Disc degeneration in Scheuermann disease

New information on paleopathologies in non-avian theropod dinosaurs: a case study on South American abelisaurids

Studies on pathological fossil bones have allowed improving the knowledge of physiology and ecology, and consequently the life history of extinct organisms. Among extinct vertebrates, non-avian dinosaurs have drawn attention in terms of pathological evidence, since a wide array of fossilized lesions and diseases were noticed in these ancient organisms. Here, we evaluate the pathological conditions observed in individuals of different brachyrostran (Theropoda, Abelisauridae) taxa, including Aucasaurus garridoi, Elemgasem nubilus, and Quilmesaurus curriei. For this, we use multiple methodological approaches such as histology and computed tomography, in addition to the macroscopic evaluation. The holotype of Aucasaurus shows several pathognomonic traits of a failure of the vertebral segmentation during development, causing the presence of two fused caudal vertebrae. The occurrence of this condition in Aucasaurus is the first case to be documented so far in non-tetanuran theropods. Regarding the holotype of Elemgasem, the histology of two fused vertebrae shows an intervertebral space between the centra, thus the fusion is limited to the distal rim of the articular surfaces. This pathology is here considered as spondyloarthropathy, the first evidence for a non-tetanuran theropod. The microstructural arrangement of the right tibia of Quilmesaurus shows a marked variation in a portion of the outer cortex, probably due to the presence of the radial fibrolamellar bone tissue. Although similar bone tissue is present in other extinct vertebrates and the cause of its formation is still debated, it could be a response to some kind of pathology. Among non-avian theropods, traumatic injuries are better represented than other maladies (e.g., infection, congenital or metabolic diseases, etc.). These pathologies are recovered mainly among large-sized theropods such as Abelisauridae, Allosauridae, Carcharodontosauridae, and Tyrannosauridae, and distributed principally among axial elements. Statistical tests on the distribution of injuries in these theropod clades show a strong association between taxa-pathologies, body regions-pathologies, and taxa-body regions, suggesting different life styles and behaviours may underlie the frequency of different injuries among theropod taxa.

Magnetic resonance imaging findings of the lumbar spine, back symptoms and physical function among male adult patients with Scheuermann's disease

Background

There are only a few studies on untreated Scheuermann's disease and magnetic resonance imaging (MRI) findings in the lumbar spine. The primary aim of this study was to clarify lumbar MRI findings in patients with Scheuermann's disease and to compare with subjects without diagnosed spine disease.

Methods

Twenty-two male adult Scheuermann's patients (mean age 64.7 years (Standard Deviation [SD] 6.4) and 26 males (mean age 59.7 years [SD 7.4]) from a national health survey were included in this study. From MR images, the dimensions of the vertebral bodies, intervertebral discs and the dural sac were measured. Spondylolisthesis, Modic changes (MC), high intensity zone values (HIZ), and Schmorl's nodes were registered from both groups as well as self-reported data concerning general health, quality of life, and back pain symptoms.

Results

Significantly more patients with Scheuermann's disease had at least one MC compared to the controls at the level L1/L2 (Odds Ratio [OR] 21.11, 95% Confidence Interval [95% CI] 2.31-192.96), at the level L3/L4 (OR 13.62, 95% CI 1.41-131.26), and at the level L5/S1 (OR 6.11, 95% CI 1.50-24.83). Patients had significantly more Schmorl's nodes compared to the controls (64% vs. 8%, p < 0.001). The area of the dura sac (L3/L4) was larger (mean 201 mm² vs. 152 mm², p = 0.017) in the patients compared to controls. At level L1/L2 patients had higher disc than controls (mean 7.9 mm vs. 6.8 mm, p = 0.038). After adjusting for age patients had more commonly constant back pain (OR 9.4, 95% CI 1.56-56.97), and difficulties in walking up one floor without resting (OR 9.8, 95% CI 1.01-95.34) than controls.

Conclusions

Schmorl's nodes and Modic changes on lumbar MRI, back pain and physical function restrictions seem to be more prevalent among patients with Scheuermann's disease than in the general population.

Evaluation and management of paediatric and adolescent back pain: Epidemiology, presentation, investigation, and clinical management: A narrative review

This narrative review will summarise a clinical approach to the investigation of back pain in children and adolescent patients, including a discussion of the epidemiology, presentation, investigation and clinical management of back pain in children and adolescents. This will assist the prompt and accurate diagnosis of spinal disorders that require significant medical intervention. Existing evidence suggests a relatively high incidence of non-specific back pain among young people; 27-48% of presentations of back pain in children and adolescents are attributed to non-specific back pain. Low back pain among schoolchildren is often linked to psychosocial factors and only occasionally requires medical attention, as pain is benign and self-limiting. Nonetheless, those young patients who seek medical assistance exhibit a higher incidence of organic conditions underlying the major symptom of spinal pain. A cautious and comprehensive strategy - including a detailed history, examination, radiographic imaging and diagnostic laboratory studies - should be employed, which must be accurate, reliable, consistent and reproducible in identifying spinal pathologies. A specific diagnosis can be reached in 52-73% of the cases. For cases in which a specific diagnosis cannot be made, re-evaluation after a period of observation is recommended. At this later stage, minor symptoms unrelated to underlying pathology will resolve spontaneously, whereas serious pathologies will advance and become easily identified.

Lumbar vertebral endplate defects on magnetic resonance images: prevalence, distribution patterns, and associations with back pain

BACKGROUND CONTEXT

Although the roles of Modic Changes (MCs) and disc degeneration in back pain remain controversial, clues from cadaveric studies suggest that lumbar vertebral endplate lesions may be important in back pain. Endplate lesions can be detected on magnetic resonance (MR) images as various endplate defects, including focal, corner, and erosive defects. Yet, the clinical significance of such endplate defects remains unknown.

PURPOSE

To determine the prevalence and distribution patterns of lumbar vertebral endplate defects and their associations with back pain in a population-based sample.

STUDY DESIGN

Cross-sectional study.

PATIENT SAMPLE

Subjects were randomly selected from a typical community in Hangzhou Eastern China, regardless of back pain status.

OUTCOME MEASURES

Each subject underwent a structured interview and lumbar MR imaging. Back pain history, including today, over the past 4 weeks, 12 months, and lifetime, were acquired. Endplate defects, MCs, and disc degeneration were evaluated on MRIs. Age, gender and body mass index (kg/m²), as well as lifetime exposures, including smoking history, riding in motorized vehicles and associated vibration, and occupational physical demands were assessed.

METHODS

Descriptive statistics were used to depict prevalence and distribution patterns of endplate defects in the lumbar spine. Logistic regressions were used to examine associations of endplate defects with back pain. The research grant was obtained from the National Natural Science Foundation of China (115,000 USD), Key Platform Project of the Health Department of Zhejiang Province (14,000 USD), Technology Program of Traditional Chinese Medicine Department of Zhejiang Province (21,000 USD), and 2015 Qianjiang Talent Program of Zhejiang Province (7,000 USD) toward this work. There is no conflict to disclose.

RESULTS

There were 478 subjects (53.3±14.4 years, range 20-88 years) studied. Endplate defects presented in 301 (63.0%) subjects and 842 (16.0%) endplates. The presence of endplate defects, but not MCs and disc degeneration, was associated with lifetime back pain (odds ratio=1.64, p=.026) in multivariate analyses. Focal and erosive endplate defects were associated with lifetime back pain history (odds ratio=1.74-2.23, p<.05 for both), whereas all three types of defects were associated with intensity of worst back pain over the past 12 months (Coef=5.84-7.19, p<.05 for all).

CONCLUSIONS

Endplate defects are common findings on lumbar MRIs in adults. Specific types of endplate defects were associated with back pain history. Endplate defects may be an independent risk factor for back pain.

Wedge-shaped vertebrae is a risk factor for symptomatic upper lumbar disc herniation

Background

At present, much is unknown about the etiology and pathogenesis of ULDH. However, it is interesting to note that many ULDH patients have a radiographic feature of adjacent vertebral wedge deformation. The purpose of this study is to investigate the relationship between symptomatic upper lumbar disc herniation (ULDH) and wedge-shaped vertebrae (WSV).

Methods

This was a retrospective study of 65 patients with single-level ULDH, who had undergone surgery at our medical center between January 2012 and December 2016. Clinical data including clinical and radiological evaluation results were performed.

Results

The incidence of WSV in the ULDH group (44.6%, 29/65) was more than in the lower lumbar disc herniation group (21.5%, 14/65). And there were statistically significant differences in WSV (χ² = 7.819, P = 0.005), wedging angle of the vertebrae (WAV) (t = 9.013, P < 0.001), and thoracolumbar kyphotic angle (TL) (t = 8.618, P < 0.001) between two groups. Based on multivariate logistic regression analysis, WAV (OR = 0.783, 95% CI = 0.687–0.893, P < 0.001) and TL (OR = 0.831, 95% CI = 0.746–0.925, P = 0.001) were independently associated with ULDH. The cutoff values of WAV and TL were 5.35° and 8.35°, which were significantly associated with ULDH (OR = 3.667, 95% CI = 1.588–8.466, P = 0.002).

Conclusion

The WSV is an independent risk factor for ULDH. WAV > 5.35° and TL > 8.35° were the predictors for ULDH. It should be noted that the patients with vertebral wedge deformation combined with thoracolumbar kyphosis have a higher risk of ULDH.

Permian metabolic bone disease revealed by microCT: Paget's disease-like pathology in vertebrae of an early amniote

Bone remodeling is an essential physiological process in growth and healing. In modern systems deviations from normal bone physiology in the form of pathologies aid in the understanding of normal bone metabolism. Here we use external morphology and X-ray microtomography to diagnose and describe a metabolic bone disease in an amniote from the early Permian. The specimen consists of two fused tail vertebrae of a small varanopid from early Permian (289 million years old) cave deposits near Richards Spur, Oklahoma, USA. Inspection of the outer morphology reveals that the fusion encompasses the vertebral centra, zygopophyses and haemal arches, with the fusion zones distinctly swollen on the left side of the specimen. With visualization of its internal structure by microCT, this specimen is diagnosed as a complex metabolic bone disease. The radiological imaging suggests a pathologically high bone turnover rate, as shown by abnormal bone formation in some areas and increased bone resorption in others. This supports that the varanopid suffered from a metabolic bone disease similar to Paget’s disease of bone as seen in humans today, which is linked to both genetic and viral factors. This finding extends the occurrence of Paget-like disease to the early Permian, and–provided a viral component was present–would also be by far the oldest evidence of viral infection in the fossil record.

Trends in Treatment of Scheuermann Kyphosis: A Study of 1,070 Cases From 2003 to 2012

STUDY DESIGN

Retrospective review of KID Inpatient Database (KID) from 2003, 2006, 2009, and 2012.

OBJECTIVES

The aim of this study was to evaluate the impact of advances in spinal surgery on patient outcomes in the treatment of Scheuermann kyphosis (SK).

SUMMARY OF BACKGROUND DATA

SK is one of the most common causes of back pain in adolescents. Trends in diagnoses and surgical treatment and approach to SK have not been well described.

METHODS

SK patients aged 0-20 years in KID were identified by ICD-9 code 732.0. KID-supplied year- and hospital-trend weights were used to establish prevalence. Patient demographics, surgical details, and outcomes were analyzed with analysis of variance.

RESULTS

A total of 1,070 SK patients were identified (33.2% female), with increasing incidence of SK diagnosed from 2003 to 2012 (3.6-7.5 per 100,000, p < .001). The average age of operative patients was 16.1±2.0 years and did not change (16.27-16.06 years, p = .905). The surgical rate has not changed over time (72.8%-72.8%, p = .909). Overall, 96.3% of operative patients underwent fusion, with 82.2% of cases spanning ≥4 levels; in addition, 8.6% underwent an anterior-only surgery, 74.6% posterior-only, and 13.6% combined approach. From 2003 to 2012, rates of posterior-only surgeries increased (62.4%-84.4%, p < .001) whereas the rate of combined-approach surgeries decreased (37.6%-8.8%, p < .001). Overall complication rates for SK surgeries have decreased (2003: 20.9%; 2012: 11.9%, p = .029). Concurrently, the rate of ≥4-level fusions has increased (43.5%-89.6%, p < .001), as well as the use of Smith-Peterson (7.8%-23.6%, p < .001) and three-column osteotomies (0.0%-2.7%, p = .011). In subanalysis comparing posterior to combined approaches, complication rates were significantly different (posterior: 9.88%, combined: 19.46%, p = .005). Patients undergoing a combined approach have a longer length of stay (LOS) than patients undergoing a posterior-only approach (7.8 vs. 5.6 days, p < .001).

CONCLUSIONS

Despite unchanged demographics and operative rates in SK, there has been a shift from combined to isolated posterior approaches, with a concurrent increase in levels treated. A combined approach was associated with increased complication rates, LOS, and total charges compared to isolated approaches. Awareness of these inherent differences is important for surgical decision making and patient education.

LEVELS OF EVIDENCE

Level III.

Long term prognosis of Scheuermann's disease: The association with fragility fracture - The MINOS cohort

The aim was to assess the association of Scheuermann's disease (SCD) with fracture risk (vertebral, peripheral) and bone mineral density (BMD) in older men. SCD was assessed on the baseline lateral spine radiographs using the Berlin criteria in 766 men aged 50-85. We evaluated the association of SCD and its diagnostic criteria with incident fracture (vertebral over 7.5 years, peripheral over 10 years) and BMD (baseline). SCD prevalence was 25.2%. SCD and its criteria showed inconsistent associations with BMD at different skeletal sites. Eighty-four men had incident fractures. After adjustment for age, weight, spine BMD, prevalent vertebral fractures, prior falls and score of disc space narrowing due to osteoarthritis (DSN-OA), SCD was not associated with vertebral fracture risk. Vertebral endplate irregularities (EI), one of its diagnostic criteria, were associated with higher vertebral fracture risk (OR = 3.26, 95% CI: 1.34-7.94, p < 0.01). Vertebral fracture risk was higher in men with EI and low spine BMD vs. men without these characteristics (OR = 12.84, 95% CI: 3.12-52.83, p < 0.005). EI was associated with higher vertebral fracture risk in men without severe DSN-OA and without prevalent vertebral fractures. Peripheral fracture risk was lower in men with SCD (HR = 0.39, 95% CI: 0.18-0.83, p < 0.02) and EI. Peripheral fracture risk was higher in men without SCD who had low femoral neck BMD vs. men with SCD and normal BMD (HR = 4.68, 95% CI: 1.09-20.03, p < 0.05). In conclusion, EI were associated with high vertebral fracture risk. SCD and EI were associated with lower peripheral fracture risk. The associations of SCD and its criteria with BMD were inconsistent.

Quantitative MRI in early intervertebral disc degeneration: T1rho correlates better than T2 and ADC with biomechanics, histology and matrix content

Introduction

Low-back pain (LBP) has been correlated to the presence of intervertebral disc (IVD) degeneration on T2-weighted (T2w) MRI. It remains challenging, however, to accurately stage degenerative disc disease (DDD) based on T2w MRI and measurements of IVD height, particularly for early DDD. Several quantitative MRI techniques have been introduced to detect changes in matrix composition signifying early DDD. In this study, we correlated quantitative T2, T1rho and Apparent Diffusion Coefficient (ADC) values to disc mechanical behavior and gold standard early DDD markers in a graded degenerated lumbar IVD caprine model, to assess their potential for early DDD detection.

Methods

Lumbar caprine IVDs were injected with either 0.25 U/ml or 0.5 U/ml Chondroïtinase ABC (Cabc) to trigger early DDD-like degeneration. Injection with phosphate-buffered saline (PBS) served as control. IVDs were cultured in a bioreactor for 20 days under axial physiological loading. High-resolution 9.4 T MR images were obtained prior to intervention and after culture. Quantitative MR results were correlated to recovery behavior, histological degeneration grading, and the content of glycosaminoglycans (GAGs) and water.

Results

Cabc-injected IVDs showed aberrancies in biomechanics and loss of GAGs without changes in water-content. All MR sequences detected changes in matrix composition, with T1rho showing largest changes pre-to-post in the nucleus, and significantly more than T2 and ADC. Histologically, degeneration due to Cabc injection was mild. T1rho nucleus values correlated strongest with altered biomechanics, histological degeneration score, and loss of GAGs.

Conclusions

T2- and T1rho quantitative MR-mapping detected early DDD changes. T1rho nucleus values correlated better than T2 and ADC with biomechanical, histological, and GAG changes. Clinical implementation of quantitative MRI, T1rho particularly, could aid in distinguishing DDD more reliably at an earlier stage in the degenerative process.

Spinal cord ischemia in Scheuermann disease: A report of three cases

BACKGROUND

Neurological complications in Scheuermann's disease are rare but serious.

CASE REPORTS

We report three cases of severe neurological deficit due to medullar ischemia attributable to the compression of a radiculomedullar artery by thoracic (two cases) and lumbar (one case) disc herniations associated with Scheuermann's disease. They were not treated surgically because of the absence of direct spinal cord compression or definitive spinal cord ischemia. Those young patients still have severe neurological damage. An earlier management could have prevented them.

CONCLUSION

When doubting about any compressive sign, MRI should be performed with diffusion weighted imaging (DWI) and apparent diffusion coefficient (ADC) sequences in emergency.

Successful brace treatment of Scheuermann's kyphosis with different angles

Background:

Scheuermann's disease is regarded as the most common cause of structural hyperkyphosis within adolescents without any proper treatment. It may lead to progressive deformity and back pain which influences patient's quality of life during adolescence and adulthood. Treatment approach to Scheuermann's kyphosis has not been clearly defined due to its different definitions and obscure natural history. The goal of treatment is not only to prevent progression but also to obtain permanent correction. Bracing, especially Milwaukee brace and physiotherapy are two of the common nonoperative treatment modalities. Hence, the present study intended to evaluate the effectiveness of Milwaukee brace on progression control as well as correction of Scheuermann's kyphosis.

Materials and Methods:

In a retrospective, observational study, all the patients diagnosed with Scheuermann's kyphosis were reviewed in 2003–2013, who were treated by Milwaukee brace at a single center. There was a minimum of 2-year follow-up after completion of bracing, during which clinical and radiological parameters were identified and recorded.

Results:

The mean angle of kyphosis in these patients at the presentation was 63.24 ± 9.96 and at the end of this study was 36.5° ± 13.4° (P < 0.001). Moreover, mean improved angle in those patients with <75° of kyphosis was 25.26° ± 7.78° and in those with 75° or more than 75° of kyphosis was 26.77° ± 19.76° (P < 0.001).

Conclusion:

Conservative treatment with Milwaukee brace and physiotherapy was effective in our hand for halting kyphosis progression in 97.5% of Scheuermann's kyphosis, which could be advised for cases up to 90° of kyphosis before skeletal maturity. As a result, a trial of brace treatment could be recommended in patients with severe kyphosis (up to 90°) which can open a new insight in conservative treatment of Scheuermann's kyphosis.

Radiological imaging findings of scheuermann disease

AIM

To find accompanying anomalies of typical and atypical Scheuermann’s disease (SD) is reported in the present study.

METHODS

Study included 20 patients (16 men and 4 women) who had radiological imaging radiography, magnetic resonance imaging (MRI) and computed tomography, if available, due to back pain, curved back and low back pain in November 2011-February 2016 period. Patients were categorized into typical and atypical patterns based on the region involved. Thoracic kyphosis values were measured using real Cobb angle. Accompanying disc degeneration, herniations and spinal cord pathologies were studied using MRI.

RESULTS

Age of the patients ranged from 11.0 to 23.0 (mean 17.2 ± 3.0). Typical pattern of SD were detected in 15 patients while atypical pattern were detected in 5 patients. Cobb angle range was 40.2-67.2 (mean 55.5 ± 8.7) in typical Scheuermann’s patients and 24.7-49.9 (mean 36.7 ± 10.8) in atypical ones. Intervertebral level was affected and had the measures of 3-8 (mean 5.3 ± 1.6) and 7-9 (mean 8.2 ± 0.8) in typical and atypical Scheuermann’s patients, respectively. Level of degenerative disc disease in MRI was 1-7 discs (mean 4.1 ± 1.7) in typical patients and 5-10 discs (mean 7.6 ± 1.9) in atypical patients.

CONCLUSION

SD can be seen in typical and atypical patterns, typical being more frequent. Because degenerative disc diseases, herniations and cord pathologies such as syringomyelia can accompany SD (albeit more common in atypical pattern), it is necessary to evaluate these patients with plain radiography and MRI together.

Evaluation of the disco-vertebral junction using ultrashort time-to-echo magnetic resonance imaging: inter-reader agreement and association with vertebral endplate lesions

OBJECTIVE

To evaluate ultrashort time to echo (UTE) magnetic resonance (MR) morphology of the cartilaginous endplates (CEP) in cadaveric lumbar spines with bony vertebral endplate (VEP) lesions, to determine inter-reader agreement as well as associations between the CEP morphology and VEP lesions as well as other abnormalities.

MATERIALS AND METHODS

MR imaging of cadaveric lumbar spines from 10 donors was performed at 3T using a UTE MR sequence. Two musculoskeletal radiologists identified the location of vertebral endplate lesions in consensus. The morphology of the CEP overlying the lesions and in the adjacent normal regions was assessed individually. A total of 55 vertebral lesions and 55 normal regions were assessed. The presence of osteophytosis, morphological changes of the anterior and posterior longitudinal ligament, and intervertebral disc signal and morphology was also assessed. Agreement between observers was determined using Cohen's kappa analysis, and association between CEP and vertebral endplate lesions was determined using the chi square test.

RESULTS

Fifty-five vertebral endplate lesions were identified and the morphology of CEP evaluated by two readers was in substantial agreement with Cohen's kappa of 0.78. The presence of vertebral endplate abnormality was associated with the presence of osteophytes (39 out of 55 levels), altered morphology and signal of the anterior longitudinal ligament (23 out of 55 levels) and intervertebral discs (30 out of 55 levels).

CONCLUSION

UTE MRI enables evaluation of the CEP with substantial inter-reader agreement. Abnormal changes of the CEP may facilitate formation of lesions of vertebral endplate over time and are associated with degenerative changes of the lumbar spine.

MR imaging of Schmorl's nodes: Imaging characteristics and epidemio-clinical relationships

PURPOSE

The purpose of our prospective study was to assess the presentation of Schmorl's nodes (SN) on magnetic resonance imaging (MRI) and investigate their possible association with demographic and clinical findings.

MATERIALS AND METHODS

Three hundred and thirty-three patients were prospectively included. Thirteen (3.9%) patients were excluded because of contraindication to MRI and/or Scheuermann's disease. The final study population included 320 patients. T1-weighted and short TI inversion recovery sequences were performed to assess SN prevalence, the vertebral level and their anatomical distribution in vertebra. Medical history was recorded focusing on previous diseases including degenerative, rheumatoid and neoplastic disease, and any existing spinal traumatism. Epidemiological information was also obtained, including age, gender, ethnicity, professional and sporting activity.

RESULTS

The final study population included 320 patients (172 men, 148 women) with a mean age of 54 years±17.5 (SD) (range: 19-87 years). A total of 421 SN were found in 158/320 patients (49.4%). SN were localized in thoracic spine for 48%, in lumbar spine for 46% and cervical spine for 6%. The middle part of the thoracic vertebra was the most affected area (80%), mostly in the middle superior endplate (41%). SN were more frequently observed in manual workers who worked more than 10 years (P<0.0001) and less frequently in patients of the 30-39-year-old age group (P=0.0048). No significant associations were found with gender (P=0.17) and remarkable medical history (P=0.21). SN were less frequently observed in patients with sport activities of 1-5hours/week (P=0.04) and those with an African origin (P<0.0001).

CONCLUSION

Our study suggests a potential role for ethnical and physical factors in the pathogenesis of SN. Furthers studies are mandatory to evaluate their clinical relevance, especially in patients such as Caucasian manual workers in whom SN have a high prevalence.

The Influence of Lumbar Spinal Subtype on Lumbar Intervertebral Disc Degeneration in Young and Middle-Aged Adults

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To identify whether an in vivo correlation exists between lumbar spinal subtype (LSS) and lumbar disc degeneration (LDD) in young adults.

SUMMARY OF BACKGROUND DATA

Lumbar disc degeneration has largely been ascribed to biomechanical and structural alterations to the disc, which are attributed to aging and pathological physical loading. Sagittal alignment in the asymptomatic spine has also been considered. A biomechanical study by Roussouly and Pinheiro-Franco proposed level-specific patterns in LDD. To date, no in vivo correlation between the LSS and LDD has been established.

METHODS

The authors screened 608 consecutive patients over 5.3 years. Lumbar spinal subtype and pelvic parameters were collected from standing lumbar radiographs and were categorized using the classification of Roussouly and Pinheiro-Franco. Lumbar disc degeneration at all lumbar intervertebral levels was classified using criteria of Pfirrmann et al. A stratified disc degeneration score was derived for each patient. Lumbar disc degeneration in type I, II, and IV LSS was compared using chi-square test. Pelvic incidence was correlated with stratified disc degeneration score using Spearman R, to determine whether a high PI was protective against LDD. Statistical significance was accepted at p < .05.

RESULTS

A total of 139 patients were included, with 91 females and a mean age of 32.6 years (range, 13-49 years). For LSS grades I to IV, there were 10 (7.3%), 43 (30.9%), 50 (35.9%), and 36 (25.9%) patients, respectively. The proportion of high-grade (Pfirrmann grades IV and V) LDD increased distally toward the lower intervertebral levels, affecting 2.88%, 2.9%, 5%, 9.4%, 33.1%, and 54% of discs at each sequential lumbar level from T12-L1 to L5-S1, respectively. Age but not gender was statistically significant for higher-grade LDD (p < .0001 and p = .442, respectively). Pelvic incidence across all LSS grades was not significantly correlated with stratified disc degeneration score (Spearman R = 0.0933; p = .335). No LSS (type I-IV) reached statistical significance for a specific pattern of LDD.

CONCLUSIONS

In this study, LSS was not statistically significantly correlated with LDD, nor was a high pelvic incidence protective against LDD.

Radiological signs of Scheuermann disease and low back pain: retrospective categorization of 188 hospital staff members with 6-year follow-up

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To investigate the relationship between radiological signs of Scheuermann disease (SD) and low back pain (LBP) in a local population using lumbar magnetic resonance (MR) images.

SUMMARY OF BACKGROUND DATA

SD is a spinal disorder, and both its classic and atypical (lumbar) forms are associated with LBP. However, radiological signs of SD are present in 18% to 40% of the general population, in whom the clinical significance of "SD-like" spine remains largely unknown.

METHODS

This retrospective cohort study included 188 staff members from a single hospital. Participants' lumbar MR images and self-administered questionnaires concerning demographic information, LBP status, consequences, and functional limitations were collected. Participants were classified into 2 groups according to whether lumbar MR images met SD diagnostic criteria, and LBP status, consequences, and functional limitation were compared. Follow-up interviews were conducted after 6 years to compare LBP progression.

RESULTS

Thirty-four participants (18.1%) had SD-like spine. Rates of lifetime, previous 1-year, and point LBP did not significantly differ between groups. However, among participants who had ever had LBP, SD-like spine was associated with higher rates of work absence (42.1% vs. 9.5%, χ = 9.620, P = 0.002) and seeking medical care (68.4% vs. 39.2%, χ = 5.216, P = 0.022) due to LBP, as well as significantly greater intensity of the most severe LBP episode in the past 2 years (6.4 ± 2.5 vs. 4.1 ± 2.5, t = 3.564, P = 0.001). Among the 159 participants who completed the 6-year follow-up, a significantly higher proportion of people with SD-like spine reported aggravated LBP during the follow-up.

CONCLUSION

Our results suggest that in the general population, lumbar MR images of many people meet SD diagnostic criteria, and having SD-like spine seemed to be associated with the severity and progressive nature of LBP. Our findings should inspire further research in this field.

LEVEL OF EVIDENCE

3.

Scheuermann's disease: an update

Scheuermann's disease is a juvenile osteochondrosis of the spine. It is a disease of the growth cartilage endplate, probably due to repetitive strain on the growth cartilage weakened by a genetic background. The radiographic aspects are related to the vertebral endplate lesions and include vertebral wedging, irregularity of the vertebral endplate, and Schmorl's node (intraossous disk herniation). Disc alterations are frequent and may be secondary to dysfunction of the disc-vertebra complex. The definitions of Scheuermann's disease are varied; it can refer to the classical form of juvenile kyphosis, described by Scheuermann as well as asymptomatic radiographic abnormalities. Lumbar involvement is probably as frequent as the thoracic form and might be more painful. The first-line treatment is medical and includes rehabilitation and bracing. The earlier the start of treatment, the better the outcome, which highlights the importance of early diagnosis. Surgery is uncommon and must be limited to severe involvement after failure of conservative treatment. The natural history of Scheuermann's disease is unknown, but it might be associated with increased risk of back pain. The evolution of thoracolumbar and lumbar disease is unknown.

Acute Schmorl's Node during Strenuous Monofin Swimming: A Case Report and Review of the Literature

Study Design This case report describes an acute Schmorl's node (SN) in an elite monofin athlete during exercise. The patient presented with severe back pain and leg numbness and was managed successfully with conservative treatment. Objective The aim of our communication was to describe a rare presentation of a common pathological condition during an intense sport. Background Swimming is not generally considered to be a sport activity that leads to spinal injuries. SNs are usually asymptomatic lesions, incidentally found on imaging studies. There is no correlation between swimming and symptomatic SN formation. Case Report A 16-year-old monofin elite athlete suffered from an acute nonradiating back pain during extreme exercise. His back pain was associated with a fracture of the superior L5 end plate and an acute SN at the L5 vertebral body with perilesional bone marrow edema. The pain resolved with nonsteroidal anti-inflammatory drugs and bed rest. The athlete had an excellent outcome and returned to his training activities 6 months after his incident. Conclusion SN should be considered in the differential diagnosis of severe back pain, especially in sport-related injuries. SNs present with characteristic imaging findings. Due to the benign nature of these lesions, surveillance-only management may be the best course of action.

Back pain in the pediatric and adolescent athlete

Clinicians taking care of athletes are likely to see many young patients complaining of back pain. The young athlete places significant repetitive stresses across the growing thoracolumbar spine, which can cause acute and overuse injuries that are unique to this age and patient population. Fortunately, by using a careful and systematic approach, with a sport-specific history, careful physical exam, and proper imaging, most problems can be properly identified. Although it is important to always remember that rare and more serious problems such as a neoplasm or infection maybe a source of pain in the athletic patient, most problems are benign and can be treated conservatively. Accurate diagnosis and management of back pain not only can prevent long-term deformity and disability, but it can also allow young athletes to return to doing what they love to do most: play sports.

A population-based study of juvenile disc degeneration and its association with overweight and obesity, low back pain, and diminished functional status

BACKGROUND

Little is known regarding juvenile disc degeneration in individuals with normal spinal alignment. Consequently, the purpose of this study was to assess the prevalence, determinants, and clinical relevance associated with juvenile disc degeneration of the lumbar spine in individuals without spinal deformities.

METHODS

A cross-sectional assessment of disc degeneration in juveniles was performed as part of a population-based study of 1989 Southern Chinese volunteers. Adolescents and young adults from thirteen to twenty years of age were defined as "juveniles." Juvenile subjects with no spinal deformity (n = 83) were stratified into two groups, those with and those without juvenile disc degeneration. Sagittal T2-weighted magnetic resonance images (MRI) were evaluated for the presence and extent of disc degeneration as well as other spinal findings. Demographics were assessed and clinical profiles were collected with use of standardized questionnaires.

RESULTS

Juvenile disc degeneration was present in 35% (twenty-nine) of the juveniles without spinal deformity. Disc bulging or extrusion (p < 0.001), high-intensity zones on MRI (p = 0.040), and greater weight (p < 0.001) and height (p = 0.002) were significantly more prevalent in subjects with juvenile disc degeneration. Adjusted multivariate logistic regression modeling demonstrated that Asian-modified body-mass index (BMI) values in the overweight or obese range had a significant association with juvenile disc degeneration (odds ratio = 14.19; 95% confidence interval = 1.44 to 140.40; p = 0.023). Overweight and obese individuals had greater severity of disc degeneration than underweight and normal-weight individuals (p = 0.036). Furthermore, individuals with juvenile disc degeneration had an increased prevalence of low back pain and/or sciatica (p = 0.002), greater low back pain intensity (p < 0.001), diminished social functioning (p = 0.049), and greater physical disability (p < 0.05) than individuals without disc degeneration. The p value of <0.05 for physical disability represents both the physical function (p = 0.006) and the physical component (p = 0.032) of the SF-36.

CONCLUSIONS

This study demonstrated that the presence of juvenile disc degeneration was strongly associated with overweight and obesity, low back pain, increased low back pain intensity, and diminished physical and social functioning. Furthermore, an elevated BMI was significantly associated with increased severity of disc degeneration. This study has public health implications regarding overweight and obesity and the development of lumbar disc disease.

ISSLS prize winner: prevalence, determinants, and association of Schmorl nodes of the lumbar spine with disc degeneration: a population-based study of 2449 individuals

STUDY DESIGN

A cross-sectional population-based magnetic resonance imaging study of Schmorl nodes (SN) in the lumbar spine.

OBJECTIVE

To determine the prevalence and potential determinants of SN, and their association with intervertebral disc degeneration.

SUMMARY OF BACKGROUND DATA

SN represent intravertebral disc herniation and are commonly seen in the spine. Their reported prevalence and determinants vary, and their association with disc degeneration remains uncertain. Data based on this large scale population-based study of intervertebral disc degeneration would provide important information for understanding SN and their pathomechanism.

METHODS

Sagittal T2-weighted magnetic resonance imagings of the lumbar spine were analyzed in 2449 volunteers. Two independent observers assessed the images for the presence of SN, and scored for additional radiologic features (e.g., severity of degeneration, presence of disc bulge/extrusion). Subject demographics were assessed by standardized questionnaire.

RESULTS

SN were found in 16.4% (n = 401; 219 males, 182 females; mean age = 42.3) of our study population (981 males, 1468 females; mean age = 40.4), being most common at L1/2 and L2/3 (54.1%). Multivariate logistic regression revealed that males, taller and heavier individuals had an increased likelihood of SN (P < 0.005), but association between SN and age were not discerned. Overall presence of SN was associated with disc degeneration (P < 0.001), and linearly correlated (R = 0.97) with increase in severity of degeneration. SN were particularly associated with severe disc degeneration at L1/2 and L2/3 with 22- to 15-fold increased odds, respectively (P < 0.0001), but less than 5-fold increased odds (P < 0.001) were noted in the lower lumbar spine.

CONCLUSION

In a population-based cohort, 16.4% of Southern Chinese subjects had SN at 1 or more lumbar levels. Males, taller and heavier individuals had increased likelihood of SN. Interestingly, SN were highly associated with severity of disc degeneration.

Acute injury of an intervertebral disc in an elite tennis player: a case report

STUDY DESIGN

A case report.

OBJECTIVE

To present a previously not described rare case of intradiscal hematoma due to acute trauma in an elite tennis player.

SUMMARY OF BACKGROUND DATA

Several studies have demonstrated a high frequency of radiological changes in the spine of athletes, especially in sports with high loads on the back. Signs of disc degeneration without disc herniation have frequently been found in magnetic resonance imaging (MRI) studies of the spine of athletes. It has also been shown that radiological abnormalities of the spine in young athletes are correlated to back pain.

METHODS

An elite male tennis player experienced pain in the right buttock after a backhand stroke. He was successfully treated for hip problems and started to play competitive tennis, 2 weeks later. After few games, a backhand stroke again resulted in intense pain projected in the os coccyx region. At examination, there were no neurologic disturbances. At palpation over the spinal processes (Springing test) of L1-L2, the patient experienced intense pain projected to the os coccyx region.

RESULTS

MRI examination showed an injured L1-L2 disc with fluid inside the disc with a signal similar to blood. Four additional MRI examinations were performed 2 weeks and 2 years after the injury until disc degeneration is formed. Radiograph examination before and 2 years after the injury is available.

CONCLUSION

In conclusion, trauma in athletes can cause intradiscal hematoma, which probably is a new etiology for disc degeneration. Also that sudden onset of pain in the hip or the gluteal region may be caused by referred pain due to a disc lesion. Intradiscal hematoma can be visualized using MRI.

Spontaneous fusion across the apex of severe thoracolumbar Scheuermann's kyphosis: A surgical consideration

Considerable debate exists regarding the pathogenesis, natural history and treatment of Scheuermann's kyphosis. Surgical correction is indicated in the presence of severe kyphosis which carries the risk of neurological complications, persistent back pain and significant cosmetic deformity. This can be achieved through a posterior-only or an anteroposterior approach. Spontaneous fusion in association with Scheuermann's kyphosis has not been previously described. This is an important consideration if surgical correction of the kyphosis is planned. Two patients with severe thoracolumbar Scheuermann's kyphosis who developed spontaneous posterior and anteroposterior fusion across the apex of the deformity are presented. The surgical treatment and final outcome is discussed.

Modic type III lesions and Schmorl's nodes are the same pathological changes?

INTRODUCTION

Degenerative disc disease (DDD) is a major health problem worldwide. Both Modic lesions and Schmorl's nodes are considered to correlate with DDD such as low back pain. Modic lesions are the changes of degenerative vertebral endplate and adjacent bone marrow observed on magnetic resonance imaging and are divided into three types. Modic type III lesions are thought to represent extensive subchondral bone sclerosis within the bone marrow of adjacent endplate. The pathological performance of Schmorl's nodes is cystic lesions around indistinct sclerotic margins and beneath the cartilaginous endplate. Coincidently, there are many similarities between Modic type III lesions and Schmorl's nodes including pathological appearances, pathogenetic location and related diseases.

HYPOTHESIS

We hypothesize that Modic type III lesions and Schmorl's nodes are the same pathological changes, and Modic type III lesions may be the quiescent or incipient pathology phrase of Schmorl's nodes. The clinical symptoms of DDD are also accompanied by emergence of these pathological changes.

TESTING

A longitudinal study could be used to test this hypothesis. We could measure and analyze whether Modic type III lesions have increased in size or evolved into Schmorl's nodes as time goes on.

SIGNIFICANCE

This hypothesis explains the possible pathologic process of Modic type III lesions and Schmorl's nodes. If the hypothesis were conformed, Modic type III lesions and Schmorl's nodes will be rediscovered, which provides the new basis for the clinical treatment of DDD. In additions, this hypothesis also has crucial significances for the classification of Modic lesions.

The pathophysiology of disc degeneration: a critical review

The pathophysiology of intervertebral disc degeneration has been extensively studied. Various factors have been suggested as influencing its aetiology, including mechanical factors, such as compressive loading, shear stress and vibration, as well as ageing, genetic, systemic and toxic factors, which can lead to degeneration of the disc through biochemical reactions. How are these factors linked? What is their individual importance? There is no clear evidence indicating whether ageing in the presence of repetitive injury or repetitive injury in the absence of ageing plays a greater role in the degenerative process. Mechanical factors can trigger biochemical reactions which, in turn, may promote the normal biological changes of ageing, which can also be accelerated by genetic factors. Degradation of the molecular structure of the disc during ageing renders it more susceptible to superimposed mechanical injuries. This review supports the theory that degeneration of the disc has a complex multifactorial aetiology. Which factors initiate the events in the degenerative cascade is a question that remains unanswered, but most evidence points to an age-related process influenced primarily by mechanical and genetic factors.

MRI follow-up of subchondral signal abnormalities in a selected group of chronic low back pain patients

Subchondral signal abnormalities have been suggested to play an important role in chronic low back pain (LBP) syndromes. Their natural course is not well known. In this study the morphology and natural course of isolated subchondral signal abnormalities in the lumbosacral spine were analyzed with MRI. Twenty-four chronic LBP patients with a subchondral hypointensity on T1-weighted image (hyperintense on T2), indicating edema, were selected from a base population of 1,015 consecutive LBP patients to a follow-up MRI study within 18-72 months. Exclusion criteria were age >60 years, nerve root compression, a more specific back disease or a recent or major spine operation. The size and location of each subchondral signal abnormality and endplate lesion and the degree of degenerative disc changes were evaluated and compared between the baseline and follow-up studies. Most subchondral hypointensities were found at the L4/L5 or L5/S1 disc space, anteriorly and in both adjacent endplates. Almost all (53/54) hypointensities were associated with an endplate lesion. Twelve of the 54 subchondral hypointensities enlarged, six remained constant and 36 decreased or disappeared while five new ones appeared. Twenty-two (41%) hypointensities changed totally to hyperintensities or to mixed lesions. If the hypointensity increased, decreased or changed into hyperintensity, a change tended to develop in the adjacent endplate. If the hypointensity was absent or unchanged, endplate lesions did not tend to progress. In the absence of disc herniation or other specific spinal disease, subchondral hypointensities indicating edema are uncommon. They seem to have a highly variable course. There appears to be a link between endplate lesions and subchondral signal abnormalities. Further study is needed to explain the contribution of these findings to low back symptoms.

Evidence based medicine: analysis of Scheuermann kyphosis

STUDY DESIGN

: A review of the current literature using evidence-based medicine (EBM) regarding etiology, natural history, and treatment of Scheuermann kyphosis.

OBJECTIVE

: To provide current concepts for the rational evaluation and treatment of Scheuermann kyphosis supported by EBM.

SUMMARY OF BACKGROUND DATA

: The literature concerning etiology, natural history, and treatment of Scheuermann disease has mixed views and recommendations, most of which are not strongly supported with levels of evidence.

METHODS

: A thorough database search was performed in order to obtain the best current information and levels of evidence on etiology, natural history, and treatment options for Scheuermann kyphosis based on EBM criteria.

RESULTS AND CONCLUSION

: Scheuermann kyphosis is the most common cause of hyperkyphosis in adolescence. Its true etiology remains unknown, but there appears to be a strong genetic as well as an environmental contribution. The kyphotic deformity is frequently attributed to "poor posture" resulting in delayed diagnosis, and treatment indications remain debated because the natural history has not been clearly defined. When recognized early in adolescence with progressive kyphosis, bracing treatment will usually result in modest correction of the deformity. Symptomatic adolescents with severe deformity have demonstrated significant deformity correction following surgical intervention; however, clinical outcomes data are not yet available, and the studies available do not have strong levels of evidence.

Scheuermann's kyphosis

Scheuermann's disease is the most common cause of structural kyphosis in adolescents. The kyphotic deformity is frequently attributed to "poor posture," resulting in delayed diagnosis and treatment. Indications for treatment remain somewhat debated, because the true natural history of the disease has not been clearly defined. Brace treatment is almost always successful in patients with kyphosis between 55 degrees and 80 degrees if the diagnosis is made before skeletal maturity. Kyphosis greater than 80 degrees in the thoracic spine or 65 degrees in the thoracolumbar spine is almost never treated successfully without surgery in symptomatic patients. Surgical treatment in adolescents and young adults should be considered if there is documented progression, refractory pain, loss of sagittal balance, or neurologic deficit. The major postoperative complication after surgical treatment is junctional kyphosis proximally or distally, which is usually related to not including all levels of the kyphosis or overcorrection of the deformity (>50%). With proper patient selection, excellent outcomes can be expected with nonoperative or operative treatment in patients with Scheuermann's disease.

Schmorl's nodes: Common, highly heritable, and related to lumbar disc disease

OBJECTIVE

Schmorl's nodes (SN) are common, but little is known of their relationship with degenerative change and back pain or genetic and environmental factors influencing their expression. We studied healthy female twin volunteers to determine the prevalence and clinical features associated with SN.

METHODS

Serial sagittal T1- and T2-weighted magnetic resonance images of the lower thoracic and lumbar spine were analyzed in 516 healthy female twins (150 monozygotic and 366 dizygotic). The images were scored for lumbar degenerative change. Presence of SN was noted at cranial and caudal vertebral levels T9 to L5. Data on physical activity and back pain were collected by questionnaire. Heritability of SN was calculated using variance components modeling.

RESULTS

SN were found in 30% of subjects. Of the 374 SN, 153 (41%) were in the lumbar spine and 221 (59%) were in the thoracic spine. SN heritability was >70%. There was a positive association between SN and lumbar disc disease (LDD). SN were more frequent in subjects with back pain (for >/=2 SN: odds ratio [OR] 2.68, 95% confidence interval [95% CI] 1.11-6.47, P = 0.03), but this was largely accounted for by the association of SN with LDD (OR 1.97, 95% CI 0.78-5.0, P = 0.15 adjusted for LDD). No independent association of SN with back pain was identified.

CONCLUSION

SN are common in middle-aged women and are strongly genetically determined. They are associated with lumbar degenerative change, which is a risk factor for back pain, but are not themselves an independent risk factor for back pain.

Scheuermann kyphosis: the importance of tight hamstrings in the surgical correction

STUDY DESIGN

A historic cohort study of the sagittal alignment in 33 consecutive patients with surgically corrected thoracic Scheuermann kyphosis.

OBJECTIVES

To determine if postsurgical imbalance, sagittal malalignment, and decreased lumbar-pelvic range of motion in patients with thoracic Scheuermann kyphosis is related to tight hamstrings.

SUMMARY OF BACKGROUND DATA

Tight hamstrings are a frequent sign in Scheuermann kyphosis. The importance of tight hamstrings in the surgical management of Scheuermann kyphosis has not yet been studied.

METHODS

Thirty-three patients with Scheuermann kyphosis were managed by surgical correction and fusion. Tight hamstrings, lumbar-pelvic range of motion, and sagittal balance were evaluated. Sixteen patients had tight hamstrings, and 17 patients had nontight hamstrings. Hamstrings were considered tight if the popliteal angle was >30 degrees.

RESULTS

Patients with tight hamstrings have a significantly greater risk of postoperative imbalance (P = 0.05), and these patients can only compensate for this risk by reducing their lumbar lordosis (P = 0.0227). Furthermore, the limitations in the lumbar and pelvic range of motion are predicted by tight hamstrings (P <or= 0.005).

CONCLUSION

Tight hamstrings can be considered as an important factor in the surgical management of thoracic Scheuermann kyphosis. Tight hamstring patients can be classified as "lumbar compensators" and as such are prone to overcorrection and imbalance. Preoperative assessment of the lumbar-pelvic range of motion and tight hamstrings should therefore be advised. Extensive fusion of the lumbar segments might compromise the lumbar compensation mechanism and induces further risk of imbalance.

Radiologic phenotypes in lumbar MR imaging for a gene defect in the COL9A3 gene of type IX collagen

PURPOSE

To evaluate whether the COL9A3 tryptophan allele (Trp3 allele) is associated with a specific radiologic phenotype among patients with sciatica.

MATERIALS AND METHODS

One hundred fifty-three patients with sciatica were evaluated for the presence of Trp3 allele, Scheuermann disease, intervertebral disk degeneration, Schmorl nodules, dorsal anular tears, hyperintense lesions, and endplate degeneration on sagittal T2-weighted lumbar magnetic resonance images. The Trp3 genotype was determined by means of sequencing the COL9A3 gene. Radiologic phenotypes were evaluated while blinded to the genotype. Scheuermann disease was diagnosed if either endplate irregularities or Schmorl nodules and two of the other three criteria (disk space narrowing, disk dehydration, and wedging of anterior vertebral body margins) were present at three or more adjacent disk levels from T10-11 to L3-4. Disk degeneration was evaluated separately for each disk (T11-12 to L5-S1) and for all disks combined. Frequencies of radiologic phenotypes between individuals with or without Trp3 allele were compared.

RESULTS

Thirty-four patients had at least one Trp3 allele. When compared with the matched control subjects, they had an increased likelihood of Scheuermann disease (P =.035) and an increased number of degenerated disks from T11 to S1 (P =.021). Comparisons at individual disks showed a statistically significant increase in disk degeneration at T11-12 (analysis of all grades of degeneration [graded], P =.018; analysis of any degeneration vs none [dichotomous], P =.039) and L4-5 (graded, P =.011; dichotomous, P =.016). Prevalences of anular tears, endplate degeneration, Schmorl nodules, and hyperintense lesions were comparable.

CONCLUSION

The results of this study indicate that the presence of Trp3 allele is associated with Scheuermann disease and intervertebral disk degeneration. No associations were found for other radiologic phenotypes.

Lumbar disc excision in children and adolescents

STUDY DESIGN

The authors examined a case series of patients under the age of 18 years treated for lumbar intervertebral disc herniation.

OBJECTIVES

To evaluate postoperative and long-term results of surgery in patients younger than 18 years.

SUMMARY OF BACKGROUND DATA

There are only a few series, with controversial results, available on the surgical treatment of disc herniation in growing patients.

METHODS

Between 1975 and 1991, a consecutive series of 129 patients 9-18 years of age (average age, 16.2 years) underwent surgery for lumbar intervertebral disc herniation. Low back pain associated with leg pain was the main clinical symptom in 106 subjects (82%), back pain in 17 (13%), and leg pain in 6 (5%).

RESULTS

Short-term results were excellent or good for 123 cases (95%), with complete pain relief in 97 (75%) and moderate but incomplete relief in 26 (20%). A total of 98 (76%) long-term responses obtained at a mean follow-up of 12.4 years revealed excellent outcomes in 40% of the cases, good in 47%, and poor in 13%. Ten patients (10%) underwent reintervention after 9 years on average (2 fusions and 8 re-explorations for herniated disc).

CONCLUSIONS

Results have confirmed a tendency for outcomes to deteriorate between the short-term and long-term follow-up in young patients treated by discectomy: this tendency and the rate of reintervention (10%) confirmed the need for long-term follow-up of children and adolescents treated for disc herniation.

Schmorl nodes of the thoracic and lumbar spine: radiographic-pathologic study of prevalence, characterization, and correlation with degenerative changes of 1,650 spinal levels in 100 cadavers

PURPOSE

To investigate the frequency and characteristics of Schmorl nodes in an elderly population and to correlate these findings with degenerative spinal changes.

MATERIALS AND METHODS

Cadaveric thoracic and lumbar spines were removed at autopsy (mean age at death, 68.2 years; range, 43-93 years). Parasagittal sections of approximately 5-mm thickness were obtained and radiographed. At each of 3,300 endplates from T1 to L5, the presence of Schmorl nodes was noted. Vertebral endplate contour was analyzed, and abnormalities of the discovertebral junction were noted. The height of each interspace was measured, and the presence or absence of vacuum phenomena and spondylosis was recorded.

RESULTS

Schmorl nodes were found in 58 specimens and were multiple in 41. Of 3,300 vertebral endplates, 225 revealed Schmorl nodes: 88 cranial and 137 caudal. More than 182 were between T7 and L2. Schmorl nodes correlated with disk space loss (P <.001) but not with evidence of advanced disk degeneration: marked disk space loss (P =.53), vacuum phenomena (P =.82), or discogenic sclerosis or erosion (P =.35). Schmorl nodes were associated with claw (P <.001) but not traction (P =.72) osteophytes. Straight (P <.001) and fractured (P <.001) vertebral endplates were associated with Schmorl nodes.

CONCLUSION

Schmorl nodes are common in the spines in an elderly population, with a frequency similar to that in a younger population. Schmorl nodes are associated with moderate but not advanced degenerative changes. Geometric observations regarding the vertebral endplates support the concept that Schmorl nodes are caused by an abnormality of the discovertebral junction.

Post-traumatic findings of the spine after earlier vertebral fracture in young patients: clinical and MRI study

STUDY DESIGN

A study comparing magnetic resonance imaging findings of degenerative changes in intervertebral discs in young patients with previous wedge-shaped compression fracture and age-matched and sex-matched control subjects.

OBJECTIVES

To find out the role of fractures in disc degeneration and to assess the clinical outcome of the patients.

SUMMARY OF BACKGROUND DATA

Several experimental studies have postulated that trauma is one of the major reasons for disc degeneration. Wedge compression fractures in vertebrae of children have been considered insignificant, but this has not been verified in the literature.

METHODS

Fourteen patients 8.8 to 20.8 years of age (mean, 15.5 years) with a history of wedge-shaped vertebral compression fracture at least 1 year previously (mean, 3.8 years) and asymptomatic healthy control subjects were studied by thoracolumbar spine magnetic resonance imaging. The patients also underwent a clinical examination.

RESULTS

Eight (57%) of the 14 patients had disc degeneration, and seven of them had it at the trauma level. Of these 7 subjects, 6 also had endplate damage at this level. The association between endplate damage and adjacent intervertebral disc degeneration was significant (P < 0.01). Only 2 of the patients were symptomatic. In the control group, only 1 subject had disc degeneration with endplate changes and disc herniation.

CONCLUSIONS

The patients had more disc degeneration than did those in the control group. Endplate injury was strongly associated with disc degeneration. No correlation between previous vertebral fracture and back pain was seen in this study.

Scheuermann's disease

Scheuermann's disease is the most common cause of structural kyphosis in adolescence. The mode of inheritance is likely autosomal dominant and the etiology remains largely unknown. Indications for treatment remain controversial because the true natural history of the disease has not been clearly defined. Brace treatment appears to be very effective if the diagnosis is made early. Surgical treatment is rarely indicated for severe kyphosis (> 75 degrees ) with curve progression, refractory pain, or neurologic deficit.

Thoracic and lumbar fusions for degenerative disorders: rationale for selecting the appropriate fusion techniques

This article defines the indications for spinal fusion surgery based on the current literature as well as a rationale for selecting the appropriate spinal fusion techniques for the more common degenerative lumbar and thoracic conditions.

Scheuermann's kyphosis in adolescents and adults: diagnosis and management

Scheuermann's thoracic kyphosis is a structural deformity classically characterized by anterior wedging of 5 degrees or more of three adjacent thoracic vertebral bodies. Secondary radiographic findings of Schmorl's nodes, endplate narrowing, and irregular endplates confirm the diagnosis. The etiology remains unclear. Adolescents typically present to medical attention because of cosmetic deformity; adults more commonly present because of increased pain. The indications for treatment are similar to those for other spinal deformities, namely, progression of the deformity, pain, neurologic compromise, and cosmesis. The adolescent with pain associated with Scheuermann's kyphosis usually responds to physical therapy and a short course of anti-inflammatory medications. Bracing has been shown to be effective in controlling a progressive curve in the adolescent patient. For the adult who presents with pain, the early mainstays of treatment are physical therapy, anti-inflammatory medications, and behavioral modification. In patients, either adolescent or adult, with a progressive deformity, refractory pain, or neurologic deficit, surgical correction of the deformity may be indicated. Surgical correction should not exceed 50% of the initial deformity. Distally, instrumentation should be extended beyond the end vertebral body to the first lordotic disk to prevent the development of distal junctional kyphosis.

Disc degeneration of pediatric patients in lumbar MRI

Magnetic resonance imaging (MRI) is widely used in pediatric spinal disorders, but the prevalence of associated lumbar disc degeneration (DD) has not been evaluated previously. In this study we investigated whether children with suspected spinal disease had increased tendency to early DD. We analyzed lumbar MRI scans of 32 patients and 49 control subjects under 15 years old. Only four patients (13%) had DD on T2-weighted MRI and they were all over 10 years old. Eleven subjects (22%) in the control group had DD. It seems that disc degeneration is seldom found in patients under 10 years old.

Scintigraphy of spinal disorders in adolescents

Bone scintigraphy in adolescents is useful in helping to differentiate between developmental (atypical lumbar Scheuermann disease), infectious (discitis, osteomyelitis), neoplastic (osteoid osteoma, osteoblastoma), and traumatic (occult fractures, spondylolysis, pseudoarthrosis) disease of the spine. Double-phase (blood pool, delayed images) scintigraphy can characterize the pattern (i.e., linear in fracture, ovoid in nidus of osteoid osteoma). Single-photon emission computed tomography (SPECT) can be helpful in detecting the subtle presence of stress reaction (spondylolyses) not noted on routine planar scintigraphy and radiography. Bone scintigraphy is most beneficial when correlated with other imaging modalities in refining the diagnosis of spinal diseases.