with SPSS software in this study. FJA was defined as at least one joint affected by facet joint disease (grade 2).

Results:

In our study, Seventy two men (68.5%) and eighty four women (80%) had Facet Joint arthritis. The difference between men and women in the prevalence of FJA was not statistically significant (P = 0.058). The increasing age demonstrated a higher prevalence of facet joint arthritis with statistical significance (P = 0.000). In dorsal and lumbar spine region, there was a statistically significant difference in prevalence of FJA according to spinal level. The prevalence of FJA grade 2 in cervical and dorsal spine region was associated with spinal pain in both men (P = 0.000) and women (P = 0.000). However, no statistically significant association was found between FJA grade 2 and spinal pain in lumbar spine region in both males (P = 0.680) and females (P = 0.680) as well as in total population (P = 0.513).

Conclusions:

People residing and actually ambulating in the mountain regions and exposed to the terrain have higher prevalence of Facet joint arthritis as compared to general population and this may be an independent risk factor for development of facet joint arthritis. However, a statistically significant relation between FJA and spinal pain exists only in cervical and dorsal spine.

Facet joint injections for management of low back pain: a clinically focused review

Lumbar facet joints have been implicated in chronic low back pain in up to 45% of patients with low back pain (LBP). Facet joint pain diagnosis and management are always challenging for pain physicians. Facet joint pain is not diagnosed by specific demographic features, pain characteristics, or physical findings, even though electrodiagnostic studies and imaging modalities are available. Although comparative local anesthetics or placebo saline injections can be used, diagnostic blocks are the only reliable diagnostic measures according to the current literature. Treatment of chronic LBP arising due to facet joint includes intraarticular injections, medial branch blocks, and radiofrequency neurotomy. However, the evidence of their clinical efficacy is continuously under scrutiny. Pain physicians must have a detailed understanding of the spinal anatomy in order to perform safe and effective interventional procedures. This review outlines the important aspects of spinal anatomy as they relate to interventional pain management related to facet joint injections. Additionally, we provide a comprehensive review of the procedure and clinical evidence.

Association between lumbar disc herniation and facet joint osteoarthritis

Background

This study was performed to investigate the association between lumbar disc herniation (LDH) and facet joint osteoarthritis (FJOA) using magnetic resonance imaging (MRI).

Methods

Between March 2012 and September 2018, a total of 441 segments from 394 patients with LDH were included in the study. LDH was classified according to the Michigan State University (MSU) classification, in which the degree of LDH is divided into 3 levels (expressed as 1, 2, and 3) and the location of LDH is divided into 4 zones (described as A, AB, B, and C). Bilateral FJOA was graded from 0 to 3 using the criteria introduced by Weishaupt et al., and bilateral facet orientations were measured on axial MRI slices. A mixed-effects ordinal logistic regression model was utilized to determine the potential factors that may be associated with FJOA, including sex, age, body mass index (BMI), segment, facet orientation and tropism, and the degree and location of LDH.

Results

In general, the prevalence of FJOA (grade ≥ 2) was 66.2% in LDH segments. For both the left and right sides, the degree of LDH was associated with the severity of FJOA (p < 0.01). Age and BMI were also associated with the severity of left and right FJOA (p = 0.002 and p < 0.001 for age, p < 0.001 and p = 0.003 for BMI, respectively), while segment, facet orientation, and facet tropism were not (p > 0.05 for all). Notably, MSU-B LDH was associated with greater odds of having more severe FJOA on the herniation side (left: p < 0.001, odds ratio (OR) = 2.714, 95% confidence interval (CI) = 1.583~4.650; right: p = 0.003, OR = 2.615, 95% CI = 1.405~4.870). However, other locations of LDH were not associated with the severity of FJOA (p > 0.05 for all).

Conclusions

Both the degree of LDH and MSU-B LDH are associated with the severity of FJOA. The association between LDH and FJOA highlights the complexity of the etiology of FJOA.

Predictors of Pain Recurrence After Lumbar Facet Joint Injections

Introduction

Facet joint injections (FJIs) of anesthetic and corticosteroids are useful for the diagnosis and treatment of low back pain (LBP). In the current study, we evaluated the efficacy of FJI on LBP treatment and the predictive variables of pain recurrence after FJI.

Methods

We included and followed prospectively forty-three consecutive patients with chronic LBP treated with FJI. Clinical assessments were carried out at a baseline 1 week before FJIs and after a 6-month follow-up visit using the visual analog scale (VAS) for pain, Oswestry Disability Index (ODI) for disability-specific measure and MacNab criteria for global effectiveness, and compared through analysis using paired-samples “t” tests. Multiple cox-regression analysis was used to identify the presurgical variables independently associated with pain recurrence anytime during the follow-up. In addition to the demographic, clinical, and surgical data, we also analyzed psychometric scales: Pain Catastrophizing Scale (PCS), Beck Anxiety Inventory (BAI), and Beck Depression Inventory (BDI).

Results

After a 6-month follow-up, thirty-two patients (74.4%) showed a clinically significant reduction of pain and twenty-seven (62.8%) reported a clinically significant improvement of disability. Presurgical catastrophizing (PCS score ≥ 5, adjusted HR 4.4, CI 95% 1.7–11.3, p = 0.002) and smoking (Adjusted HR 12.5, CI 95% 1.1–138.9, p = 0.04) remains associated with pain recurrence.

Conclusion

FJI reduces LBP and disability of patients with unresponsive LBP. Pain-related cognitive and behavioral factors determined by pain catastrophizing and smoking were independently associated with pain recurrence after lumbar FJI. The results support the need of a multidisciplinary approach for presurgical evaluation of patients with chronic pain.

Controlled immobilization-traction based on intervertebral stability is conducive to the regeneration or repair of the degenerative disc: an in vivo study on the rat coccygeal model

BACKGROUND CONTEXT

Previous studies have shown the potential for intervertebral disc tissue regeneration is very limited. While in vivo and in vitro studies have shown that traction can restore disc height and internal pressure, in many clinical studies it was shown that axial mechanical traction for the treatment of low back pain is ineffective.

PURPOSE

The aim of this study was to identify how the disc could be distracted, how to define the state of traction, and to further examine the feasibility of regenerating or restoring the degenerative disc by means of traction.

STUDY DESIGN

A macro- and microlevel structural analysis of degenerative discs of rat tail before and after controlled immobilization-traction.

METHODS

In this study, 49 6-month-old male Sprague-Dawley rats were randomly assigned to one of seven groups. Group A was the sham control group in which caudal vertebrae were instrumented with K-wires only. In Group B (model group), caudal vertebrae were immobilized using a custom-made external device to fix four caudal vertebrae (Co7-Co10) and Co8-Co9 underwent 4 weeks of compression to induce moderate disc degeneration. In Group C, vertebrae Co8-Co9 underwent 4 weeks of compression to induce moderate disc degeneration, followed by removal of the external apparatus. Rats in the other four groups (Groups D-G), Co8-Co9 underwent 4 weeks of compression to induce moderate disc degeneration followed by 2 weeks, 4 weeks, 6 weeks, and 8 weeks of distraction, respectively. Caudal vertebrae were harvested and disc height, T2 signal intensity of the discs, disc morphology, total glycosaminoglycan content of the nucleus pulposus and the structure of the Co8-Co9 end plate were evaluated.

RESULTS

After 4 weeks of compression, the intervertebral height and T2 signal intensity of Co8-Co9 vertebrae of rats in Groups B to G were significantly reduced compared with Group A (sham group, all p<.0001). Histological scores of rats in Group B averaged 10.14 and the total glycosaminoglycan (GAG) of nucleus pulposus averaged 238.21μg GAG/ng DNA. The bony end plate structure showed significant changes in comparison with the control Group. After 2 weeks to 8 weeks of traction, the disc space and T2 signal intensity of Co8-Co9 vertebrae in Group E were significantly recovered compared to that of rats in Group B (p<.0001), and the intervertebral height of the Co8-Co9 in Group D, Group F, and Group G when compared with Group B (p<.0001). Meanwhile, the T2 signal intensity of Co8-Co9 in Group D, F, and G when compared with Group B (p<.001). Histological scores dropped from an average of 10.14 in Group B to 5.57 in Group E, and 5.86 in Group F (all p<.0001). Furthermore, the total GAG content of the nucleus pulposus increased from an average of 238.21μg GAG/ng DNA in Group B to 601.02μg GAG/ng DNA in Group E (p<.0001). The number of pores of end plates in rats in Groups D and E both were significantly increased when compared to that of rats in Group B (Groups D vs Groups B, p<.05; Groups E vs Groups B, p<.0001).

CONCLUSIONS

A mechanical degenerative model was successfully established by using a custom-made device. We demonstrated that disc degeneration is a cascade of biochemical, mechanical, and structural changes mediated by cells in an abnormal mechanical environment. Not all levels of disc degeneration can be regenerated or repaired. Regeneration or recovery of disc degeneration requires specific conditions. Based on the immobilization-traction mode, the cascade cycle of disc degeneration is interrupted. Traction of 2 to 6 weeks is a sensitive period for regeneration of the degenerative disc. Moreover, the duration and extent of the traction loading must be moderately controllable, and beyond the limits that can lead to significant degeneration. These data may help improve our understanding of the pathogenesis of clinical disc degeneration and how to optimize the use of traction devices for possible regeneration.

Prevalence and risk factors of axial neck pain in patients undergoing multilevel anterior cervical decompression with fusion surgery

Objectives

The aim of this study was to explore the prevalence and risk factors for axial neck pain in patients undergoing multilevel anterior cervical decompression with fusion surgery.

Methods

In this study, 88 patients, who underwent multilevel anterior cervical decompression with fusion surgery from January 2012 to January 2017, were retrospectively reviewed. Based on the postoperative axial neck pain, the patients were classified into two groups: axial pain group and no axial pain group. The patients were followed up 3 weeks, 3 months, and 1 year after cervical anterior surgery for the early- and long-term clinical evaluation. The possible effect factors included demographic variables (age, sex, BMI, smoking, drinking, heart disease, hypertension, diabetes, preoperative kyphosis, preoperative axial neck pain, preoperative JOA scores, and ODI) and surgery-related variables (surgical option, vertebral lesions, spinal canal stenosis rate, superior fusion segment, presence of intramedullary high signal intensity).

Results

The prevalence of axial neck pain was 27.3% (24 cases of 88). Our results showed that preoperative axial neck pain (62% vs 23%, P < 0.001) and preoperative kyphosis (42% vs 21.9%, P < 0.001) were risk factors for axial pain after multilevel anterior cervical surgery. Additionally, for patients with preoperative cervical kyphosis, compared to no axial pain group, the axial neck group was significantly more likely to exist a higher preoperative angle of C2–7 (13.31 ± 2.33 vs 7.33 ± 2.56, P < 0.001) and a higher correction range for kyphosis (20.24 ± 4.12 vs 12.34 ± 3.12, P < 0.001). However, for all the patients with postoperative axial symptoms, the improvement rate of axial pain was significantly higher for patients without cervical kyphosis at the early-term follow-up (3 weeks) (P = 0.032), no significant differences were found at the medium-term (P = 0.554) and long-term follow-up (P = 0.902), and improvements of clinical symptom have no obvious difference at the last follow-up.

Conclusions

Overall, preoperative axial neck pain and kyphosis could predict axial neck pain for patients undergoing multilevel anterior cervical decompression with fusion surgery, and recovery of cervical kyphosis may contribute to the long-term recovery of neural function, but may also suffer from risk of short-term axial pain, which could be reduced through moderate cervical curvature recovery.

Cryopreserved amniotic membrane and umbilical cord particulate for managing pain caused by facet joint syndrome: A case series

Treatment of back pain due to facet joint syndrome has been a challenge for physicians since its recognition ∼80 years ago. Intra-articular injections of steroids, local anesthetics, and phenol have been widely adopted despite their known shortcomings. Recently, intra-articular injection of amniotic membrane-umbilical cord (AMUC) has been utilized in various orthopedic indications, including those involving synovial joints, due to its reported anti-inflammatory properties. Herein, use of AMUC for facet joint syndrome was evaluated.A single-center case series was conducted on patients presenting with pain caused by facet joint syndrome, confirmed by single blocking anesthetic injection and treated using a single intra-articular injection of 50 mg particulate AMUC (CLARIX FLO) suspended in preservative-free saline. Patient reported back pain severity (numerical scale 0-10) and opioid use were compared between baseline and 6 months following treatment.A total of 9 patients (7 males, 2 females), average age 52.1 ± 15.9 years, were included. Five patients with cervical pain had a history of trauma, 1 patient had suffered lumbar facet injury and 3 had degenerative lumbar facet osteoarthritis. All patients had severe pain prior to injection (8.2 ± 0.8) and 4 (44%) were taking opioids (>100 morphine milligram equivalents). Six-month post-treatment, average pain had decreased to 0.4 ± 0.7 (P <.05). All patients had ceased use of prescription pain medications, including opioids. No adverse events, repeat procedures, or complications were reported.Intra-articular injection of AMUC appears to be promising for managing facet pain and mitigating opioid use. Further investigation with larger sample size is warranted.

Angiopoietin-Like Protein 2 Induces Synovial Inflammation in the Facet Joint Leading to Degenerative Changes via Interleukin-6 Secretion

Study Design

Experimental human study.

Purpose

To determine whether angiopoietin-like protein 2 (ANGPTL2) is highly expressed in the hyperplastic facet joint (FJ) synovium and whether it activates interleukin-6 (IL-6) secretion in FJ synoviocytes.

Overview of Literature

Mechanical stress-induced synovitis is partially, but significantly, responsible for degenerative and subsequently osteoarthritic changes in the FJ tissues in patients with lumbar spinal stenosis (LSS). However, the underlying molecular mechanism remains unclear. IL-6 is highly expressed in degenerative FJ synovial tissue and is responsible for local chronic inflammation. ANGPTL2, an inflammatory and mechanically induced mediator, promotes the expression of IL-6 in many cells.

Methods

FJ tissues were harvested from five patients who had undergone lumbar surgery. Immunohistochemistry for ANGPTL2, IL-6, and cell markers was performed in the FJ tissue samples. After cultured synoviocytes from the FJ tissues were subjected to mechanical stress, ANGPTL2 expression and secretion were measured quantitatively using real-time quantitative reverse-transcription–polymerase chain reaction and enzyme-linked immunosorbent assay (ELISA), respectively. Following ANGPTL2 administration in the FJ synoviocytes, anti-nuclear factor-κB (NF-κB) activation was investigated using immunocytochemistry, and IL-6 expression and secretion were assayed quantitatively with or without NF-κB inhibitor. Moreover, we assessed whether ANGPTL2-induced IL-6 modulates leucocyte recruitment in the degenerative process by focusing on the monocyte chemoattractant protein-1 (MCP-1) expression.

Results

ANGPTL2 and IL-6 were highly expressed in the hyperplastic FJ synovium samples. ANGPTL2 was co-expressed in both, fibroblast-like and macrophage-like synoviocytes. Further, the expression and secretion of ANGPTL2 in the FJ synoviocytes increased in response to stimulation by mechanical stretching. ANGPTL2 protein promoted the nuclear translocation of NF-κB and induced IL-6 expression and secretion in the FJ synoviocytes. This effect was reversed following treatment with NF-κB inhibitor. Furthermore, ANGPTL2-induced IL-6 upregulated the MCP-1 expression in the FJ synoviocytes.

Conclusions

Mechanical stress-induced ANGPTL2 promotes chronic inflammation in the FJ synovium by activating IL-6 secretion, leading to FJ degeneration and subsequent LSS.

VALIDATION OF A NEW CLINICAL SIGN OF LUMBAR FACET SYNDROME

ABSTRACT Objective: Facet joints are true synovial joints, which derive their nerve supply from the sinuvertebral or recurrent nerve of Luschka as well as the posterior primary division of the corresponding spinal nerve. Diagnosis of low-back pain originating in the facet joints is difficult, and has traditionally relied upon invasive tests. To aid in the clinical diagnosis of this condition, the senior author described a new clinical sign. The following research project was designed to test the utility of this sign in the diagnosis of lumbar facet joint pain. Methods: We conducted a prospective evaluation of patients suspected of having low back pain secondary to facet joint involvement (Lumbar Facet joint Pain Syndrome – LFPS) during a twelve month observation period; candidate patients were evaluated clinically using the new diagnostic sign, which was then compared to findings on radionuclide bone scans and diagnostic medial branch blocks. Contingency table analysis was performed to calculate the sensitivity, specificity, positive and negative predictive values and accuracy of the new clinical sign. Results: Contingency table analysis showed the following operating characteristics for the new diagnostic sign: Sensitivity: 70.37%, Specificity: 50%, Positive predictive value: 90.47%, Negative predictive value: 20% and accuracy 67.7%. Conclusions: Although the new clinical sign failed to show the same operating characteristics as the ones originally described, it has high sensitivity coupled with a good positive predictive value. We consider that although the sign by itself is not diagnostic of lumbar facet joint pain, its presence should alert the clinician to the diagnosis and the possibility of requiring additional testing. Level of Evidence III; Case control studyg.

Lumbar Facet Joint Kinematics and Load Effects During Dynamic Lifting

OBJECTIVE

To examine the lumbar facet joint kinematics in vivo during dynamic lifting and the effects of the load lifted.

BACKGROUND

Although extensive efforts have been dedicated to investigating the risk factors of low back pain (LBP) associated with load handling in the workplace, the biomechanics of lumbar facet joints during such activities is not well understood.

METHOD

Fourteen healthy participants performed a load-lifting task while a dynamic stereo-radiography system captured their lumbar motion continuously. Data from 11 participants were included for subsequent analysis. A randomized block design was employed to study the load effect (4.5 kg, 9.0 kg, and 13.5 kg) on bilateral facet joint motions at approximately 60°, 40°, 20°, and 0° trunk-flexion postures. The facet orientations were also examined.

RESULTS

Significant load effects were found for the flexion and lateral bending and superior-inferior translation of the facet joints. The L5-S1 displayed greater lateral bending and twisting, which was due to its more posterolateral orientation than the L2-L3, L3-L4, and L4-L5 facet joints. The left-right asymmetry in facet orientation was observed, most prominently at L3-L4 and L5-S1 facet joints.

CONCLUSION

The lumbar facet joint kinematics are affected by the magnitude of the lifted load and are dependent on the orientations of articulating adjacent facets.

APPLICATION

This study provided new insights into the role of lumbar facet joints in vivo during lifting. Alterations in the facet joint kinematics due to vigorous functional demand can be one of the primary but overlooked mechanical factors in the causation of LBP.

Effects of spinal manipulation and pain education on pain in patients with chronic low back pain: a protocol of randomized sham-controlled trial

Background

Low back pain (LBP) has more than doubled in the last 20 years, probably influenced by biopsychosocial factors. Noninvasive treatments have been applied in individuals with chronic nonspecific LBP as spinal manipulation and pain education. However, the neurophysiological effects of these treatments are not clear. The aim of this research is to verify the pain control, functional and neurophysiological effects of spinal manipulation, and pain education in individuals with chronic nonspecific LBP.

Methods

This research is an assessor and subject blinded, 2-arm, randomized sham-controlled trial and will be conducted at Governador Celso Ramos Hospital, Florianópolis, Brazil. One hundred and twenty-eight individuals with chronic nonspecific LBP will be recruited for this study. Individuals will be randomly allocated into one of the two groups: (1) spinal manipulation plus pain education or (2) sham treatment plus pain education. Each group will be received two sessions per week over six weeks of treatment. The measures will be applied at baseline, six weeks, and three months after randomization. The primary outcome will be a pain intensity at six weeks postrandomization. Secondary outcomes will be pressure pain threshold, disability, fear and avoidance beliefs, kinesiophobia, risk of poor prognosis, quality of life, and inflammatory biomarkers.

Discussion

Evidence has shown that psychosocial factors are more involved in chronic pain than we thought a few years ago. Then, studies investigating both functional and neurophysiological effects of these interventions to evaluate the effectiveness of treatment and what else is happening at the cellular level in nervous system are needed.

Exploration of the Inter-Relationships Between Obesity, Physical Inactivity, Inflammation, and Low Back Pain

STUDY DESIGN

Retrospective analysis wherein 103 patients were considered, and 76 patients were included: 49 were classified as chronic non-specific low back pain (CNSLBP) (Study group) and 27 had identifiable cases of specific chronic low back pain (LBP) (Control group).

OBJECTIVE

Elucidate markers of systemic inflammation in patients with CNSLBP.

SUMMARY OF BACKGROUND DATA

Mechanisms of LBP are poorly understood. Pro-inflammatory cytokines are increased in obesity and involved with pain modulation; we previously proposed a theoretical model of their mediating role in LBP.

METHODS

Demographic information was acquired via questionnaire, chart review, and blood test data. Univariate analysis identified factors associated with CNSLBP and markers of systemic inflammation. A receiver operating curve and Youden Index were used to select optimal cut-off points for elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Multivariable logistic regression analysis calculated the adjusted strength of relationship between factors that were proposed in our theoretical model for CNSLBP.

RESULTS

Unadjusted CRP was significantly correlated with ESR (R = 0.63, P < 0.0001) and body mass index (BMI) (R = 0.38, P = 0.0015). Physically inactive patients had significantly higher CRP (6.1 vs. 1.2, P = 0.0050). ESR was significantly correlated with number of comorbidities (R = 0.34, P = 0.0047), BMI (R = 0.38, P = 0.0014), and age (R = 0.36, P = 0.0026). Physically inactive patients (10.4 vs. 3.6, P = 0.0001) and females (11.2 vs. 6.4, P = 0.0422) had significantly higher ESR. Adjusted analyses indicated significant relationships between physical inactivity and markers of systemic inflammation (adjusted odds ratios for ESR and CRP: 15.9, P = 0.0380; 15.2, P = 0.0272, respectively), and between elevated CRP and CNSLBP (adjusted odds ratio: 8.0, P = 0.0126).

CONCLUSION

Systemic inflammation may act as a mediator for physical inactivity and obesity in the pathogenesis of CNSLBP.

LEVEL OF EVIDENCE

2.