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Méndez-Gutiérrez A, Marín Navas F, Acevedo-González JC. Frequency of use of discography findings for the diagnosis of low back pain of discogenic origin. Systematic review of the literature. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:209-222. [PMID: 36906136 DOI: 10.1016/j.recot.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 03/12/2023] Open
Abstract
INTRODUCTION There are different techniques and interpretations of discography findings to determine it positive for the diagnosis of discogenic pain. This study aims to evaluate the frequency of use of discography findings for the diagnosis of low back pain of discogenic origin. MATERIAL AND METHODS A systematic review of the literature of the last 17 years was performed in MEDLINE and BIREME. A total of 625 articles were identified, 555 were excluded for duplicates, title and abstract. We obtained 70 full texts of which 36 were included in the analysis after excluding 34 for not meeting the inclusion criteria. RESULTS Among the criteria in discography to determine it as positive, 8 studies used only the pain response to the procedure, 28 studies used more than one criterion during discography to consider it as positive, the evaluation of at least one adjacent intervertebral disc with a negative result was necessary in 26 studies to consider a discography as positive. Five studies formally expressed the use of the technique described by SIS/IASP to determine a discography as positive. CONCLUSIONS Pain in response to contrast medium injection, assessed with the visual analog pain scale≥6, was the most used criterion in the studies included in this review. Although there are already criteria to determine a discography as positive, the use of different techniques and interpretations of discography findings to determine a positive discography for low back pain of discogenic origin persists.
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Affiliation(s)
- A Méndez-Gutiérrez
- Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia.
| | - F Marín Navas
- Semillero de Neurocirugía y Neurología, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - J C Acevedo-González
- Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
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Méndez-Gutiérrez A, Marín Navas F, Acevedo-González JC. [Translated article] Frequency of use of discography findings for the diagnosis of low back pain of discogenic origin. Systematic review of the literature. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:T209-T222. [PMID: 38508378 DOI: 10.1016/j.recot.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 03/22/2024] Open
Abstract
INTRODUCTION There are different techniques and interpretations of discography findings to determine it positive for the diagnosis of discogenic pain. This study aims to evaluate the frequency of use of discography findings for the diagnosis of low back pain of discogenic origin. MATERIAL AND METHODS A systematic review of the literature of the last 17 years was performed in MEDLINE and BIREME. A total of 625 articles were identified, 555 were excluded for duplicates, title and abstract. We obtained 70 full texts of which 36 were included in the analysis after excluding 34 for not meeting the inclusion criteria. RESULTS Among the criteria in discography to determine it as positive, 8 studies used only the pain response to the procedure, 28 studies used more than one criterion during discography to consider it as positive, the evaluation of at least one adjacent intervertebral disc with a negative result was necessary in 26 studies to consider a discography as positive. Five studies formally expressed the use of the technique described by SIS/IASP to determine a discography as positive. CONCLUSIONS Pain in response to contrast medium injection, assessed with the visual analogue pain scale ≥6, was the most used criterion in the studies included in this review. Although there are already criteria to determine a discography as positive, the use of different techniques and interpretations of discography findings to determine a positive discography for low back pain of discogenic origin persists.
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Affiliation(s)
- A Méndez-Gutiérrez
- Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia.
| | - F Marín Navas
- Semillero de Neurocirugía y Neurología, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - J C Acevedo-González
- Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
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Sima S, Chen X, Sheldrick K, Kuan J, Diwan AD. Reconsidering high intensity zones: its role in intervertebral disk degeneration and low back pain. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1474-1483. [PMID: 38381388 DOI: 10.1007/s00586-024-08185-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/12/2023] [Accepted: 02/04/2024] [Indexed: 02/22/2024]
Abstract
PURPOSE High intensity zones (HIZ) in the lumbar intervertebral disk (IVD) can be associated with degenerative changes which may ultimately manifest as low back pain (LBP). However, the relationship between the prevalence of HIZ and lumbar degenerative parameters is still unclear. The purpose of this study was to determine the prevalence of HIZ in the lumbar spine, analyze the independent relationship between HIZ and lumbar degenerative parameters measured on MRI and X-ray and determine the association between HIZ and the presence of LBP. METHODS A retrospective review of MRI data, X-ray data, and radiology reports for 136 consecutively recruited patients, above 18-years-age and with both lumbar MRI and X-ray scans was conducted. 57 patients with HIZ were identified. Patients without HIZ (n = 79) made up the control group. RESULTS HIZ was prevalent in 41.9% of patients and in 11.0% of all lumbar IVDs. The odds of developing HIZ were 6.4 (Exp(B) 6.4, 95%CI [3.157-12.988]) and 3.0 (Exp(B) 3.0, 95%CI [1.603, 5.674]) times higher in IVDs with disk bulge/protrusion and nucleus degeneration, respectively. Odds of HIZ was also increased in disks with larger IVD angle (Exp(B) 1.1, 95%CI [1.034, 1.169]). The odds of patients presenting to imaging with LBP was 3.0 (OR 3.0, 95%CI [1.478-6.338]) times higher in the HIZ compared to the control group. CONCLUSIONS HIZ was prevalent in 41.9% of participants that were recruited in this study. Nucleus degeneration, disk bulge/protrusion and increased IVD angle were found to be independently associated with HIZ and since there is an increased likelihood of LBP, we posit that HIZ is likely a symptomatic and clinically meaningful diagnostic tool in the assessment of LBP.
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Affiliation(s)
- Stone Sima
- Spine Labs, St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Xiaolong Chen
- Spine Labs, St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia.
- Department of Orthopaedic Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Kyle Sheldrick
- Spine Labs, St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Jeff Kuan
- St. George MRI, Healthcare Imaging, Kirk Place, Kogarah, NSW, Australia
| | - Ashish D Diwan
- Spine Labs, St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
- Spine Service, Department of Orthopaedic Surgery, St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
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Yang L, Li W, Yang Y, Zhao H, Yu X. The correlation between the lumbar disc MRI high-intensity zone and discogenic low back pain: a systematic review and meta-analysis. J Orthop Surg Res 2023; 18:758. [PMID: 37805519 PMCID: PMC10559531 DOI: 10.1186/s13018-023-04187-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 09/10/2023] [Indexed: 10/09/2023] Open
Abstract
OBJECTIVE This study aimed to investigate the correlation between the MRI high-intensity zone (HIZ) and the pathogenesis of discogenic low back pain. METHODS Literature from PubMed, EMBASE, Cochrane Library, Science Direct, China Knowledge Network, Wanfang Database, and China Biomedical Literature Database was searched until August 2023. Cohort studies including patients with low back pain who underwent lumbar spine MRI and discography, as well as the results evaluating the correlation between HIZ and discography for morphological changes in the disc and pain replication phenomena, were included in the analysis. The literature that met the inclusion criteria was screened, and the methodological quality of the included studies was evaluated. Meta-analysis of the extracted data was performed by using RevMan 5.1.1. RESULTS In total, 28 reports were included in this meta-analysis. There was a statistically significant correlation between a positive HIZ and abnormal disc morphology in discography (OR 28.15, 95% CI [7.38, 107.46], p < 0.00001). Patients with HIZ-positive discs had a significantly higher incidence of consistent pain (71.0%, 969/1365) than those with HIZ-negative imaging (29.0%, 1314/4524) (OR 7.71, 95% CI [5.29, 11.23], p < 0.00001).Segments that were HIZ-positive and had abnormal disc morphology had a higher incidence of consistent pain (86.1%, 230/267) than HIZ-negative subjects (32.2%, 75/233) (OR 14.09, 95% CI [2.12, 93.48], p = 0.006). CONCLUSION A positive MRI T2-weighted image of the lumbar disc with HIZ indicates disc degeneration. In addition, HIZ may be a specific indicator for the physical diagnosis of discogenic low back pain. A more advanced degree of disc degeneration on the basis of HIZ positivity corresponded to a greater probability of discography-induced consistent pain, whereas the degree of disc degeneration on the basis of HIZ negativity was less correlated with contrast-induced consistent pain.
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Affiliation(s)
- Lei Yang
- Department of Acupuncture and Moxibustion, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Wenhao Li
- Department of Orthopedics III, Dongzhimen Hospital, Beijing University of Chinese Medicine, No. 5 Haiyun Warehouse, Dongcheng District, Beijing, 100700, China
| | - Yongdong Yang
- Department of Orthopedics III, Dongzhimen Hospital, Beijing University of Chinese Medicine, No. 5 Haiyun Warehouse, Dongcheng District, Beijing, 100700, China
| | - He Zhao
- Department of Orthopedics III, Dongzhimen Hospital, Beijing University of Chinese Medicine, No. 5 Haiyun Warehouse, Dongcheng District, Beijing, 100700, China.
| | - Xing Yu
- Department of Orthopedics III, Dongzhimen Hospital, Beijing University of Chinese Medicine, No. 5 Haiyun Warehouse, Dongcheng District, Beijing, 100700, China.
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Kilpikoski S, Suominen EN, Repo JP, Häkkinen AH, Kyrölä K, Kautiainen H, Ylinen J. Comparison of magnetic resonance imaging findings among sciatica patients classified as centralizers or non-centralizers. J Man Manip Ther 2023; 31:358-367. [PMID: 36756675 PMCID: PMC10566442 DOI: 10.1080/10669817.2023.2174555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 01/22/2023] [Indexed: 02/10/2023] Open
Abstract
OBJECTIVE To compare if the degenerative findings from MRI differ between the sciatica patients classified as centralizers (CEN) and non-centralizers (Non-CEN) according to the McKenzie Method of mechanical diagnosis and therapy. STUDY DESIGN A cross-sectional study. METHODS Patients (N = 100) referred to a spine clinic of a single tertiary hospital for specialist consultation for sciatica. The McKenzie-based assessment was performed by the mechanical diagnosis and therapy-trained physiotherapists. Clinical data and prevalence of lumbar MRI findings were compared between the groups. RESULTS There was no significant difference in leg pain intensity between the groups. The Non-CEN had significantly more intense back pain, mean 56 (SD 30) and were more disabled 44 (SD 15) compared to the CEN mean 41 (SD 25) and mean 31 (11), measured with a visual analogue scale (0-100), and the Oswestry Disability Index (0-100), respectively. The CEN had more severe degenerative findings on MRI than the Non-CEN: vertebral end-plate changes were 63% and 43%; mean Pfirrmann's disc degeneration lumbar summary score was 12.8, and 10.6; and severity score of total damage was 12.0 and 10.1, respectively. There were differences neither in disc contour changes nor nerve root stenosis on MRI. CONCLUSIONS Sciatica patients classified as non-centralizers had significantly more severe back pain, and were significantly more disabled than centralizers, who instead had more severe degenerative findings on MRI. Thus, classification to non-centralizers by the McKenzie method seems not predict higher incidence of degenerative findings on MRI compared to centralizers.
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Affiliation(s)
- Sinikka Kilpikoski
- Department of Physical and Rehabilitation Medicine, Centra’ Finland Health Care District Hospital, Jyvaskyla, Finland
| | | | - Jussi P Repo
- Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland
| | - Arja H Häkkinen
- Faculty of Health Sciences, Univeristy of Jyväskylä, Jyväskylä, Finland
| | - Kati Kyrölä
- Consultant Surgeon Orthopaedics and Traumatology, Docent. Chief Orthopaedic Surgeon, Hospital NOVA, Central Finland Health Care District, Jyvaskyla, Finland
| | - Hannu Kautiainen
- Primary Health Care Unit, Kuopio University Hospital, Helsinki, Finland
| | - Jari Ylinen
- Department of Physical and Rehabilitation Medicine, Centra’ Finland Health Care District Hospital, Jyvaskyla, Finland
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Pre-procedural Imaging. Regen Med 2023. [DOI: 10.1007/978-3-030-75517-1_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Zhang J, Sun T, Zhang W, Yang M, Li Z. Autologous cultured adipose derived mesenchymal stem cells combined with hyaluronic acid hydrogel in the treatment of discogenic low back pain: a study protocol for a phase II randomised controlled trial. BMJ Open 2022; 12:e063925. [PMID: 36283750 PMCID: PMC9608519 DOI: 10.1136/bmjopen-2022-063925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Discogenic low back pain (DLBP) is a common disease, and its occurrence is closely related to intervertebral disc (IVD) degeneration. At present, none of the traditional treatment methods can repair the degenerated IVD. The emergence of stem cell therapy makes it possible to repair and regenerate IVD tissue, among which adipose derived mesenchymal stem cells (ADMSCs) transplantation therapy has become a hot spot of current research. Therefore, this trial aimed to investigate the safety and efficacy of using autologous cultured ADMSCs combined with hyaluronic acid (HA) hydrogel in the treatment of DLBP. METHODS AND ANALYSIS This study is a randomised, dose-escalation, placebo-controlled, double-blind, single-centre, phase II clinical trial to evaluate the efficacy and safety of autologous cultured ADMSCs combined with HA hydrogel in the treatment of patients with DLBP. The 100 eligible patients will be randomly divided into three experimental groups with different doses and one placebo control group in a ratio of 1:1:1:1. All patients will undergo liposuction to obtain ADMSCs, followed by autologous cultured ADMSC mixtures or placebo transplantation after 3 weeks. The patients will be followed up to 24 months after the transplant. The primary end point of this trial is the Visual Analogue Scale. Secondary end points include the Oswestry Disability Index, Japanese Orthopaedic Association Scores, the Mos 36-item short form, the Modic classification, Pfirrmann grade, height and segment range of motion of the IVD, vital signs (temperature, pulse, respiration, blood pressure), blood routine, liver and kidney function, immunological examination, urinalysis and treatment emergent adverse events. ETHICS AND DISSEMINATION The study protocol has been approved by the Ethics Committee of the First Affiliated Hospital of Dalian Medical University and registered in the Chinese Clinical Trial Registry. Dissemination of the results will be presented at a conference and in peer-reviewed publications. TRIAL REGISTRATION NUMBER ChiCTR2200058291.
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Affiliation(s)
- Jing Zhang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, Dalian, China
| | - Tianze Sun
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, Dalian, China
| | - Wentao Zhang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, Dalian, China
| | - Ming Yang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, Dalian, China
| | - Zhonghai Li
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, Dalian, China
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, China
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Kim DH, Jeong KW, Jo W, Lee SY, Im JA, Jung JY. Therapeutic effect of intradiscal pulsed radiofrequency on internal disc disruption: A case report. Medicine (Baltimore) 2022; 101:e28831. [PMID: 35147124 PMCID: PMC8830845 DOI: 10.1097/md.0000000000028831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/28/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Discogenic low back pain often persists despite medication and medical intervention. In this study, intradiscal pulsed radiofrequency (PRF) was performed in a patient with discogenic low back pain who did not respond to oral medication, posterior medial branch block, epidural steroid injection, and percutaneous epidural adhesiolysis. PATIENT CONCERNS A 28-year-old woman visited a pain clinic complaining of low back pain that was scored 8 out of 10 on a numerical rating scale. Her pain was present in any position throughout the day and worsened in the sitting position. DIAGNOSES Magnetic resonance imaging showed L5-S1 internal discal disruption. Based on the medical history, physical examination, and magnetic resonance imaging, we determined that her pain originated from the L5-S1 disc. INTERVENTIONS We performed an intradiscal PRF on the affected disc under C-arm fluoroscopy guidance. PRF was performed at 5 Hz, 20-ms pulse width, and 70 V for 15 minutes while ensuring that the electrode tip temperature was maintained below 42°C. OUTCOMES Immediately after the procedure, the patient's pain subsided. At the 1-month follow-up visit, the patient reported complete relief of her low back pain. The Oswestry disability index, which indicates the degree of disability, improved significantly. She also reported that she could sit for long periods because the pain was reduced. No adverse effects from the procedure were found. LESSONS Applying intradiscal PRF seems an effective and safe technique for treating discogenic low back pain.
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Wang ZX, Hu YG. Imaging Analysis of the High-Intensity Zone on Lumbar Spine Magnetic Resonance Images: Classification, Features and Correlation with Low Back Pain. J Pain Res 2021; 14:2981-2989. [PMID: 34588808 PMCID: PMC8473715 DOI: 10.2147/jpr.s332509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/10/2021] [Indexed: 11/23/2022] Open
Abstract
Aim Early studies suggested that the high-intensity zone (HIZ) on lumbar MRI was a diagnostic sign of painful internal disc disruption (IDD). However, recent studies have questioned its diagnostic value. This study is conducted to explore imaging features of HIZ and to investigate the correlation between these characteristics and low back pain (LBP), further studying the predictive value of HIZ. Methods A retrospective study of 1188 cases was performed. MR images were read and analyzed by two experienced, blinded radiologists. Results A total of 575 (48.4%) individuals exhibited HIZ. The prevalence of posterior HIZ (32.3%) was significantly higher than that of anterior HIZ (23.6%; P < 0.01). Round type was the most common shape (61.0%) on sagittal view. Only 37 HIZs (4.6%) were identified on axial views. A total of 263 HIZ discs (32.5%) were found to have additional diagnostic signs of IDD, which is difficult to distinguish from the annulus fibrosus. In subjects with consecutive slides showing HIZ, the incidence of LBP was significantly higher than in single-slide HIZ individuals (58.0% vs 48.6%, P < 0.05). Conclusion MRI-visualized HIZ is a highly valuable method of screening for lumbar IDD. It is demonstrated that consecutive-slide HIZ was a more reliable indicator for discogenic LBP than single-slide HIZ.
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Affiliation(s)
- Zi-Xuan Wang
- Department of Interventional Radiology, Qingdao Municipal Hospital, Qingdao, People's Republic of China
| | - You-Gu Hu
- Department of Spinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, People's Republic of China
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Jain A, Jain S, Barasker SK, Agrawal A. Predictors of discogenic pain in magnetic resonance imaging: a retrospective study of provocative discography performed by posterolateral approach. Korean J Pain 2021; 34:447-453. [PMID: 34593662 PMCID: PMC8494962 DOI: 10.3344/kjp.2021.34.4.447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/01/2021] [Accepted: 07/05/2021] [Indexed: 11/11/2022] Open
Abstract
Background Provocative discography (PD) is a test that is useful in diagnosing discogenic pain (DP). In this study, to diagnose DP, we used a posterolateral approach of needle placement and followed pressure criteria laid down by the Spine Intervention Society. The aim was to identify the correlation between magnetic resonance imaging (MRI) findings (desiccation, high intensity zone and change in shape and size of the disc) and the results of PD. Methods Records of 50 patients who underwent PD for DP were analyzed. A total of 109 PDs were performed, with 54 suspect and 55 control discs. Alternate pain generators were ruled out. Results A total of 35 suspect discs were positive on PD. The mean disc pressure in the suspect disc was 31.9 ± 7.9 psi (range, 15-44). Of the 50 patients who underwent PD, 35 had positive MRI findings. A significant positive correlation was found only between disc desiccation and discography result (r = 0.6, P < 0.001). Logistic regression analysis revealed that only desiccation successfully predicted the result of discography (OR = 26.5, P < 0.001); a high intensity zone and a disc protrusion/extrusion had an OR 2.3 and 1.24, respectively. Disc desiccation of Pfirmann grade 3 or more had a sensitivity and specificity of 0.93 and 0.64 respectively in identifying painful discs; the positive likelihood ratio was 2.58 while the negative likelihood ratio was 0.11. Conclusions In patients with DP, disc desiccation is the most useful MRI feature that predicts a painful disc on PD.
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Affiliation(s)
- Anuj Jain
- Department of Anesthesiology, All India Institute of Medical Science, Bhopal, India
| | - Suruchi Jain
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Bhopal, India
| | - Swapnil Kumar Barasker
- Department of Anesthesiology, Sri Aurobindo Medical College and Post Graduate Institute, Indore, India
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Science, Bhopal, India
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Pelled G, Salas MM, Han P, Gill HE, Lautenschlager KA, Lai TT, Shawver CM, Hoch MB, Goff BJ, Betts AM, Zhou Z, Lynch C, Schroeder G, Bez M, Maya MM, Bresee C, Gazit Z, McCallin JP, Gazit D, Li D. Intradiscal quantitative chemical exchange saturation transfer MRI signal correlates with discogenic pain in human patients. Sci Rep 2021; 11:19195. [PMID: 34584114 PMCID: PMC8478892 DOI: 10.1038/s41598-021-97672-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 08/22/2021] [Indexed: 12/13/2022] Open
Abstract
Low back pain (LBP) is often a result of a degenerative process in the intervertebral disc. The precise origin of discogenic pain is diagnosed by the invasive procedure of provocative discography (PD). Previously, we developed quantitative chemical exchange saturation transfer (qCEST) magnetic resonance imaging (MRI) to detect pH as a biomarker for discogenic pain. Based on these findings we initiated a clinical study with the goal to evaluate the correlation between qCEST values and PD results in LBP patients. Twenty five volunteers with chronic low back pain were subjected to T2-weighted (T2w) and qCEST MRI scans followed by PD. A total of 72 discs were analyzed. The average qCEST signal value of painful discs was significantly higher than non-painful discs (p = 0.012). The ratio between qCEST and normalized T2w was found to be significantly higher in painful discs compared to non-painful discs (p = 0.0022). A receiver operating characteristics (ROC) analysis indicated that qCEST/T2w ratio could be used to differentiate between painful and non-painful discs with 78% sensitivity and 81% specificity. The results of the study suggest that qCEST could be used for the diagnosis of discogenic pain, in conjunction with the commonly used T2w scan.
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Affiliation(s)
- Gadi Pelled
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
- Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
| | - Margaux M Salas
- Division of Pain Management, Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, TX, 78234, USA
- 59th Medical Wing Air Force, San Antonio, TX, 78236, USA
| | - Pei Han
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
- Biomedical Research Imaging Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Howard E Gill
- Division of Pain Management, Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, TX, 78234, USA
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Karl A Lautenschlager
- Division of Pain Management, Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, TX, 78234, USA
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Tristan T Lai
- Division of Pain Management, Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, TX, 78234, USA
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Cameron M Shawver
- Division of Pain Management, Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, TX, 78234, USA
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Matthew B Hoch
- Division of Pain Management, Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, TX, 78234, USA
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Brandon J Goff
- Division of Pain Management, Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, TX, 78234, USA
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Aaron M Betts
- Division of Pain Management, Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, TX, 78234, USA
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Zhengwei Zhou
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
- Biomedical Research Imaging Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Cody Lynch
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
- Biomedical Research Imaging Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Grant Schroeder
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Maxim Bez
- Medical Corps, Israel Defense Forces, Tel HaShomer, Israel
| | - Marcel M Maya
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Catherine Bresee
- Biostatistics and Bioinformatics Research Center, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Zulma Gazit
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
- Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - John P McCallin
- Division of Pain Management, Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, TX, 78234, USA
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Dan Gazit
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
- Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
- Faculty of Dental Medicine, Hebrew University, 91120, Jerusalem, Israel
| | - Debiao Li
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
- Biomedical Research Imaging Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA, 90095, USA
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12
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Yoo BR, Son S, Lee SG, Kim WK, Jung JM. Factors Predicting the Clinical Outcome After Trans-sacral Epiduroscopic Laser Decompression for Lumbar Disc Herniation. Neurospine 2021; 18:336-343. [PMID: 34218614 PMCID: PMC8255758 DOI: 10.14245/ns.2040824.412] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 02/21/2021] [Indexed: 11/19/2022] Open
Abstract
Objective Previous literatures have demonstrated widely variable clinical results after transsacral epiduroscopic laser decompression (SELD) and the factors predicting outcomes are not yet established. Therefore, we analyzed the clinical outcome and associated predictive factors of SELD in patients with lumbar disc herniation.
Methods Between 2015 and 2018, 82 patients who underwent single-level SELD and followed up at least 6 months were enrolled. The overall success rate (excellent or good results at final follow-up) was 58.5% according to Odom’s criteria. Based on this result, patients were divided to 2 groups: a favorable group (n = 48) and an unfavorable group (n = 34). A retrospective review of the baseline characteristics and clinical outcome were conducted to reveal the predictive factors.
Results As expected, improvement of pain and patient satisfaction, was more favorable in the favorable group (p < 0.05). Moreover, the rate of additional procedure was lower in the favorable group (4.2%, 2 of 48 patients) than in the unfavorable group (35.3%, 12 of 34 patients) (p = 0.011). Among the various baseline characteristics, the only significant predictive factor for favorable outcome was the presence of a high-intensity zone (HIZ) on preoperative magnetic resonance imaging (50.0% [24 of 48 patients] in the favorable group vs. 11.8% [4 of 34 patients] in the unfavorable group; odds ratio, 15.67; p = 0.024).
Conclusion Although SELD for lumbar disc herniation resulted in a less favorable clinical outcome than that reported in previous studies, in patients with a HIZ, SELD can be an effective minimally invasive surgery to relieve low back pain and/or leg pain.
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Affiliation(s)
- Byung Rhae Yoo
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Seong Son
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Sang Gu Lee
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Woo Kyung Kim
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jong Myung Jung
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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Wang ZX, Hou ZT, Hu YG. Anterior High-Intensity Zone in Lumbar Discs: Prevalence and Association with Low Back Pain. PAIN MEDICINE 2021; 21:2111-2116. [PMID: 32951055 DOI: 10.1093/pm/pnaa236] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To explore the features of high-intensity zone (HIZ) in anterior annulus fibrosus and assess the association of anterior HIZ with low back pain (LBP). DESIGN, SETTING, AND SUBJECTS A retrospective study of 5,940 discs in 1,188 individuals was conducted. METHODS Subjects' information and LBP symptoms confirmed by an orthopedic surgeon were acquired from the medical record. Magnetic resonance (MR) image reading and analysis were performed by two experienced blinded radiologists. RESULTS Two hundred eighty individuals exhibited 355 anterior HIZs in 355 discs. The prevalence was 23.57%; 88.45% were located in the inferior part of the annulus fibrosus. It frequently occurred in the middle and upper segments of lumbar spine, especially at L3/4 (45.63%). Of the 355 anterior HIZs, only 79 (22.25%) were consecutive-slides HIZ. Round type (63.38%) was the most common shape of anterior HIZs. The highest prevalence was found in individuals aged 60-69 years. LBP was confirmed in 141 anterior-HIZ individuals. The incidence of LBP in anterior-HIZ individuals was significantly higher than in non-HIZ subjects (50.36% vs 35.24%, χ2 = 18.314, P < 0.001). CONCLUSIONS Anterior HIZ is a lower-prevalence, age-related sign on lumbar MR images. The spatial distribution of anterior HIZ can be distinguished from posterior HIZ. The number of consecutive anterior HIZ slides might suggest fewer Dallas grade 4 anterior annular disruptions in this sample. Anterior HIZ was correlated with LBP.
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Affiliation(s)
- Zi-Xuan Wang
- Department of Interventional Radiology, Qingdao Municipal Hospital, Qingdao, Shandong, China
| | - Zeng-Tao Hou
- Department of Orthopedics, Qingdao Municipal Hospital, Qingdao, Shandong, China
| | - You-Gu Hu
- Department of Spinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
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14
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Xu W, Ran B, Luo W, Li Z, Gu R. Is Lumbar Fusion Necessary for Chronic Low Back Pain Associated with Degenerative Disk Disease? A Meta-Analysis. World Neurosurg 2020; 146:298-306. [PMID: 33253955 DOI: 10.1016/j.wneu.2020.11.121] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/20/2020] [Accepted: 11/21/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVE We sought to evaluate the efficacy and safety of lumbar fusion versus nonoperative care for the treatment of chronic low back pain associated with degenerative disk disease. METHODS A comprehensive duplicate electronic database search including PubMed, Embase, Cochrane Library, and China National Knowledge Infrastructure was conducted to identify relevant prospective studies published up to June 30, 2020. The main outcomes including clinical results, complications, and all-cause additional surgeries were presented in the form of short- (<2 years) and long-term (≥2 years) follow-up results. Analyses were performed in Review Manager software 5.3. RESULTS Six prospective studies involving 159 patients for short-term follow-up and 675 for long-term follow-up were included. The 2 interventions exhibited little difference in regard to short- and long-term Oswestry Disability Index and visual analog scale scores for back and leg pain, except that lumbar fusion might bring about lower additional surgery rate (risk ratio, 0.40; 95% confidence interval, 0.17 to 0.98; P = 0.04), and higher complication rate (risk ratio, 21.46; 95% confidence interval, 4.34 to 106.04; P = 0.0002) in the long term. CONCLUSIONS The present meta-analysis determined that fusion surgery was no better than nonoperative treatment in terms of the pain and disability outcomes at either short- or long-term follow-up. It is necessary for clinicians to weigh the risk of complications associated with fusion surgery against additional surgeries after nonoperative treatment. Considering lax patient inclusion criteria in the existing randomized clinical trials, the result needs to be further confirmed by high-quality research with stricter selection criteria in the future.
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Affiliation(s)
- Wenbo Xu
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin, P. R. China
| | - Bingbing Ran
- Department of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin, P. R. China
| | - Wenqi Luo
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin, P. R. China
| | - Zimeng Li
- Department of Endocrinology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, P. R. China
| | - Rui Gu
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin, P. R. China.
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MRI During Spinal Loading Reveals Intervertebral Disc Behavior Corresponding to Discogram Findings of Annular Fissures and Pain Provocation. Spine (Phila Pa 1976) 2020; 45:E1500-E1506. [PMID: 32756277 DOI: 10.1097/brs.0000000000003631] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of prospectively collected data. OBJECTIVE The aim of this study was to investigate whether spinal loading, depicted with magnetic resonance imaging (MRI), induces regional intervertebral disc (IVD) differences associated with presence and width of annular fissure and induced pain at discography. SUMMARY OF BACKGROUND DATA Annular fissures play a role in low back pain (LBP) but cannot be accurately characterized with conventional MRI. Recently, annular fissures were suggested to influence different load-induced IVD behavior during MRI when comparing LBP-patients and controls. Thus, the loading effect could characterize behavior related to annular fissures noninvasively with MRI. METHODS Lumbar spines of 30 LBP-patients were investigated with MRI with and without loading, discography and CT. Five IVD regions were outlined on sagittal MRI images. Difference in normalized signal intensity (SI) with and without loading was calculated for each region. Eighty-three CT-discograms were graded regarding presence and width of fissures. Discograms were classified as pain-positive if a concordant pain response was obtained at a pressure <50 psi. RESULTS Comparing IVDs with outer fissures with IVDs without fissures, loading induced different behavior in the two ventral regions and in the posterior region. Higher SI increase in the central region was induced in IVDs with narrower fissures compared to IVDs with wider fissures. In the group of pain-negative discograms, a SI decrease was induced in the dorsal region whereas lack of such in the pain-positive group. CONCLUSION The spinal loading-effect, depicted with MRI, reveals different regional behaviors between IVDs with outer fissures compared to those without, and between IVDs with narrow and broad fissures, as well as within posterior annulus between pain-positive and pain-negative discograms. Findings are of importance for future attempts to uncover phenotypes of painful IVDs. LEVEL OF EVIDENCE 2.
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Wang ZX, Hu YG. Factors associated with lumbar disc high-intensity zone (HIZ) on T2-weighted magnetic resonance image: a retrospective study of 3185 discs in 637 patients. J Orthop Surg Res 2018; 13:307. [PMID: 30514333 PMCID: PMC6280348 DOI: 10.1186/s13018-018-1010-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 11/19/2018] [Indexed: 11/10/2022] Open
Abstract
Background It is well known that internal disc disruption (IDD) is accelerated by factors such as aging and injury. High- intensity zone (HIZ) on lumbar MRI is usually considered a marker of painful IDD. However, many painful IDD show no HIZ. This suggests that the risk factors of HIZ may be different to these of IDD. The purpose was to clarify the correlation between the HIZ on lumbar MR and the factors, including gender, age, body weight, and low back pain (LBP). Methods Characteristics were obtained from the medical record. The MR images, biplanar post-discography radiographs, and post-discography CT images were reviewed and rated by two experienced radiologists in a blinded fashion. Results Annular HIZ correlated significantly with age (OR = 1.011), body weight (OR = 1.022), and LBP symptom (OR = 1.527). The lowest two HIZ prevalence rates were in the second and the third decades (11.54% and 7.84%). The highest prevalence was in the sixth decade (38.03%). The body weight was positively associated with the HIZ prevalence. There was a significant difference in HIZ prevalence between symptomatic and asymptomatic patients (36.16% vs. 26.96%, P < 0.05). All the HIZ discs exhibited grade 3 or grade 4 disruptions, but only 9 discs (9/16, 8 exhibited grade 4 annular tears) were detected with exact pain reproduction. Conclusions It is demonstrated that the presence of HIZ on lumbar MR image was associated with aging, high body weight, and low back pain symptom. HIZ sign indicated a part of the natural history of disc degeneration but was not an actual source of low back pain.
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Affiliation(s)
- Zi-Xuan Wang
- Department of Interventional Radiology, Qingdao Municipal Hospital, Qingdao, 266000, Shandong, People's Republic of China.
| | - You-Gu Hu
- Department of Spinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, 266003, Shandong, People's Republic of China
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