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Zhu W, Yang Z, Zhou S, Zhang J, Xu Z, Xiong W, Liu P. Modic changes: From potential molecular mechanisms to future research directions (Review). Mol Med Rep 2025; 31:90. [PMID: 39918002 PMCID: PMC11836598 DOI: 10.3892/mmr.2025.13455] [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: 10/09/2024] [Accepted: 01/14/2025] [Indexed: 02/13/2025] Open
Abstract
Low back pain (LBP) is a leading cause of disability worldwide. Although not all patients with Modic changes (MCs) experience LBP, MC is often closely associated with LBP and disc degeneration. In clinical practice, the focus is usually on symptoms related to MC, which are hypothesized to be associated with LBP; however, the link between MC and nerve compression remains unclear. In cases of intervertebral disc herniation, nerve compression is often the definitive cause of symptoms. Recent advances have shed light on the pathophysiology of MC, partially elucidating its underlying mechanisms. The pathogenesis of MC involves complex bone marrow‑disc interactions, resulting in bone marrow inflammation and edema. Over time, hematopoietic cells are gradually replaced by adipocytes, ultimately resulting in localized bone marrow sclerosis. This process creates a barrier between the intervertebral disc and the bone marrow, thereby enhancing the stability of the vertebral body. The latest understanding of the pathophysiology of MC suggests that chronic inflammation plays a significant role in its development and hypothesizes that the complement system may contribute to its pathological progression. However, this hypothesis requires further research to be confirmed. The present review we proposed a pathological model based on current research, encompassing the transition from Modic type 1 changes (MC1) to Modic type 2 changes (MC2). It discussed key cellular functions and their alterations in the pathogenesis of MC and outlined potential future research directions to further elucidate its mechanisms. Additionally, it reviewed the current clinical staging and pathogenesis of MC, recommended the development of an updated staging system and explored the prospects of integrating emerging artificial intelligence technologies.
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Affiliation(s)
- Weijian Zhu
- Department of Orthopedics, Liyuan Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430077, P.R. China
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, P.R. China
| | - Zhou Yang
- Department of Orthopedics, Hongxin Harmony Hospital, Li Chuan, Hubei 445400 P.R. China
| | - Sirui Zhou
- Department of Respiration, Liyuan Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430077, P.R. China
| | - Jinming Zhang
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, P.R. China
| | - Zhihao Xu
- Department of Hepatobiliary Surgery, Huaqiao Hospital, Jinan University, Guangzhou, Guangdong 510630, P.R. China
| | - Wei Xiong
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, P.R. China
| | - Ping Liu
- Department of Orthopedics, Liyuan Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430077, P.R. China
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Yang F, Zhang J, Zha J, Zhang G, Li J, Du W, Liu L, Di J. 2bRAD-M reveals differences in microbial communities between Modic changes and disc herniation. Front Cell Infect Microbiol 2025; 15:1449873. [PMID: 40191136 PMCID: PMC11968760 DOI: 10.3389/fcimb.2025.1449873] [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] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Accepted: 03/10/2025] [Indexed: 04/09/2025] Open
Abstract
Background Modic changes are caused by various factors, such as degenerative processes, inflammation, biomechanical, genetic, and metabolic factors, infection, and smoking. Bacteria have been identified in human intervertebral discs by 16S rRNA sequencing; however, the low microbial biomass in intervertebral disc tissue limits species-level analyses using this approach. In this study, we employed 2bRAD-M (2b Restriction Site Associated DNA sequencing for Microbiome), a new sequencing technology capable of accurately characterizing bacteria, fungi, and archaea in samples with low microbial biomass at species-level resolution. Methods We surveyed 20 intervertebral disc (IVD) samples, including 10 IVD samples with Modic changes and 10 herniated disc samples. 2bRAD-M was performed to explore whether microbial differences existed between Modic change and herniated disc samples. Results In total, 332 microbial species were identified, including 75 species shared between the two groups. Enrichment for Escherichia_coli, Cupriavidus_pauculus, and Bradyrhizobium_denitrificans was observed in the Modic change group, while Afipia_broomeae, Phyllobacterium_calauticae, Tardiphaga_sp002256345, Mesorhizobium_sp004136315, Afipia_sp000497575, Burkholderia_contaminans, and Afipia_sp017474385 were more abundant in the herniated disc group. Additionally, 19 discriminatory taxa were determined by linear discriminant analysis effect size (LEfSe). In a random forest model for partitioning the two groups, the species with the highest variable importance were Afipia_broomeae, Phyllobacterium_calauticae, and Escherichia_coli. Moreover, a newly constructed random forest model based on an optimal marker set consisting of eight highly abundant species successfully distinguished between the Modic change and herniated disc groups, with an accuracy of 81.0%. A functional annotation analysis showed that differentially abundant taxa between the Modic change and herniated disc groups could be assigned to 4093 COGs (Clusters of Orthologous Groups) and 342 related signaling pathways. Conclusion This study represents the first application of 2bRAD-M to Modic changes and disc herniation, revealing significant differences in microbial taxa between the two groups. These results suggest that microbial dysbiosis in the intervertebral disc is associated with Modic changes and provide candidate targets for further studies of the mechanisms underlying the development and progression of Modic changes.
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Affiliation(s)
- Fang Yang
- Department of Radiotherapy, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jingtao Zhang
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Junpu Zha
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Guolei Zhang
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jia Li
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Wei Du
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Lin Liu
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jun Di
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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Feng Z, Ding S, Wu H, Liu M, Hu X, Chen L, Wu K, Battie´ MC, Wang Y. Cartilaginous Endplate Damage May be a Root Pathology Underlying Modic Changes on Lumbar Spine MR Images. Global Spine J 2025:21925682251318700. [PMID: 39983704 PMCID: PMC11846092 DOI: 10.1177/21925682251318700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2025] Open
Abstract
STUDY DESIGN Rabbit model study. OBJECTIVE To examine whether cartilaginous endplate (CEP) destruction leads to endplate and vertebral marrow signal changes (Modic changes, MCs) on MR images. METHODS Sixteen adult rabbits were used in the study and underwent an anterolateral procedure to expose the L2-6 intervertebral discs. The L4/5, L3/4 and L2/3 discs underwent annulotomy, annulotomy and CEP curettage, or annulotomy and chemonucleolysis, respectively, while the L5/6 disc served as a shame control. MR imaging was performed preoperatively and at 1, 3, and 6 months postoperatively to evaluate the presence or absence of MCs. After the last imaging, animals were sacrificed for histological study, focusing on endplate pathologies and their associations with MCs. RESULTS Among the 64 endplates that underwent CEP curettage or were exposed to chemonucleolysis, there were 6 (9.4%), 19 (29.7%), and 32 (50%) endplates with MCs at 1, 3 and 6 months, respectively. No MCs developed in the sham controls. Both surgical curettage and chymopapain injection successfully induced CEP destruction. Endplates with full layer CEP defects were most likely to develop MCs (59.6% vs 11.4%, P < 0.001). Moreover, endplates with MCs had a greater histological degeneration score than those without (8.97 ± 1.92 vs 5.35 ± 2.28, P < 0.001) and higher expression levels of inflammatory factors (IL-1β, TNF-α, and IL-6, P < 0.05 for all) in the subchondral vertebral marrow. CONCLUSIONS CEP destruction, induced either by physical curettage or chemical lysis, can lead to long-lasting inflammation in the vertebral marrow and Modic-like signal changes on MR images. CEP destruction may be a root pathology underlying MCs.
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Affiliation(s)
- Zhiyun Feng
- Spine lab, Department of Orthopedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shuchen Ding
- Center of Orthopedics, No.903 Hospital of People’s Liberation Army Joint Logistic Support Force, Hangzhou, China
| | - Honghao Wu
- Spine lab, Department of Orthopedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Miao Liu
- Department of Radiology, No.903 Hospital of People’s Liberation Army Joint Logistic Support Force, Hangzhou, China
| | - Xiaojian Hu
- Spine lab, Department of Orthopedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lunhao Chen
- Spine lab, Department of Orthopedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Kai Wu
- Spine lab, Department of Orthopedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Michele C. Battie´
- School of Physical Therapy, Faculty of Health Sciences and Western’s Bone & Joint Institute, Western University, London, ON, Canada
| | - Yue Wang
- Spine lab, Department of Orthopedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Dou Y, Zhang Y, Liu Y, Sun X, Liu X, Li B, Yang Q. Role of macrophage in intervertebral disc degeneration. Bone Res 2025; 13:15. [PMID: 39848963 PMCID: PMC11758090 DOI: 10.1038/s41413-024-00397-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 12/04/2024] [Accepted: 12/16/2024] [Indexed: 01/25/2025] Open
Abstract
Intervertebral disc degeneration is a degenerative disease where inflammation and immune responses play significant roles. Macrophages, as key immune cells, critically regulate inflammation through polarization into different phenotypes. In recent years, the role of macrophages in inflammation-related degenerative diseases, such as intervertebral disc degeneration, has been increasingly recognized. Macrophages construct the inflammatory microenvironment of the intervertebral disc and are involved in regulating intervertebral disc cell activities, extracellular matrix metabolism, intervertebral disc vascularization, and innervation, profoundly influencing the progression of disc degeneration. To gain a deeper understanding of the inflammatory microenvironment of intervertebral disc degeneration, this review will summarize the role of macrophages in the pathological process of intervertebral disc degeneration, analyze the regulatory mechanisms involving macrophages, and review therapeutic strategies targeting macrophage modulation for the treatment of intervertebral disc degeneration. These insights will be valuable for the treatment and research directions of intervertebral disc degeneration.
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Affiliation(s)
- Yiming Dou
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, 300211, China
| | - Yiming Zhang
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, 300211, China
- Clinical School of Orthopedics, Tianjin Medical University, Tianjin, 300070, China
| | - Yang Liu
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, 300211, China
| | - Xun Sun
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, 300211, China
| | - Xinyu Liu
- Department of Orthopaedics, Qilu Hospital of Shandong University, Jinan, 250012, China.
| | - Bin Li
- Orthopedic Institute, Department of Orthopedic Surgery, The First Affiliated Hospital, School of Biology & Basic Medical Sciences, Suzhou Medical College, Soochow University, Suzhou, Jiangsu, 215007, China.
| | - Qiang Yang
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, 300211, China.
- Clinical School of Orthopedics, Tianjin Medical University, Tianjin, 300070, China.
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Hagger G, Guest S, Birchall S, Bradley A, Brindley C, Corbett D, Cummings PJ, Freire C, Harris J, Wise A, Wood M, Czaplewski LG. Preclinical development and characterisation of PP353, a formulation of linezolid for intradiscal administration. JOR Spine 2024; 7:e70010. [PMID: 39544355 PMCID: PMC11561648 DOI: 10.1002/jsp2.70010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 07/15/2024] [Accepted: 10/10/2024] [Indexed: 11/17/2024] Open
Abstract
Introduction Bacterial infection of the intervertebral disc can lead to vertebral endplate edema known as Modic changes, with associated chronic low back pain. Oral antimicrobial therapy has shown efficacy but relies on prolonged dosing and may not be optimal in terms of patient outcome, side effects, or antibiotic stewardship. There is no antibiotic formulation approved for intradiscal administration. Here, we describe the development and preclinical characterization of a formulation of linezolid, a suspension of 50 mg/mL micronized powder, for intradiscal administration. Methods Micronization, particle size analysis, Franz cell diffusion assays, ex vivo bioassay, and estimates of gelling temperature were used to optimize the composition and properties of the formulation. Performance of the formulation was assessed using sheep to characterize the pharmacokinetics and a model of intradiscal infection was developed to demonstrate efficacy. Suitability for human administration was demonstrated in a Good Laboratory Practice (GLP) local tolerance study. Results Micronized linezolid, formulated as a powder suspension using a vehicle containing poloxamer 407 and iohexol, provided a temperature-dependent radio-opaque gel that was suitable for image-guided percutaneous intradiscal administration. Efficacy in a sheep model of intradiscal Staphylococcus aureus infection was demonstrated. The formulation provides a high level of sheep disc tissue exposure, with Cmax of 6500 μg/g and limited systemic exposure, with a plasma Cmax of 0.04 μg/mL per 0.1 mL dose (5 mg of linezolid). Deconvolution of plasma linezolid pharmacokinetics correlated with linezolid remaining in the disc over time. Observations from a GLP local tolerance study with the linezolid formulation were of a minor nature and related to the intradiscal administration procedure. Conclusions Linezolid can be formulated for image-guided percutaneous intradiscal administration. The formulation is now in a Phase 1b clinical trial to evaluate safety, pharmacokinetics, and efficacy in patients with CLBP and suspected bacterial infection.
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Aboushaala K, Chee AV, Adnan D, Toro SJ, Singh H, Savoia A, Dhillon ES, Yuh C, Dourdourekas J, Patel IK, Vucicevic R, Espinoza‐Orias AA, Martin JT, Oh C, Keshavarzian A, Albert HB, Karppinen J, Kocak M, Wong AYL, Goldberg EJ, Phillips FM, Colman MW, Williams FMK, Borgia JA, Naqib A, Green SJ, Forsyth CB, An HS, Samartzis D. Gut microbiome dysbiosis is associated with lumbar degenerative spondylolisthesis in symptomatic patients. JOR Spine 2024; 7:e70005. [PMID: 39398942 PMCID: PMC11467165 DOI: 10.1002/jsp2.70005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 09/17/2024] [Accepted: 09/18/2024] [Indexed: 10/15/2024] Open
Abstract
Background Lumbar degenerative spondylolisthesis (LDS), characterized as degeneration of the intervertebral disc and structural changes of the facet joints, is a condition with varying degrees of instability that may lead to pain, canal stenosis, and subsequent surgical intervention. However, the etiology of LDS remains inconclusive. Gut microbiome dysbiosis may stimulate systemic inflammation in various disorders. However, the role of such dysbiosis upon spine health remains under-studied. The current study assessed the association of gut microbiome dysbiosis in symptomatic patients with or without LDS. Methods A cross-sectional analysis within the framework of a prospective study was performed. DNA was extracted from fecal samples collected from adult symptomatic patients with (n = 21) and without LDS (n = 12). Alpha and beta diversity assessed differences in fecal microbial community between groups. Taxon-by-taxon analysis identified microbial features with differential relative abundance between groups. Subject demographics and imaging parameters were also assessed. Results There was no significant group differences in age, sex, race, body mass index, smoking/alcohol history, pain profiles, spinopelvic alignment, and Modic changes (p >0.05). LDS subjects had significantly higher disc degeneration severity (p = 0.018) and alpha diversity levels compared to non-LDS subjects (p = 0.002-0.003). Significant differences in gut microbial community structure were observed between groups (p = 0.046). Subjects with LDS exhibited distinct differences at the phylum level, with a significantly higher Firmicutes to Bacteroidota ratio compared to non-LDS (p = 0.003). Differential relative abundance analysis identified six taxa with significant differences between the two groups, with LDS demonstrating an increase in putative pro-inflammatory bacteria (Dialister, CAG-352) and a decrease in anti-inflammatory bacteria (Slackia, Escherichia-Shigella). Conclusion This study is the first to report a significant association of gut microbiome dysbiosis and LDS in symptomatic patients, noting pro-inflammatory bacterial taxa. This work provides a foundation for future studies addressing the role of the gut microbiome in association with spine health and disease.
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Affiliation(s)
- Khaled Aboushaala
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Ana V. Chee
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Darbaz Adnan
- Center for Integrated Microbiome & Chronobiology Research, Rush Medical College, Rush University Medical CenterChicagoIllinoisUSA
| | - Sheila J. Toro
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Harmanjeet Singh
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Andrew Savoia
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Ekamjeet S. Dhillon
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Catherine Yuh
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Jake Dourdourekas
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Ishani K. Patel
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Rajko Vucicevic
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | | | - John T. Martin
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Chundo Oh
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Ali Keshavarzian
- Department of Internal MedicineRush University Medical CenterChicagoIllinoisUSA
| | - Hanne B. Albert
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Jaro Karppinen
- Research Unit of Health Sciences and TechnologyUniversity of OuluOuluFinland
| | - Mehmet Kocak
- Department of Radiology & Nuclear MedicineRush University Medical CenterChicagoIllinoisUSA
| | - Arnold Y. L. Wong
- Department of Rehabilitation SciencesThe Hong Kong Polytechnic UniversityHong KongChina
| | - Edward J. Goldberg
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Frank M. Phillips
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Matthew W. Colman
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Frances M. K. Williams
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
- Department of Twins Research and Genetic EpidemiologyKing's CollegeLondonUK
| | - Jeffrey A. Borgia
- Departments of Anatomy & Cell Biology and PathologyRush University Medical CenterChicagoIllinoisUSA
| | - Ankur Naqib
- Department of Internal MedicineRush University Medical CenterChicagoIllinoisUSA
| | - Stefan J. Green
- Department of Internal MedicineRush University Medical CenterChicagoIllinoisUSA
| | | | - Howard S. An
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Dino Samartzis
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
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Camacho J, Carbone J, Suresh RI, Khanna S, Ye IB, Thomson AE, Bruckner J, Gopinath R, McGowan S, O’Hara N, Bivona LJ, Jauregui JJ, Cavanaugh DL, Koh EY, Ludwig SC. Positive Cutibacterium acnes Intervertebral Discs Are Not Associated with Subsidence Following Anterior Cervical Discectomy and Fusion at 3 or 6 Months. J Clin Med 2024; 13:5619. [PMID: 39337106 PMCID: PMC11432799 DOI: 10.3390/jcm13185619] [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: 07/31/2024] [Revised: 09/08/2024] [Accepted: 09/18/2024] [Indexed: 09/30/2024] Open
Abstract
Background/Objectives:Cutibacterium acnes (C. acnes), formerly known as Propionibacterium acnes (P. acnes), is an anaerobic, low-virulent bacterium that has been associated with postoperative infections of the shoulder, knee, and cervical spine. Recent studies have highlighted an association between C. acnes and the development of degenerative disc disease (DDD). The aim of this study is to ascertain whether C. acnes increases the risk of subsidence following anterior cervical discectomy and fusion (ACDF). Methods: After IRB approval, consecutive patients undergoing elective ACDF for DDD from 2017 to 2018 were enrolled in this prospective cohort study. Intervertebral disc samples were taken at each affected level and cultured. A total of 66 patients with radiographic follow-ups were included in the final analysis. The extent of subsidence and cervical lordosis was determined immediately postoperatively and at the 3- and 6-month follow-ups. Results: No significant difference in subsidence was observed at 3 months (p = 0.07) or 6 months (p = 0.11) between culture-positive and -negative cohorts. Additionally, there was no significant difference detected in the change in cervical lordosis observed at 3 months (p = 0.16) or 6 months (p = 0.27) between culture-positive and -negative cohorts. For the most inferiorly fused segment, there was a significant difference in subsidence observed at 3 months (1.5 mm, 95% CI: 0.2-2.7 mm, p = 0.02) but not at 6 months (p = 0.17). Conclusions: Intervertebral discs with a positive C. acnes culture were not associated with greater levels of subsidence at 3 or 6 months following ACDF for DDD. Further research is necessary to endorse these results and to gauge the clinical significance of C. acnes infection.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Steven C. Ludwig
- Division of Spine Surgery, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD 21201, USA (J.J.J.)
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Mengis T, Bernhard L, Nüesch A, Heggli I, Herger N, Devan J, Marcus R, Laux CJ, Brunner F, Farshad M, Distler O, Le Maitre CL, Dudli S. The Expression of Toll-like Receptors in Cartilage Endplate Cells: A Role of Toll-like Receptor 2 in Pro-Inflammatory and Pro-Catabolic Gene Expression. Cells 2024; 13:1402. [PMID: 39272974 PMCID: PMC11394474 DOI: 10.3390/cells13171402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Revised: 08/14/2024] [Accepted: 08/21/2024] [Indexed: 09/15/2024] Open
Abstract
INTRODUCTION The vertebral cartilage endplate (CEP), crucial for intervertebral disc health, is prone to degeneration linked to chronic low back pain, disc degeneration, and Modic changes (MC). While it is known that disc cells express toll-like receptors (TLRs) that recognize pathogen- and damage-associated molecular patterns (PAMPs and DAMPs), it is unclear if CEP cells (CEPCs) share this trait. The CEP has a higher cell density than the disc, making CEPCs an important contributor. This study aimed to identify TLRs on CEPCs and their role in pro-inflammatory and catabolic gene expression. METHODS Gene expression of TLR1-10 was measured in human CEPs and expanded CEPCs using quantitative polymerase chain reaction. Additionally, surface TLR expression was measured in CEPs grouped into non-MC and MC. CEPCs were stimulated with tumor necrosis factor alpha, interleukin 1 beta, small-molecule TLR agonists, or the 30 kDa N-terminal fibronectin fragment. TLR2 signaling was inhibited with TL2-C29, and TLR2 protein expression was measured with flow cytometry. RESULTS Ex vivo analysis found all 10 TLRs expressed, while cultured CEPCs lost TLR8 and TLR9 expression. TLR2 expression was significantly increased in MC1 CEPCs, and its expression increased significantly after pro-inflammatory stimulation. Stimulation of the TLR2/6 heterodimer upregulated TLR2 protein expression. The TLR2/1 and TLR2/6 ligands upregulated pro-inflammatory genes and matrix metalloproteases (MMP1, MMP3, and MMP13), and TLR2 inhibition inhibited their upregulation. Endplate resorptive capacity of TLR2 activation was confirmed in a CEP explant model. CONCLUSIONS The expression of TLR1-10 in CEPCs suggests that the CEP is susceptible to PAMP and DAMP stimulation. Enhanced TLR2 expression in MC1, and generally in CEPCs under inflammatory conditions, has pro-inflammatory and pro-catabolic effects, suggesting a potential role in disc degeneration and MC.
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Affiliation(s)
- Tamara Mengis
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital, University of Zurich, 8008 Zurich, Switzerland (I.H.); (J.D.); (O.D.); (S.D.)
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland;
| | - Laura Bernhard
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital, University of Zurich, 8008 Zurich, Switzerland (I.H.); (J.D.); (O.D.); (S.D.)
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland;
| | - Andrea Nüesch
- School of Medicine and Population Health, University of Sheffield, Sheffield S10 2RX, UK; (A.N.); (C.L.L.M.)
| | - Irina Heggli
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital, University of Zurich, 8008 Zurich, Switzerland (I.H.); (J.D.); (O.D.); (S.D.)
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland;
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai New York, New York, NY 10029, USA
| | - Nick Herger
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital, University of Zurich, 8008 Zurich, Switzerland (I.H.); (J.D.); (O.D.); (S.D.)
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland;
| | - Jan Devan
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital, University of Zurich, 8008 Zurich, Switzerland (I.H.); (J.D.); (O.D.); (S.D.)
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland;
| | - Roy Marcus
- Department of Radiology, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Christoph J. Laux
- University Spine Center Zürich, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland; (C.J.L.); (M.F.)
| | - Florian Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland;
| | - Mazda Farshad
- University Spine Center Zürich, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland; (C.J.L.); (M.F.)
| | - Oliver Distler
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital, University of Zurich, 8008 Zurich, Switzerland (I.H.); (J.D.); (O.D.); (S.D.)
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland;
| | - Christine L. Le Maitre
- School of Medicine and Population Health, University of Sheffield, Sheffield S10 2RX, UK; (A.N.); (C.L.L.M.)
| | - Stefan Dudli
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital, University of Zurich, 8008 Zurich, Switzerland (I.H.); (J.D.); (O.D.); (S.D.)
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland;
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9
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Jia Y, Chen H, Huang S, Huo Z, Xu B. Causal effects of skin microbiota on intervertebral disk degeneration, low back pain and sciatica: a two-sample Mendelian randomization study. J Orthop Surg Res 2024; 19:476. [PMID: 39138503 PMCID: PMC11321032 DOI: 10.1186/s13018-024-04980-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 08/06/2024] [Indexed: 08/15/2024] Open
Abstract
OBJECTIVE The purpose of this study is to use two-sample Mendelian randomization (MR) to investigate the causal relationship between skin microbiota, especially Propionibacterium acnes, and intervertebral disc degeneration (IVDD), low back pain (LBP) and sciatica. METHODS We conducted a two-sample MR using the aggregated data from the whole genome-wide association studies (GWAS). 150 skin microbiota were derived from the GWAS catalog and IVDD, LBP and sciatica were obtained from the IEU Open GWAS project. Inverse-variance weighted (IVW) was the primary research method, with MR-Egger and Weighted median as supplementary methods. Perform sensitivity analysis and reverse MR analysis on all MR results and use multivariate MR to adjust for confounding factors. RESULTS MR revealed five skin microbiota associated with IVDD, four associated with LBP, and two with sciatica. Specifically, P.acnes in sebaceous skin environments were associated with reduced risk of IVDD; IVDD was found to increase the abundance of P.acnes in moist skin. Furthermore, ASV010 [Staphylococcus (unc.)] from dry skin was a risk factor for LBP and sciatica; ASV045 [Acinetobacter (unc.)] from dry skin and Genus Rothia from dry skin exhibited potential protective effects against LBP; ASV065 [Finegoldia (unc.)] from dry skin was a protective factor for IVDD and LBP. ASV054 [Enhydrobacter (unc.)] from moist skin, Genus Bacteroides from dry skin and Genus Kocuria from dry skin were identified as being associated with an increased risk of IVDD. Genus Streptococcus from moist skin was considered to be associated with an increased risk of sciatica. CONCLUSIONS This study identified a potential causal relationship between skin microbiota and IVDD, LBP, and sciatica. No evidence suggests skin-derived P.acnes is a risk factor for IVDD, LBP and sciatica. At the same time, IVDD can potentially cause an increase in P.acnes abundance, which supports the contamination theory.
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Affiliation(s)
- Yuchao Jia
- Department of Graduate School, Tianjin Medical University, Tianjin, 300070, China
| | - Houcong Chen
- Department of Graduate School, Tianjin Medical University, Tianjin, 300070, China
| | - Shengbo Huang
- Department of Graduate School, Tianjin Medical University, Tianjin, 300070, China
| | - Zhenxin Huo
- Department of Graduate School, Tianjin Medical University, Tianjin, 300070, China
| | - Baoshan Xu
- Department of Minimally Invasive Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, 300211, China.
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10
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Mengis T, Zajac N, Bernhard L, Heggli I, Herger N, Devan J, Marcus R, Brunner F, Laux C, Farshad M, Distler O, Dudli S. Intervertebral disc microbiome in Modic changes: Lack of result replication underscores the need for a consensus in low-biomass microbiome analysis. JOR Spine 2024; 7:e1330. [PMID: 38585427 PMCID: PMC10995447 DOI: 10.1002/jsp2.1330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/14/2024] [Accepted: 03/22/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction The emerging field of the disc microbiome challenges traditional views of disc sterility, which opens new avenues for novel clinical insights. However, the lack of methodological consensus in disc microbiome studies introduces discrepancies. The aims of this study were to (1) compare the disc microbiome of non-Modic (nonMC), Modic type 1 change (MC1), and MC2 discs to findings from prior disc microbiome studies, and (2) investigate if discrepancies to prior studies can be explained with bioinformatic variations. Methods Sequencing of 16S rRNA in 70 discs (24 nonMC, 25 MC1, and 21 MC2) for microbiome profiling. The experimental setup included buffer contamination controls and was performed under aseptic conditions. Methodology and results were contrasted with previous disc microbiome studies. Critical bioinformatic steps that were different in our best-practice approach and previous disc microbiome studies (taxonomic lineage assignment, prevalence cut-off) were varied and their effect on results were compared. Results There was limited overlap of results with a previous study on MC disc microbiome. No bacterial genera were shared using the same bioinformatic parameters. Taxonomic lineage assignment using "amplicon sequencing variants" was more sensitive and detected 48 genera compared to 22 with "operational taxonomic units" (previous study). Increasing filter cut-off from 4% to 50% (previous study) reduced genera from 48 to 4 genera. Despite these differences, both studies observed dysbiosis with an increased abundance of gram-negative bacteria in MC discs as well as a lower beta-diversity. Cutibacterium was persistently detected in all groups independent of the bioinformatic approach, emphasizing its prevalence. Conclusion There is dysbiosis in MC discs. Bioinformatic parameters impact results yet cannot explain the different findings from this and a previous study. Therefore, discrepancies are likely caused by different sample preparations or true biologic differences. Harmonized protocols are required to advance understanding of the disc microbiome and its clinical implications.
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Affiliation(s)
- Tamara Mengis
- Center of Experimental Rheumatology, Department of RheumatologyUniversity Hospital, University of ZurichZurichSwitzerland
- Department of Physical Medicine and Rheumatology, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Natalia Zajac
- Functional Genomics Center ZurichUniversity and ETH ZurichZurichSwitzerland
| | - Laura Bernhard
- Center of Experimental Rheumatology, Department of RheumatologyUniversity Hospital, University of ZurichZurichSwitzerland
- Department of Physical Medicine and Rheumatology, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Irina Heggli
- Center of Experimental Rheumatology, Department of RheumatologyUniversity Hospital, University of ZurichZurichSwitzerland
- Department of Physical Medicine and Rheumatology, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Nick Herger
- Center of Experimental Rheumatology, Department of RheumatologyUniversity Hospital, University of ZurichZurichSwitzerland
- Department of Physical Medicine and Rheumatology, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Jan Devan
- Center of Experimental Rheumatology, Department of RheumatologyUniversity Hospital, University of ZurichZurichSwitzerland
- Department of Physical Medicine and Rheumatology, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Roy Marcus
- Department of Radiology, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Florian Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Christoph Laux
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Oliver Distler
- Center of Experimental Rheumatology, Department of RheumatologyUniversity Hospital, University of ZurichZurichSwitzerland
- Department of Physical Medicine and Rheumatology, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Stefan Dudli
- Center of Experimental Rheumatology, Department of RheumatologyUniversity Hospital, University of ZurichZurichSwitzerland
- Department of Physical Medicine and Rheumatology, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
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11
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Rolfsen MP, Gammelsrud KW, Espeland A, Bråten LC, Mjønes SB, Austevoll I, Dolatowski FC, Årrestad MB, Toppe MK, Orlien IE, Holberg-Petersen M, Fagerland M, Zwart JA, Storheim K, Hellum C. Bacterial growth in patients with low back pain and Modic changes: protocol of a multicentre, case-control biopsy study. BMJ Open 2024; 14:e082244. [PMID: 38719329 PMCID: PMC11086543 DOI: 10.1136/bmjopen-2023-082244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/22/2024] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION Bacterial infection and Modic changes (MCs) as causes of low back pain (LBP) are debated. Results diverged between two randomised controlled trials examining the effect of amoxicillin with and without clavulanic acid versus placebo on patients with chronic LBP (cLBP) and MCs. Previous biopsy studies have been criticised with regard to methods, few patients and controls, and insufficient measures to minimise perioperative contamination. In this study, we minimise contamination risk, include a control group and optimise statistical power. The main aim is to compare bacterial growth between patients with and without MCs. METHODS AND ANALYSIS This multicentre, case-control study examines disc and vertebral body biopsies of patients with cLBP. Cases have MCs at the level of tissue sampling, controls do not. Previously operated patients are included as a subgroup. Tissue is sampled before antibiotic prophylaxis with separate instruments. We will apply microbiological methods and histology on biopsies, and predefine criteria for significant bacterial growth, possible contamination and no growth. Microbiologists, surgeons and pathologist are blinded to allocation of case or control. Primary analysis assesses significant growth in MC1 versus controls and MC2 versus controls separately. Bacterial disc growth in previously operated patients, patients with large MCs and growth from the vertebral body in the fusion group are all considered exploratory analyses. ETHICS AND DISSEMINATION The Regional Committees for Medical and Health Research Ethics in Norway (REC South East, reference number 2015/697) has approved the study. Study participation requires written informed consent. The study is registered at ClinicalTrials.gov (NCT03406624). Results will be disseminated in peer-reviewed journals, scientific conferences and patient fora. TRIAL REGISTRATION NUMBER NCT03406624.
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Affiliation(s)
- Mads Peder Rolfsen
- Division of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo Faculty of Medicine, Oslo, Norway
| | - Karianne Wiger Gammelsrud
- Department of Microbiology, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway
- University of Oslo Faculty of Medicine, Oslo, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen Faculty of Medicine and Dentistry, Bergen, Norway
| | | | | | - Ivar Austevoll
- Kysthospitalet in Hagavik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | | | | | | | - Ingvild Elise Orlien
- Department of Microbiology, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway
| | - Mona Holberg-Petersen
- Department of Microbiology, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway
| | - Morten Fagerland
- Biostatistics & Epidemiology, Oslo University Hospital, Oslo, Norway
| | - John-Anker Zwart
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - Kjersti Storheim
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - Christian Hellum
- Division of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
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Marcus JL, Westerhaus BD, Chernicki B, Giuffrida A. Basivertebral nerve ablation with concurrent lumbar laminotomy. BMJ Case Rep 2024; 17:e259695. [PMID: 38575334 PMCID: PMC11002411 DOI: 10.1136/bcr-2024-259695] [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] [Indexed: 04/06/2024] Open
Abstract
Lumbar radiculopathy due to impingement of nerve roots from facet hypertrophy and/or disc herniation can often coincide with vertebrogenic low back pain. This is demonstrated on MRI with foraminal stenosis and Modic changes. We examine the potential of using a combination of basivertebral nerve ablation (BVNA) and lumbar laminotomy as an alternative to traditional spinal fusion in specific patient populations. This unique combination of surgical techniques has not been previously reported in the medical literature. We report a man in his late 30s with chronic low back pain and lumbar radiculopathy, treated with BVNA and concurrent laminotomy. The patient reported progressive improvements in his mobility and pain over the next 2 years. We discuss the advantages of using this technique for lumbar radiculopathy and Modic changes compared with conventional surgical modalities.
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Affiliation(s)
- Jason L Marcus
- Nova Southeastern University Dr Kiran C Patel College of Osteopathic Medicine, Clearwater, Florida, USA
- Cantor Spince Center, Interventional Spine, Paley Orthopedic & Spine Institute, Fort Lauderdale, Florida, USA
| | - Benjamin D Westerhaus
- Cantor Spince Center, Interventional Spine, Paley Orthopedic & Spine Institute, Fort Lauderdale, Florida, USA
| | - Brendan Chernicki
- Nova Southeastern University Dr Kiran C Patel College of Osteopathic Medicine, Clearwater, Florida, USA
| | - Anthony Giuffrida
- Cantor Spince Center, Interventional Spine, Paley Orthopedic & Spine Institute, Fort Lauderdale, Florida, USA
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Heggli I, Mengis T, Laux C, Opitz L, Herger N, Menghini D, Schuepbach R, Farshad-Amacker N, Brunner F, Fields A, Farshad M, Distler O, Dudli S. Low back pain patients with Modic type 1 changes exhibit distinct bacterial and non-bacterial subtypes. OSTEOARTHRITIS AND CARTILAGE OPEN 2024; 6:100434. [PMID: 38322145 PMCID: PMC10844677 DOI: 10.1016/j.ocarto.2024.100434] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/13/2023] [Accepted: 01/08/2024] [Indexed: 02/08/2024] Open
Abstract
Objectives Modic type 1 changes (MC1) are vertebral endplate bone marrow (BM) lesions observed on magnetic resonance images in sub-populations of chronic low back pain (CLBP) patients. The etiopathogenesis remains unknown and treatments that modify the underlying pathomechanisms do not exist. We hypothesized that two biological MC1 subtypes exist: a bacterial and a non-bacterial. This would have important implications for developing treatments targeting the underlying pathomechanisms. Methods Intervertebral disc (IVD) samples adjacent to MC1 (n = 34) and control (n = 11) vertebrae were collected from patients undergoing spinal fusion. Cutibacterium acnes (C.acnes) genome copy numbers (GCNs) were quantified in IVD tissues with 16S qPCR, transcriptomic signatures and cytokine profiles were determined in MC1 and control BM by RNA sequencing and immunoassay. Finally, we assessed if C.acnes GCNs are associated with blood plasma cytokines. Results IVD tissues from control levels had <870 C.acnes GCNs/gram IVD. MC1-adjacent IVDs had either "low" (<870) or "high" (>870) C.acnes GCNs. MC1 patients with "high" C.acnes GCNs had upregulated innate immune cell signatures (neutrophil, macrophage/monocyte) and pro-inflammatory cytokines related to neutrophil and macrophage/monocyte function in the BM, consistent with a host defense against bacterium. MC1 patients with "low" C.acnes GCNs had increased adaptive immune cell signatures (T-and B-cell) in the BM and elevated IL-13 blood plasma levels. Conclusion Our study provides the first evidence for the existence of bacterial (C.acnes "high") and non-bacterial (C.acnes "low") subtypes in MC1 patients with CLBP. This supports the need for different treatment strategies.
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Affiliation(s)
- I. Heggli
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - T. Mengis
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - C.J. Laux
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - L. Opitz
- Functional Genomics Center Zurich, University and ETH Zurich, Zurich, Zurich, Switzerland
| | - N. Herger
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - D. Menghini
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - R. Schuepbach
- Unit of Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - N.A. Farshad-Amacker
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - F. Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - A.J. Fields
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - M. Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - O. Distler
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - S. Dudli
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
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14
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Heggli I, Teixeira GQ, Iatridis JC, Neidlinger‐Wilke C, Dudli S. The role of the complement system in disc degeneration and Modic changes. JOR Spine 2024; 7:e1312. [PMID: 38312949 PMCID: PMC10835744 DOI: 10.1002/jsp2.1312] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 12/15/2023] [Accepted: 01/04/2024] [Indexed: 02/06/2024] Open
Abstract
Disc degeneration and vertebral endplate bone marrow lesions called Modic changes are prevalent spinal pathologies found in chronic low back pain patients. Their pathomechanisms are complex and not fully understood. Recent studies have revealed that complement system proteins and interactors are dysregulated in disc degeneration and Modic changes. The complement system is part of the innate immune system and plays a critical role in tissue homeostasis. However, its dysregulation has also been associated with various pathological conditions such as rheumatoid arthritis and osteoarthritis. Here, we review the evidence for the involvement of the complement system in intervertebral disc degeneration and Modic changes. We found that only a handful of studies reported on complement factors in Modic changes and disc degeneration. Therefore, the level of evidence for the involvement of the complement system is currently low. Nevertheless, the complement system is tightly intertwined with processes known to occur during disc degeneration and Modic changes, such as increased cell death, autoantibody production, bacterial defense processes, neutrophil activation, and osteoclast formation, indicating a contribution of the complement system to these spinal pathologies. Based on these mechanisms, we propose a model how the complement system could contribute to the vicious cycle of tissue damage and chronic inflammation in disc degeneration and Modic changes. With this review, we aim to highlight a currently understudied but potentially important inflammatory pathomechanism of disc degeneration and Modic changes that may be a novel therapeutic target.
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Affiliation(s)
- Irina Heggli
- Center of Experimental Rheumatology, Department of RheumatologyUniversity Hospital Zurich, University of ZurichZurichSwitzerland
- Department of Physical Medicine and RheumatologyBalgrist University Hospital, Balgrist Campus, University of ZurichZurichSwitzerland
- Leni and Peter W. May Department of OrthopaedicsIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Graciosa Q. Teixeira
- Institute of Orthopedic Research and Biomechanics, Trauma Research Centre, Ulm UniversityUlmGermany
| | - James C. Iatridis
- Leni and Peter W. May Department of OrthopaedicsIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | | | - Stefan Dudli
- Center of Experimental Rheumatology, Department of RheumatologyUniversity Hospital Zurich, University of ZurichZurichSwitzerland
- Department of Physical Medicine and RheumatologyBalgrist University Hospital, Balgrist Campus, University of ZurichZurichSwitzerland
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15
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Crump KB, Alminnawi A, Bermudez‐Lekerika P, Compte R, Gualdi F, McSweeney T, Muñoz‐Moya E, Nüesch A, Geris L, Dudli S, Karppinen J, Noailly J, Le Maitre C, Gantenbein B. Cartilaginous endplates: A comprehensive review on a neglected structure in intervertebral disc research. JOR Spine 2023; 6:e1294. [PMID: 38156054 PMCID: PMC10751983 DOI: 10.1002/jsp2.1294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 09/15/2023] [Accepted: 09/26/2023] [Indexed: 12/30/2023] Open
Abstract
The cartilaginous endplates (CEP) are key components of the intervertebral disc (IVD) necessary for sustaining the nutrition of the disc while distributing mechanical loads and preventing the disc from bulging into the adjacent vertebral body. The size, shape, and composition of the CEP are essential in maintaining its function, and degeneration of the CEP is considered a contributor to early IVD degeneration. In addition, the CEP is implicated in Modic changes, which are often associated with low back pain. This review aims to tackle the current knowledge of the CEP regarding its structure, composition, permeability, and mechanical role in a healthy disc, how they change with degeneration, and how they connect to IVD degeneration and low back pain. Additionally, the authors suggest a standardized naming convention regarding the CEP and bony endplate and suggest avoiding the term vertebral endplate. Currently, there is limited data on the CEP itself as reported data is often a combination of CEP and bony endplate, or the CEP is considered as articular cartilage. However, it is clear the CEP is a unique tissue type that differs from articular cartilage, bony endplate, and other IVD tissues. Thus, future research should investigate the CEP separately to fully understand its role in healthy and degenerated IVDs. Further, most IVD regeneration therapies in development failed to address, or even considered the CEP, despite its key role in nutrition and mechanical stability within the IVD. Thus, the CEP should be considered and potentially targeted for future sustainable treatments.
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Affiliation(s)
- Katherine B. Crump
- Tissue Engineering for Orthopaedics & Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical FacultyUniversity of BernBernSwitzerland
- Department of Orthopaedic Surgery and Traumatology, InselspitalBern University Hospital, Medical Faculty, University of BernBernSwitzerland
- Graduate School for Cellular and Biomedical Sciences (GCB)University of BernBernSwitzerland
| | - Ahmad Alminnawi
- GIGA In Silico MedicineUniversity of LiègeLiègeBelgium
- Skeletal Biology and Engineering Research Center, KU LeuvenLeuvenBelgium
- Biomechanics Research Unit, KU LeuvenLeuvenBelgium
| | - Paola Bermudez‐Lekerika
- Tissue Engineering for Orthopaedics & Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical FacultyUniversity of BernBernSwitzerland
- Department of Orthopaedic Surgery and Traumatology, InselspitalBern University Hospital, Medical Faculty, University of BernBernSwitzerland
- Graduate School for Cellular and Biomedical Sciences (GCB)University of BernBernSwitzerland
| | - Roger Compte
- Twin Research & Genetic EpidemiologySt. Thomas' Hospital, King's College LondonLondonUK
| | - Francesco Gualdi
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM)BarcelonaSpain
| | - Terence McSweeney
- Research Unit of Health Sciences and TechnologyUniversity of OuluOuluFinland
| | - Estefano Muñoz‐Moya
- BCN MedTech, Department of Information and Communication TechnologiesUniversitat Pompeu FabraBarcelonaSpain
| | - Andrea Nüesch
- Division of Clinical Medicine, School of Medicine and Population HealthUniversity of SheffieldSheffieldUK
| | - Liesbet Geris
- GIGA In Silico MedicineUniversity of LiègeLiègeBelgium
- Skeletal Biology and Engineering Research Center, KU LeuvenLeuvenBelgium
- Biomechanics Research Unit, KU LeuvenLeuvenBelgium
| | - Stefan Dudli
- Center of Experimental RheumatologyDepartment of Rheumatology, University Hospital Zurich, University of ZurichZurichSwitzerland
- Department of Physical Medicine and RheumatologyBalgrist University Hospital, Balgrist Campus, University of ZurichZurichSwitzerland
| | - Jaro Karppinen
- Research Unit of Health Sciences and TechnologyUniversity of OuluOuluFinland
- Finnish Institute of Occupational HealthOuluFinland
- Rehabilitation Services of South Karelia Social and Health Care DistrictLappeenrantaFinland
| | - Jérôme Noailly
- BCN MedTech, Department of Information and Communication TechnologiesUniversitat Pompeu FabraBarcelonaSpain
| | - Christine Le Maitre
- Division of Clinical Medicine, School of Medicine and Population HealthUniversity of SheffieldSheffieldUK
| | - Benjamin Gantenbein
- Tissue Engineering for Orthopaedics & Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical FacultyUniversity of BernBernSwitzerland
- Department of Orthopaedic Surgery and Traumatology, InselspitalBern University Hospital, Medical Faculty, University of BernBernSwitzerland
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Mylenbusch H, Schepers M, Kleinjan E, Pol M, Tempelman H, Klopper-Kes H. Efficacy of stepped care treatment for chronic discogenic low back pain patients with Modic I and II changes. INTERVENTIONAL PAIN MEDICINE 2023; 2:100292. [PMID: 39239218 PMCID: PMC11372892 DOI: 10.1016/j.inpm.2023.100292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 09/07/2024]
Abstract
Objective This study investigated whether patients with Modic changes (MC) of types I, I/II, and II would respond to an anti-inflammatory-based, stepped care treatment with three treatment steps: first, oral administration of NSAIDs, 2 × 200 mg celecoxib daily for two weeks; second, an intradiscal steroid injection (ID) with dexamethasone and cefazolin; and third, oral treatment with antibiotics (AB), 3 × 1 g amoxicillin daily for 100 days. Design This was an observational clinical study based on analyses of categorical data of patient-reported outcome measurements. Subjects Subjects were consecutive patients with chronic low back pain (CLBP), diagnosed by assessment of anamnestic signs of inflammation; a pain score ≥6 on the Numeric Pain Rating Scale (NPRS); a mechanical assessment; MC I, I/II, or II based on MRI; and lack of response to conservative treatment. Methods From January 1, 2015, to December 31, 2021, 833 eligible patients were selected for the stepped care treatment. A total of 332 patients completed requested follow-up questionnaires at baseline and 12 months (optional at 3 and 6 months). Primary outcomes were pain (at least 50 % pain relief) and/or a minimum of 40 % improvement in functionality as measured by the Roland Morris Disability Questionnaire (RMDQ) or the Oswestry Disability Questionnaire (ODI). Secondary outcome measures were use of pain medication and return to work. Results At 1 year of follow-up, 179 (53.6 %) of 332 patients reported improvement according to the responder criteria. Of the 138 patients that had received only NSAIDs, 88 (63.8 %) had improved. In addition, 50 (56.8 %) of the 183 patients that had received ID had improved, and 41 (38.7 %) of the 106 patients treated with AB had improved. None of the patients reported complications. 12.0 % of patients using AB stopped preterm due to undesirable side effects. Conclusion Treatment with a stepped care model for inflammatory pain produced clinically relevant, positive reported outcomes on pain and/or function. Our stepped care model appears to be a useful, safe, and cost-saving treatment option that is easily reproducible. Further studies, including randomized controlled trials and analyses of subgroups, may help to develop a more patient-tailored approach and further avoidance of less-effective treatments and costs.
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Affiliation(s)
- Heidi Mylenbusch
- Stichting Rugpoli Twente, Veluwe, Brabant, Randstad - Multidisciplinary Center for Spine and Musculoskeletal Disorders, the Netherlands
| | - Michiel Schepers
- Stichting Rugpoli Twente, Veluwe, Brabant, Randstad - Multidisciplinary Center for Spine and Musculoskeletal Disorders, the Netherlands
| | - Elmar Kleinjan
- Stichting Rugpoli Twente, Veluwe, Brabant, Randstad - Multidisciplinary Center for Spine and Musculoskeletal Disorders, the Netherlands
| | - Marije Pol
- Stichting Rugpoli Twente, Veluwe, Brabant, Randstad - Multidisciplinary Center for Spine and Musculoskeletal Disorders, the Netherlands
| | - Henk Tempelman
- Stichting Rugpoli Twente, Veluwe, Brabant, Randstad - Multidisciplinary Center for Spine and Musculoskeletal Disorders, the Netherlands
| | - Hanneke Klopper-Kes
- Stichting Rugpoli Twente, Veluwe, Brabant, Randstad - Multidisciplinary Center for Spine and Musculoskeletal Disorders, the Netherlands
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Hebelka H, Erkmar A, Brisby H, Lagerstrand K. Coexistence of Vertebral and Intervertebral Disc Changes in Low Back Pain Patients-In Depth Characterization with Same Day MRI and CT Discography. Diagnostics (Basel) 2023; 13:3528. [PMID: 38066769 PMCID: PMC10706685 DOI: 10.3390/diagnostics13233528] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/16/2023] [Accepted: 11/22/2023] [Indexed: 04/01/2025] Open
Abstract
The aim of this study was to investigate to what extent annular fissures, vertebral and endplate changes, and Modic changes (MCs), coexist in low back pain (LBP) patients by using multiple imaging modalities. Sixty-two LBP patients (mean age 45 years, range 24-63, 53% men) were examined with same-day CT-discography and MRI. Intervertebral discs punctured for discography (n = 204) were evaluated on MRI [Pfirrmann grade, High-Intensity Zone (HIZ)] and on CT-discograms [Modified Dallas Discogram Score (DDS)]. DDS≥ 1, i.e., disc fissures involving the outer annulus were further digitomized into delimitable fissuring (<50% of annulus affected) or non-delimitable annular fissuring. Using both MRI and CT, adjacent vertebrae and endplates were assessed for MC, vertebral sclerosis, and a modified endplate defect score (EPS). In 194 discs the contrast agent was adequately injected during discography, of which 160 (83%) displayed outer annular fissures, with 91 (47%) of the latter being delimitable fissures. Most discs with delimitable fissures were moderately degenerated; 68% Pfirrmann grade ≤3, 71% EPS ≤ 2, and 12% displayed MC. The majority (76%) of MCs were associated with advanced adjacent disc degeneration; 84% Pfirrmann grade ≥4, 76% with non-delimitable annular fissuring, 59% EPS≥ 4, and 34% EPS of 3. A total 95 HIZ (47%) were found, of which 54 had delimitable fissuring, while the remainder displayed non-delimitable fissuring. Vertebral sclerosis was commonly observed (26%), both with MCs (73%) and without MCs (27%), and not specifically linked to MC type 3. A total of 97% of segments with vertebral sclerosis displayed outer annular fissures. These findings were significant (0.046 > p > 0.0001), except between HIZ and adjacent sclerosis (p = 0.303). To conclude, the present study confirmed a close interplay between the disc and adjacent vertebra and endplates. The fact that a majority of discs with delimitable annular fissures did not coexist with pronounced endplate changes and/or MCs, however, supports the theory that disc fissuring is an early event in the degenerative cascade. This was further supported by the fact that MCs were strongly linked to extensive disc fissuring and to advanced endplate damage. Further, vertebral sclerosis was common also in vertebra without MCs and strongly associated to annular fissuring, indicating that sclerosis is a previously underestimated feature of a general degenerative process.
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Affiliation(s)
- Hanna Hebelka
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45 Gothenburg, Sweden; (A.E.); (H.B.); (K.L.)
- Department of Radiology, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - Alfred Erkmar
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45 Gothenburg, Sweden; (A.E.); (H.B.); (K.L.)
- Department of Orthopaedics, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - Helena Brisby
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45 Gothenburg, Sweden; (A.E.); (H.B.); (K.L.)
- Department of Orthopaedics, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - Kerstin Lagerstrand
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45 Gothenburg, Sweden; (A.E.); (H.B.); (K.L.)
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
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Aboushaala K, Wong AYL, Barajas JN, Lim P, Al-Harthi L, Chee A, Forsyth CB, Oh CD, Toro SJ, Williams FMK, An HS, Samartzis D. The Human Microbiome and Its Role in Musculoskeletal Disorders. Genes (Basel) 2023; 14:1937. [PMID: 37895286 PMCID: PMC10606932 DOI: 10.3390/genes14101937] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
Musculoskeletal diseases (MSDs) are characterized as injuries and illnesses that affect the musculoskeletal system. MSDs affect every population worldwide and are associated with substantial global burden. Variations in the makeup of the gut microbiota may be related to chronic MSDs. There is growing interest in exploring potential connections between chronic MSDs and variations in the composition of gut microbiota. The human microbiota is a complex community consisting of viruses, archaea, bacteria, and eukaryotes, both inside and outside of the human body. These microorganisms play crucial roles in influencing human physiology, impacting metabolic and immunological systems in health and disease. Different body areas host specific types of microorganisms, with facultative anaerobes dominating the gastrointestinal tract (able to thrive with or without oxygen), while strict aerobes prevail in the nasal cavity, respiratory tract, and skin surfaces (requiring oxygen for development). Together with the immune system, these bacteria have coevolved throughout time, forming complex biological relationships. Changes in the microbial ecology of the gut may have a big impact on health and can help illnesses develop. These changes are frequently impacted by lifestyle choices and underlying medical disorders. The potential for safety, expenses, and efficacy of microbiota-based medicines, even with occasional delivery, has attracted interest. They are, therefore, a desirable candidate for treating MSDs that are chronic and that may have variable progression patterns. As such, the following is a narrative review to address the role of the human microbiome as it relates to MSDs.
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Affiliation(s)
- Khaled Aboushaala
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA; (K.A.); (J.N.B.); (P.L.); (A.C.); (C.-d.O.); (S.J.T.); (H.S.A.)
- International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL 60612, USA
| | - Arnold Y. L. Wong
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China;
| | - Juan Nicolas Barajas
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA; (K.A.); (J.N.B.); (P.L.); (A.C.); (C.-d.O.); (S.J.T.); (H.S.A.)
- International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL 60612, USA
| | - Perry Lim
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA; (K.A.); (J.N.B.); (P.L.); (A.C.); (C.-d.O.); (S.J.T.); (H.S.A.)
- International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL 60612, USA
| | - Lena Al-Harthi
- Department of Microbial Pathogens and Immunity, Rush University Medical Center, Chicago, IL 60612, USA;
| | - Ana Chee
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA; (K.A.); (J.N.B.); (P.L.); (A.C.); (C.-d.O.); (S.J.T.); (H.S.A.)
- International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL 60612, USA
| | - Christopher B. Forsyth
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL 60612, USA;
| | - Chun-do Oh
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA; (K.A.); (J.N.B.); (P.L.); (A.C.); (C.-d.O.); (S.J.T.); (H.S.A.)
- International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL 60612, USA
| | - Sheila J. Toro
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA; (K.A.); (J.N.B.); (P.L.); (A.C.); (C.-d.O.); (S.J.T.); (H.S.A.)
- International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL 60612, USA
| | | | - Howard S. An
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA; (K.A.); (J.N.B.); (P.L.); (A.C.); (C.-d.O.); (S.J.T.); (H.S.A.)
- International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL 60612, USA
| | - Dino Samartzis
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA; (K.A.); (J.N.B.); (P.L.); (A.C.); (C.-d.O.); (S.J.T.); (H.S.A.)
- International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL 60612, USA
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Gualdi F, Smith IG, Boixader RC, Williams FMK. Modic change is associated with increased BMI but not autoimmune diseases in TwinsUK. 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 2023; 32:3379-3386. [PMID: 37555954 DOI: 10.1007/s00586-023-07870-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 06/24/2023] [Accepted: 07/22/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE Low back pain (LBP) is one of the largest causes of morbidity worldwide. The aetiology of LBP is complex, and many factors contribute to the onset. Bone marrow lesions within the vertebra adjacent to an intervertebral degenerate disc named Modic change (MC) have been suggested as a diagnostic subgroup of LBP. Autoimmune response has been proposed to be one of the causes that promote the development of MC. The aim of the current investigation is to assess prevalence and severity of MC and LBP in participants with an autoimmune disease diagnosis in a well-documented cohort of adult twin volunteers. METHODS Multivariate generalized mixed linear models (GLMM) were implemented in order to calculate the association between having an autoimmune disorder and MC prevalence, width and severe and disabling LBP. The model was corrected for family structure as well as for covariates such as age, BMI and smoking. RESULTS No association was found between diagnosis of autoimmune disorder and MC. Interestingly, BMI was independently associated with MC width but not to MC prevalence. These results help to shed light on the relationship between MC and autoimmunity as well as the role of BMI in the development of the lesions. CONCLUSION This study is the first to examine autoimmune disorders and MC prevalence in a large, population-based female cohort. The study was well powered to detect a small effect. No association was found between having a diagnosis of one or more autoimmune conditions and MC prevalence, width or LBP.
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Affiliation(s)
- Francesco Gualdi
- Research Programme on Biomedical Informatics (GRIB), Hospital del Mar Medical Research Institute (IMIM), Pompeu Fabra University (UPF), Barcelona, Spain.
- Structural Bioinformatics Lab (GRIB-IMIM), Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08005, Barcelona, Catalonia, Spain.
- Department Twin Research and Genetic Epidemiology, King's College London, St Thomas Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Isabelle Granville Smith
- Department Twin Research and Genetic Epidemiology, King's College London, St Thomas Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Roger Compte Boixader
- Department Twin Research and Genetic Epidemiology, King's College London, St Thomas Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Frances M K Williams
- Department Twin Research and Genetic Epidemiology, King's College London, St Thomas Hospital, Westminster Bridge Road, London, SE1 7EH, UK
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Rajasekaran S, Vasudevan G, Easwaran M, Devi Ps N, Anand K S SV, Muthurajan R, Tangavel C, Murugan C, B T P, Shetty AP, Kanna RM. "Are we barking up the wrong tree? Too much emphasis on Cutibacterium acnes and ignoring other pathogens"- a study based on next-generation sequencing of normal and diseased discs. Spine J 2023; 23:1414-1426. [PMID: 37369253 DOI: 10.1016/j.spinee.2023.06.396] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/19/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND The majority of literature on bacterial flora in the disc stands disadvantaged in utilizing traditional culture methods and targeting a single bacterium, Cutibacterium acnes. PURPOSE Our objective was to document the diversity in the bacterial flora between normal and degenerated discs for shortlisting potential pathogens using next-generation genomic tools. STUDY DESIGN Experimental case-control study. METHODS Researchers employed 16S metagenome sequencing to profile bacterial diversity in magnetic resonance imaging normal healthy discs from brain-dead organ voluntary donors (n=20) and 40 degenerated disc samples harvested during surgery (Modic [MC]=20 and non-Modic [NMC]=20). The V3-V4 region was amplified using universal bacterial primers 341F and 806R, and the libraries were sequenced using Illumina NovoSeq 6000 platform. Statistical significance was set at bacteria with a minimum of 100 operational taxonomic unit (OTU) and present in at least 70% of the samples. The quality check-filtered reads were processed using the QIIME-2 pipeline. The OTU clustering and taxonomic classification were carried out for the merged reads using the Greengenes/SILVA reference database. Validation was done by identification of bacterial metabolites in samples using the liquid chromatography-mass spectrometry approach. RESULTS Abundant bacteria differing widely in diversity, as evidenced by Alfa and Beta diversity analysis, were present in all control and degenerative samples. The number of bacterial genera was 27 (14-gram-positive: 13-gram-negative) in the control group, 23 (10-gram-positive: 11-gram-negative) in the Modic group, and 16 (11-gram-positive: 5-gram-negative) in the non-Modic group. In the Modic group, gram-negative bacteria OTUs were found to be predominant (more than 50% of the total bacteria identified), whereas in control and non-Modic groups the OTUs of gram-positive bacteria were predominant. Species-level analysis revealed an abundance of opportunistic gram-negative pathogens like Pseudomonas aeruginosa, Sphingomonos paucibacillus, and Ochrobactrum quorumnocens in the discs with Modic changes, more than in non-Modic discs. The presence of bacterial metabolites and quorum-sensing molecules like N-decanoyl-L-homoserine lactone, 6-hydroxynicotinic acid, 2-aminoacetophenone, 4-hydroxy-3-polyprenylbenzoate, PE (16:1(9Z)/18:0) and phthalic acid validated the colonization and cell-cell communication of bacteria in disc ruling out contamination theory. Cutibacterium acnes was not the predominant bacteria in any of the three groups of discs and in fact was in the 16th position in the order of abundance in the control discs (0.72%), seventh position in the Modic discs (1.41%), and 12th position (0.53%) in the non-Modic discs. CONCLUSION This study identified a predominance of gram-negative bacteria in degenerated discs and highlights that Cutibacterium acnes may not be the only degeneration-causing bacteria. This may be attributed to the environment, diet, and lifestyle habits of the sample population. Though the study does not reveal the exact pathogen, it may pave the way for future studies on the subject. CLINICAL SIGNIFICANCE These findings invite further investigation into causal relationships of bacterial profile with disc degeneration phenotypes as well as phenotype-driven clinical treatment protocols.
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Affiliation(s)
- Shanmuganathan Rajasekaran
- Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Rd, Coimbatore, Tamil Nadu, 641043, India.
| | - Gowdaman Vasudevan
- Ganga Research Centre, SF No.442, Vattamalaipalayam, Rd, NGGO Colony Post, Coimbatore, Tamil Nadu, 641022, India
| | - Murugesh Easwaran
- Ganga Research Centre, SF No.442, Vattamalaipalayam, Rd, NGGO Colony Post, Coimbatore, Tamil Nadu, 641022, India
| | - Narmatha Devi Ps
- Ganga Research Centre, SF No.442, Vattamalaipalayam, Rd, NGGO Colony Post, Coimbatore, Tamil Nadu, 641022, India
| | - Sri Vijay Anand K S
- Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Rd, Coimbatore, Tamil Nadu, 641043, India
| | - Raveendran Muthurajan
- Department of Plant Biotechnology, Tamil Nadu Agricultural University, Lawley Rd, Coimbatore, Tamil Nadu, 641003, India
| | - Chitraa Tangavel
- Ganga Research Centre, SF No.442, Vattamalaipalayam, Rd, NGGO Colony Post, Coimbatore, Tamil Nadu, 641022, India
| | - Chandhan Murugan
- Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Rd, Coimbatore, Tamil Nadu, 641043, India
| | - Pushpa B T
- Department of Radiodiagnosis, Ganga Hospital, 313, Mettupalayam Rd, Coimbatore, Tamil Nadu, 641043, India
| | - Ajoy Prasad Shetty
- Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Rd, Coimbatore, Tamil Nadu, 641043, India
| | - Rishi Mugesh Kanna
- Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Rd, Coimbatore, Tamil Nadu, 641043, India
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Bråten LCH, Gjefsen E, Gervin K, Pripp AH, Skouen JS, Schistad E, Pedersen LM, Wigemyr M, Selmer KK, Aass HCD, Goll G, Brox JI, Espeland A, Grøvle L, Zwart JA, Storheim K, On behalf of The AIM-study group. Cytokine Patterns as Predictors of Antibiotic Treatment Effect in Chronic Low Back Pain with Modic Changes: Subgroup Analyses of a Randomized Trial (AIM Study). J Pain Res 2023; 16:1713-1724. [PMID: 37252109 PMCID: PMC10224727 DOI: 10.2147/jpr.s406079] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/21/2023] [Indexed: 05/31/2023] Open
Abstract
Objective Randomized trials testing the effect of antibiotics for chronic low back pain (LBP) with vertebral bone marrow changes on MRI (Modic changes) report inconsistent results. A proposed explanation is subgroups with low grade discitis where antibiotics are effective, but there is currently no method to identify such subgroups. The objective of the present study was to evaluate whether distinct patterns of serum cytokine levels predict any treatment effect of oral amoxicillin at one-year follow-up in patients with chronic low back pain and Modic changes at the level of a previous lumbar disc herniation. Design We used data from an overpowered, randomized, placebo-controlled trial (the AIM study) that tested 100 days of oral 750 mg amoxicillin vs placebo three times daily in hospital outpatients with chronic (>6 months) LBP with pain intensity ≥5 on a 0-10 numerical rating scale and Modic changes type 1 (oedema type) or 2 (fatty type). We measured serum levels of 40 inflammatory cytokines at baseline and analysed six predefined potential predictors of treatment effect based on cytokine patterns in 78 randomized patients; three analyses with recursive partitioning, one based on cluster analysis and two based on principal component analyses. The primary outcome was the Roland-Morris Disability Questionnaire score at one-year follow-up in the intention to treat population. The methodology and overall results of the AIM study were published previously. Results The 78 patients were 25-62 years old and 47 (60%) were women. None of the three recursive partitioning analyses resulted in any suggested subgroups. Of all main analyses, the largest effect estimate (mean difference between antibiotic and placebo groups) was seen in a subgroup not predefined as of main interest (Cluster category 3+4; -2.0, 95% CI: -5.2-1.3, RMDQ points; p-value for interaction 0.54). Conclusion Patterns of inflammatory serum cytokine levels did not predict treatment effect of amoxicillin in patients with chronic LBP and Modic changes. Clinical Trial Registration Number ClinicalTrials.gov (identifier: NCT02323412).
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Affiliation(s)
- Lars Christian Haugli Bråten
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital HF, Oslo, Norway
| | - Elisabeth Gjefsen
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital HF, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kristina Gervin
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital HF, Oslo, Norway
| | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology Research Support Services, Oslo University Hospital Ulleval, Oslo, Norway
| | - Jan Sture Skouen
- Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Bergen, Norway
| | - Elina Schistad
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, Oslo, Norway
| | - Linda Margareth Pedersen
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital HF, Oslo, Norway
| | - Monica Wigemyr
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital HF, Oslo, Norway
| | - Kaja Kristine Selmer
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital HF, Oslo, Norway
| | | | - Guro Goll
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, Oslo, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Grøvle
- Department of Rheumatology, Østfold Hospital Trust, Grålum, Norway
| | - John-Anker Zwart
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital HF, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kjersti Storheim
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital HF, Oslo, Norway
- Oslo Metropolitan University, Department of Physiotherapy, Oslo, Norway
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22
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Heggli I, Laux CJ, Mengis T, Karol A, Cornaz F, Herger N, Aradi‐Vegh B, Widmer J, Burkhard MD, Farshad‐Amacker NA, Pfammatter S, Wolski WE, Brunner F, Distler O, Farshad M, Dudli S. Modic type 2 changes are fibroinflammatory changes with complement system involvement adjacent to degenerated vertebral endplates. JOR Spine 2023; 6:e1237. [PMID: 36994463 PMCID: PMC10041382 DOI: 10.1002/jsp2.1237] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 11/04/2022] [Accepted: 12/02/2022] [Indexed: 12/25/2022] Open
Abstract
Background Vertebral endplate signal intensity changes visualized by magnetic resonance imaging termed Modic changes (MC) are highly prevalent in low back pain patients. Interconvertibility between the three MC subtypes (MC1, MC2, MC3) suggests different pathological stages. Histologically, granulation tissue, fibrosis, and bone marrow edema are signs of inflammation in MC1 and MC2. However, different inflammatory infiltrates and amount of fatty marrow suggest distinct inflammatory processes in MC2. Aims The aims of this study were to investigate (i) the degree of bony (BEP) and cartilage endplate (CEP) degeneration in MC2, (ii) to identify inflammatory MC2 pathomechanisms, and (iii) to show that these marrow changes correlate with severity of endplate degeneration. Methods Pairs of axial biopsies (n = 58) spanning the entire vertebral body including both CEPs were collected from human cadaveric vertebrae with MC2. From one biopsy, the bone marrow directly adjacent to the CEP was analyzed with mass spectrometry. Differentially expressed proteins (DEPs) between MC2 and control were identified and bioinformatic enrichment analysis was performed. The other biopsy was processed for paraffin histology and BEP/CEP degenerations were scored. Endplate scores were correlated with DEPs. Results Endplates from MC2 were significantly more degenerated. Proteomic analysis revealed an activated complement system, increased expression of extracellular matrix proteins, angiogenic, and neurogenic factors in MC2 marrow. Endplate scores correlated with upregulated complement and neurogenic proteins. Discussion The inflammatory pathomechanisms in MC2 comprises activation of the complement system. Concurrent inflammation, fibrosis, angiogenesis, and neurogenesis indicate that MC2 is a chronic inflammation. Correlation of endplate damage with complement and neurogenic proteins suggest that complement system activation and neoinnervation may be linked to endplate damage. The endplate-near marrow is the pathomechanistic site, because MC2 occur at locations with more endplate degeneration. Conclusion MC2 are fibroinflammatory changes with complement system involvement which occur adjacent to damaged endplates.
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Affiliation(s)
- Irina Heggli
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of ZurichZurichSwitzerland
| | - Christoph J. Laux
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Tamara Mengis
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of ZurichZurichSwitzerland
| | - Agnieszka Karol
- Department of Molecular Mechanisms of DiseaseUniversity of ZurichZurichSwitzerland
| | - Frédéric Cornaz
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Nick Herger
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of ZurichZurichSwitzerland
| | - Borbala Aradi‐Vegh
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of ZurichZurichSwitzerland
| | - Jonas Widmer
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Marco D. Burkhard
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | | | - Sibylle Pfammatter
- Functional Genomics Center Zurich, University and ETH ZurichZurichSwitzerland
| | - Witold E. Wolski
- Functional Genomics Center Zurich, University and ETH ZurichZurichSwitzerland
- Swiss Institute of BioinformaticsLausanneSwitzerland
| | - Florian Brunner
- Department of Physical Medicine and RheumatologyBalgrist University Hospital, University of ZurichZurichSwitzerland
| | - Oliver Distler
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of ZurichZurichSwitzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Stefan Dudli
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of ZurichZurichSwitzerland
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23
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Amoxicillin Did Not Reduce Modic Change Edema in Patients With Chronic Low Back Pain: Subgroup Analyses of a Randomised Trial (the AIM Study). Spine (Phila Pa 1976) 2023; 48:147-154. [PMID: 36223435 PMCID: PMC9812422 DOI: 10.1097/brs.0000000000004513] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 10/05/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Exploratory subgroup analyses of a randomised trial [Antibiotics in Modic changes (AIM) study]. OBJECTIVE The aim was to assess the effect of amoxicillin versus placebo in reducing Modic change (MC) edema in patients with chronic low back pain. SUMMARY OF BACKGROUND DATA The AIM study showed a small, clinically insignificant effect of amoxicillin on pain-related disability in patients with chronic low back pain and MC type 1 (edema type) on magnetic resonance imaging (MRI). MATERIALS AND METHODS A total of 180 patients were randomised to receive 100 days of amoxicillin or placebo. MC edema was assessed on MRI at baseline and one-year follow-up. Per-protocol analyses were conducted in subgroups with MC edema on short tau inversion recovery (STIR) or T1/T2-weighted MRI at baseline. MC edema reductions (yes/no) in STIR and T1/T2 series were analyzed separately. The effect of amoxicillin in reducing MC edema was analyzed using logistic regression adjusted for prior disk surgery. To assess the effect of amoxicillin versus placebo within the group with the most abundant MC edema on STIR at baseline ("STIR3" group), we added age, STIR3 (yes/no), and STIR3×treatment group (interaction term) as independent variables and compared the marginal means (probabilities of edema reduction). RESULTS Compared to placebo, amoxicillin did not reduce MC edema on STIR (volume/intensity) in the total sample with edema on STIR at baseline (odds ratio 1.0, 95% CI: 0.5, 2.0; n=141) or within the STIR3 group (probability of edema reduction 0.69, 95% CI: 0.47, 0.92 with amoxicillin and 0.61, 95% CI: 0.43, 0.80 with placebo; n=41). Compared with placebo, amoxicillin did not reduce MC edema in T1/T2 series (volume of the type 1 part of MCs) (odds ratio: 1.0, 95% CI: 0.5, 2.3, n=104). Edema declined in >50% of patients in both treatment groups. CONCLUSIONS From baseline to one-year follow-up, amoxicillin did not reduce MC edema compared with placebo. LEVEL OF EVIDENCE 2.
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Fresquez Z, Chang KE, Pereira R, Hunter C, Myntti M, Wang JC, Buser Z. The potential reversibility of Cutibacterium acnes-related disc degeneration: a rabbit model. Spine J 2023; 23:780-782. [PMID: 36708926 DOI: 10.1016/j.spinee.2023.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/09/2023] [Accepted: 01/18/2023] [Indexed: 01/26/2023]
Affiliation(s)
- Zoe Fresquez
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ki-Eun Chang
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Renata Pereira
- Department of Pediatrics, University of California, Los Angeles, CA, USA
| | | | | | - Jeffrey C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Gerling Institute, Brooklyn, NY, USA; Department of Orthopedic Surgery, Grossman School of Medicine, New York University, New York, NY, USA.
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He S, Zhou X, Yang G, Zhou Z, Zhang Y, Shao X, Liang T, Lv N, Chen J, Qian Z. Proteomic comparison between physiological degeneration and needle puncture model of disc generation disease. 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 2022; 31:2920-2934. [PMID: 35842490 DOI: 10.1007/s00586-022-07284-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: 10/08/2021] [Revised: 04/20/2022] [Accepted: 05/31/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The completeness of the intervertebral disc proteome is fundamental to the integrity and functionality of the intervertebral disc. METHODS The 20 experimental rats were placed into two groups randomly, normal group (NG) and acupuncture pathological degeneration group-2 weeks (APDG-2w). The ten 24-month-old rats were grouped into physiological degeneration group (PDG). Magnetic resonance imaging, X-ray examination, histological staining (hematoxylin & eosin, safranin-O cartilage, and alcian blue staining), and immunohistochemical examination were carried out for assessing the degree of disc degradation. Intervertebral disc was collected, and protein composition was determined by LC- MS, followed by bioinformatic analysis including significance analysis, subcellular localization prediction, protein domain prediction, GO function and KEGG pathway analysis, and protein interaction network construction. LC-PRM was done for protein quantification. RESULTS Physiological degeneration and especially needle puncture decreased T2 signal intensity and intervertebral disc height. Results from hematoxylin & eosin, safranin-O, and alcian blue staining revealed that the annulus fibrosus apparently showed the wavy and collapsed fibrocartilage lamellas in APDG-2w and PDG groups. The contents of the nucleus pulposus were decreased in physiological degeneration group and APDG-2w group compared with NG. Results from immunohistochemical analysis suggested the degeneration of intervertebral disc and inflammation in APDG-2w and PDG groups. The protein composition and expression between needle puncture rat models and the physiological degeneration group showed significant difference. CONCLUSIONS Our studies produced point-reference datasets of normal rats, physiological degeneration rats, and needle puncture rat models, which is beneficial to subsequent pathological studies. There is differential expression of protein expression in degenerative discs with aging and acupuncture, which may be used as a potential discriminating index for different intervertebral degenerations.
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Affiliation(s)
- Shuangjun He
- Department of Orthopedic Surgery, Affiliated Danyang Hospital of Nantong University, The People's Hospital of Danyang, Xinmin Road 2, Danyang, Zhenjiang, 212300, Jiangsu, China
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Xinfeng Zhou
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Guotao Yang
- Department of Orthopedic Surgery, Affiliated Danyang Hospital of Nantong University, The People's Hospital of Danyang, Xinmin Road 2, Danyang, Zhenjiang, 212300, Jiangsu, China
| | - Zhangzhe Zhou
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Yijian Zhang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Xiaofeng Shao
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Ting Liang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Nanning Lv
- Department of Orthopedic Surgery, The Second People's Hospital of Lianyungang, 41 Hailian Street, Lianyungang, Jiangsu, China.
| | - Jianhong Chen
- Department of Orthopedic Surgery, Affiliated Danyang Hospital of Nantong University, The People's Hospital of Danyang, Xinmin Road 2, Danyang, Zhenjiang, 212300, Jiangsu, China.
| | - Zhonglai Qian
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China.
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Hebelka H, Brisby H, Erkmar A, Lagerstrand K. Loading of the Spine in Low Back Pain Patients Does Not Induce MRI Changes in Modic Lesions: A Prospective Clinical Study. Diagnostics (Basel) 2022; 12:diagnostics12081815. [PMID: 36010166 PMCID: PMC9406333 DOI: 10.3390/diagnostics12081815] [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: 05/25/2022] [Revised: 06/22/2022] [Accepted: 07/26/2022] [Indexed: 11/16/2022] Open
Abstract
Modic changes (MCs) are gaining increased interest as potential generators of low back pain (LBP). The current aim was to investigate possible spinal loading effects on the MRI signal in MCs in patients with LBP. Supine lumbar MRIs were performed and immediately repeated with axial loading in 100 LBP patients. A total of 43 patients (23 male, mean age 45.7 years) had MCs. Each Modic was outlined on all sagittal T2-weighted images (>25% affected vertebrae). For reference, regions of interest were placed in both vertebrae without Modic and in Modic-free tissue in vertebrae with Modic. The Modic signal intensity, normalized to cerebrospinal fluid, and Modic volume were compared between MRIs with and without spinal loading. Of the 94 MCs, 36.2% (n = 34) were type I, 58.5% (n = 55) were type II, and 5.3% (n = 5) were type III. No differences in Modic volume (mean 0.046 cm3; p = 0.25) between the MRIs with and without spinal loading were found. In addition, no significant changes in Modic signal were induced by loading (mean 1.5% difference; p = 0.308). Loading increased the signal in the reference regions of interest in vertebrae both with Modic (mean 5.5%; p = 0.002) and without (mean 3.5%; SD 0.09; p = 0.02). To conclude, MRIs performed with and without spinal loading showed no change in either volume or signal of MCs, suggesting that most MCs are not instantaneously influenced by biomechanical load.
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Affiliation(s)
- Hanna Hebelka
- Department of Radiology, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (H.B.); (A.E.); (K.L.)
- Correspondence: ; Tel.: +46-(0)-31-3436494
| | - Helena Brisby
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (H.B.); (A.E.); (K.L.)
- Department of Orthopaedics, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - Alfred Erkmar
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (H.B.); (A.E.); (K.L.)
- Department of Orthopaedics, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - Kerstin Lagerstrand
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (H.B.); (A.E.); (K.L.)
- Department of Medical Physics and Biomedicine, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
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Schweizer TA, Andreoni F, Acevedo C, Scheier TC, Heggli I, Maggio EM, Eberhard N, Brugger SD, Dudli S, Zinkernagel AS. Intervertebral disc cell chondroptosis elicits neutrophil response in Staphylococcus aureus spondylodiscitis. Front Immunol 2022; 13:908211. [PMID: 35967370 PMCID: PMC9366608 DOI: 10.3389/fimmu.2022.908211] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/06/2022] [Indexed: 11/13/2022] Open
Abstract
To understand the pathophysiology of spondylodiscitis due to Staphylococcus aureus, an emerging infectious disease of the intervertebral disc (IVD) and vertebral body with a high complication rate, we combined clinical insights and experimental approaches. Clinical data and histological material of nine patients suffering from S. aureus spondylodiscitis were retrospectively collected at a single center. To mirror the clinical findings experimentally, we developed a novel porcine ex vivo model mimicking acute S. aureus spondylodiscitis and assessed the interaction between S. aureus and IVD cells within their native environment. In addition, the inflammatory features underlying this interaction were assessed in primary human IVD cells. Finally, mirroring the clinical findings, we assessed primary human neutrophils for their ability to respond to secreted inflammatory modulators of IVD cells upon the S. aureus challenge. Acute S. aureus spondylodiscitis in patients was characterized by tissue necrosis and neutrophil infiltration. Additionally, the presence of empty IVD cells’ lacunae was observed. This was mirrored in the ex vivo porcine model, where S. aureus induced extensive IVD cell death, leading to empty lacunae. Concomitant engagement of the apoptotic and pyroptotic cell death pathways was observed in primary human IVD cells, resulting in cytokine release. Among the released cytokines, functionally intact neutrophil-priming as well as broad pro- and anti-inflammatory cytokines which are known for their involvement in IVD degeneration were found. In patients as well as ex vivo in a novel porcine model, S. aureus IVD infection caused IVD cell death, resulting in empty lacunae, which was accompanied by the release of inflammatory markers and recruitment of neutrophils. These findings offer valuable insights into the important role of inflammatory IVD cell death during spondylodiscitis and potential future therapeutic approaches.
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Affiliation(s)
- Tiziano A. Schweizer
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Federica Andreoni
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Claudio Acevedo
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Thomas C. Scheier
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Irina Heggli
- Center of Experimental Rheumatology, University Hospital Zurich and Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, University Hospital Zurich and Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Ewerton Marques Maggio
- Department of Pathology and Molecular Pathology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nadia Eberhard
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Silvio D. Brugger
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Stefan Dudli
- Center of Experimental Rheumatology, University Hospital Zurich and Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland
| | - Annelies S. Zinkernagel
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland
- *Correspondence: Annelies S. Zinkernagel,
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Herger N, Bermudez-Lekerika P, Farshad M, Albers CE, Distler O, Gantenbein B, Dudli S. Should Degenerated Intervertebral Discs of Patients with Modic Type 1 Changes Be Treated with Mesenchymal Stem Cells? Int J Mol Sci 2022; 23:ijms23052721. [PMID: 35269863 PMCID: PMC8910866 DOI: 10.3390/ijms23052721] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 12/16/2022] Open
Abstract
Low back pain (LBP) has been among the leading causes of disability for the past 30 years. This highlights the need for improvement in LBP management. Many clinical trials focus on developing treatments against degenerative disc disease (DDD). The multifactorial etiology of DDD and associated risk factors lead to a heterogeneous patient population. It comes as no surprise that the outcomes of clinical trials on intradiscal mesenchymal stem cell (MSC) injections for patients with DDD are inconsistent. Intradiscal MSC injections have demonstrated substantial pain relief and significant disability-related improvements, yet they have failed to regenerate the intervertebral disc (IVD). Increasing evidence suggests that the positive outcomes in clinical trials might be attributed to the immunomodulatory potential of MSCs rather than to their regenerative properties. Therefore, patient stratification for inflammatory DDD phenotypes may (i) better serve the mechanisms of action of MSCs and (ii) increase the treatment effect. Modic type 1 changes—pathologic inflammatory, fibrotic changes in the vertebral bone marrow—are frequently observed adjacent to degenerated IVDs in chronic LBP patients and represent a clinically distinct subpopulation of patients with DDD. This review discusses whether degenerated IVDs of patients with Modic type 1 changes should be treated with an intradiscal MSC injection.
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Affiliation(s)
- Nick Herger
- Center of Experimental Rheumatology, University Hospital Zurich and Balgrist University Hospital, University of Zurich, CH-8008 Zurich, Switzerland; (N.H.); (O.D.)
| | - Paola Bermudez-Lekerika
- Tissue Engineering for Orthopaedics and Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical Faculty, University of Bern, CH-3008 Bern, Switzerland; (P.B.-L.); (B.G.)
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Medical Faculty, University of Bern, CH-3010 Bern, Switzerland;
| | - Mazda Farshad
- Department of Orthopaedics, Balgrist University Hospital, CH-8008 Zurich, Switzerland;
| | - Christoph E. Albers
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Medical Faculty, University of Bern, CH-3010 Bern, Switzerland;
| | - Oliver Distler
- Center of Experimental Rheumatology, University Hospital Zurich and Balgrist University Hospital, University of Zurich, CH-8008 Zurich, Switzerland; (N.H.); (O.D.)
| | - Benjamin Gantenbein
- Tissue Engineering for Orthopaedics and Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical Faculty, University of Bern, CH-3008 Bern, Switzerland; (P.B.-L.); (B.G.)
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Medical Faculty, University of Bern, CH-3010 Bern, Switzerland;
| | - Stefan Dudli
- Center of Experimental Rheumatology, University Hospital Zurich and Balgrist University Hospital, University of Zurich, CH-8008 Zurich, Switzerland; (N.H.); (O.D.)
- Correspondence: ; Tel.: +41-4451-07511
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The Effect of Cutibacterium acnes Infection on Nerve Penetration in the Annulus Fibrosus of Lumbar Intervertebral Discs via Suppressing Oxidative Stress. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:9120674. [PMID: 35265268 PMCID: PMC8898795 DOI: 10.1155/2022/9120674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/14/2022] [Accepted: 01/29/2022] [Indexed: 11/18/2022]
Abstract
Modic changes (MCs) and low back pain are highly correlated and an economic burden to the society. Previous studies have shown that Cutibacterium acnes (C. acnes) infection can lead to MCs. The purpose of this study was to clarify whether and how C. acnes contributes to oxidative stress and nerve growth that potentially leads to low back pain. Neurons from the hippocampus or dorsal root ganglion (DRG) of Sprague-Dawley (SD) rats were cocultured with annulus fibrosus cells (AFCs) with or without the presence of the C. acnes supernatant in vitro. Cell viability, neurite length, oxidative stress, and neuro-related gene expression were examined. Furthermore, samples from the patients with MCs and SD rat model of MCs were used to validate the nerve growth results. Neurons from both the hippocampus and DRG showed neurites when cocultured with AFCs in the environment with/without the C. acnes supernatant. The average neurite length was significantly longer when exposed to the C. acnes supernatant in the hippocampal neuron (217.1 ± 90.0 μm versus 150.1 ± 68.1 μm in the control group) and in the DRG neuron (229.1 ± 91.3 μm versus 149.2 ± 64.8 μm in the control group). Hippocampal neurons showed upregulated expression levels of NeuN, Map2, and Psd95, while upregulation was only seen in Tuj-1 in DRG neurons. Suppressed oxidative stress could be observed using axon growth symbols. Degenerated disc structures and abnormal bone remodelling were found in animal models and clinical samples of MCs, with astrocytes, microglia, and neurons in the disc. Therefore, C. acnes infection was found to cause back pain in the presence of MCs by promoting nerve penetration into the annulus fibrosus by suppressing oxidative stress.
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Lumbar intervertebral disc degeneration, end-plates and paraspinal muscle changes in children and adolescents with low-back pain. J Pediatr Orthop B 2022; 31:93-102. [PMID: 33252539 DOI: 10.1097/bpb.0000000000000833] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The prevalence of low-back pain (LBP) in adolescents ranges from 7 to 72%. We aimed to define the radiologic characteristics of the lumbar spine in children and adolescents with LBP with/without leg pain. Two hundred and fourteen children and adolescents, who were born between 2001 and 2009 and had lumbar spine MRI for LBP with/without leg pain, were evaluated in terms of intervertebral disc degeneration (IVDD), end-plates and paraspinal muscle changes on lumbar spine MRIs. Severe IVDD was detected at all lumbar levels except for L2-L3. Modic changes were present in 4.2% of the patients. Modic changes were more common in patients with severe IVDD than in those with mild-to-moderate IVDD. Severe IVDD was significantly associated with Modic changes at the corresponding L1-L2 and L3-L4 disc levels. Girls had significantly more fatty infiltration in the paraspinal muscles when compared to boys. The risk of having severe IVDD concomitant with Modic changes was high [odds ratio (OR), 8.6]. The OR was 20.7 for predicting the presence of severe IVDD at any level if Modic changes presented particularly at the L3-L4 level. The ORs of Modic changes presented at any lumbar level at the background of fat-infiltrated multifidus at L3-L4 and L4-L5 levels were 8.3 and 9.1, respectively. Fatty infiltration in the paraspinal muscles and IVDD were closely associated with Modic changes in children and adolescents with LBP. Lumbar IVDD in children and adolescents could be the result of a mechanical pathology.
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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: 0.5] [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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Gjefsen E, Gervin K, Goll G, Bråten LCH, Wigemyr M, Aass HCD, Vigeland MD, Schistad E, Pedersen LM, Pripp AH, Storheim K, Selmer KK, Zwart JA. Macrophage migration inhibitory factor: a potential biomarker for chronic low back pain in patients with Modic changes. RMD Open 2021; 7:rmdopen-2021-001726. [PMID: 34344830 PMCID: PMC8336134 DOI: 10.1136/rmdopen-2021-001726] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/19/2021] [Indexed: 01/20/2023] Open
Abstract
Background Low back pain (LBP) is a leading cause of disability worldwide, but the aetiology remains poorly understood. Finding relevant biomarkers may lead to better understanding of disease mechanisms. Patients with vertebral endplate bone marrow lesions visualised on MRI as Modic changes (MCs) have been proposed as a distinct LBP phenotype, and inflammatory mediators may be involved in the development of MCs. Objectives To identify possible serum biomarkers for LBP in patients with MCs. Methods In this case control study serum levels of 40 cytokines were compared between patients with LBP and MC type 1 (n=46) or type 2 (n=37) and healthy controls (n=50). Results Analyses identified significantly higher levels of six out of 40 cytokines in the MC type 1 group (MC1), and five in the MC type 2 group (MC2) compared with healthy controls. Six cytokines were moderately correlated with pain. Principal component analyses revealed clustering and separation of patients with LBP and controls, capturing 40.8% of the total variance, with 10 cytokines contributing to the separation. Macrophage migration inhibitory factor (MIF) alone accounted for 92% of the total contribution. Further, receiver operating characteristics analysis revealed that MIF showed an acceptable ability to distinguish between patients and controls (area under the curve=0.79). Conclusions These results suggest that cytokines may play a role in LBP with MCs. The clinical significance of the findings is unknown. MIF strongly contributed to clustering of patients with LBP with MCs and controls, and might be a biomarker for MCs. Ultimately, these results may guide future research on novel treatments for this patient group.
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Affiliation(s)
- Elisabeth Gjefsen
- Communication and Research Unit for Musculoskeletal Disorders, Oslo universitetssykehus Ulleval, Oslo, Norway .,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kristina Gervin
- Department of Research and Innovation, Oslo University Hospital, Oslo, Norway
| | - Guro Goll
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | | | - Monica Wigemyr
- Department of Research and Innovation, Oslo University Hospital, Oslo, Norway
| | | | - Maria Dehli Vigeland
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Research and Innovation, Oslo University Hospital, Oslo, Norway
| | - Elina Schistad
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | | | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology Research Support Services, Oslo University Hospital Ullevaal, Oslo, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Disorders, Oslo universitetssykehus Ulleval, Oslo, Norway.,Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
| | | | - John Anker Zwart
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Research and Innovation, Oslo University Hospital, Oslo, Norway
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Takahashi M, Iwamoto K, Kuzuyama M, Inami H, Matsumoto Y, Ueda S, Miyauchi Y. Incidence of spinal instability among patients with discogenic low back pain with different backgrounds. J Phys Ther Sci 2021; 33:601-605. [PMID: 34393371 PMCID: PMC8332637 DOI: 10.1589/jpts.33.601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/24/2021] [Indexed: 12/19/2022] Open
Abstract
[Purpose] To investigate the incidence of spinal instability among patients with
discogenic low back pain and its various effects with respect to the patients’ age,
gender, sports activity, and occupation. [Participants and Methods] We assessed 65
patients diagnosed with discogenic low back pain at our clinic between May 2016 and May
2020. After measuring segmental angulation using plain radiographs, we divided these
patients into two groups: (1) instability group with >10° of segmental angulation or
>3 mm of sagittal translation and (2) stability group with <10° of segmental
angulation and <3 mm of sagittal translation. Patient data such as age, gender, sports
activity, and occupation were collected using their medical records. [Results] The
incidence of spinal instability was 57% (37 patients) among the patients with discogenic
low back pain. No significant differences in age, gender, sports activity, and occupation
were identified between the groups. [Conclusion] The incidence of spinal instability
accounted for more than half of the total number of patients. Additionally, age, gender,
sports activity, and occupation did not affect the incidence of spinal instability. Our
results support the importance of rehabilitation, such as stability training for spinal
instability, for patients with discogenic low back pain.
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Affiliation(s)
- Makoto Takahashi
- Department of Physical Therapy School of Health Sciences, Japan University of Health Sciences: 2-555 Hirasuka, Satte-City, Saitama 340-0145, Japan.,Department of Rehabilitation, Hitachino Orthopedic Clinic, Japan
| | - Koji Iwamoto
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences, Japan
| | - Motoki Kuzuyama
- Mansfield/Bulimba, PhysioWorks, Australia.,Moto Mobile Physio Pty Ltd, Australia
| | - Hiroshi Inami
- Department of Rehabilitation, Hitachino Orthopedic Clinic, Japan
| | - Yuto Matsumoto
- Department of Rehabilitation, Hitachino Orthopedic Clinic, Japan
| | - Shinji Ueda
- Department of Rehabilitation, Hitachino Orthopedic Clinic, Japan
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Jha SC, Sairyo K. The role of Propionibacterium acnes in and Modic type 1 changes : A literature review. THE JOURNAL OF MEDICAL INVESTIGATION 2021; 67:21-26. [PMID: 32378611 DOI: 10.2152/jmi.67.21] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Propionibacterium acnes (P. acnes) is part of the normal flora of human skin, oral cavity, intestinal tract and external ear canal. However, breach in the mucosa as well as ruptured annulus fibrosus provide favorable pathway for P. acnes to nucleus pulposus where it can proliferate under anaerobic condition. In past two decades many authors have identified P. acnes in routine culture of discs. There studies showed that almost 50% of discs cultured were positive for various organism, and in vast majority of culture positive disc, P. acnes was the primary organism isolated. However, there are few studies that refute the hypothesis that P. acnes has a role in pathogenesis of Modic type 1 changes. Identification of P. acnes in culture indicates the infective patho-mechanism in the pathogenesis of Modic type 1 changes, which may be ameable to antibiotic treatment. However, it is still difficult to identify which subset of these patients (patients with low back pain with type 1 Modic change) are infective in nature. Further investigation and more clinical trails will be required for clear identification of the infective subgroup among low back patient in general. J. Med. Invest. 67 : 21-26, February, 2020.
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Affiliation(s)
- Subash Chandra Jha
- Department of Orthopedics, Birat Medical College and Teaching Hospital, Biratnagar, Nepal
| | - Koichi Sairyo
- Department of Orthopedics, Tokushima University, Tokushima, Japan
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Manniche C, Hall GM. Chronic low back pain, Modic changes and low-grade virulent infection: efficacy of antibiotic treatment. Future Sci OA 2021; 7:FSO703. [PMID: 34046205 PMCID: PMC8147823 DOI: 10.2144/fsoa-2021-0026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/11/2021] [Indexed: 11/23/2022] Open
Abstract
Chronic low back pain (CLBP) has consistently been associated with the longest number of years lived with a disability in global studies, while commonly used treatments for CLBP are largely ineffective. In 2013 a randomized, double-blind, controlled study demonstrated significant improvements in CLBP patients demonstrating Modic changes type 1 on their MRI scans and undergoing long-term oral antibiotic treatment (100 days). Much of the ensuing debate has focused on whether this was a true infection or contamination. Newer and more advanced technologies clearly point to an ongoing low-grade infection. We have reviewed all of the clinical trials published in the recent past and conclude that there is compelling evidence for the effect of long-term oral antibiotic treatment for this patient group.
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Affiliation(s)
- Claus Manniche
- Department of Occupational & Environmental Medicine, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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36
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Sheep as a Potential Model of Intradiscal Infection by the Bacterium Cutibacterium acnes. Vet Sci 2021; 8:vetsci8030048. [PMID: 33809558 PMCID: PMC8002071 DOI: 10.3390/vetsci8030048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/09/2021] [Accepted: 03/13/2021] [Indexed: 12/12/2022] Open
Abstract
The anaerobic bacterium Cutibacterium acnes has been increasingly linked to the development of degenerative disc disease (DDD), although causality is yet to be conclusively proven. To better study how this organism could contribute to the aetiology of DDD, improved animal models that are more reflective of human disc anatomy, biology and mechanical properties are required. Against this background, our proof-of concept study aimed to be the first demonstration that C. acnes could be safely administered percutaneously into sheep intervertebral discs (IVDs) for in vivo study. Following our protocol, two sheep were successfully injected with a strain of C. acnes (8.3 × 106 CFU/disc) previously recovered from a human degenerative disc. No adverse reactions were noted, and at one-month post inoculation all triplicate infected discs in our first animal grew C. acnes, albeit at a reduced load (5.12 × 104 to 6.67 × 104 CFU/disc). At six months, no growth was detected in discs from our second animal indicating bacterial clearance. This pilot study has demonstrated the feasibility of safe percutaneous injection of C. acnes into sheep IVDs under fluoroscopic guidance. The design of follow-up sheep studies to investigate the potential of C. acnes to drive pathological changes within infected discs should now be pursued.
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37
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Tang G, Han X, Lin Z, Qian H, Chen B, Zhou C, Chen Y, Jiang W. Propionibacterium acnes Accelerates Intervertebral Disc Degeneration by Inducing Pyroptosis of Nucleus Pulposus Cells via the ROS-NLRP3 Pathway. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:4657014. [PMID: 33603947 PMCID: PMC7870295 DOI: 10.1155/2021/4657014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 12/14/2020] [Accepted: 01/11/2021] [Indexed: 11/17/2022]
Abstract
Our previous study verified the occurrence of Propionibacterium acnes (P. acnes), a low-virulence anaerobic bacterium, latently residing in degenerated intervertebral discs (IVDs), and the infection had a strong association with IVD degeneration. We explored whether P. acnes induces nucleus pulposus cell (NPC) pyroptosis, a more dangerous cell death process than apoptosis, and accelerates IVD degeneration via the pyroptotic products interleukin- (IL-) 1β and IL-18. After coculturing with P. acnes, human NPCs showed significant upregulation of NOD-like receptor 3 (NLRP3), cleaved IL-1β, cleaved caspase-1, and cleaved gasdermin D in response to the overexpression of IL-1β and IL-18 in a time- and dose-dependent manner. In addition, the gene expression of inflammatory factors and catabolic enzymes significantly increased in normal NPCs when cocultured with pyroptotic NPCs in a transwell system, and the adverse effects were inhibited when NPC pyroptosis was suppressed. Furthermore, inoculation of P. acnes into the IVDs of rats caused significant pyroptosis of NPCs and remarkable IVD degeneration. Finally, coculture of NPCs with P. acnes induced the overexpression of reactive oxygen species (ROS) and NLRP3, while inhibition of both factors reduced NPC pyroptosis. Therefore, P. acnes induces NPC pyroptosis via the ROS-NLRP3 signaling pathway, and the pyroptotic NPCs cause an IVD degeneration cascade. Targeting the P. acnes-induced pyroptosis of NPCs may become an alternative treatment strategy for IVD degeneration in the future.
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Affiliation(s)
- Guoqing Tang
- Orthopedic Center, The First Affiliated Hospital of Soochow University, Suzhou 215000, China
- Kunshan Hospital of Traditional Chinese Medicine, Kunshan 215300, China
- Institute of Translational Medicine, Medical College, Yangzhou University, Yangzhou 225001, China
| | - Xiaoguang Han
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Zhijie Lin
- Institute of Translational Medicine, Medical College, Yangzhou University, Yangzhou 225001, China
- Jiangsu Key Laboratory of Experimental & Translational Non-coding RNA Research, Yangzhou 225001, China
| | - Hongbin Qian
- Kunshan Hospital of Traditional Chinese Medicine, Kunshan 215300, China
- Institute of Translational Medicine, Medical College, Yangzhou University, Yangzhou 225001, China
| | - Bing Chen
- Kunshan Hospital of Traditional Chinese Medicine, Kunshan 215300, China
- Institute of Translational Medicine, Medical College, Yangzhou University, Yangzhou 225001, China
| | - Chengliang Zhou
- Kunshan Hospital of Traditional Chinese Medicine, Kunshan 215300, China
- Institute of Translational Medicine, Medical College, Yangzhou University, Yangzhou 225001, China
| | - Yong Chen
- Kunshan Hospital of Traditional Chinese Medicine, Kunshan 215300, China
- Institute of Translational Medicine, Medical College, Yangzhou University, Yangzhou 225001, China
| | - Weimin Jiang
- Orthopedic Center, The First Affiliated Hospital of Soochow University, Suzhou 215000, China
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Longitudinal time-lapse in vivo micro-CT reveals differential patterns of peri-implant bone changes after subclinical bacterial infection in a rat model. Sci Rep 2020; 10:20901. [PMID: 33262377 PMCID: PMC7708479 DOI: 10.1038/s41598-020-77770-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 11/17/2020] [Indexed: 02/06/2023] Open
Abstract
Subclinical infection associated with orthopedic devices can be challenging to diagnose. The goal of this study was to evaluate longitudinal, microcomputed tomography (microCT) imaging in a rat model of subclinical orthopedic device-related infection caused by Staphylococcus epidermidis and four different Cutibacterium (previously Propionibacterium) acnes strains, and compare outcomes with non-inoculated and historical S. aureus-inoculated controls. Sterile screws or screws colonized with bacteria were placed in the tibia of 38 adult Wistar rats [n = 6 sterile screws; n = 6 S. epidermidis-colonized screws; n = 26 C. acnes-colonized screws (covering all three main subspecies)]. Regular microCT scans were taken over 28 days and processed for quantitative time-lapse imaging with dynamic histomorphometry. At euthanasia, tissues were processed for semiquantitative histopathology or quantitative bacteriology. All rats receiving sterile screws were culture-negative at euthanasia and displayed progressive bony encapsulation of the screw. All rats inoculated with S. epidermidis-colonized screws were culture-positive and displayed minor changes in peri-implant bone, characteristic of subclinical infection. Five of the 17 rats in the C. acnes inoculated group were culture positive at euthanasia and displayed bone changes at the interface of the screw and bone, but not deeper in the peri-implant bone. Dynamic histomorphometry revealed significant differences in osseointegration, bone remodeling and periosteal reactions between groups that were not measurable by visual observation of still microCT images. Our study illustrates the added value of merging 3D microCT data from subsequent timepoints and producing inherently richer 4D data for the detection and characterization of subclinical orthopedic infections, whilst also reducing animal use.
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Rao PJ, Maharaj M, Chau C, Taylor P, Phan K, Choy WJ, Scherman D, Mews P, Scholsem M, Coughlan M, Mobbs R. Degenerate-disc infection study with contaminant control (DISC): a multicenter prospective case-control trial. Spine J 2020; 20:1544-1553. [PMID: 32339766 DOI: 10.1016/j.spinee.2020.03.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/14/2020] [Accepted: 03/16/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND A bacterial cause of disc degeneration has evoked several controversies and, if true, would lead to a major shift in treatment paradigm. Earlier studies analyzing the relationship of bacterial disc infection within a degenerative cohort featured prolonged cultures susceptible to contamination. The degenerate-disc infection study with contaminant control (DISC) trial aims to investigate this theory further by examining infection rates using a non-degenerative control cohort in comparison to a degenerative internal control cohort and a sham cohort (sampling only sterile paraspinal tissue). To our knowledge, the current study is the largest evaluating the growth of organisms (or possible contamination rate) in paraspinal tissue if prolonged cultures are performed. Protocols on methodology have been previously published. PURPOSE (1) To investigate the infection rates across cohorts (degenerative vs. nondegenerative control; paraspinal and/or disc controls vs. combined sampling cohorts) using stringent standardized aseptic surgical technique and laboratory processing. (2) To compare our findings to that of the literature and make a statement in support and/or against a possible contamination theory to positive cultures. STUDY DESIGN Multicenter, multisurgeon case-control trial. PATIENT SAMPLE In all, 812 surgical samples were retrieved across a 3.5-year period (2013-2016) including 25 trauma controls (nondegenerative), 550 "disc and paraspinal" samples (degenerative cases with internal control), 190 disc-only samples (degenerative cases without internal control), and 46 paraspinal only controls (sham group). OUTCOME MEASURES Growth and/or Contamination rate (%) per cohort. Chi-square of growth in disc versus paraspinal samples as a means of examining the distribution of false positive and contaminant growth. The impact of previous injections and/or surgery on positive disc or paraspinal growth. Correlation of Modic changes with positive growth rates analyzed with the Kruskal-Wallis Test. The distribution of species in positive samples were also analyzed. METHODS The DISC trial is registered under Australian and New Zealand clinical trials registry-ACTRN12616000541404. Institutional ethics review was obtained (HREC northern sector 13/218) at the primary center and further centers (n=6) were recruited. Patients undergoing spinal surgery with discectomy were eligible for trial entry with tissue specimens obtained using strict aseptic technique for microbiological examination. All specimens were handled with sterile instruments only and by a fresh instrument to a sterile pot that was closed immediately. Separate pots were used for the disc and paraspinal tissue respectively with similar stringent processing during microbiological assessment. A cohort of the degenerative cases at one single institution also underwent an additional histopathological examination. RESULTS There was an expected significant difference in gender and age associated with the non-degenerative control group (due to trauma patients) compared with other cohorts. There was a higher percentage of positive-growth in the control group in comparison to the disc and paraspinal and disc only groups across positive disc growth (48% vs. 27% vs. 17%, p<.001). A similar infection rate was observed in the paraspinal samples across the equivalent controls (44% vs. 36% vs. 37%, p=.739). There was a significant difference in the proportions of positive growth with a large proportion of false positives (growth in both disc and paraspinal samples; p<.001). There was no difference in true positive growth between the case and control groups (16.0 vs. 7.7%, p=.112). These trends were preserved across all cohorts and when stratifying by spinal segment (cervical or lumbar). There was no correlation between Modic changes and positive disc culture growth (p=.398, n=144 samples). Cutibacterium (formerly Propionibacterium) acnes was the most dominant pathogen isolated, representing between 50% and 70% of positive disc and paraspinal specimens, followed by staphylococcal species. CONCLUSIONS Our study failed to find a difference in true infection rates between the nondegenerative and degenerative disc populations. These findings are suggestive of a contamination theory and against a common infective etiology in the setting of discogenic back and neck pain. We believe the rationale for antibiotic therapy in the management of discogenic back pain warrants further evidence to establish efficacy.
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Affiliation(s)
- Prashanth J Rao
- School of Medical Sciences, University of New South Wales, Sydney, Australia; Neurosurgical Research Group (NSURG), Sydney, Australia
| | - Monish Maharaj
- School of Medical Sciences, University of New South Wales, Sydney, Australia; Neurosurgical Research Group (NSURG), Sydney, Australia; Department of Neurosurgery, Prince of Wales Public and Private Hospitals, Suite 7, Level 7, Randwick 2031, Australia.
| | - Christine Chau
- Department of Pathology, Prince of Wales Hospital Randwick, Australia
| | - Peter Taylor
- Department of Neurosurgery, The Canberra Hospital, Canberra, Australia
| | - Kevin Phan
- School of Medical Sciences, University of New South Wales, Sydney, Australia; Neurosurgical Research Group (NSURG), Sydney, Australia; Department of Neurosurgery, Prince of Wales Public and Private Hospitals, Suite 7, Level 7, Randwick 2031, Australia
| | - Wen Jie Choy
- School of Medical Sciences, University of New South Wales, Sydney, Australia; Neurosurgical Research Group (NSURG), Sydney, Australia
| | - Daniel Scherman
- Department of Neurosurgery, Westmead Hospital, Sydney, Australia
| | - Peter Mews
- School of Medical Sciences, University of New South Wales, Sydney, Australia; Dept Microbiology NSW Health Pathology, St George Hospital, Kogarah, Australia
| | - Martin Scholsem
- Department of Neurosurgery, St George Hospital, Kogarah, Australia
| | - Marc Coughlan
- Department of Neurosurgery, Prince of Wales Public and Private Hospitals, Suite 7, Level 7, Randwick 2031, Australia
| | - Ralph Mobbs
- School of Medical Sciences, University of New South Wales, Sydney, Australia; Neurosurgical Research Group (NSURG), Sydney, Australia; Department of Neurosurgery, Prince of Wales Public and Private Hospitals, Suite 7, Level 7, Randwick 2031, Australia
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Wang J, Zheng Z, Huang B, Wu H, Zhang X, Chen Y, Liu J, Shan Z, Fan S, Chen J, Zhao F. Osteal Tissue Macrophages Are Involved in Endplate Osteosclerosis through the OSM-STAT3/YAP1 Signaling Axis in Modic Changes. THE JOURNAL OF IMMUNOLOGY 2020; 205:968-980. [PMID: 32690652 DOI: 10.4049/jimmunol.1901001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 06/22/2020] [Indexed: 11/19/2022]
Abstract
Modic changes (MCs) are radiographic manifestations of lumbar degenerative diseases. Various types of MCs are often associated with endplate osteosclerosis. Osteal tissue macrophages (Osteomacs) were reported to be crucial for bone homeostasis and bone repair, but whether osteomacs participate in the endplate osteosclerosis in MCs remained unclear. In this study, we tried to explore the critical role of osteomacs in regulating osteogenesis in MCs. We collected MCs from patient samples and developed a Propionibacterium acnes-induced rat MCs model, using microcomputed tomography and immunohistochemistry to detect the endplate bone mass and distribution of osteomacs. In patients' MCs, osteomacs increased in endplate subchondral bone, especially in Modic type II. Endplate in Modic type III presented a stable osteosclerosis. In rat MCs model, osteomacs increased in the bone hyperplasia area but not in the inflammation area of the endplate region, whereas the distribution of osteomacs was consistent with the area of osteosclerosis. To further explore the functions of osteomacs in vitro, we isolated osteomacs using MACS technology and found osteomacs secreted oncostatin M (OSM) and strongly promoted osteoblast differentiation rather than osteoclast through the mechanism of OSM-mediated tyrosine phosphorylation and interaction of STAT3 and Yes-associated protein 1 (YAP1). STAT3 phosphorylation inhibition or YAP1 knockdown attenuated OSM-mediated osteoblast differentiation. Finally, we confirmed that blockade of OSM in vivo using anti-OSM-neutralizing Ab prevented endplate osteosclerosis in rat MCs model. Taken together, these findings confirmed that endplate osteosclerosis in MCs was accompanied by an increased number of osteomacs, which regulated osteogenesis via the OSM-STAT3/YAP1 signaling axis.
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Affiliation(s)
- Jiasheng Wang
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China; and Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou 310016, China
| | - Zeyu Zheng
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China; and Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou 310016, China
| | - Bao Huang
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China; and Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou 310016, China
| | - Hao Wu
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China; and Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou 310016, China
| | - Xuyang Zhang
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China; and Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou 310016, China
| | - Yilei Chen
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China; and Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou 310016, China
| | - Junhui Liu
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China; and Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou 310016, China
| | - Zhi Shan
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China; and Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou 310016, China
| | - Shunwu Fan
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China; and Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou 310016, China
| | - Jian Chen
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China; and Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou 310016, China
| | - Fengdong Zhao
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China; and Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou 310016, China
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41
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Bråten LCH, Grøvle L, Espeland A, Pripp AH, Grotle M, Helllum C, Haugen AJ, Froholdt A, Rolfsen MP, Nygaard ØP, Lutro O, Kristoffersen PM, Anke A, Schistad EI, Skouen JS, Brox JI, Zwart JA, Storheim K. Clinical effect modifiers of antibiotic treatment in patients with chronic low back pain and Modic changes - secondary analyses of a randomised, placebo-controlled trial (the AIM study). BMC Musculoskelet Disord 2020; 21:458. [PMID: 32660517 PMCID: PMC7359501 DOI: 10.1186/s12891-020-03422-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/15/2020] [Indexed: 01/13/2023] Open
Abstract
Background Randomised trials on antibiotic treatment for patients with chronic low back pain and vertebral endplate changes visible on MRI (Modic changes) have shown mixed results. A possible explanation might be a real treatment effect in subgroups of the study populations. The purpose of the present study was to explore potential clinical effect modifiers of 3-months oral amoxicillin treatment in patients with chronic low back pain and type I or II Modic changes at the level of a previous lumbar disc herniation. Methods We performed analyses of effect modifiers on data from AIM, a double-blind parallel-group multicentre trial. One hundred eighty patients with chronic low back pain, previous disc herniation, Modic change type I (n = 118) or type II (n = 62) were randomised to 3-months oral treatment with 750 mg amoxicillin (n = 89) or placebo (n = 91) three times daily. The primary outcome was the Roland-Morris Disability Questionnaire (RMDQ) score (possible values 0–24) at 1-year follow-up in the intention-to-treat population. The predefined minimal clinically important between-group mean difference was 4 RMDQ points (not reached in the primary analysis of AIM). Predefined baseline characteristics were analysed as potential effect modifiers, four primary (type I Modic changes, previous disc surgery, positive pain provocation test, high CRP) and five exploratory (disturbed sleep, constant low back pain, short duration of low back pain, younger age, and male) using ANCOVA with interaction terms. Results None of the four primary potential effect modifiers had strong evidence of modifying the treatment effect. In patients younger than 40 years the difference in mean RMDQ score between the treatment groups was − 4.0 (95%CI, − 6.9 to − 1.2), compared to − 0.5 (95%CI, − 2.3 to 1.3) in patients 40 years or older, both in favour of amoxicillin treatment (exploratory analysis). Conclusions We did not find evidence for convincing clinical effect modifiers of antibiotic treatment in patients with chronic low back pain and Modic changes. Our results for younger age in these explorative analyses should not affect clinical treatment decisions without confirmation in future studies. Trial registration ClinicalTrials.gov NCT02323412, First registered 23 December 2014.
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Affiliation(s)
- Lars Christian Haugli Bråten
- FORMI, Oslo University Hospital HF, Ulleval, Bygg 37b, Postbox 4956, Nydalen, 0424, Oslo, Norway. .,Faculty of Medicine, University of Oslo, PO BOX 1078 Blindern, 0316, Oslo, Norway.
| | - Lars Grøvle
- Department of Rheumatology, Østfold Hospital Trust, PB 300, 1714, Grålum, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Klinisk institutt 1, Postboks 7804, NO-5020, Bergen, Norway
| | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Postbox 4950 Nydalen, 0424, Oslo, Norway
| | - Margreth Grotle
- FORMI, Oslo University Hospital HF, Ulleval, Bygg 37b, Postbox 4956, Nydalen, 0424, Oslo, Norway.,Department of Physiotherapy, Oslo Metropolitan University, PO box 4 St. Olavs plass, NO-0130, Oslo, Norway
| | - Christian Helllum
- Department of Orthopaedic surgery, Oslo University Hospital, Postbox 4956, Nydalen, 0424, Oslo, Norway
| | - Anne Julsrud Haugen
- Department of Rheumatology, Østfold Hospital Trust, PB 300, 1714, Grålum, Norway
| | - Anne Froholdt
- Department of Physical Medicine and Rehabilitation, Drammen Hospital, Vestre Viken Hospital Trust Drammen, Postboks 800, 3004, Drammen, Norway
| | - Mads Peder Rolfsen
- Faculty of Medicine, University of Oslo, PO BOX 1078 Blindern, 0316, Oslo, Norway.,Department of Orthopaedic surgery, Oslo University Hospital, Postbox 4956, Nydalen, 0424, Oslo, Norway
| | - Øystein Petter Nygaard
- Department of Neurosurgery, St. Olavs University Hospital, Postbox 3250 Torgarden, NO-7006, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Faculty of Medicine and Health Sciences, N-7491, Trondheim, Norway.,National Advisory Unit on Spinal Surgery, St Olavs Hospital, Postboks 3250 Torgarden, 7006, Trondheim, Norway
| | - Olav Lutro
- Stavanger University Hospital, Helse Stavanger HF, Postboks 8100, 4068, Stavanger, Norway
| | - Per Martin Kristoffersen
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Klinisk institutt 1, Postboks 7804, NO-5020, Bergen, Norway
| | - Audny Anke
- Department of Rehabilitation, University Hospital of North Norway, Postboks 100, 9038, Tromsø, Norway.,Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037, Tromsø, Norway
| | - Elina Iordanova Schistad
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, Ulleval, Postbox 4956, Nydalen, 0424, Oslo, Norway
| | - Jan Sture Skouen
- Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Helse Bergen HF, Box 1, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Postboks 7804, NO-5020, Bergen, Norway
| | - Jens Ivar Brox
- Faculty of Medicine, University of Oslo, PO BOX 1078 Blindern, 0316, Oslo, Norway.,Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, Ulleval, Postbox 4956, Nydalen, 0424, Oslo, Norway
| | - John-Anker Zwart
- FORMI, Oslo University Hospital HF, Ulleval, Bygg 37b, Postbox 4956, Nydalen, 0424, Oslo, Norway.,Faculty of Medicine, University of Oslo, PO BOX 1078 Blindern, 0316, Oslo, Norway
| | - Kjersti Storheim
- FORMI, Oslo University Hospital HF, Ulleval, Bygg 37b, Postbox 4956, Nydalen, 0424, Oslo, Norway.,Department of Physiotherapy, Oslo Metropolitan University, PO box 4 St. Olavs plass, NO-0130, Oslo, Norway
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Bone Flap Resorption Associated with Indolent Propionibacterium acnes Infection After Cranioplasty: Case Report with Pathological Analysis. World Neurosurg 2020; 138:313-316. [PMID: 32217177 DOI: 10.1016/j.wneu.2020.03.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/10/2020] [Accepted: 03/13/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Autologous bone resorption is a frequent complication of cranioplasty, often necessitating reoperation. The etiology of this phenomenon is unknown, although it has recently been associated with indolent Propionibacterium acnes infection. CASE DESCRIPTION A 59-year-old man initially presented with a traumatic acute subdural hematoma treated with emergent decompressive hemicraniectomy and hematoma evacuation. His bone flap was cryopreserved. He underwent cranioplasty with autologous bone 3 months later. Over the subsequent 14 months, serial imaging demonstrated progressive bone flap resorption, ultimately requiring repeat cranioplasty with a custom allograft. Although there was no evidence of infection at the time of repeat cranioplasty, routine culture swabs were taken and grew P. acnes after the patient had been discharged home. Pathologic analysis of the fragments of the original bone flap that were removed demonstrated osteonecrosis with marrow fibrosis but no evidence of inflammation or infection. He was treated with 6 weeks of intravenous antibiotics and had no evidence of infection at 8-month follow-up. CONCLUSIONS Indolent P. acnes infection can precipitate autologous bone flap resorption. While the mechanism of this is unknown, pathologic analysis of a partially resorbed bone flap in the setting of an indolent P. acnes infection found no evidence of an infectious process or inflammation within the bone. Further studies are needed to elucidate the mechanism of action of P. acnes in bone flap resorption.
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Schwarz-Nemec U, Friedrich KM, Stihsen C, Schwarz FK, Trattnig S, Weber M, Grohs JG, Nemec SF. Vertebral Bone Marrow and Endplate Assessment on MR Imaging for the Differentiation of Modic Type 1 Endplate Changes and Infectious Spondylodiscitis. J Clin Med 2020; 9:jcm9030826. [PMID: 32197459 PMCID: PMC7141365 DOI: 10.3390/jcm9030826] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/16/2020] [Indexed: 12/11/2022] Open
Abstract
On magnetic resonance (MR) imaging, Modic type 1 (MT1) endplate changes and infectious spondylodiscitis share similar findings. Therefore, this study investigated vertebral bone marrow and endplate changes to enable their differentiation. The lumbar spine MR examinations of 91 adult patients were retrospectively included: 39 with MT1; 19 with early spondylodiscitis without abscess; and 33 with advanced spondylodiscitis with abscess. The assessment included percentage of bone marrow edema on sagittal short tau inversion recovery images, and the signal ratio of edema to unaffected bone and endplate contour (normal; irregular, yet intact; blurred; destructive) on sagittal unenhanced T1-weighted images. Differences were tested for statistical significance by Chi-square test and mixed model analysis of variance. The MR diagnostic accuracy in differentiating MT1 and spondylodiscitis was assessed by cross-tabulation and receiver-operating characteristic analysis. The endplate contours, edema extents, and T1-signal ratios of MT1 (extent, 31.96%; ratio, 0.83) were significantly different (p < 0.001) from early spondylodiscitis (56.42%; 0.60), and advanced spondylodiscitis (91.84%; 0.61). The highest diagnostic accuracy (sensitivity, 94.87%; specificity, 94.23%; accuracy, 94.51%) in identifying MT1 was provided by an irregular, yet intact endplate contour. This may be a useful MR feature for the differentiation between MT1 and spondylodiscitis, particularly in its early stage.
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Affiliation(s)
- Ursula Schwarz-Nemec
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria; (U.S.-N.); (F.K.S.); (M.W.); (S.F.N.)
| | - Klaus M. Friedrich
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria; (U.S.-N.); (F.K.S.); (M.W.); (S.F.N.)
- Correspondence: ; +43-140400-48950
| | - Christoph Stihsen
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, A-1090 Vienna, Austria; (C.S.); (J.G.G.)
| | - Felix K. Schwarz
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria; (U.S.-N.); (F.K.S.); (M.W.); (S.F.N.)
| | - Siegfried Trattnig
- MR Center of Excellence, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria;
| | - Michael Weber
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria; (U.S.-N.); (F.K.S.); (M.W.); (S.F.N.)
| | - Josef G. Grohs
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, A-1090 Vienna, Austria; (C.S.); (J.G.G.)
| | - Stefan F. Nemec
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria; (U.S.-N.); (F.K.S.); (M.W.); (S.F.N.)
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Tang G, Chen Y, Chen J, Wang Z, Jiang W. Higher proportion of low-virulence anaerobic bacterial infection in young patients with intervertebral disc herniation. Exp Ther Med 2019; 18:3085-3089. [PMID: 31572548 PMCID: PMC6755454 DOI: 10.3892/etm.2019.7910] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 07/29/2019] [Indexed: 12/13/2022] Open
Abstract
Intervertebral disc (IVD) degeneration caused by the latent infection of low-virulence anaerobic bacteria (LVAB) is a hot research topic. The present study analyzed and compared the positive rate of LVAB within IVDs of patients of different ages. IVD samples were intraoperatively retrieved from 176zpatients with disc herniation and subjected to microbiological culture. Subsequently, all the patients were classified into 3 groups based on their ages as follows: Group A (age <30 years), group B (age from 30 to 50 years) and group C (age >50 years) and the positive rates of LVAB were compared among the three groups. The severity of IVD degeneration was also assessed by measuring intervertebral height. Of the 176 cultured discs, 39 samples had bacterial growth, while 6 of them were suspiciously contaminated. Follwoing the exclusion of the 6 suspicious samples, 31 samples were Propionibacterium acnes and 2 samples were coagulase-negative Staphylococci of the remaining 33 samples, The bacterial positive rates were significantly higher in younger patients, with 34.4% (11/32), 25.5% (13/51) and 10.3% (9/87) in group A, B and C, respectively. More importantly, the bacterial-positive samples had a significantly lower disc height compared with the negative samples in groups A and B. Therefore, it can be reasonably concluded that younger patients have a much higher prevalence of LVAB infection in herniated IVDs and a greater severity of IVD degeneration when infected by bacteria. The LVAB may have a strong association with IVD degeneration, particularly in young patients.
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Affiliation(s)
- Guoqing Tang
- Orthopedic Center, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China.,Orthopedic Center, Kunshan Hospital of Traditional Chinese Medicine, Suzhou, Jiangsu 215300, P.R. China
| | - Yong Chen
- Orthopedic Center, Kunshan Hospital of Traditional Chinese Medicine, Suzhou, Jiangsu 215300, P.R. China.,Department of Orthopaedics, The Second Hospital Affiliated to Soochow University, Suzhou, Jiangsu 215008, P.R. China
| | - Ji Chen
- Orthopedic Center, Kunshan Hospital of Traditional Chinese Medicine, Suzhou, Jiangsu 215300, P.R. China
| | - Zhuo Wang
- Orthopedic Center, Kunshan Hospital of Traditional Chinese Medicine, Suzhou, Jiangsu 215300, P.R. China
| | - Weimin Jiang
- Orthopedic Center, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China
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Rao PJ, Maharaj M, Tang K, Lambie N, Scherman D, Phan K, Mobbs RJ. Degenerate-disc infection study with contaminant control (DISC): Application of a proposed histological scoring system. J Clin Neurosci 2019; 66:87-91. [DOI: 10.1016/j.jocn.2019.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 03/03/2019] [Accepted: 05/11/2019] [Indexed: 12/15/2022]
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Jiao Y, Lin Y, Zheng Y, Yuan Y, Chen Z, Cao P. The bacteria-positive proportion in the disc tissue samples from surgery: a systematic review and meta-analysis. 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 2019; 28:2941-2950. [PMID: 31312913 DOI: 10.1007/s00586-019-06062-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 04/08/2019] [Accepted: 06/10/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE The role of bacteria, especially Propionibacterium acnes (P. acnes), in human intervertebral disc diseases has raised attention in recent years. However, limited sample size of these studies and diverse bacteria-positive proportion made this topic still controversial. We aimed to review related articles and summarize the bacteria-positive proportion in these studies. METHODS We searched the PubMed, Cochrane Library, Embase for related literature from January 2001 to May 2018, and the reference articles were also searched. The random effects or fixed effects meta-analysis was used to pool the overall positive proportion or odds ratio of these studies. RESULTS We found 16 relevant articles and 2084 cases of the bacteria culture from surgery. Within the 16 included studies, 12 studies' results supported the infection in the discs. The pooled bacterial infection rate was 25.3%. The pooled P. acnes infection rate was 15.5%. The overall pooled P. acnes proportion in bacteria-positive discs was 56.4%. We also found that the presence of bacteria may contribute to the development of Modic change with the odds ratio as 1.27 (95% CI: 0.44-3.64), but this result is not significant due to heterogeneity, so further study is needed. CONCLUSION The existence of bacteria in the intervertebral discs was proved by many studies. However, the variety in sample collecting and culture methods is still obvious and the positive rate also fluctuated within the studies. Standardized and reliable methods should be taken to promote the study in the future. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Yucheng Jiao
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.,Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases with Integrated Chinese-Western Medicine, Shanghai Institute of Traumatology and Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Yazhou Lin
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.,Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases with Integrated Chinese-Western Medicine, Shanghai Institute of Traumatology and Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Yuehuan Zheng
- Department of Orthopedics, Ruijin Hospital North, Shanghai Jiaotong University School of Medicine, Shanghai, 201800, China
| | - Ye Yuan
- Department of Orthopaedics, Chang Gung Hospital, Tsinghua University, Beijing, 102202, China
| | - Zhe Chen
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China. .,Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases with Integrated Chinese-Western Medicine, Shanghai Institute of Traumatology and Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China.
| | - Peng Cao
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China. .,Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases with Integrated Chinese-Western Medicine, Shanghai Institute of Traumatology and Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China.
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Abstract
Cutibacterium acnes, long thought to be skin flora of pathological insignificance, has seen a surge in interest for its role in spine pathology. C acnes has been identified as a pathogen in native spine infection and osteomyelitis, which has implications in the management compared with more commonly recognized pathogens. In addition, It has also been recognized as a pathogen in postoperative and implant-associated infections. Some evidence exists pointing to C acnes as an unrecognized source of otherwise aseptic pseudarthrosis. Recently, it is hypothesized that low virulent organisms, in particular C acnes, may play a role in degenerative disk disease and the development of Modic end plate changes found in MRI. To this end, controversial implications exist in terms of the use of antibiotics to treat certain patients in the setting of degenerative disk disease. C acnes continues to remain an expanding area of interest in spine pathology, with important implications for the treating spine surgeon.
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48
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The Relationship Between Low-Grade Infection and Degenerative Disk Disease: A Review of Basic Science and Clinical Data. J Am Acad Orthop Surg 2019; 27:509-518. [PMID: 30575599 DOI: 10.5435/jaaos-d-18-00257] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Low back pain resulting from intervertebral disk degeneration is a cause of substantial disability and productivity loss. Over the past few years, growing evidence exists which suggests that low-grade bacterial infection, particularly infection with Cutibacterium acnes, may be associated with degenerative disk disease in the lumbar spine. Positive cultures are obtained in approximately 30% of intervertebral disk specimens removed at the time of surgery. In addition, one randomized trial has shown that antibiotic therapy for low back pain in patients with disk degeneration can slow the progression of degeneration and improve pain and disability levels. Although these results are encouraging, the link between infection and disk degeneration remains controversial. Investigators have attempted to address the limitations of clinical research by using translational methods and animal models. These methods have shown that seeding of the disk with bacteria can lead to increased local inflammation and an in vivo phenotype that is similar to human disk degeneration. This review seeks to provide an overview of the clinical, translational, and animal model data linking infection to disk degeneration. We review mechanisms for disk degeneration in the setting of infection and explore areas for future investigation.
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49
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Jensen OK, Andersen MH, Østgård RD, Andersen NT, Rolving N. Probiotics for chronic low back pain with type 1 Modic changes: a randomized double-blind, placebo-controlled trial with 1-year follow-up using Lactobacillus Rhamnosis GG. 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 2019; 28:2478-2486. [DOI: 10.1007/s00586-019-06046-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/14/2019] [Accepted: 06/20/2019] [Indexed: 02/02/2023]
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50
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New insights link low-virulent disc infections to the etiology of severe disc degeneration and Modic changes. Future Sci OA 2019. [DOI: 10.4155/fsoa-2019-0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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