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Zhang M, Jia J, Deng L, Cao Z, Hu X, Lei S, Zhang G, Zhu D, Duan Y, Kang X. Risk factors associated with low-grade virulent infection in intervertebral disc degeneration: a systematic review and meta-analysis. Spine J 2024; 24:1034-1045. [PMID: 38365007 DOI: 10.1016/j.spinee.2024.02.001] [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: 07/14/2023] [Revised: 12/26/2023] [Accepted: 02/06/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND An increasing number of research indicates an association between low-grade bacterial infections, particularly those caused by Propionibacterium acnes (P. acnes), and the development of intervertebral disc degeneration (IDD). However, no previous meta-analysis has systematically assessed the risk factors for low-grade bacterial infections that cause IDD. PURPOSE This study reviewed the literature to evaluate the risk factors associated with low-grade bacterial infection in patients with IDD. STUDY DESIGN Systematic review and meta-analysis. METHODS The systematic literature review was conducted using the PubMed, Web of Science, Embase, and Cochrane Library databases. Eligible articles explicitly identified the risk factors for low-grade bacterial infections in IDD patients. Patient demographics and total bacterial infection rates were extracted from each study. Meta-analysis was performed using random- or fixed-effects models, with statistical analyses conducted using Review Manager (RevMan) 5.4 software.aut. RESULTS Thirty-three studies involving 4,109 patients were included in the meta-analysis. The overall pooled low-grade bacterial infection rate was 30% (range, 24%-37%), with P. acnes accounting for 25% (range, 19%-31%). P. acnes constituted 66.7% of bacteria-positive discs. Fourteen risk factors were identified, of which 8 were quantitatively explored. Strong evidence supported male sex (odds ratio [OR] = 2.15; 95% confidence interval [CI]=1.65-2.79; p<.00001) and Modic changes (MCs) (OR=3.59; 95% CI=1.68-7.76; p=.0009); moderate evidence of sciatica (OR=2.31; 95% CI=1.33-4.00; p=.003) and younger age (OR=-3.47; 95% CI=-6.42 to -0.53; p=.02). No evidence supported previous disc surgery, MC type, Pfirrmann grade, smoking, or diabetes being risk factors for low-grade bacterial infections in patients with IDD. CONCLUSIONS Current evidence highlights a significant association between IDD and low-grade bacterial infections, predominantly P. acnes being the most common causative agent. Risk factors associated with low-grade bacterial infections in IDD include male sex, MCs, sciatica, and younger age.
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Affiliation(s)
- Mingtao Zhang
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China.
| | - Jingwen Jia
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China
| | - Liangna Deng
- Department of Radiology, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730000, Gansu, China
| | - Zhenyu Cao
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China
| | - Xuchang Hu
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China
| | - Shuanhu Lei
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China
| | - Guangzhi Zhang
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China
| | - Daxue Zhu
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China
| | - Yanni Duan
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China
| | - Xuewen Kang
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China.
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Cetintas SC, Akyol S, Alizada O, Akgun MY, Tahmazoglu B, Hanci M, Isler C. The Relationship Between Inflammatory Processes and Apoptosis in Lumbar Disc Degeneration. World Neurosurg 2024; 186:e261-e272. [PMID: 38548052 DOI: 10.1016/j.wneu.2024.03.121] [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: 01/12/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE Degenerative Disc Disease (DDD) is a common health problem in the population. There are recent studies focusing on relationship between DDD and immunological factors. However, there is still a lack of data on the role of apoptosis in DDD pathophysiology. Therefore, we aimed to investigate the relationship between Modic-type changes and the apoptosis in DDD. MATERIALS AND METHODS Ninety adult male patients who presented with low back and/or radicular pain and were operated on due to lumbar disc herniation were included. Three groups were formed based on Modic type degeneration observed on magnetic resonance imaging. Specific parameters involved in the intrinsic and extrinsic pathways of apoptosis were assessed in excised disc materials using the enzyme-linked immunosorbent assay method. RESULTS All three groups formed according to Modic degeneration types were homogenous in all variances. Cytochrome-C was significantly decreased only in the Modic type-3 group, whereas Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand Receptor-1, B-Cell Lymphoma-2 (Bcl-2) Homologous Antagonist Killer-1, Direct Inhibitor of Apoptosis-Binding Protein with Low Pi, and Bcl-2 Associated X Apoptosis Regulator levels were significantly different in both Modic type-2 and -3 groups. However, BH3 interacting domain death agonist and Bcl-2 levels were similar across all groups. CONCLUSIONS In conclusion, this study suggests that Direct Inhibitor of Apoptosis-Binding Protein with Low Pi, cytochrome - c, Bcl-2 Associated X Apoptosis Regulator, Bcl-2 Homologous Antagonist Killer-1, and Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand Receptor-1proteins play important roles in the development and progression of DDD and are correlated with Modic types. Further studies are needed to explore the potential therapeutic role of inhibiting these apoptotic proteins in DDD.
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Affiliation(s)
- Semih Can Cetintas
- Department of Neurosurgery, Turkish Ministry of Health, Bitlis State Hospital, Bitlis, Turkey
| | - Sibel Akyol
- Department of Physiology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Orkhan Alizada
- Department of Neurosurgery, Baskent University, School of Medicine, Istanbul, Turkey
| | | | - Burak Tahmazoglu
- Department of Neurosurgery, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Murat Hanci
- Department of Neurosurgery, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Cihan Isler
- Department of Neurosurgery, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey.
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Chen X, Lu S, Chopra N, Cui P, Zhang S, Narulla R, Diwan AD. The association between low virulence organisms in different locations and intervertebral disc structural failure: A meta-analysis and systematic review. JOR Spine 2023; 6:e1244. [PMID: 37361324 PMCID: PMC10285758 DOI: 10.1002/jsp2.1244] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/12/2022] [Accepted: 12/22/2022] [Indexed: 06/28/2023] Open
Abstract
Many factors may trigger intervertebral disc (IVD) structural failure (intervertebral disc degeneration (IDD) and endplate changes), including inflammation, infection, dysbiosis, and the downstream effects of chemical factors. Of these, microbial diversity in the IVD and elsewhere in the body has been considered as one of the potential reasons for disc structural failure. The exact relationships between microbial colonization and IVD structural failure are not well understood. This meta-analysis aimed to investigate the impact of microbial colonization and its location (such as skin, IVD, muscle, soft tissues, and blood) on IVD structural failure and corresponding low back pain (LBP) if any. We searched four online databases for potential studies. The potential relationships between microbial colonization in different sample sources (such as skin, IVD, muscle, soft tissues, and blood) and IDD and endplate change were considered as primary outcomes. Odds ratio (OR) and 95% confidence intervals (CI) for direct comparisons were reported. Grading of Recommendations Assessment, Development and Evaluation (GRADE) scale was used to assess the quality of evidence. Twenty-five cohort studies met the selection criteria. Overall pooled prevalence of microbial colonization in 2419 patients with LBP was 33.2% (23.6%-43.6%). The pooled prevalence of microbial colonization in 2901 samples was 29.6% (21.0%-38.9%). Compared with the patients without endplate change, the patients with endplate changes had higher rates of microbial colonization of disc (OR = 2.83; 95% CI = 1.93-4.14; I 2 = 37.6%; p = 0.108). The primary pathogen was Cutibacterium acnes which was present in 22.2% of cases (95% CI = 13.3%-32.5%; I 2 = 96.6%; p = 0.000). This meta-analysis and systematic review found low-quality grade evidence for an association between microbial colonization of disc with endplate changes. The primary pathogen was C. acnes. Due to lack of enough high-quality studies and methodological limitations of this review, further studies are required to improve our understanding of the potential relationships and mechanisms of microbiota, dysbiosis, IVD colonization and IVD structural failure.
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Affiliation(s)
- Xiaolong Chen
- Spine Labs, St. George & Sutherland Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia
- Department of OrthopaedicsXuanwu Hospital Capital Medical UniversityBeijingChina
| | - Shibao Lu
- Department of OrthopaedicsXuanwu Hospital Capital Medical UniversityBeijingChina
| | - Neha Chopra
- Spine Labs, St. George & Sutherland Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia
- Spine Service, Department of Orthopaedic SurgerySt. George Hospital CampusSydneyNew South WalesAustralia
| | - Peng Cui
- Department of OrthopaedicsXuanwu Hospital Capital Medical UniversityBeijingChina
| | - Sitao Zhang
- Department of OrthopaedicsXuanwu Hospital Capital Medical UniversityBeijingChina
| | - Rajpal Narulla
- Spine Labs, St. George & Sutherland Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia
| | - Ashish D. Diwan
- Spine Labs, St. George & Sutherland Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia
- Spine Service, Department of Orthopaedic SurgerySt. George Hospital CampusSydneyNew South WalesAustralia
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Granville Smith I, Danckert NP, Freidin MB, Wells P, Marchesi JR, Williams FMK. Evidence for infection in intervertebral disc degeneration: a systematic review. 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 2021; 31:414-430. [PMID: 34862912 PMCID: PMC8873132 DOI: 10.1007/s00586-021-07062-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 09/30/2021] [Accepted: 11/10/2021] [Indexed: 12/19/2022]
Abstract
Purpose Back pain is a major problem worldwide and is linked to intervertebral disc degeneration and Modic change. Several studies report growth of bacteria following extraction of degenerate discs at spine surgery. A pathophysiological role for infection in back pain has been proposed. Method We conducted a PRISMA systematic review. MEDLINE, PubMed, Scopus and Web of Science were searched with the terms Modic change, intervertebral dis*, bacteria, microb*, and infect*. Date limits of 2001–2021 were set. Human studies investigating the role of bacteria in disc degeneration or Modic change in vertebrae were included. Results Thirty-six articles from 34 research investigations relating to bacteria in human degenerate discs were found. Cutibacterium acnes was identified in pathological disc material. A ‘candidate bacterium’ approach has been repeatedly adopted which may have biased results to find species a priori, with disc microbial evidence heavily weighted to find C. acnes. Conclusion Evidence to date implicates C. acnes identified through culture, microscopy and sequencing, with some suggestion of diverse bacterial colonisation in the disc. This review found studies which used culture methods and conventional PCR for bacterial detection. Further agnostic investigation using newer methods should be undertaken. Supplementary Information The online version contains supplementary material available at 10.1007/s00586-021-07062-1.
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Affiliation(s)
- Isabelle Granville Smith
- Department of Twin Research and Genetic Epidemiology, King's College London, 3rd and 4th Floor, Block D, South Wing, St. Thomas' Hospital, Westminster Bridge Rd., London, SE1 7EH, UK.
| | - Nathan P Danckert
- Department of Metabolism, Digestion and Reproduction, Imperial College, London, UK
| | - Maxim B Freidin
- Department of Twin Research and Genetic Epidemiology, King's College London, 3rd and 4th Floor, Block D, South Wing, St. Thomas' Hospital, Westminster Bridge Rd., London, SE1 7EH, UK
| | - Philippa Wells
- Department of Twin Research and Genetic Epidemiology, King's College London, 3rd and 4th Floor, Block D, South Wing, St. Thomas' Hospital, Westminster Bridge Rd., London, SE1 7EH, UK
| | - Julian R Marchesi
- Department of Metabolism, Digestion and Reproduction, Imperial College, London, UK
| | - Frances M K Williams
- Department of Twin Research and Genetic Epidemiology, King's College London, 3rd and 4th Floor, Block D, South Wing, St. Thomas' Hospital, Westminster Bridge Rd., London, SE1 7EH, UK
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Gilligan CJ, Cohen SP, Fischetti VA, Hirsch JA, Czaplewski LG. Chronic low back pain, bacterial infection and treatment with antibiotics. Spine J 2021; 21:903-914. [PMID: 33610802 DOI: 10.1016/j.spinee.2021.02.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/14/2021] [Accepted: 02/15/2021] [Indexed: 02/03/2023]
Abstract
The contribution of bacterial infection to chronic low back pain and its treatment with antibiotics have generated considerable controversy in literature. If efficacious, antibiotics have the potential to transform the treatment of chronic low back pain in a significant subset of patients. Some microbiology studies of disc tissue from patients with CLBP have shown that bacteria are present, most likely due to infection, while others conclude they are absent or if found, it is due to surgical contamination. Clinical studies testing the efficacy of oral antibiotics to treat CLBP have either shown that the treatment is efficacious leading to significantly reduced pain and disability or that their effect is modest and not clinically significant. Critical review of the literature on CLBP, bacterial infection and treatment with antibiotics identified five well-designed and executed microbiology studies characterizing bacteria in disc samples that demonstrate that bacteria do infect herniated disc tissue, but that the bacterial burden is low and may be below the limits of detection in some studies. Two randomized, controlled clinical trials evaluating oral antibiotics in patients with CLBP indicate that for certain subsets of patients, the reduction in pain and disability achieved with antibiotic therapy may be significant. In patients for whom other therapies have failed, and who might otherwise progress to disc replacement or fusion surgery, antibiotic therapy may well be an attractive option to reduce the individual suffering associated with this debilitating condition. Additional clinical research is recommended to refine the selection of patients with CLBP caused or complicated by bacterial infection and most likely to respond to antibiotics, to optimize antibiotic therapy to maximize patient benefit, to minimize and manage side effects, and to address legitimate concerns about antibiotic stewardship.
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Affiliation(s)
- Christopher J Gilligan
- Brigham and Women's Hospital, Department of Anesthesiology, Perioperative and Pain Medicine, Boston, MA, USA
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 550 N. Broadway, Ste 301, Baltimore, MD 21029, USA; Department of Anesthesiology, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Vincent A Fischetti
- Laboratory of Bacterial Pathogenesis and Immunology, The Rockefeller University, New York, New York
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Lloyd G Czaplewski
- Persica Pharmaceuticals Ltd, 7 Denne Hill Business Centre, Womenswold, Canterbury, Kent, CT4 6HD, UK.
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Zaworski K, Latosiewicz R. The effectiveness of manual therapy and proprioceptive neuromuscular facilitation compared to kinesiotherapy: a four-arm randomized controlled trial. Eur J Phys Rehabil Med 2021; 57:280-287. [PMID: 33650840 DOI: 10.23736/s1973-9087.21.06344-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Low back pain (LBP) has a negative impact on patients' life, not only from the physical point of view, but also in terms of psychic, social and economic wellbeing. The increasing costs of treatment and health care encourage the search for the most effective methods of treatment. AIM The aim of the study was to determine whether the use of combined therapy consisting of manual therapy and proprioceptive neuromuscular facilitation (PNF) is more effective than the use of manual therapy techniques, PNF or traditional kinesiotherapy as single methods in the treatment of LBP. DESIGN A four-arm RCT. SETTING Rehabilitation Department of Hospital in Parczew (Poland). METHODS The study was designed as four-arm randomized comparative controlled RCT and conducted on a group of 200 patients aged 27-55y. (44.9±9.2 years). The patients were randomly divided into four 50-person groups: 1) group A - manual therapy; 2) B - PNF; 3) C - manual therapy and PNF; and 4) group D - traditional kinesiotherapy and control group. Pain intensity was measured using VAS and Laitinen's questionnaire. Functional disability was assessed using Oswestry Disability Index (ODI) and Back Pain Functional Scale (BPFS). RESULTS There was a statistically significant difference in pain reduction (VAS Scale) between Group C (4.8 points) and Group D (3.9 points). In all the groups there was a statistically significant reduction in a degree of disability as measured by the ODI. A level of functional capabilities (BPFS) increased significantly only in Group C (8.8 points) as compared to Group D (5.7 points). CONCLUSIONS All the evaluated methods caused pain reduction which lasted for at least 2 weeks after the end of treatment. The degree of disability as measured by ODI lowered evenly in all groups. Patients' functional ability assessed with BPFS improved significantly in the group treated with combined therapy (manual therapy and PNF) as compared to the group of traditional kinesiotherapy. CLINICAL REHABILITATION IMPACT The therapy consisting of manual therapy and the PNF method seemed to be more effective than the traditional kinesitherapy in improving functioning of patients with non-specific low back pain.
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Affiliation(s)
- Kamil Zaworski
- Department of Physiotherapy, Pope John Paul II State School of Higher Education, Biala Podlaska, Poland -
| | - Robert Latosiewicz
- Department of Rehabilitation and Physiotherapy, Medical University of Lublin, Lublin, Poland
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Schmid B, Hausmann O, Hitzl W, Achermann Y, Wuertz-Kozak K. The Role of Cutibacterium acnes in Intervertebral Disc Inflammation. Biomedicines 2020; 8:biomedicines8070186. [PMID: 32629986 PMCID: PMC7400222 DOI: 10.3390/biomedicines8070186] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 12/19/2022] Open
Abstract
Recently, the role of infection of the intervertebral disc (IVD) with Cutibacterium acnes (C. acnes) as a contributor to disc-related low back pain (LBP) has been discussed. The aim of this study was to investigate whether and how C. acnes contributes to the inflammatory processes during IVD disease. The prevalence of C. acnes infection in human IVD tissue was determined by aerobic and anaerobic culture. Thereafter, primary human IVD cells were infected with a reference and a clinical C. acnes strain and analyzed for pro-inflammatory markers (gene/protein level). In a subsequent experiment, the involvement of the Toll-like receptor (TLR) pathway was investigated by co-treatment with sparstolonin B, a TLR2/4 inhibitor. We detected C. acnes in 10% of IVD biopsies (with either herniation or degeneration). Stimulating IVD cells with both C. acnes strains strongly and significantly upregulated expression of Interleukin (IL)-1β, IL-6, IL-8, and inducible nitric oxide synthase (iNOS). IL-6, cyclooxygenase (COX)-2, and iNOS expression was reduced upon TLR2/4 inhibition in 3 out of 5 donors, whereby responders and non-responders could not be differentiated by their basal TLR2 or TLR4 expression levels. We demonstrate that exposure of IVD cells to C. acnes induces an inflammatory response that may contribute to the development of discogenic LBP by involving TLR2/4 activation, yet only in a subgroup of patients. Whether the same response will be observed in vivo and where lower inoculums are present remains to be proven in future studies.
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Affiliation(s)
- Bettina Schmid
- Department of Dermatology, University Hospital Zurich, Gloriastrasse 31, 8091 Zurich, Switzerland;
- Faculty of Science, University of Zurich, Gloriastrasse 31, 8091 Zurich, Switzerland
| | - Oliver Hausmann
- Neuro- and Spine Centre, Klinik St. Anna, St. Anna Street 32, 6006 Lucerne, Switzerland;
- Department of Neurosurgery, Inselspital Berne, University of Berne, Murtenstrasse 11, 3010 Berne, Switzerland
- CABMM Center for Applied Biotechnology and Molecular Medicine, University of Zurich, 8057 Zurich, Switzerland;
| | - Wolfgang Hitzl
- Research Office (Biostatistics), Paracelsus Medical University, Strubergasse 20, 5020 Salzburg, Austria;
- Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Müllner Hauptstr. 48, 5020 Salzburg, Austria
- Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, 2020 Salzburg, Austria
| | - Yvonne Achermann
- CABMM Center for Applied Biotechnology and Molecular Medicine, University of Zurich, 8057 Zurich, Switzerland;
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Karin Wuertz-Kozak
- CABMM Center for Applied Biotechnology and Molecular Medicine, University of Zurich, 8057 Zurich, Switzerland;
- Department of Biomedical Engineering, Rochester Institute of Technology (RIT), 106 Lomb Memorial Dr., Rochester, NY 14623, USA
- Institute for Biomechanics, D-HEST, ETH Zurich, Hönggerbergring 64, 8093 Zurich, Switzerland
- Spine Center, Schön Clinic Munich Harlaching (Academic Teaching Hospital and Spine Research Institute of the Paracelsus Medical University Salzburg), Harlachinger Str. 51, 81547 Munich, Germany
- Correspondence: or ; Tel.: +1585-475-7355
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Viswanathan VK, Shetty AP, Rajasekaran S. Modic changes - An evidence-based, narrative review on its patho-physiology, clinical significance and role in chronic low back pain. J Clin Orthop Trauma 2020; 11:761-769. [PMID: 32879563 PMCID: PMC7452231 DOI: 10.1016/j.jcot.2020.06.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Lumbar degenerative spinal ailments are the most important causes for chronic low back pain. Modic changes (MC) are vertebral bone marrow signal intensity changes seen on MRI, commonly in association with degenerative disc disease (DDD). Despite being widely studied, majority of issues concerning MC are still controversial. The current narrative, evidence-based review comprehensively discusses the various aspects related to MC. LITERATURE SEARCH An elaborate search was made using keywords "Modic changes", "lumbar Modic changes", "Modic changes in lumbar spine", and "vertebral Endplate Spinal Changes", on pubmed and google (scholar.google.com) databases on the 3rd of March 2020. We identified crucial questions regarding Modic changes and included relevant articles pertaining to these topics for this narrative review. RESULTS The initial search using the keywords "Modic changes", "lumbar Modic changes", "Modic changes in lumbar spine", and "vertebral Endplate Spinal Changes" on pubmed yielded a total of 568, 412, 394 and 216 articles on "pubmed" database, respectively. A similar search using the aforementioned keywords yielded a total of 3650, 3548, 3726 and 21570 articles on "google scholar" database. The initial screening involved exclusion of duplicate articles, articles unrelated to MC, animal or other non-clinical studies, and articles in non-English literature based on abstracts or the titles of articles. This initial screening resulted in the identification of 405 articles. Full manuscripts were obtained for all these selected articles and thoroughly scrutinised at the second stage of article selection. All articles not concerning Modic changes, not pertaining to concerned questions, articles concerning other degenerative phenomena, articles discussing cervical or thoracic MC, case reports or animal studies, articles in non-English language and duplicate articles were excluded. Review articles, randomised controlled trials and level 1 studies were given preference. Overall, 69 articles were included in this review. CONCLUSION Modic change (MC) is a dynamic phenomenon and its true etiology is still not definitely known. Disc/end plate injury, occult discitis and autoimmune reactions seem to trigger an inflammatory cascade, which leads to their development. Male sex, older age, diabetes mellitus, genetic factors, smoking, obesity, spinal deformities, higher occupational loads and DDD are known risk factors. There is no conclusive evidence on the causative role of MC in chronic low back pain (LBP) or any influence on the long term outcome in patients with LBP or lumbar disc herniations (LDH). Patients with MC have been reported to have less satisfactory outcome following conservative treatment or discectomy, although the evidence is still unclear.
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Affiliation(s)
| | - Ajoy Prasad Shetty
- Department of Spine Surgery, Ganga Medical Center and Hospitals, Coimbatore, India,Corresponding author.
| | - S. Rajasekaran
- Department of Spine Surgery, Ganga Medical Center and Hospitals, Coimbatore, India,Department of Orthopedics, Ganga Medical Center and Hospitals, Coimbatore, India
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