MRI-detected spinal disc degenerative changes in athletes participating in the Rio de Janeiro 2016 Summer Olympics games

Swimming for low back pain: A scoping review

BACKGROUND

Guidelines recommend exercise for treatment of chronic low back pain and prevention, but the amount and quality of evidence for different exercise modes is highly variable. Swimming is commonly recommended by health professionals, but the extent and quality of research supporting its relationship with back pain is not clear.

OBJECTIVES

The aim of this scoping review was to map the extent, characteristics and findings of research investigating the relationship between swimming and low back pain.

DESIGN

Scoping review.

METHOD

Four electronic databases (MEDLINE, EMBASE, CINAHL, and SPORT Discus) were searched from inception to February 2023. We included primary studies and reviews that reported an association between swimming and low back pain. Hydrotherapy studies were excluded.

RESULTS

3093 articles were identified, and 44 studies included. Only one randomised controlled trial and one longitudinal cohort study were included. Most studies were cross-sectional (37/44; 84.1%), included competitive athletes (23/39; 59.0%), and did not primarily focus on the association between swimming and low back pain in the aims (41/44; 93.2%). Instead, most data available were largely incidentally collected or a secondary outcome. The reported associations between swimming and low back pain were highly variable regardless of whether the comparison was to other sports (odds ratio: 0.17 to 17.92) or no sport (odds ratio: 0.54 to 3.01).

CONCLUSION

Most available literature investigating swimming and low back pain is cross-sectional in design. We did not identify any clear pattern of association between swimming and low back pain, based on the available literature.

Prevalence of degenerative vertebral disc changes in elite female Crossfit athletes - a cross-sectional study

BACKGROUND

Crossfit athletes consistently recruit or transfer high levels of repetitive forces through the spine, and MRI has documented a higher rate of intervertebral disc degeneration in athletes compared with matched controls. The aim of this study was to evaluate early degenerative spinal disc changes in elite female CrossFit athletes quantified by 3.0 Tesla magnetic resonance imaging (MRI) matched with female none-athletes.

METHODS

In a cross-sectional single-center study 19 asymptomatic adult participants, nine German female elite Crossfit athletes and ten female participants underwent spinal MRI (3.0T). Demographic data, spinal clinical examination results and sport-specific performance parameters were collected prior to the MRI. The primary outcome was the prevalence of degenerative spinal disc changes. The secondary outcome was the grade of degeneration using Pfirrmann grading.

RESULTS

A total of 437 discs underwent spinal MRI (3.0T). The prevalence of early degenerative disc disease was not increased. Pfirrmann degenerative grade did not show significant differences among groups.

CONCLUSION

Asymptomatic female elite Crossfit athletes do not show an increased prevalence of degenerative disc disease. Compared to a sex-matched control group, high training volume in Crossfit does not correlate to a higher incidence of degenerative disc changes in young females.

The imaging of cervical spondylotic myeloradiculopathy

This review provides a detailed description of the imaging features of cervical spondylotic myelopathy and radiculopathy, with a focus on MRI. Where relevant, we will outline grading systems of vertebral central canal and foraminal stenosis. Whilst post-operative appearances of the cervical spine are outside the scope of this paper, we will touch on imaging features recognised as predictors of clinical outcome and neurological recovery. This paper will serve as a reference for both radiologists and clinicians involved in the care of patients with cervical spondylotic myeloradiculopathy.

Comparative histopathological analysis of age-associated intervertebral disc degeneration in CD-1 and C57BL/6 mice: Anatomical and sex-based differences

Background

Intervertebral disc (IVD) degeneration is a major contributor to back pain and disability. The cause of IVD degeneration is multifactorial, with no disease-modifying treatments. Mouse models are commonly used to study IVD degeneration; however, the effects of anatomical location, strain, and sex on the progression of age-associated degeneration are poorly understood.

Methods

A longitudinal study was conducted to characterize age-, anatomical-, and sex-specific differences in IVD degeneration in two commonly used strains of mice, C57BL/6 and CD-1. Histopathological evaluation of the cervical, thoracic, lumbar, and caudal regions of mice at 6, 12, 20, and 24 months of age was conducted by two blinded observers at each IVD for the nucleus pulposus (NP), annulus fibrosus (AF), and the NP/AF boundary compartments, enabling analysis of scores by tissue compartment, summed scores for each IVD, or averaged scores for each anatomical region.

Results

C57BL/6 mice displayed mild IVD degeneration until 24 months of age; at this point, the lumbar spine demonstrated the most degeneration compared to other regions. Degeneration was detected earlier in the CD-1 mice (20 months of age) in both the thoracic and lumbar spine. In CD-1 mice, moderate to severe degeneration was noted in the cervical spine at all time points assessed. In both strains, age-associated IVD degeneration in the thoracic and lumbar spine was associated with increased histopathological scores in all IVD compartments. In both strains, minimal degeneration was detected in caudal IVDs out to 24 months of age. Both C57BL/6 and CD-1 mice displayed sex-specific differences in the presentation and progression of age-associated IVD degeneration.

Conclusions

These results showed that the progression and severity of age-associated degeneration in mouse models is associated with marked differences based on anatomical region, sex, and strain. This information provides a fundamental baseline characterization for users of mouse models to enable effective and appropriate experimental design, interpretation, and comparison between studies.

Radiological Findings of the Lumbar Spine in High School and Collegiate Sumo Wrestlers

Background

Sumo wrestling is a traditional sport in Japan and becoming popular worldwide. Risk factors for lower back injuries in sumo wrestlers are heavier weight and larger body mass index (BMI). The mawashi (loincloth belt) worn by sumo wrestlers has been shown to restrict motion of the lumbar spine.

Purpose

To study the effects of sumo wrestling on the lumbar spine of high school and freshmen collegiate wrestlers, investigating the relationship between radiological findings, wearing of the mawashi during training, and lower back symptoms.

Study Design

Case series; Level of evidence, 4.

Methods

From 2001 to 2017, a total of 197 members of the Japanese Sumo Federation (55 high school and 142 college freshman students) underwent routine radiographic examination of their lumbar spines and answered a questionnaire regarding lumbar symptoms. Wrestlers were classified as symptomatic and asymptomatic based on responses to a custom questionnaire. We used the unpaired t test to evaluate patient demographics and the chi square test to analyze radiographic lumbar spine abnormalities between symptomatic and asymptomatic wrestlers.

Results

The wrestlers' mean height, weight, BMI, and duration in the sport were 174.0 ± 6.7 cm, 107.1 ± 22.4 kg, 35.2 ± 6.4, and 8.0 ± 3.2 years, respectively. There were 91 participants in the symptomatic group (46.2%) and 106 (53.8%) in the asymptomatic group. Ten wrestlers (5.1%) had osteophyte formations in the lumbar body; 8 of the 11 osteophytes (72.7%) appeared in the upper lumbar spine. Of the total, 48 wrestlers (24.4%) had deformities (Schmorl nodules) in the lumbar body, and 23 of 50 (46.0%) and 10 of 16 (62.5%) deformities were found in the upper lumbar spine of collegiate and high school wrestlers, respectively. Five wrestlers of the total 197 athletes (2.5%) had disc space narrowing in the lumbar body, with 3 of the 5 cases of disc space narrowing (60.0%) found in the upper lumbar spine. Spondylolysis in the lumbar body was found in 25 wrestlers (12.7%); 19 of the 91 symptomatic wrestlers (20.9%) had spondylolysis, compared with 6 of the 106 (5.7%) asymptomatic wrestlers (P = .0028).

Conclusion

Almost one-third of sumo wrestlers had ≥1 abnormal radiological finding in the lumbar spine. There was a significant relationship between symptomatic wrestlers and spondylolysis.

Low occurrence of MRI spinal changes in elite climbing athletes; a cross-sectional study

OBJECTIVES

To examine the occurrence of magnetic resonance imaging (MRI) changes in the thoracolumbar spine among elite climbing athletes.

METHODS

All climbers of the Swedish national sport climbing team (n = 8), and individuals having trained for selection to the national team (n = 11), were prospectively included. A control group, matched in age and sex, were recruited. All participants underwent a thoracolumbar MRI (1.5 T, T1- and T2-weighted imaging), evaluated according to Pfirrmann classification, modified Endplate defect score, Modic changes, apophyseal injuries and spondylolisthesis. Pfirrmann ≥ 3, Endplate defect score ≥ 2 and Modic ≥ 1 was defined as degenerative findings.

RESULTS

Fifteen individuals, 8 women, participated in both the climbing group (mean age 23.1, SD 3.2 years) and the control group respectively (mean age 24.3, SD 1.5 years). In the climbing group, 6.1% of the thoracic and 10.6% of the lumbar intervertebral discs showed signs of degeneration according to Pfirrmann. One disc with a grade above 3 was present. Modic changes in the thoracic/lumbar spine were prevalent in 1.7%/1.3% of the vertebrae. Degenerative endplate changes according to the Endplate defect score were found in 8.9% and 6.6% of the thoracic and lumbar spinal segments of the climbing group, respectively. Two apophyseal injuries were found, while no participants displayed signs of spondylolisthesis. There was no difference in point-prevalence of radiographic spinal changes between climbers and controls (0.07 < p < 1.0).

CONCLUSION

In this small cross-sectional study, only a low proportion of elite climbers displayed changes of the spinal endplates or intervertebral discs, as opposed to other sports with high spinal loads. Most observed abnormalities were low grade degenerative changes and did not differ statistically compared to controls.

Effects of Competition Level on the Prevalence and Incidence of Lumbar Disk Degeneration in Japanese Collegiate Gymnasts

Background:

Lumbar disk degeneration (LDD) occurs frequently in athletes. Researchers have found that LDD occurs mainly in the lower disks (L4/L5 and L5/S1) in the general and athletic populations. However, a retrospective study showed a high prevalence of LDD in the upper lumbar disks (L1/L2), especially in elite gymnasts.

Purpose:

To investigate the effect of competition level on the prevalence and incidence of LDD in the upper lumbar disks (L1/L2).

Study Design:

Cross-sectional study; Level of evidence, 3; and cohort study; Level of evidence, 2.

Methods:

We conducted 2 studies to evaluate the effect of competition level on the prevalence and incidence of LDD in Japanese collegiate gymnasts. In study 1, a cross-sectional study of 298 collegiate gymnasts was conducted between 2011 and 2015. Competition levels were categorized as regional, national, and international, and T2-weighted magnetic resonance imaging (MRI) was used to evaluate LDD. Chi-square testing was applied to assess differences in the prevalence of LDD and spinal levels among the 3 competition levels. In study 2–-a prospective cohort study–-LDD progression and its related risk factors were investigated in 51 collegiate gymnasts. Baseline lumbar MRI scans and measurements of physical function (generalized joint laxity and finger-floor distance test) were performed in March 2014. Follow-up lumbar MRI scans were obtained 2 years later, in February 2016. Logistic regression analyses were performed to investigate the relationship between competition level and LDD progression.

Results:

In study 1, the prevalence of at least 1 degenerated disk in the regional, national, and international groups was 44.2% (19/43), 44.7% (98/219), and 52.8% (19/36), respectively (P = .655). The prevalence of LDD at L1/L2 in the international group was significantly higher than that in the other 2 groups (P = .018). In study 2, the presence of LDD at L1/L2 was associated significantly with international-level competition (adjusted odds ratio, 47.8; 95% CI, 2.75-830.50).

Conclusion:

In Japanese collegiate gymnasts, competing at the international level was found to be a risk factor for LDD at L1/L2.

Patterns of Intervertebral Disk Alteration in Asymptomatic Elite Rowers: A T2* MRI Mapping Study

Background:

Repetitive loading of the back puts elite rowers at risk for acute and chronic back injuries.

Hypothesis:

That asymptomatic elite rowers would demonstrate characteristic intervertebral disk (IVD) alterations on T2* magnetic resonance imaging (MRI) mapping compared with asymptomatic nonrowers.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

This study included 20 asymptomatic elite rowers (mean age, 23.4 ± 3.03 years; 9 women, 11 men) studied at 2 different times, once before (t₁) and once after (t₂) the competition phase. MRI including T2* mapping was performed on a 3-T scanner. The authors derived normative T2* data from a previous study on 40 asymptomatic volunteers (20 men, 20 women) who were not competitive rowers; based on complete T2* data sets, 37 controls were included. T2* values were compared between groups in 4 lumbar IVDs, and midsagittal T2* values were compared in 5 zones: anterior annulus fibrosus (AF), anterior nucleus pulposus (NP), central NP, posterior NP, and posterior AF. The Pfirrmann grade was used for morphological assessment of disk degeneration. Statistical analysis was conducted using the Mann-Whitney U test, Wilcoxon matched-pairs test, and Spearman rank correlation coefficient.

Results:

Lower T2* values were noted in the rower group compared with the controls (37.08 ± 33.63 vs 45.59 ± 35.73 ms, respectively; P < .001). The intersegmental comparison revealed lower mean T2* values among rowers (P ≤ .027 for all). The interzonal comparison indicated significantly lower mean T2* values for the rowers in all zones except for the anterior NP (P ≤ .008 for all). Lower mean T2* values were observed for the rowers at t₁ versus t₂ (39.25 ± 36.19 vs 43.97 ± 38.67 ms, respectively; P = .008). The authors noted a higher level of IVD damage according to Pfirrmann assessment in the rower cohort (P < .001); the Pfirrmann grade distributions of rowers versus controls, respectively, were as follows: 51.3% versus 73.7% (grade 1), 20.5% versus 19.5% (grade 2), 21.8% versus 6.8% (grade 3), 5.1% versus 0% (grade 4), and 1.3% versus 0% (grade 5). The authors also noted a correlation between low T2* and high Pfirrmann grade at t₁ (r =–0.48; P < .001) and t₂ (r =–0.71; P < .001).

Conclusion:

The cohort of elite rowers revealed more degenerative IVD changes compared with controls. The T2* values suggest that repetitive loading of the spine has demonstrable short-term and possibly permanent effects on the lumbar IVD.

Magnetic Resonance Imaging Findings in High School Football Players: Brain and Cervical Spine

Football exposes its players to traumatic brain, neck, and spinal injury. It is unknown whether the adolescent football player develops imaging abnormalities of the brain and spine that are detectable on magnetic resonance imaging (MRI). The objective of this observational study was to identify potential MRI signatures of early brain and cervical spine (c-spine) injury in high school football players. Eighteen football players (mean age, 17.0 ± 1.5 years; mean career length, 6.3 ± 4.0 years) had a baseline brain MRI, and 7 had a follow-up scan 9–42 months later. C-spine MRIs were performed on 11 of the 18 subjects, and 5 had a follow-up scan. C-spine MRIs from 12 age-matched hospital controls were also retrospectively retrieved. Brain MRIs were reviewed by a neuroradiologist, and no cerebral microbleeds were detected. Three readers (a neuroradiologist, a neurosurgeon, and an orthopedic spine surgeon) studied the cervical intervertebral discs at six different cervical levels and graded degeneration using an established five-grade scoring system. We observed no statistically significant difference in disc degeneration or any trend toward increased disc degeneration in the c-spine of football players as compared with age-matched controls. Further research is needed to validate our findings and better understand the true impact of contact sports on young athletes.

What happens to the lower lumbar spine after marathon running: a 3.0 T MRI study of 21 first-time marathoners

OBJECTIVE

To better understand the impact of long-distance running on runners' lumbar spines by assessing changes before and after their first marathon run.

MATERIALS AND METHODS

The lumbar spines of 28 asymptomatic adults (14 males, 14 females, mean age: 30 years old), who registered for their first marathon, the 2019 London Richmond Marathon, were examined 16 weeks before (time point 1) and 2 weeks after (time point 2) the marathon. Participants undertook a pre-race 16-week training programme. Magnetic resonance imaging (MRI) of high-resolution 3.0 Tesla was used at each time point. Senior musculoskeletal radiologists assessed the lower lumbar spine condition.

RESULTS

Out of 28 participants, 21 completed both the training and the race and 7 neither completed the training nor started the marathon but not due to spine-related issues. At time point 1, disc degeneration was detected in 17/28 (61%), most predominantly at spinal segments L4-L5 and L5-S1. No back pain/other symptoms were reported. When compared to time point 2, there was no progression in the extent of disc degeneration, including intervertebral disc (IVD) height (p = 0.234), width (p = 0.359), and intervertebral distance (p = 0.641). There was a regression in 2 out of 8 (25%) participants who had pre-marathon sacroiliac joint bone marrow oedema, and a small increase in the size of a pre-marathon subchondral cyst in one participant, all asymptomatic.

CONCLUSION

Running 500 miles over 4 months plus a marathon for the first time had no adverse effects on the lumbar spine, even when early degenerative changes were present. Additionally, there was evidence of regression of sacroiliac joint abnormalities.

Expression of ANGPTL4 in Nucleus Pulposus Tissues Is Associated with Intervertebral Disc Degeneration

Objective

Angiopoietin-like protein 4 (ANGPTL4), encoding a glycosylated secreted protein, has been reported to be closely related to many kinds of diseases, including diabetes, tumor, and some musculoskeletal pathologies, such as rheumatoid arthritis, osteoarthritis, and osteoporosis. The aim of the current study is to investigate the role of ANGPTL4 in intervertebral disc degeneration and analyze the association of ANGPTL4 expression with Pfirrmann grades.

Methods

A total of 162 nucleus pulposus tissues were collected from lumbar intervertebral disc herniation patients undergoing interforaminal endoscopic surgery. Real-time quantitative PCR and western blot were performed to determine the mRNA and protein expression of ANGPTL4 in nucleus pulposus samples. Statistical analysis was performed to analyze the association of ANGPTL4 expression with Pfirrmann grades.

Results

Based on the clinical data of 162 patients, results showed that Pfirrmann grades were significantly associated with patients' age (r = 0.162, P = 0.047) and were not significantly associated with patients' gender (P > 0.05). RT-qPCR and western blot results showed that the mRNA (r = 0.287, P < 0.05) and protein (r = 0.356, P < 0.05) expressions of ANGPTL4 were both closely associated with Pfirrmann grades. The expression of ANGPTL4 was remarkably increased in the groups of high IVDD Pfirrmann grades.

Conclusion

The results demonstrated that ANGPTL4 expression was positively associated with the Pfirrmann grades and the severity of intervertebral disc degeneration. ANGPTL4 may be served as a candidate biomarker for intervertebral disc degeneration.

Single-cell RNA-seq analysis identifies unique chondrocyte subsets and reveals involvement of ferroptosis in human intervertebral disc degeneration

OBJECTIVE

Nucleus pulposus (NP) plays a central role in disc degeneration pathogenesis, however, as a heterogeneous tissue, cell subsets in NP and their corresponding biological process in intervertebral disc degeneration (IVDD) are unreported.

METHOD

Nucleus pulposus were isolated from normal control and IVDD, and then subjected to single-cell RNA sequencing (scRNA-seq). Unsupervised clustering of the cells based on the gene expression profiles using the Seurat package and passed to tSNE for clustering visualization. Rat model of disc degeneration was built to validate the pathways identified by scRNA-Seq.

RESULTS

Seven chondrocyte subsets were revealed in NP based on differential gene expression, among which 4 subsets (C1-C4) were reported for the first time. Furthermore, GO and KEGG analyses discovered that ferroptosis pathways were enriched. Rat model of disc degeneration was built (n = 6/group, control vs. model) to validate the pathways identified by scRNA-Seq. Iron levels of NP were significantly higher in model group than control group (means 0.712 vs. 0.248, respectively, mg/gpro, p = 0.0026), and the levels of Heme Oxygenase 1 (HO-1) were also elevated in model group (means 14.33 vs. 5.16 IOD, respectively, p = 0.0002). However, the levels of ferritin light chain (FTL) were significantly decreased in model group compared to control group (means 26.17 vs. 9.00 FTL⁺ cell number, respectively, p = 0.0011).

CONCLUSIONS

Novel chondrocyte subsets in nucleus pulposus were discovered through scRNA-Seq, which provided novel insight to understand the pathological change during the development of IVDD. Ferroptosis participated in disc degeneration pathogenesis and it might serve as a new target for intervening IVDD.

Imaging of exercise-induced spinal remodeling in elite rowers

OBJECTIVES

As in-vivo knowledge of training-induced remodeling of intervertebral discs (IVD) is scarce, this study assessed how lumbar IVDs change as a function of long-term training in elite athletes and age-matched controls using compositional Magnetic Resonance Imaging (MRI).

DESIGN

Prospective case-control study.

METHODS

Prospectively, lumbar spines of 17 elite rowers (ERs) of the German national rowing team (mean age: 23.9 ± 3.3 years) were imaged on a clinical 3.0 T MRI scanner. ERs were imaged twice during the annual training cycle, i.e., at training intensive preseason preparations (t₀) and 6 months later during post-competition recovery (t₁). Controls (n = 22, mean age: 26.3 ± 1.9 years) were imaged once at corresponding time points (t₀: n = 11; t₁: n = 11). Segment-wise, the glycosaminoglycan (GAG) content of lumbar IVDs (n = 195) was determined using glycosaminoglycan chemical exchange saturation transfer (gagCEST). Linear mixed models were set up to assess the influence of cohort and other variables on GAG content.

RESULTS

During preseason, IVD GAG values of ERs were significantly higher than those of controls (ERs(t₀): 2.58 ± 0.27% (mean ± standard deviations); controls(t₀): 1.43 ± 0.36%; p ≤ 0.001), while during post-competition recovery, such differences were not present anymore (ERs(t₁): 2.11 ± 0.18%; controls(t₁): 1.89 ± 0.24%; p = 0.362).

CONCLUSIONS

Professional elite-level rowing is transiently associated with significantly higher gagCEST values, which indicate increased lumbar IVD-GAG content and strong remodeling effects in response to training. Beyond professional rowing, core-strengthening full-body exercise may help to enhance the resilience of the lumbar spine as a potential therapeutic target in treating back pain.

Is there a place for surgical repair in adults with spondylolysis or grade-I spondylolisthesis-a systematic review and treatment algorithm

OBJECTIVES

Pars repair is less explored in adults due to associated disc degeneration with advancing age. The aim of our systematic review was to define optimal characteristics of adults with spondylolysis/grade-I spondylolisthesis suitable for pars repair and evaluate the feasibility, effectiveness, and safety of standard repair techniques in these adults.

METHODS

This systematic review is reported in line with PRISMA-P and protocol is registered with PROSPERO (CRD42020189208). Electronic searches were conducted in PubMed, Embase, Scopus, and Web of Science in June 2020 using systematic search strategy. Studies involving adults aged ≥18-years with spondylolysis/grade-1 isthmic spondylolisthesis treated with standard pars repair techniques were considered eligible. A two-staged (titles/abstracts and full-text) screening was conducted independently by three authors followed by quality assessment using the Joanna Briggs Institute critical appraisal checklist for selection of final articles for narrative synthesis.

RESULTS

A total of 5,813-articles were retrieved using systematic search strategy. First screening followed by removal of duplicates resulted in 111-articles. Second (full-text) screening resulted in exclusion of 64-articles. A final 47-articles were considered for data extraction after quality assessment. A total of 590-adults were enrolled across 47-studies; 93% were 'young adults' (18-35 years); 82% were males. Persistent low back pain was the common presenting complaint. Lysis defect was primarily bilateral (96.4%) and L5 was the most involved level (68.5%). Majority had no disc degeneration (83.5%) and had spondylolysis as the primary diagnosis (86%); only 14% had grade-I spondylolisthesis. Pars infiltration test was conducted in 22-studies and discography in 8-studies. Duration of prior conservative therapy was 3 to 72-months. Buck's repair was the commonest technique (27-studies, 372-adults). Successful repair was reported in 86% of patients treated with Buck's and ≥90% treated with Scott's, Morscher's and pedicle-screw-based techniques. Improvement in pain/functional outcomes, union rate and rate-of-return to sports/activity was high and comparable across all techniques. Intraoperative blood loss was low with minimally invasive versus traditional repair. The overall complication rate was 11.9%, with implant failure being the major complication.

CONCLUSIONS

Our systematic review establishes a definite place for lysis repair in carefully selected adults with spondylolysis/grade-I spondylolisthesis. We propose a treatment algorithm for optimizing patient selection and outcomes. We conclude that adults with age 18 to 45 years, no/mild disc or facet degenerative changes, positive diagnostic infiltration test, and normal preoperative discography will have successful outcomes with pars repair, regardless of the technique.

Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care

OBJECTIVES

The largest proportion of general practitioner (GP) magnetic resonance imaging (MRI) is musculoskeletal (MSK), with consistent annual growth. With limited supporting evidence and potential harms from early imaging overuse, we evaluated practice to improve pathways and patient safety.

METHODS

Cohort evaluation of routinely collected diagnostic and general practice data across a UK metropolitan primary care population. We reviewed patient characteristics, results and healthcare utilisation.

RESULTS

Of 306 MSK-MRIs requested by 107 clinicians across 29 practices, only 4.9% (95% CI ±2.4%) appeared clearly indicated and only 16.0% (95% CI ±4.1%) received appropriate prior therapy. 37.0% (95% CI ±5.5%) documented patient imaging request. Most had chronic symptoms and half had psychosocial flags. Mental health was addressed in only 11.8% (95% CI ±6.3%) of chronic sufferers with psychiatric illness, suggesting a solely pathoanatomical approach to MSK care. Only 7.8% (95% CI ±3.0%) of all patients were appropriately managed without additional referral. 1.3% (95% CI ±1.3%) of scans revealed diagnoses leading to change in treatment (therapeutic yield). Most imaged patients received pathoanatomical explanations to their symptoms, often based on expected age or activity-related changes. Only 16.7% (95% CI ±4.2%) of results appeared correctly interpreted by GPs, with spurious overperception of surgical targets in 65.4% (95% CI ±5.3%) who suffered 'low-value' (ineffective, harmful or wasteful) post-MRI referral cascades due to misdiagnosis and overdiagnosis. Typically, 20%-30% of GP specialist referrals convert to a procedure, whereas MRI-triggered referrals showed near-zero conversion rate. Imaged patients experienced considerable delay to appropriate care. Cascade costs exceeded direct-MRI costs and GP-MSK-MRI potentially more than doubles expenditure compared with physiotherapist-led assessment services, for little-to-no added therapeutic yield, unjustifiable by cost-consequence or cost-utility analysis.

CONCLUSION

Unfettered GP-MSK-MRI use has reached unaccceptable indication creep and disutility. Considerable avoidable harm occurs through ubiquitous misinterpretation and salient low-value referral cascades for two-thirds of imaged patients, for almost no change in treatment. Any marginally earlier procedural intervention for a tiny fraction of patients is eclipsed by negative consequences for the vast majority. Only 1-2 patients need to be scanned for one to suffer mismanagement. Direct-access imaging is neither clinically, nor cost-effective and deimplementation could be considered in this setting. GP-MSK-MRI fuels unnecessary healthcare utilisation, generating nocebic patient beliefs and expectations, whilst appropriate care is delayed and a high burden of psychosocial barriers to recovery appear neglected.

Lumbar Disk Herniations and Radiculopathy in Athletes

Lumbar disk herniation is the most common surgical condition of the spine. High-level athletes participate in activities that place extreme loads on the intervertebral disks. These repetitive loads may lead to an elevated risk for degenerative disk disease, which in turn predisposes to disk herniations. Treatment algorithms for athletes with disk herniations are similar to those in the nonathletic population; however, success in the athletic population is often measured in the ability to return to play. Both nonoperative and operative treatment show a high success rate in return to play in athletes treated for disk herniations.

Sports injuries at the Rio de Janeiro 2016 Summer Paralympic Games: use of diagnostic imaging services

OBJECTIVE

To describe the occurrence of imaging-depicted sports-related injuries (bone, muscle, tendon, and ligament injuries) during the Rio 2016 Summer Paralympic Games.

METHODS

Descriptive data on all imaging examinations by using radiography, ultrasonography (US), and MRI were collected and retrospectively analyzed centrally by five musculoskeletal radiologists according to imaging modality, country of origin of the athletes, type of sport, type of disability, and type and location of injury.

RESULTS

We report 109 injuries in 4378 athletes. A total of 382 radiologic examinations were performed in 261 athletes, including 118 (31%) radiographic, 22 (6%) US, and 242 (63%) MRI examinations. Para athletes from Africa had the highest utilization rate (20.1%, 67 out of 333). Athletes from Europe underwent the most examinations with 29 radiographic, 12 US, and 66 MRI examinations. The highest utilization rate of imaging modalities by sport was among Judo para athletes (16.7%, 22 out of 132). Most injuries were reported in athletics discipline (37.6%, 41 out of 109). Most injuries were also reported among para athletes with visual impairment (40 injuries, 36.7% of all injuries). Bone stress injuries were most common among para athletes with visual impairment (6 out of 7). Para athletes with visual impairment were also more prone to bone stress injuries than traumatic fractures, unlike para athletes with neurologic and musculoskeletal impairments.

CONCLUSIONS

Imaging was used in 6.0% of para athletes. MRI comprised 63% of imaging utilization. Identification of patterns of injuries may help building future prevention programs in elite para athletes.

KEY POINTS

• The highest imaging utilization rates were found among para athletes competing in Judo, sitting volleyball, powerlifting, and football. • Utilization of diagnostic imaging at the Rio 2016 Paralympic Games demonstrated similar trends to what was observed at the Rio 2016 Olympic Games. • Comparison of the rate of imaging-depicted injuries between Olympic and Paralympic athletes is limited due to inherent differences between the two athlete populations and the manner in which injury risk in the Paralympic athlete varies dependent on impairment type, which is not the case for the Olympic athlete.

Asymptomatic Degenerative Changes in the Lumbar Spine Among Professional Soccer Players

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

The aim of this study was to evaluate the actual prevalence of degenerative spinal changes and their association with age in a cohort of professional soccer players.

SUMMARY OF BACKGROUND DATA

Presently, there are data that athletes have more degenerative changes than nonathletes; however, the research examining the prevalence of degenerative spinal conditions among professional elite soccer players is scarce.

METHODS

Professional male soccer players were included in the study (n = 40, average age 26,6 ± 4,5 years, average height 18 ± 0.07 m, weight 76.7 ± 7.1 kg). Lumbosacral spine MRI scanning at the L1-S1 level has been performed. Two radiologists with at least 7 years of experience of working with athletes evaluated all images independently of each other.

RESULTS

92.5% (n = 37) of soccer players had ≥1 spinal degenerative condition. Thirty-five percent (n = 14) of players had three to five, and 50% (n = 20) had six or more conditions. The average age of players who had six or more conditions was significantly higher than those who had zero to five or three to five conditions-28.1 ± 4.8 years versus 25.1 ± 3.6 years (P = 0.029), and 24.8 ± 3.6 years, respectively.Kruskal-Wallis test has shown no association between the number of degenerative conditions and weight (P = 0.98) as well as body mass index (P = 0.99). The age was associated with degenerative changes (P = 0.008).Disc desiccation was the most common pathologic condition, which was found in 82.5% of athletes. Facet joint arthropathy and spondylosis were present in 70, and 50% of the studied lumbar spine MRI scans, respectively. The spondylolysis prevalence of 20% was noted.

CONCLUSION

Elite professional soccer players demonstrate a high prevalence of asymptomatic degenerative lumbar spinal degenerative changes, which are significantly associated with age. These conditions might lead to the development of symptomatic lower back pain, given the high-intensity exercise required in professional soccer. It is presently unclear what measures might be applied for the primary prevention of these degenerative spinal conditions.Level of Evidence: 4.