Pathobiology of Modic changes

TNF induces catabolism in human cartilaginous endplate cells in 3D agarose culture under dynamic compression

Intervertebral disc (IVD) degeneration is the leading cause of low back pain in young adults, and the cartilaginous endplate (CEP) is likely to play a key role in early IVD degeneration. To elucidate the effects of pro-inflammatory cytokines on the mechanobiology of the CEP, human CEP cells were seeded into 2% agarose, dynamically compressed up to 7%, and stimulated with tumor necrosis factor (TNF). It was hypothesized that dynamic compression would be sufficient to induce anabolism, while stimulation with TNF would induce catabolism. TNF was sufficient to induce a catabolic, time-dependent response in human CEP cells through downregulation of anabolic gene expression and increased secretion of pro-inflammatory proteins associated with herniated discs, bacteria inhibition, and pain. However, 7% strain or scaffold material, agarose, may not lead to full activation of integrins and downregulation of pro-inflammatory pathways, demonstrated in part through the unchanged gene expression of integrin subunits α5 and β1.

Contribution of MRI and imaging exams in the diagnosis of lumbar pseudarthrosis

INTRODUCTION

The diagnosis of pseudoarthrosis is based on imaging and clinical exam findings. The standard for pseudarthrosis diagnosis remains postoperative observation through computer tomography (CT) and patient's symptoms. This can be further augmented by dynamic X-ray imaging or nuclear positron emission tomography (PET) CT to demonstrate an absence of fusion by showing a persistence of mobility. However, there is not a uniform diagnostic approach that is a standard of care amongst spine practioners. The aim of this study is to describe the timeline and diagnostic analysis for pseudoarthrosis between the initial surgery and follow-up procedure.

METHODS

This is a single-center retrospective observational study. The aim was to enroll patients reoperated for pseudarthrosis after 1 or 2 level lumbar fusions, between August 1st, 2008 and August 1st, 2018. The exams were reviewed by one surgeon and one radiologist, defining a status either in favor of pseudarthrosis, or against it, or inconclusive, based on the radiological criteria mentioned below. We then investigated different combinations of exams and their specific chronology before a diagnosis was established.

RESULTS

Forty-four patients were included, 70.5% male and with a mean age of 47.3 years. The median time between the 2 surgeries was 23.7 months. Plain X-rays supported the diagnosis in 38.7% of cases, dynamic X-rays showed hypermobility in 50% of cases. The CT-scan demonstrated pseudarthrosis in 94,4% of cases. A MODIC 1 signal was observed in 87,2% of cases on MRI. SPECT-CT showed a tracer uptake in 70% of cases.

CONCLUSION

Reducing the time to reintervention is a key objective for improving the management and clinical outcomes of these patients. We suggest that MRI is an additional tool in combination with CT in the assessment of suspected mechanical pseudarthrosis, in order to optimize the diagnosis and shorten the time to revision surgery.

LEVEL OF EVIDENCE

IV.

Pyroptosis: A spoiler of peaceful coexistence between cells in degenerative bone and joint diseases

BACKGROUND

As people age, degenerative bone and joint diseases (DBJDs) become more prevalent. When middle-aged and elderly people are diagnosed with one or more disorders such as osteoporosis (OP), osteoarthritis (OA), and intervertebral disc degeneration (IVDD), it often signals the onset of prolonged pain and reduced functionality. Chronic inflammation has been identified as the underlying cause of various degenerative diseases, including DBJDs. Recently, excessive activation of pyroptosis, a form of programed cell death (PCD) mediated by inflammasomes, has emerged as a primary driver of harmful chronic inflammation. Consequently, pyroptosis has become a potential target for preventing and treating DBJDs.

AIM OF REVIEW

This review explored the physiological and pathological roles of the pyroptosis pathway in bone and joint development and its relation to DBJDs. Meanwhile, it elaborated the molecular mechanisms of pyroptosis within individual cell types in the bone marrow and joints, as well as the interplay among different cell types in the context of DBJDs. Furthermore, this review presented the latest compelling evidence supporting the idea of regulating the pyroptosis pathway for DBJDs treatment, and discussed the potential, limitations, and challenges of various therapeutic strategies involving pyroptosis regulation.

KEY SCIENTIFIC CONCEPTS OF REVIEW

In summary, an interesting identity for the unregulated pyroptosis pathway in the context of DBJDs was proposed in this review, which was undertaken as a spoiler of peaceful coexistence between cells in a degenerative environment. Over the extended course of DBJDs, pyroptosis pathway perpetuated its activity through crosstalk among pyroptosis cascades in different cell types, thus exacerbating the inflammatory environment throughout the entire bone marrow and joint degeneration environment. Correspondingly, pyroptosis regulation therapy emerged as a promising option for clinical treatment of DBJDs.

Efficacy of a Tumor Necrosis Factor Inhibitor in Chronic Low-Back Pain With Modic Type 1 Changes: A Randomized Controlled Trial

OBJECTIVE

The efficacy of tumor necrosis factor inhibitors for treating chronic low-back pain with Modic changes is uncertain. This study investigated the superiority of infliximab over placebo in patients with Modic type 1 changes.

METHODS

In this multicenter, randomized, triple-blind, placebo-controlled trial, patients aged 18 to 65 years with moderate to severe chronic low-back pain and Modic type 1 changes were enrolled from five Norwegian public hospitals between January 2019 and October 2022. Participants were randomly assigned to four intravenous infusions of 5 mg/kg infliximab or placebo. The primary outcome was difference in change in the Oswestry Disability Index (ODI) score from baseline to five months. Secondary outcomes included changes in low-back pain intensity, disability, and health-related quality of life. A linear mixed model was used for efficacy analyses.

RESULTS

A total of 128 patients (mean age 43 years, 65.6% women) participated (64 in each group). All patients who received at least one dose of the allocated infusion were included in the primary analyses. The average ODI score (±SD) change was -7.0 (±9.7) in the group who received infliximab and -6.4 (±10.4) in the group who received placebo. The difference in the ODI score change between the two groups was 1.3 ODI points (95% confidence interval -2.1 to 4.6, P = 0.45). Analyses showed no effect of infliximab compared to placebo on secondary outcomes. Adverse event rates were similar between groups.

CONCLUSION

Infliximab did not demonstrate superiority over placebo in reducing pain-related disability in patients with moderate to severe chronic low-back pain with Modic type 1 changes at five months.

Postoperative Sclerotic Modic Changes After Transforaminal Lumbar Interbody Fusion: Whether It Is Different Between Nano-hydroxyapatite/Polyamide 66 and Polyetheretherketone Cage?

OBJECTIVE

This study aimed to compare short-term outcomes between nano-hydroxyapatite/polyamide 66 (n-HA/PA66) cage and polyetheretherketone (PEEK) cage in sclerotic Modic changes (MCs) following transforaminal lumbar interbody fusion and explore the effects of these cages on postoperative sclerotic MCs.

METHODS

We retrospectively screened 1076 patients from September 2012 to September 2024 identifying 134 patients (154 levels) with sclerotic MCs after transforaminal lumbar interbody fusion. Patients were divided into the n-HA/PA66 group and the PEEK group. The incidence, timing, location of sclerotic MCs, clinical and radiological outcomes were compared between the 2 groups.

RESULTS

The incidence of sclerotic MCs was 9.9% (66/669) in the n-HA/PA66 group and 16.7% (68/407) in the PEEK group (P < 0.001). Visual analog scale and Oswestry Disability Index scores were comparable between the 2 groups. Both the n-HA/PA66 and PEEK groups demonstrated similar fusion rates at 3 and 6 months after operation and at the final follow-up. At the final follow-up, the mean cage union ratios exposed to the upper and lower endplates of the n-HA/PA66 group on the coronal and sagittal plane were significantly larger than those of the PEEK group (all P < 0.001). However, there were no significant differences between the 2 groups in intervertebral space height, lumbar lordosis, and segmental lordosis.

CONCLUSIONS

The incidence of postoperative sclerotic MCs in the n-HA/PA66 cage was significantly lower than that in the PEEK, which may be attributed to the better fusion status of the n-HA/PA66 cage. These results indicate that the n-HA/PA66 cage is a good biomimetic cage and may be beneficial for postoperative sclerotic MCs.

Identification of aging-related biomarkers for intervertebral disc degeneration in whole blood samples based on bioinformatics and machine learning

Introduction

Aging is characterized by gradual structural and functional changes in the body over time, with intervertebral disc degeneration (IVDD) representing a key manifestation of spinal aging and a major contributor to low back pain (LBP).

Methods

This study utilized bioinformatics and machine learning approaches to identify aging-related biomarkers associated with IVDD in whole blood samples. By analyzing GEO datasets alongside aging-related databases such as GeneCards, HAGR, and AgeAnno, we identified 15 aging-related differentially expressed genes (AIDEGs). Correlation and immune infiltration analyses were conducted on these AIDEGs, and diagnostic models were developed using WGCNA, logistic regression, random forest, support vector machine, k-nearest neighbors, and LASSO regression to identify key genes.

Results

Among these, FCGR1A, CBS, and FASLG emerged as significant biomarkers with strong predictive capabilities for IVDD. Further exploration of biological pathways involving AIDEGs provided insights into their potential roles in IVDD pathogenesis. To further validate these findings, we collected human blood specimens and conducted in vitro experiments. ELISA assays confirmed that CBS and FASLG are crucial biomarkers of IVDD, with distinct expression patterns in patients with moderate versus severe degeneration.

Discussion

These results highlight the diagnostic potential of AIDEGs and provide a new perspective for early intervention and treatment strategies in IVDD.

Piezo1 exacerbates inflammation-induced cartilaginous endplate degeneration by activating mitochondrial fission via the Ca2+/CaMKII/Drp1 axis

Mitochondrial homeostasis plays a crucial role in degenerative joint diseases, including cartilaginous endplate (CEP) degeneration. To date, research into mitochondrial dynamics in IVDD is at an early stage. Since Piezo1 is a novel Ca2+-permeable channel, we asked whether Piezo1 could modulate mitochondrial fission through Ca2+ signalling during CEP degeneration. In vitro and in vivo models of inflammation-induced CEP degeneration were established with lipopolysaccharide (LPS). We found increased expression of Piezo1 in degenerated CEP tissues and LPS-treated CEP cells. The Piezo1 activator Yoda1 exacerbated CEP cell senescence and apoptosis by triggering Ca2+ influx. Yoda1 also induced mitochondrial fragmentation and dysfunction. In contrast, the Piezo1 inhibitor GsMTx4 exerted cytoprotective effects in LPS-treated CEP cells. Additionally, the CaMKII inhibitor KN-93 reversed Yoda1-induced mitochondrial fission and restored mitochondrial function. Mechanistically, the phosphorylation and mitochondrial translocation of Drp1 were regulated by the Ca2+/CaMKII signalling. The Drp1 inhibitor Mdivi-1 suppressed mitochondrial fission, then reduced mitochondrial dysfunction and CEP cell death. Moreover, knockdown of Piezo1 by siRNA hindered CaMKII and Drp1 activation, facilitating the redistribution of mitochondrial Drp1 to the cytosol in LPS-treated CEP cells. Piezo1 silencing improved mitochondrial morphology and function, thereby rescuing CEP cell senescence and apoptosis under inflammatory conditions. Finally, subendplate injection of GsMTx4 or AAV-shPiezo1 alleviated CEP degeneration in a rat model. Thus, Piezo1 may exacerbate inflammation-induced CEP degeneration by triggering mitochondrial fission and dysfunction via the Ca2+/CaMKII/Drp1 axis.

M2 macrophages regulate nucleus pulposus cell extracellular matrix synthesis through the OPN-CD44 axis in intervertebral disc degeneration

OBJECTIVE

Macrophages play a crucial role in various physiological processes. In intervertebral disc degeneration (IDD), macrophage infiltration has been observed in human intervertebral disc (IVD) specimens, but how macrophages influence IDD remains unclear.

METHODS

According to the single-cell transcriptome expression profiles from GSE165722, we verified the infiltration of macrophages in IDD and the possible interaction between infiltrated macrophages and nucleus pulposus cells (NPCs). The expression of macrophage-associated markers was verified in specimens of human nucleus pulposus, lumbar spinal instability mice and annulus fibrosus puncture mice. By treating NPCs cocultured with M2 macrophages with osteopontin (OPN) neutralization antibody and siCD44, we demonstrated that both in vitro and in vivo macrophages regulated IDD through the OPN-CD44 axis. Using transforming growth factor beta 1 and siCD44 treatment, we verified that CD44 regulated the pSMAD2/3 pathway.

RESULTS

IDD engaged macrophage infiltration, mainly gathered in the endplate, and induced macrophage M2 polarization. Infiltrated macrophages showed high-level expression of OPN, and NPCs showed upregulated CD44. Depletion of macrophages significantly decreased the expression of OPN and CD44 in degenerative IVD, concurrently exacerbating IDD. The co-culture of macrophages and NPCs in vitro demonstrated that the conditioned media from NPCs induced macrophage M2 polarization. Further, M2 macrophages rescued NPCs extracellular matrix (ECM) phenotype through the OPN-CD44 axis, by regulating pSMAD2/3 nuclear translocation.

CONCLUSIONS

Our findings suggest that macrophages regulate NPC ECM expression in IDD through the OPN-CD44 axis, emphasizing the therapeutic potential of targeting macrophages and the OPN-CD44 axis for IDD prevention and treatment.

Modic changes: From potential molecular mechanisms to future research directions (Review)

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.

Inflammation and macrophage polarization are associated with Modic change type in lumbar radiculopathy

Introduction

Lumbar disc herniation (LDH) typically manifests as sciatica, attributed to nerve root mechanical compression and/or inflammation. Modic changes (MC), classified as type I or type II, are deemed to represent endplate vascular insufficiency and are hypothesized to create an inflammatory environment. Macrophages infiltrating disc tissue can be polarized into pro-inflammatory M1 or anti-inflammatory M2 phenotypes.

Research question

This study aims to investigate the interplay among inflammatory cells, including M1 and M2 macrophages, Modic Changes, and hernia size and type in patients suffering from sciatica due to a LDH.

Material and methods

This prospective cohort study selected patients undergoing microdiscectomy for LDH. Macrophage infiltration (CD68, CD192, CD163), MC classification on MRI, and hernia parameters were analyzed.

Results

132 out of 187 patients demonstrated macrophages in the lumbar disc tissue. Most samples demonstrated severe inflammation (50 %), and most macrophages were of the M1 phenotype (48 %). MC were present in 45 % of patients, and only 19 % of these demonstrated MC type I. MC type I were highly associated with both severe (p = 0.016) and M1 macrophage-dominant inflammation (p = 0.048). Larger and non-contained herniations associated with increased inflammation (p = 0.029/p = 0.002), while larger herniations associated with the presence of MC type II (p = 0.027).

Discussion and conclusions

This study elucidates a close association of MC type I and M1 macrophage. MC type II were observed more often in patients with larger HNPs. This is indicative for MC typing as an important factor in prediction modelling and it suggests the potential for personalized treatment strategies.

The Impact of Diabetes Mellitus on Patient-Reported Outcomes of Chronic Low Back Pain with Modic Changes at One Year: A Prospective Cohort Study

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

Diabetes mellitus (DM) is associated with unfavourable patient-reported outcomes after spine surgery. Chronic low back pain (CLBP) with Modic Changes (MCs) in the lumbar vertebrae, as observed on MRI, forms a specific subgroup. This study aims to investigate the potential influence of DM on CLBP with MCs.

METHODS

This study involved 259 patients with CLBP accompanied MCs. We recorded the patient-reported outcomes (visual analogue scale (VAS), Oswestry Disability Index (ODI), and Roland-Morris Disability Questionnaire (RMDQ)) at baseline, 3, 6, and 12 months. Multivariable linear regression analyses were performed to determine predictors of patient-reported outcomes.

RESULTS

103 patients had DM. Patients with DM exhibited higher VAS (P < .05), ODI (P < .001), and RMDQ (P < .001) scores at 3, 6, and 12 months, while patients without DM experienced more significant improvements in the scores over time (P < .001). Patients with DM reported longer durations of physical exercise (P = .007). Additionally, patients without DM had a significantly higher patient satisfaction index (P < .001) and a lower prevalence of hypertension (P < .001). Notably, significant differences were observed in the distribution of MCs of lumbar vertebrae (P = .034) and Pfirrmann grades of intervertebral disc degeneration between two groups (P < .001).

CONCLUSION

Patients with DM demonstrated poorer patient-reported outcomes compared to those without DM in 1-year. DM emerged as an independent predictor of adverse patient-reported outcomes. It can be utilized to enhance the management and treatment of CLBP in patients with MCs.

Magnetic resonance imaging findings in patients with dropped head syndrome

BACKGROUND

Dropped head syndrome (DHS) is difficult to diagnose only by clinical examination. Although characteristic images on X-rays of DHS have been studied, changes in soft tissue of the disease have remained largely unknown. Magnetic resonance imaging (MRI) is useful for evaluating soft tissue, and we therefore performed this study with the purpose of investigating the characteristic signal changes of DHS on MRI by a comparison with those of cervical spondylosis.

METHODS

The study involved 35 patients diagnosed with DHS within 6 months after the onset and 32 patients with cervical spondylosis as control. The signal changes in cervical extensor muscles, interspinous tissue, anterior longitudinal ligament (ALL) and Modic change on MRI were analyzed.

RESULTS

Signal changes of cervical extensor muscles were 51.4% in DHS and 6.3% in the control group, those of interspinous tissue were 85.7% and 18.8%, and those of ALL were 80.0% and 21.9%, respectively, suggesting that the frequency of signal changes of cervical extensor muscles, interspinous tissue and ALL was significantly higher in the DHS group (p < 0.05). The presence of Modic change of acute phase (Modic type I) was also significantly higher in the DHS group than in the control group (p < 0.001).

CONCLUSION

MRI findings of DHS within 6 months after the onset presented the characteristic signal changes in cervical extensor muscles, interspinous tissue, ALL and Modic change. Evaluation of MRI signal changes is useful for an objective evaluation of DHS.

The Association of Modic Changes and Disc-Endplate-Bone Marrow Complex Classification in Patients With Cervical Degenerative Disc Disease

STUDY DESIGN

Observational cohort study.

OBJECTIVE

To assess the association of Modic changes and DEBC classification in patients with cervical degenerative disc disease.

METHODS

The study includes 2 groups, neck pain patients presenting to the out-patient services (neck pain group) (n = 301) and polytrauma patients without cervical spine injury or a history of neck pain, who underwent whole spine MRI (control group) (n = 200). Degenerative changes in the MRI were classified according to the Modic changes (MC) and DEBC classification. Modifiers including End-Plate (EP) erosion and herniation (H+) presence were documented.

RESULTS

3612 EPs of 301 patients with neck pain and 2400 EPs of 200 controls were assessed. The incidence of MC and DEBC in the neck pain group was 20.93% and in the control group, it was 12%, (P < 0.05). In the neck pain group with DEBC changes, the distribution was Type A-6.51%; Type B-20.71%; Type C-71.6%; and Type D - 1.18%, while in the controls the distribution was Type A-10.29%, Type B-29.41%, Type C-54.41%, and Type D - 5.88%, The co-occurrence of H+ with DEBC in cases and controls was 13.95% vs 5.5% (P < 0.005). The odds ratio for the need for surgery was highest (OR: 6.8) when H+ and DEBC change co-occurred.

CONCLUSION

Our study highlights that patients with DEBC changes and disc herniation were more likely to experience neck pain and require surgical intervention, indicating the reliability and clinical significance of the DEBC classification in degenerative cervical spine patients.

GATA6 Facilitates Progression of Intervertebral Disc Degeneration by Regulating Ferroptosis via Targeting TLR2/AKR1C3

This study explored the role of ferroptosis in intervertebral disc degeneration (IVDD), and identified GATA6 as a key regulator of this process. A ferroptosis-related gene risk coefficient model was constructed using differential gene expression analysis of the GSE70362 dataset. The analysis identified GATA6 as a significant factor in IVDD progression. GATA6 was shown to promote ferroptosis in nucleus pulposus cells (NPCs) by regulating the expression of AKR1C3 through the TLR2 pathway. In vitro and in vivo experiments demonstrated that GATA6 knockdown reduced ferroptosis, improved cell viability, and mitigated extracellular matrix degradation, whereas GATA6 overexpression exacerbated these processes. Furthermore, AKR1C3 was found to be crucial for GATA6-mediated ferroptosis, and modulation of the TLR2-AKR1C3 axis significantly impacted the degeneration of NPCs. These findings suggest that targeting GATA6 and its downstream TLR2-AKR1C3 pathway may provide new therapeutic approaches for IVDD.

From Modic to Disc Endplate Bone Marrow Complex - The Natural Course and Clinical Implication of Vertebral Endplate Changes

STUDY DESIGN

Review article.

OBJECTIVES

A review of literature on the epidemiology, natural course, pathobiology and clinical implications of vertebral endplate changes.

METHODS

A literature search was performed using the Cochrane Database of Systematic Reviews, EMBASE, and PubMed. Studies published over the last 10 years were analysed. The searches were performed using Medical Subject Headings terms, and the subheadings used were "Vertebral endplate changes", "Modic changes", "Disc Endplate Bone Marrow complex".

RESULTS

The disc, endplate (EP), and bone marrow region of the spine constitute a unified morphological and functional unit, with isolated degeneration of any one structure being uncommon. Disc degeneration causes endplate defects, which result in direct communication and a constant cross-talk between the disc and the vertebral body. This may result in a persistent inflammatory state of the vertebral bone marrow, serving as a major pain generator. This review article focuses on vertebral endplate changes and how the current understanding has progressed from the Modic classification to the Disc Endplate Bone Marrow complex classification. It provides a clear portrayal of the natural course of these alterations and their clinical implications in low back pain.

CONCLUSIONS

In light of the heightened interest and current prominence of vertebral endplate changes within the spine community, we must progress beyond the Modic changes to achieve a comprehensive understanding. The DEBM complex classification will play a major part in disc degeneration research and clinical care, representing a considerable advancement in our understanding of the vertebral endplate changes over the classical Modic changes.

Intervertebral Disc Degeneration and Regeneration: New Molecular Mechanisms and Therapeutics: Obstacles and Potential Breakthrough Technologies

Pain and disability secondary to degenerative disc disease continue to burden the healthcare system, creating an urgent need for effective, disease-modifying therapies. Contemporary research has identified potential therapies that include protein-, cellular- and/or matrix-related approaches; however, none have yet achieved a meaningful clinical impact. The tissue-specific realities of the intervertebral disc create considerable therapeutic challenges due to the disc's location, compartmentalization, hypovascularization and delicate physiological environment. Furthermore, the imaging modalities currently used in practice are largely unable to accurately identify sources of pain ostensibly discogenic in origin. These obstacles are considerable; however, recent research has begun to shed light on possible breakthrough technologies. Such breakthroughs include revolutionary imaging to better identify tissue sources of pain. Furthermore, novel molecular therapies have been shown to be able to mediate the progression of degenerative disc disease in some large animal studies, and even provide some insight into suppressing the development of tissue sources of discogenic pain. These potential breakthrough technologies have yet to be translated for clinical use.

The effect of aspirin on lumbar degeneration: an imaging-based study

Purpose

This study aims to investigate how aspirin influences lumbar degeneration by analyzing the effect of aspirin on patients with low back pain (LBP) and concurrent atherosclerosis.

Methods

Using 1:1 nearest neighbor matching based on propensity score matching (PSM), 73 patients who regularly took aspirin were assigned to the aspirin group, while another 73 patients who did not take aspirin formed the control group. Radiographs were used to measure lumbar lordosis (LL) and intervertebral height index (IHI). Subcutaneous fat tissue thickness (SFTT), paravertebral muscle fat infiltration area (%FIA), cartilage endplate (CEP) Modic changes, and modified Pfirrmann grading scores were performed based on lumbar MRI.

Results

After PSM analysis, confounders between the aspirin and control groups were balanced. A total of 73 pairs of patients were analyzed in this study. The aspirin group showed lower SFTT(L1/2) and a reduced incidence of CEP Modic changes, compared to the control group (both P < 0.05). Additionally, the %FIA and Pfirrmann scores were lower in the aspirin group, particularly in the upper lumbar spine (both P < 0.05). No significant differences were observed in LL and IHI between the aspirin and control groups.

Conclusion

In summary, conservative treatment with aspirin protects against upper lumbar spine degeneration, although its effect on the lower lumbar spine is less pronounced.

Development of Modic Changes After Percutaneous Endoscopic Transforaminal Lumbar Discectomy: From Risk Analysis to Prediction Modeling

Objective

This study examines the occurrence of Modic changes (MC) within the first year following percutaneous endoscopic transforaminal lumbar discectomy (PETD) and investigates associated risk factors.

Methods

This study adopted a retrospective cohort design. Between January 2019 and June 2023, 538 patients diagnosed with single-level lumbar disc herniation and treated with PETD were included. The patients were divided into a training set and a validation set based on their surgery dates. Preoperative radiographic parameters and perioperative indicators were evaluated. Univariate analysis examined risk factors for postoperative MC. Gender-specific subgroups were analyzed. Binary logistic regression developed a predictive model for postoperative MC, assessed using ROC, calibration, and decision curves.

Results

The incidence of MC at one year after PETD was 24.8%. Logistic regression identified 8 significant risk factors for MC after PELD: longer symptom duration, proximity of herniated segment to sacrum, severe disc degeneration, reduced disc height, greater vertebral endplate concavity angle, segmental instability, and lumbar-sacral fusion. Menopause and herniation type were identified as female-specific risk factors. In males, total cholesterol levels were additionally found to be a risk factor for postoperative MC. The male and female subgroup models exhibited satisfactory performance across ROC analysis, calibration plots, and decision curve analysis. Specifically, for male patients, the area under the curve (AUC) was 0.831 for the training set and 0.820 for the validation set; for female patients, the AUC was 0.911 for the training set and 0.868 for the validation set. A nomogram was developed to visualize the model.

Conclusion

This study explored the relevant risk factors of MC after PETD and visualized the prediction model by nomogram, which is beneficial to optimize the surgical scheme of PETD to improve the clinical efficacy.

The pathogenesis and targeted therapies of intervertebral disc degeneration induced by cartilage endplate inflammation

Intervertebral disc degeneration (IVDD) is the leading cause of low back pain, where degeneration and death of nucleus pulposus cells within the intervertebral disc (IVD) can be obviously revealed. This degeneration can result in an imbalance in the extracellular matrix due to the loss of proteoglycans and water content, which can further lead to catabolic and anabolic dysfunction of the IVD. Recently, the dysfunction of cartilage endplate (CEP) during aging has drawn large attention due to its essential functions in contributing nutrient exchange and maintaining IVD homeostasis. Furthermore, the inflammation and disturbed homeostasis of CEP not only accelerate the degradation of nucleus pulposus extracellular matrix, but also exacerbate IVDD by causing nucleus pulposus cell death through other pathological factors. Here in this review, we summarized the possible pathological factors and the underlying mechanisms of the CEP inflammation-induced IVDD, including exosomes degeneration, CEP calcification, ferroptosis, mechanical changes, and cell senescence. Besides, changes of miRNAs, pain-related neural reflex arc and pathways associated with CEP inflammation-induced IVDD are also reviewed. In addition, new strategies specifically designed for CEP inflammation-induced IVDD are also discussed in the last section. We hope this paper can not only offer some new insights for advancing novel strategies for treating IVDD, but also serve as a valuable reference for researchers in this field.

Intraosseous basivertebral nerve ablation: A 5-year pooled analysis from three prospective clinical trials

Background

Vertebrogenic pain is a documented source of anterior column chronic low back pain (CLBP) that stems from damaged vertebral endplates. Nociceptive signals are transmitted by the basivertebral nerve (BVN) and endplate damage is observed as Type 1 or Type 2 Modic changes (MC) on magnetic resonance imaging (MRI). The clinical impact and safety of intraosseous radiofrequency ablation of the BVN (BVNA) for the treatment of vertebrogenic pain has been demonstrated in three prospective clinical trials (two randomized and one single-arm study).

Objective

Report aggregate long-term BVNA outcomes at five years from three studies.

Methods

Pooled results at 5-years post-BVNA are reported for three clinical trials with similar inclusion/exclusion criteria and outcomes measurements: 1) a prospective, open label, single-arm follow-up of the treatment arm of a randomized controlled trial (RCT) comparing BVNA to sham ablation (SMART); 2) a prospective, open label, single-arm follow-up of the treatment arm of an RCT comparing BVNA to standard care (INTRACEPT); and 3) a prospective, open label, single-arm long-term follow-up study of BVNA-treated participants (CLBP Single-Arm). Paired datasets (baseline and 5-years) for mean changes in Oswestry disability index (ODI) and numeric pain scores (NPS) were analyzed using a two-sided paired t-test with a 0.05 level of significance. Secondary outcomes included responder rates, patient satisfaction, adverse events, and healthcare utilization.

Results

Two hundred forty-nine (249) of 320 BVNA-treated participants (78 % participation rate) completed a five-year visit (mean of 5.6 years follow-up). At baseline, 71.9 % of these participants reported back pain for ≥5 years, 27.7 % were taking opioids, and 61.8 % had prior therapeutic lumbar spinal injections. Pain and functional improvements were significant at 5-years with a mean improvement in NPS of 4.32 ± 2.45 points (95 % CI 4.01, 4.63; p < 0.0001) from 6.79 ± 1.32 at baseline and a mean improvement in ODI of 28.0 ± 17.5 (95 % CI 25.8, 30.2; p < 0.0001) from 44.5 ± 11.0 at baseline. Nearly one-third (32.1 %) of patients reported being pain-free (NPS = 0) at five years, 72.7 % of patients indicated their condition improved and 68.7 % had resumed activity levels they had prior to onset of CLBP. In the sixty-nine participants taking opioids at baseline, 65.2 % were no longer taking them at 5-years, and spinal injections decreased by 58.1 %. The rate of lumbosacral treatment (therapeutic spinal injection, radiofrequency ablation, or surgery) for the same index pain source and vertebral level was 33/249 (13.2 %) at 5 years post BVNA; including a 6.0 % rate of lumbar fusion. There were no serious device or device-procedure related adverse events reported during the long-term follow-up.

Conclusion

In this 5-year aggregate analysis, BVNA significantly improved pain and function scores compared to baseline. Similarly, there were significant reductions in opioid consumption and spinal injections post BVNA. Data demonstrate a strong safety profile with no serious device or device-related events and low healthcare utilization rate for the same index pain source through a mean of 5.6 years. Results demonstrate that intraosseous BVNA treatment for patients with vertebrogenic pain is safe, effective, and durable through five years.

Minimally invasive treatments for chronic low back pain

ABSTRACT

This article describes minimally invasive treatments for managing chronic low back pain (LBP) related to lumbar spinal stenosis, facetogenic LBP, vertebrogenic LBP, or discogenic LBP. We also propose a clinical decision-making tool to guide clinicians in appropriate patient selection for various treatments.

Pre-operative collapsed disc is a negative prognostic factor of back-pain outcome in trans-foraminal endoscopic discectomy. A single cohort clinical study

PURPOSE

Trans-foraminal endoscopic discectomy (TELD) is an alternative surgical technique for lumbar disc herniation (LDH). Compared with microscope-assisted open discectomy, TELD is expected to result in less postoperative low back pain (LBP) and has a lower likelihood of complications. However, some clinical analysis report patients still had persistent LBP at follow-up. Several studies have identified different known risk factors for LBP after TELD, including the preoperative presence of disc height loss and "microinstability" of the lumbar spine, which can be detrimental to a patient's successful outcome.

METHODS

We conducted a retrospective review of a cohort of 86 patients with symptomatic LDH who underwent TELD surgery in a single Neurosurgery Unit from 2021 to 2023 and subjected themselves to a clinical and radiological follow-up program up to one year, focusing on the presence of collapsed disc (Group A) and the presence of normal intersomatic height (Group B) at the site of lumbar herniation.

RESULTS

The two groups demonstrated no significant differences in the pain and disability scales at the preoperative and postoperative phases, both after surgery and during follow-up. However, at the 1-year clinical evaluation, patients who had signs of a collapsed disc before surgery experienced less recovery on the ODI scale compared to the other group CONCLUSION: Our study showed that the presence of severe intervertebral disc height loss, accompanied by pre-operative signs of a collapsed disc at the site of the LDH, may serve as a predictor of poor postoperative pain recovery.

Biomimetic Proteoglycans for Intervertebral Disc (IVD) Regeneration

Intervertebral disc degeneration, which leads to low back pain, is the most prevalent musculoskeletal condition worldwide, significantly impairing quality of life and imposing substantial socioeconomic burdens on affected individuals. A major impediment to the development of any prospective cell-driven recovery of functional properties in degenerate IVDs is the diminishing IVD cell numbers and viability with ageing which cannot sustain such a recovery process. However, if IVD proteoglycan levels, a major functional component, can be replenished through an orthobiological process which does not rely on cellular or nutritional input, then this may be an effective strategy for the re-attainment of IVD mechanical properties. Furthermore, biomimetic proteoglycans (PGs) represent an established polymer that strengthens osteoarthritis cartilage and improves its biomechanical properties, actively promoting biological repair processes. Biomimetic PGs have superior water imbibing properties compared to native aggrecan and are more resistant to proteolytic degradation, increasing their biological half-life in cartilaginous tissues. Methods have also now been developed to chemically edit the structure of biomimetic proteoglycans, allowing for the incorporation of bioactive peptide modules and equipping biomimetic proteoglycans as delivery vehicles for drugs and growth factors, further improving their biotherapeutic credentials. This article aims to provide a comprehensive overview of prospective orthobiological strategies that leverage engineered proteoglycans, paving the way for novel therapeutic interventions in IVD degeneration and ultimately enhancing patient outcomes.

Intervertebral Disc Magnetic Resonance Spectroscopy Changes After Spinal Manipulative Therapy for Lumbar Discogenic Pain

This study investigates the use of magnetic resonance spectroscopy (MRS) to identify the intervertebral disc (IVD) as a pain generator, explore the pathophysiology of the biochemical and structural components of discogenic low back pain (DLBP), and present potential evidence of physiological responses to spinal manipulation therapy (SMT). A 29-year-old male presented with uncomplicated low back pain (LBP). The non-specific presentation and clinical examination findings were consistent with an initial working diagnosis of non-specific LBP with the clinician suspecting IVD as a likely pain generator. Conventional magnetic resonance imaging showed findings of IVD degeneration including Modic type I changes consistent with a diagnosis of DLBP. MRS was utilized for structural and biochemical analysis of the IVDs. Altered spectral features confirmed a DLBP diagnosis. The patient underwent 16 Cox flexion-distraction SMT treatments at a chiropractic teaching clinic in Chesterfield, Missouri. A follow-up MRS was performed to compare and evaluate post-treatment results. We report the utilization of MRS to quantify the structural integrity and biochemical pain profile of the IVD in a conservatively managed chronic DLBP patient who was unresponsive to previous steroid injections. Comparison between MRS revealed improved IVD spectral features including decreased biochemical pain markers and increased glycoprotein biosynthesis. This implies that the SMT management of chronic DLBP may improve IVD structural integrity and alter pain biochemistry.

Early Endoscopic Discectomy in Preventing Degenerative Spinal Changes in Patients With Lumbar Disc Herniation

In this study, we compare the outcomes of two patients with similar spinal pathologies who chose different treatment options. The first case involves a 38-year-old female with significant lumbar disc herniation and associated degenerative spinal changes, including type I Modic changes. She presented with sciatica and, after conservative treatments failed, underwent an endoscopic discectomy. This intervention led to a marked improvement in her pain and functional status, along with a partial resolution of the Modic changes and a decrease in multifidus atrophy and fatty infiltration, on her follow-up MRI. In the second case, we discuss a 33-year-old patient with a large disc herniation. Despite three years of conservative management, she developed Modic changes and sclerosis in the adjacent vertebral endplates and a worsening of multifidus atrophy and fatty infiltration. This report supports the consideration of early minimally invasive discectomy for young patients who do not benefit from conservative treatment, as a means to prevent the progression of degenerative spinal changes.

Prevalence, risk factors, natural history, and prognostic significance of Modic changes in the cervical spine: a comprehensive systematic review and meta-analysis of 12,754 participants

OBJECTIVE

Modic changes (MCs) in the cervical spine are common, but remain an under-researched phenomenon, particularly regarding their prevalence, natural history, risk factors, and implications for surgical outcomes. This systematic review and meta-analysis endeavors to elucidate the multifactorial dimensions and clinical significance of cervical MCs.

METHODS

Following PRISMA guidelines, a comprehensive systematic search was performed using Medline (via PubMed), EMBASE, Scopus, and Web of Science databases from their dates of inceptions to September 4, 2023. All identified articles were meticulously screened based on their relevance to our investigative criteria. Bias was assessed using quality assessments tools, including Quality in Prognosis Studies (QUIPS) and Newcastle-Ottawa Scale (NOS). Diverse datasets encompassing MCs prevalence, demographic influences, risk factors, cervical sagittal parameters, and surgical outcomes were extracted. Meta-analysis using both random and common effects model was used to synthesis the metadata.

RESULTS

From a total of 867 studies, 38 met inclusion criteria and underwent full-text assessment. The overall prevalence of cervical MCs was 26.0% (95% CI: 19.0%, 34.0%), with a predominance of type 2 MCs (15% ; 95% CI: 0.10%, 0.23%). There was no significant difference between MCs and non-MCs in terms of neck pain (OR:3.09; 95% CI: 0.81, 11.88) and radicular pain (OR: 1.44; 95% CI: 0.64, 3.25). The results indicated a significantly higher mean age in the MC group (MD: 1.69 years; 95% CI: 0.29 years, 3.08 years). Additionally, smokers had 1.21 times the odds (95% CI: 1.01, 1.45) of a higher risk of developing MCs compared to non-smokers. While most cervical sagittal parameters remained unaffected, the presence of MCs indicated no substantial variation in pain intensity. However, a significant finding was the lower Japanese Orthopaedic Association (JOA) scores observed in MC patients at the 3-month (MD: -0.34, 95% CI: -0.62, -0.07) and 6-month (MD: -0.40, 95% CI: -0.80, 0.00) postoperative periods, indicating a prolonged recovery phase.

CONCLUSION

This study found a predominant of type 2 MCs in the cervical spine. However, there was no significant mean difference between MCs and non-MC groups regarding neck pain and radicular pain. The results underscore the necessity for expansive, longitudinal research to elucidate the complexity of cervical MCs, particularly in surgical and postoperative contexts.

Elective Spinal Transpedicular Ablation of the Basivertebral Nerve of the Vertebral Segment in Adult Spinal Deformity Patients

BACKGROUND

Ablation of the basivertebral nerve (BVNA) innervating the vertebral endplate has become a standard treatment of vertebrogenic chronic low back pain (CLBP) arising from vertebral endplate damage. BVNA treatment of CLBP in clinical trials was successful and durable for pain relief and return to daily activities. This case review adds new information about older patients with adult degenerative spinal deformity (ASD) and associated comorbidities not previously described in clinical trials.

METHODS

One hundred and eighteen ASD patients with vertebrogenic CLBP in a community practice setting underwent 503 levels of BVNA (average 4.3 levels). Forty-one patients with minimal comorbidities (Group A) were compared to 77 patients with significant comorbidities (Group B). Visual analog scale (VAS 10 cm) and Oswestry Disability Index (ODI 100-point scale) were obtained before BVNA and at a last follow-up (LFU).

RESULTS

Group A VAS at LFU was an average of 2 cm, a 7 cm improvement. Group B VAS at LFU was 3 cm, a 6 cm improvement. At LFU, Group A ODI mean was 14 points or minimal disability, with a 39-point improvement, and Group B improved 28 points to 29 but remained moderately disabled. At LFU, the lumbar stenosis with laminectomy and BVNA subgroup of 26 had mean VAS 2 cm and ODI 28-point improvement but remained on average 21 points with a final low moderate disability. Eleven laminectomy and BVNA patients had continued posterior column pain related to radiculopathy, and or peripheral neuropathy, and sacroiliac joint pain in 30%. Mobile spondylolisthesis in 21 patients in Group B at LFU had a 6 cm improvement of VAS and 25-point improvement of ODI but remained moderately disabled on ODI. At LFU in group B, there was a 20% incidence of continued stenosis and radiculopathy symptoms. At LFU, Lumbar fusion was recommended in 9. Vertebral compression fracture (VCF) occurred in 9 after BVNA (10%) of Group B. These patients were older (mean 78 years), and all had significant osteoporosis. Eight fractures were within the area of the BVNA, and 1 was an S2 sacral fracture. These VCF patients were treated with vertebroplasty or kyphoplasty and continued preventive care with added teriparatide. At LFU, the VCF subgroup had a modest 6 cm improvement in VAS to 4 cm and continued to have significant severe to moderate disability (Oswestry Disability Index average of 38 points).

CONCLUSION

Clinical trials of BVNA treatment of CLBP found success and durability for pain relief and daily activities. Patients with ASD without comorbidities showed durable pain relief of vertebrogenic CLBP and return of daily activities similar to clinical trials. In those with comorbidities, the result was an improvement in pain and disability that could be diminished by the complications related to the comorbidities. This is new information about BVNA for older patients with spinal deformity and other comorbidities. This study could impact research practice and policy to expand indications of BVNA to patients with adult spinal deformity.

CLINICAL RELEVANCE

This case series represents the only literature regarding patients with adult spinal deformity treated with BVNA. The results were predictable and reproducible. Many patients were satisfied, would have the procedure again and would recommend BVNA to friends and family. This finding should encourage acceptance of patients with ASD for BVNA and, in fact, BVNA should probably be done before any fusion to limit and choose levels for inclusion in fusion.

LEVEL OF EVIDENCE: 4

Prediction of transforaminal epidural injection success in sciatica (POTEISS): a protocol for the development of a multivariable prediction model for outcome after transforaminal epidural steroid injection in patients with lumbar radicular pain due to disc herniation or stenosis

BACKGROUND

Transforaminal epidural injections (TEI) can alleviate symptoms and help to maintain physical functioning and quality of life in patients with lumbar radicular pain. We aim to develop a prediction model for patient outcome after TEI in patients suffering from unilateral lumbar radicular pain due to lumbar disc herniation (LDH) or single-level spinal stenosis (LSS). The secondary aim is to estimate short-term patient outcome differences between LDH and LSS patients, the association between psychological variables and patient outcome, the rate of additional injections, surgery and complications, and to explore the short-term cost-effectiveness of TEI.

METHODS

This study is designed as a multi-centre, observational, prospective cohort study in two large regional hospitals in the Netherlands. Patients diagnosed with unilateral lumbar radicular pain secondary to LDH or LSS and congruent with MRI findings, who are referred for TEI along usual care pathways, are eligible for study participation. A total of 388 patients with LDH or LSS will be included. A pre-defined set of demographic, clinical and radiological variables will be used as the predictors in the model. The primary outcome measure is the Numerical Rating Scale (NRS) for leg pain. Secondary outcome measures include back pain, physical functioning, perceived recovery, pain coping strategies, anxiety and depression and use of analgesics and physical therapy. Patients will be evaluated at baseline, 2 weeks and 6 weeks after treatment. NRS leg pain and Likert perceived recovery data will be used as the dependent variables in a generalized linear mixed model for prediction of TEI outcome, with internal validation of performance (explained variation) by bootstrap resampling. Cost-effectiveness for a period of 6 weeks prior to and after treatment will be performed with decision-analytic modelling.

DISCUSSION

Patients with severe lumbar radicular pain often request additional treatment when conservative care is insufficient. TEI can offer relief of symptoms. Currently, it is not possible to predict responsiveness to this treatment for individual patients. This study is designed to explore predictors that can differentiate between patients that will and will not have a positive outcome after TEI. This information may support treatment strategies for this patient group.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.gov database under registry number NCT04540068 on September 1, 2020.

Modic changes in patients with lumbar disc herniation followed more than 1 year after lumbar discectomy: a systematic review and meta-analysis

Background

Modic changes (MCs) are identified as an independent risk factor for low back pain. Different subtypes of MCs vary in their impact on postoperative pain relief. However, consensus on the transformation of postoperative MC fractions in patients with distinct MC subtypes is lacking.

Methods

This comprehensive systematic review and meta-analysis searched English-language articles in PubMed, Cochrane Library, Web of Science, and Embase databases until January 2024. Studies included focused on patients transitioning between various microcrack subtypes post-discectomy. The primary outcome measure was the transformation between different postoperative microcrack fractions.

Results

Eight studies with 689 participants were analyzed. Overall, there is moderate to high-quality evidence indicating differences in the incidence of MC conversion across MC subtypes. The overall incidence of MC conversion was 27.7%, with rates of 37.0%, 20.5%, and 19.1% for MC0, MC1, and MC2 subtypes, respectively. Thus, postoperative MC type transformation, particularly from preoperative MC0 to MC1 (17.7%) or MC2 (13.1%), was more common, with MC1 transformation being predominant. Patients with preoperative comorbid MC1 types (19.0%) exhibited more postoperative transitions than those with MC2 types (12.4%).

Conclusion

This study underscores the significance of analyzing post-discectomy MCs in patients with lumbar disc herniation, revealing a higher incidence of MCs post-lumbar discectomy, particularly from preoperative absence of MC to MC1 or MC2. Preoperative MC0 types were more likely to undergo postoperative MC transformation than combined MC1 or MC2 types. These findings are crucial for enhancing surgical outcomes and postoperative care.

Mechanical consequences to the annulus fibrosus following rapid internal pressurization and endplate fracture under restrained-expansion conditions

Intervertebral disc herniation is not a common injury in the adolescent population, but the correlation between trauma and herniation warrants concern. Previous research demonstrated the capacity for rapid internal pressurization to reduce the mechanical integrity of the intervertebral disc's annulus fibrosus, even in the absence of fracture. The purpose of this study was to modify previous internal pressurization procedures towards a more transferable injury model, then investigate the capacity for these procedures to damage the mechanical integrity of the annulus fibrosus. Porcine cervical motion segments with intact facet joints were confined between a vice and force plate under 300 N of static compression, then a single, manual, rapid internal pressurization was delivered. Posterolateral annulus samples were extracted and situated in a 180° peel test configuration, exposing the interlamellar matrix of samples to separations of 0.5 mm/s, until complete separation of the sample occurred. Multilayer tensile testing was performed on superficial and mid-span samples of annulus by applying uniaxial tension of 1 %/s to 50 % strain. Compared to unpressurized controls, rapid pressurization causing fracture resulted in reduced lamellar adhesion and increased toe-region stress and strain properties in the annulus. Morphological assessment reported similar fracture patterns between endplate fractures achieved in the present experiment and endplate fractures documented in human patients. Mechanical plus morphological results suggest that rapid internal pressurization resulting in endplate fracture may represent a potent mechanism for subsequent damage to the intervertebral disc.

Association of modic changes and postoperative surgical site infection after posterior lumbar spinal fusion

PURPOSE

Postoperative surgical site infection is one of the most serious complications following spine surgery. Previous studies have reported Modic changes (MC) represent a subclinical infection. This study aims to investigate the relation between Modic changes and surgical site infection after posterior lumbar fusion surgery.

METHODS

We retrospectively reviewed the records of 424 patients who received posterior lumbar fusion. Preoperative clinical and radiological parameters were recorded. Primary outcome was the rate of postoperative surgical site infection. Covariates included age, body mass index (BMI), sex, hypertension, diabetes mellitus, chronic heart failure, Pfirrmann classification, fused levels, and operation duration. The presence of Modic changes was used as an exposition variable, and adjusted for other risk factors in multivariate analyses.

RESULTS

Of the 424 patients, 30 (7%) developed an acute surgical site infection. Infection had no relation to age, sex, BMI, and comorbidities. There were 212 (50%) patients with MC, and 23 (10.8%) had a surgical site infection, compared to 212 (50%) patients without MC in which there were 7 (3.3%) surgical site infections. MC was associated with surgical site infection in univariate analysis (odds ratio [OR] = 3.56, 95% confidence interval [CI]: 1.49-8.50, p = 0.004) and multivariate logistic regression analysis (OR = 3.05, 95% CI: 1.26-7.37, p = 0.013). There was statistically significant between specific type (p = 0.035) and grade of MCs (p = 0.0187) and SSI.

CONCLUSIONS

MCs may be a potential risk factor for SSI following posterior lumbar spinal intervertebral fusion. Type I and grade C MCs showed a higher infection rate compared with other MC types and grades.

Can Hematological Inflammatory Indices Be Used to Differentiate Modic Type 1 Changes from Brucella Spondylodiscitis?

Background and Objectives: Differentiation between brucella spondylodiscitis and Modic type I changes (MC1) includes difficulties. Hematological inflammatory indices (HII) such as neutrophil to lymphocyte ratio (NLR) and aggregate index of systemic inflammation (AISI) are suggested as indicators of inflammation and infection and have diagnostic, prognostic, and predictive roles in various diseases. This study aimed to evaluate differences between brucella spondylodiscitis and MC1 in terms of HII. Materials and Methods: Thirty-five patients with brucella spondylodiscitis and thirty-seven with MC1 were enrolled in the study. Brucella spondylodiscitis and MC1 were diagnosed by microbiological, serological, and radiological diagnostic tools. HII (NLR, MLR, PLR, NLPR, SII, SIRI, AISI) were derived from baseline complete blood count. Results: The two groups were similar for age (p = 0.579) and gender (p = 0.092), leukocyte (p = 0.127), neutrophil (p = 0.366), lymphocyte (p = 0.090), and monocyte (p = 0.756) scores. The Brucella spondylodiscitis group had significantly lower pain duration (p < 0.001), higher CRP and ESR levels (p < 0.001), and lower platelet count (p = 0.047) than the MC1 group. The two groups had similarity in terms of HII: NLR (p = 0.553), MLR (p = 0.294), PLR (p = 0.772), NLPR (p = 0.115), SII (p = 0.798), SIRI (p = 0.447), and AISI (p = 0.248). Conclusions: Increased HII can be used to differentiate infectious and non-infectious conditions, but this may be invalid in brucellosis. However, pain duration, CRP and ESR levels, and platelet count may be useful to distinguish brucella spondylodiscitis from MC1.

The Relationship Between Modic Changes and Endplate Sclerosis in Patients with Lumbar Degenerative Disease: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To explore the relationship between modic changes (MCs) and endplate sclerosis in patients with lumbar degenerative disease.

METHODS

This network meta-analysis was performed on the basis of Preffered Reporting Items for Systematic Reviews and Meta-Analysis 2020 statement. This study was registered at the International Prospective Register of Systematic Reviews (CRD42024497370). We performed a systematic search of the PubMed, Web of Science, Embase, China national knowledge infrastructure, China Science and Technology Journal Database, and Wanfang databases from inception to December 22, 2023. STATA13.0 and RevMan 5.3 were applied to perform the meta-analysis.

RESULTS

Seven studies with a total of 1510 endplates were divided into 6 groups according to the type of MCs. The endplate sclerosis rate in the single-type group was significantly lower than that in the mixed-type group. The endplate sclerosis rate in the type I MC (MC1) was significantly lower than that in the type II MC (MC2). The endplate sclerosis rate in the MC2 was significantly lower than that in the type III MC (MC3). The endplate sclerosis rate in the MC1/2 was significantly lower than that in the MC2/3. No significant difference was detected between MC1/2 and MC1/3 or between MC2/3 and MC1/3. For decreasing the endplate sclerosis rate, the order of the different types of MCs was MC1>MC2>MC1/2>MC2/3≈MC1/3>MC3.

CONCLUSIONS

Endplate sclerosis occurs in all kinds of MCs. With increasing grade of MCs, the incidence of endplate sclerosis gradually increased. The endplate sclerosis rate in mixed-type MCs was significantly greater than that in MC2 and significantly lower than that in MC3. The endplate sclerosis rate in the mixed-type, including MC3 (MC1/3 and MC2/3), was significantly greater than that in the MC1/2.

The Relationship Between Inflammatory Processes and Apoptosis in Lumbar Disc Degeneration

OBJECTIVE

Degenerative Disc Disease (DDD) is a common health problem in the population. There are recent studies focusing on relationship between DDD and immunological factors. However, there is still a lack of data on the role of apoptosis in DDD pathophysiology. Therefore, we aimed to investigate the relationship between Modic-type changes and the apoptosis in DDD.

MATERIALS AND METHODS

Ninety adult male patients who presented with low back and/or radicular pain and were operated on due to lumbar disc herniation were included. Three groups were formed based on Modic type degeneration observed on magnetic resonance imaging. Specific parameters involved in the intrinsic and extrinsic pathways of apoptosis were assessed in excised disc materials using the enzyme-linked immunosorbent assay method.

RESULTS

All three groups formed according to Modic degeneration types were homogenous in all variances. Cytochrome-C was significantly decreased only in the Modic type-3 group, whereas Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand Receptor-1, B-Cell Lymphoma-2 (Bcl-2) Homologous Antagonist Killer-1, Direct Inhibitor of Apoptosis-Binding Protein with Low Pi, and Bcl-2 Associated X Apoptosis Regulator levels were significantly different in both Modic type-2 and -3 groups. However, BH3 interacting domain death agonist and Bcl-2 levels were similar across all groups.

CONCLUSIONS

In conclusion, this study suggests that Direct Inhibitor of Apoptosis-Binding Protein with Low Pi, cytochrome - c, Bcl-2 Associated X Apoptosis Regulator, Bcl-2 Homologous Antagonist Killer-1, and Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand Receptor-1proteins play important roles in the development and progression of DDD and are correlated with Modic types. Further studies are needed to explore the potential therapeutic role of inhibiting these apoptotic proteins in DDD.

Lumbar instability remodels cartilage endplate to induce intervertebral disc degeneration by recruiting osteoclasts via Hippo-CCL3 signaling

Degenerated endplate appears with cheese-like morphology and sensory innervation, contributing to low back pain and subsequently inducing intervertebral disc degeneration in the aged population.1 However, the origin and development mechanism of the cheese-like morphology remain unclear. Here in this study, we report lumbar instability induced cartilage endplate remodeling is responsible for this pathological change. Transcriptome sequencing of the endplate chondrocytes under abnormal stress revealed that the Hippo signaling was key for this process. Activation of Hippo signaling or knockout of the key gene Yap1 in the cartilage endplate severed the cheese-like morphological change and disc degeneration after lumbar spine instability (LSI) surgery, while blocking the Hippo signaling reversed this process. Meanwhile, transcriptome sequencing data also showed osteoclast differentiation related gene set expression was up regulated in the endplate chondrocytes under abnormal mechanical stress, which was activated after the Hippo signaling. Among the discovered osteoclast differentiation gene set, CCL3 was found to be largely released from the chondrocytes under abnormal stress, which functioned to recruit and promote osteoclasts formation for cartilage endplate remodeling. Over-expression of Yap1 inhibited CCL3 transcription by blocking its promoter, which then reversed the endplate from remodeling to the cheese-like morphology. Finally, LSI-induced cartilage endplate remodeling was successfully rescued by local injection of an AAV5 wrapped Yap1 over-expression plasmid at the site. These findings suggest that the Hippo signaling induced osteoclast gene set activation in the cartilage endplate is a potential new target for the management of instability induced low back pain and lumbar degeneration.

Postoperative Sclerotic Modic Changes After Transforaminal Lumbar Interbody Fusion: The Prevalence, Risk Factors, and Impact on Fusion

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

This study aimed to assess postoperative sclerotic modic changes (MCs) following transforaminal lumbar interbody fusion for lumbar degenerative disc disease, investigating their prevalence, risk factors, and association with clinical outcomes.

SUMMARY OF BACKGROUND DATA

Sclerotic MCs may occur in patients with lumbar degenerative disc disease after lumbar interbody fusion. The incidence and characteristics of postoperative sclerotic MCs, as well as their clinical impact, are unknown.

MATERIALS AND METHODS

The study included 467 patients (510 levels) who underwent single or two-level transforaminal lumbar interbody fusion surgery, divided into a postoperative sclerotic MC group (60 patients, 66 levels) and a non-MC group (407 patients, 444 levels). The time of development and location of postoperative sclerotic MCs, fusion rate, cage subsidence, bilateral process decompression, and cross-link usage were recorded. Preoperative, postoperative, and follow-up visual analogue scale and Oswestry disability index scores were collected. Multivariable logistic regression was used to evaluate factors associated with the development of postoperative sclerotic MCs.

RESULTS

The prevalence of postoperative sclerotic MCs was 12.8%. The postoperative sclerotic MC group had a higher body mass index (BMI). The postoperative sclerotic MC group demonstrated a fusion rate of 47%, significantly lower than that of the non-MC group (71%) at six months post-operation. At final follow-up, the fusion rate in the postoperative sclerotic MC group was 62%, significantly lower than that of the non-MC group (86%). Postoperative visual analogue scale and Oswestry disability index scores were significantly higher in the group with postoperative sclerotic MCs. BMI and osteoporosis were significantly associated with the development of postoperative sclerotic MCs.

CONCLUSION

Postoperative sclerotic MCs generally appear within the first year after surgery, with a prevalence of 12.8%. The presence of postoperative sclerotic MCs can adversely impact postoperative outcomes. To prevent postoperative sclerotic MCs, the authors postulate extending the immobilization period with external bracing and improving the management of BMI and osteoporosis in the perioperative time window.

The effect of long-term alendronic acid treatment on Modic changes in the lumbar spine: a gender and age-matched study

BACKGROUND

Low back pain (LBP) affects a significant proportion of the adult population. Potent anti-resorptive drugs such as intravenous zoledronic acid have been demonstrated to reduce Modic changes (MCs) upon magnetic resonance imaging (MRI) of the spine and concomitantly decrease associated LBP. It is uncertain whether oral alendronic acid has a similar effect.

METHODS

82 subjects were recruited in this case-control study. Treatment subjects (n = 41) received oral alendronic acid treatment for at least 1-year and were matched by gender and age (± 2) to control subjects (n = 41) not receiving any anti-osteoporotic medication. The prevalence, type, and extent of MCs were quantified upon T1 and T2-weighted MRIs of the lumbosacral spine.

RESULTS

Treatment subjects received oral alendronic acid for 124.0 ± 62.1 weeks at the time of MRI assessment and exhibited a lower prevalence of MCs over the lumbosacral spine (18/41 vs. 30/41, p < 0.001) as compared to control subjects. Amongst both groups, type 2 MCs were predominant. Quantification of type 2 MCs in treatment subjects revealed a significant reduction in area (113 ± 106 mm2 vs. 231 ± 144 mm2, p < 0.01) and volume (453 ± 427 mm3 vs. 925 ± 575 mm3, p < 0.01) affected by type 2 MCs in comparison to matched controls.

CONCLUSION

Oral alendronic acid may be useful in the treatment of MC-associated LBP in patients with concomitant osteoporosis.

Bacterial growth in patients with low back pain and Modic changes: protocol of a multicentre, case-control biopsy study

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.

Mrgprb2-mediated mast cell activation exacerbates Modic changes by regulating immune niches

Modic changes are radiographic features associated with microfracture, low-virulence organism infection and chronic inflammation with inflammatory cell infiltration in the vertebral endplate region. Mast cells, as innate immune cells similar to macrophages, are present in painful degenerated intervertebral discs. However, the involvement and mechanisms of mast cells in the development of Modic changes remain unclear. Herein, we found increased mast cell infiltration in samples from patients with Modic changes and in mouse models of Modic changes. To clarify the role of mast cells in the progression of Modic changes, we used mast cell-deficient (KITW-SH/W-SH) mice to construct a model of Modic changes and found that the severity of Modic changes in KITW-SH/W-SH mice was significantly lower than that in WT mice. These findings were further supported by the use of a mast cell-specific activator (compound 48/80) and a stabilizer (cromolyn). Furthermore, we found that mast cells were not activated via the classic IgE pathway in the Modic change models and that Mrgprb2 is the specific receptor for mast cell activation reported in recent studies. Then, we utilized Mrgprb2 knockout mice to demonstrate that Mrgprb2 knockout inhibited mast cell activation and thus reduced the degree of Modic changes. Transcriptomic sequencing revealed aberrant PI3K-AKT and MAPK pathway activation in the Mrgprb2-deficient mast cells. Additionally, Mrgpbrb2-activated mast cells regulate immune niches by recruiting macrophages, promoting M1 polarization and reducing M2 polarization, thereby promoting the progression of Modic changes. These findings suggest that mast cells may serve as a novel therapeutic target for addressing Modic changes.

The effect of diabetes mellitus on lumbar disc degeneration: an MRI-based study

PURPOSE

This study aims to analyse the effect of diabetes mellitus (DM) on the radiological changes of Magnetic Resonance Imaging (MRI) on the intervertebral discs and paravertebral muscle to investigate the effect of DM on spinal degeneration.

METHODS

This retrospective study initially included 262 patients who underwent treatment between January 2020 and December 2021 because of lumbar disc herniation. Amongst these patients, 98 patients suffered from type 2 diabetes mellitus (T2DM) for more than five years; this is the poorly controlled group (haemoglobin A1c (HbA1c) ≥ 6.5%; BMI: 26.28 ± 3.60; HbA1c: 7.5, IQR = 1.3). Another 164 patients without T2DM are included in the control group. The data collected and analysed include gender, age, smoking, alcohol use, disease course, Charlson Comorbidity Index, BMI, and radiological parameters including disc height, modified Pfirrmann grading scores, percentage of fat infiltration area of paravertebral muscle, and pathological changes of the endplate.

RESULTS

After propensity score-matched analysis, the difference in general data between the control and T2DM groups was eliminated, and 186 patients were analysed. The modified Pfirrmann grading scores showed statistical differences in every lumbar segment, suggesting that the T2DM group suffered from greater disc degeneration at all L1-S1 segments compared with the control group. The disc height from L1/2 to L5/S1 was not statistically different between the two groups. Compared to the T2DM group, the control group had a lower percentage of fat infiltration areas in L4/5 and L5/S1 paravertebral muscle, whereas L1/2 to L3/4 showed no statistical difference. The T2DM group had more pathological changes of cartilage endplate compared with the control group.

CONCLUSIONS

Prolonged uncontrolled hyperglycaemia may contribute to lumbar disc degeneration, fatty infiltration of the paraspinal muscles in the lower lumbar segments, and increased incidence of endplate cartilage pathological changes in patients with degenerative disc disease.

Regional structure-function relationships of lumbar cartilage endplates

Cartilage endplates (CEPs) act as protective mechanical barriers for intervertebral discs (IVDs), yet their heterogeneous structure-function relationships are poorly understood. This study addressed this gap by characterizing and correlating the regional biphasic mechanical properties and biochemical composition of human lumbar CEPs. Samples from central, lateral, anterior, and posterior portions of the disc (n = 8/region) were mechanically tested under confined compression to quantify swelling pressure, equilibrium aggregate modulus, and hydraulic permeability. These properties were correlated with CEP porosity and glycosaminoglycan (s-GAG) content, which were obtained by biochemical assays of the same specimens. Both swelling pressure (142.79 ± 85.89 kPa) and aggregate modulus (1864.10 ± 1240.99 kPa) were found to be regionally dependent (p = 0.0001 and p = 0.0067, respectively) in the CEP and trended lowest in the central location. No significant regional dependence was observed for CEP permeability (1.35 ± 0.97 * 10-16 m4/Ns). Porosity measurements correlated significantly with swelling pressure (r = -0.40, p = 0.0227), aggregate modulus (r = -0.49, p = 0.0046), and permeability (r = 0.36, p = 0.0421), and appeared to be the primary indicator of CEP biphasic mechanical properties. Second harmonic generation microscopy also revealed regional patterns of collagen fiber anchoring, with fibers inserting the CEP perpendicularly in the central region and at off-axial directions in peripheral regions. These results suggest that CEP tissue has regionally dependent mechanical properties which are likely due to the regional variation in porosity and matrix structure. This work advances our understanding of healthy baseline endplate biomechanics and lays a groundwork for further understanding the role of CEPs in IVD degeneration.

Altered Metabolism and Inflammation Driven by Post-translational Modifications in Intervertebral Disc Degeneration

Intervertebral disc degeneration (IVDD) is a prevalent cause of low back pain and a leading contributor to disability. IVDD progression involves pathological shifts marked by low-grade inflammation, extracellular matrix remodeling, and metabolic disruptions characterized by heightened glycolytic pathways, mitochondrial dysfunction, and cellular senescence. Extensive posttranslational modifications of proteins within nucleus pulposus cells and chondrocytes play crucial roles in reshaping the intervertebral disc phenotype and orchestrating metabolism and inflammation in diverse contexts. This review focuses on the pivotal roles of phosphorylation, ubiquitination, acetylation, glycosylation, methylation, and lactylation in IVDD pathogenesis. It integrates the latest insights into various posttranslational modification-mediated metabolic and inflammatory signaling networks, laying the groundwork for targeted proteomics and metabolomics for IVDD treatment. The discussion also highlights unexplored territories, emphasizing the need for future research, particularly in understanding the role of lactylation in intervertebral disc health, an area currently shrouded in mystery.

Modic Changes in the Lumbar Spine: Exploring Their Association with Abdominal Aortic Calcification as a Potential Indicator of Systemic Atherosclerosis

BACKGROUND

This was a cross-sectional study on the correlation between abdominal aortic calcification (AAC) and Modic changes (MC). Little is known regarding the etiology of MC in the lumbar spine. Currently, insufficient vascularization of the endplate has been proposed to contribute to the appearance of MC. Our objective was to investigate whether AAC, a marker for a poor vascular status, is associated with MC in patients suffering from degenerative disc disease.

METHODS

Radiologic images of patients (n = 130) suffering from degenerative lumbar disc disease were reviewed. Type and severity of MC were assessed using magnetic resonance images, and severity of AAC was evaluated using computed tomography images or fluoroscopy. Both items were dichotomized into minimal and relevant grades. The correlation between them was studied using Spearman's correlation test, with age as a covariate.

RESULTS

Of the patients, 113 (87%) demonstrated MC (31% type I, 63% type II, and 6% type III) (55% relevant grade), and 68% had AAC (44% relevant grade). Spearman statistical analysis revealed that AAC was correlated with age (P < 0.001), whereas MC were not (P = 0.142). AAC severity was significantly correlated with MC, remaining so after age adjustment (P < 0.05). While MC type I lacked correlation with AAC, MC type II were significantly correlated with AAC (0.288, P = 0.015); however, this association lost significance after adjusting for age (P = 0.057).

CONCLUSIONS

AAC and MC (mainly MC type II) are associated, indicating that reduced blood supply or even a poor systemic vascularization status due to atherosclerotic disease may play a role in the formation of MC. Future studies focusing on the etiology of MC should pay more attention to patients' vascular status and determinants of abdominal aorta calcification.

The Clinical Significance of the Modic Changes Grading Score

STUDY DESIGN

Cross-sectional retrospective observational study.

OBJECTIVE

To evaluate the reliability and clinical utility of the Modic changes (MC) grading score.

METHOD

Patients from the Danish national spine registry, DaneSpine, scheduled for lumbar discectomy were identified. MRI of patients with MC were graded based on vertical height involvement: Grade A (<25%), Grade B (25%-50%), and Grade C (>50%). All MRIs were reviewed by 2 physicians to evaluate the reliability of the MC grade.

RESULTS

Of 213 patients included, 142 patients had MC, 71 with MC-1 and 71 with MC-2; 34% were Grade A, 45% were Grade B, and 21% were Grade C. MC grade demonstrated substantial intra-rater (κ = .68) and inter-rater (κ = .61) reliability. A significantly higher proportion (n = 40, 57%) of patients with MC-1 had a severe MC grade compared to patients with MC-2 (n = 30, 43%, P < .001). Severe MC grade was associated with the presence of severe lumbar disc degeneration (DD) (Pfirrmann grade = V, P = .024), worse preoperative ODI (52.49 vs 44.17, P = .021) and EQ-5D scores (.26 vs .46, P = .053). MC alone including type was not associated with a significant difference in patient-reported outcomes (P > .05).

CONCLUSION

The MC grade score was demonstrated to have substantial intra- and inter-observer reliability. Severe MC grade was associated with both severe DD and MC type, being more prevalent in patients with MC-1. The MC grade was also significantly associated with worse disability and reduced health-related quality of life. Results from the study suggest that MC grade is more clinically important than MC type.

Discovery of circulating blood biomarkers in patients with and without Modic changes of the lumbar spine: a preliminary analysis

PURPOSE

The following study aimed to determine the existence of blood biomarkers in symptomatic patients with or without lumbar Modic changes (MC).

METHODS

A cross-sectional sub-analyses of a prospective cohort was performed. Fasting blood samples were collected from patients with and without lumbar MC who had undergone spinal fusion or microdiscectomy. An 80-plex panel and CCL5/RANTES were used to assess preoperative plasma cytokine concentrations. Patient demographics and imaging phenotypes were also assessed.

RESULTS

Thirty-one subjects were analysed (n = 18 no MC; n = 13 MC). No significant differences were found in age, sex, body mass index, smoking and alcohol history, and surgical procedure (i.e. fusion, decompression) between the two groups (p > 0.05). Several statistically significant blood biomarkers in MC patients were identified, including elevated levels of C-C Motif Chemokine Ligand 5 (CCL5, p = 0.0006), while Macrophage Migration Inhibitory Factor (MIF) was significantly lower (p = 0.009). Additionally, C-X-C Motif Chemokine Ligand 5 (CXCL5, p = 0.052), Pentraxin 3 (PTX3, p = 0.06) and Galectin-3 (Gal-3, p = 0.07) showed potential relevance. Moreover, MC patients exhibited significantly higher levels of disc degeneration (p = 0.0001) and displacement severity (p = 0.020). Based on multivariate analyses and controlling for disc degeneration/displacement, CCL5 (OR 1.02; 95% CI 1.002-1.033; p = 0.028) and MIF (OR 0.60; 95% CI 0.382-0.951; p = 0.030) were independently associated with MC patients.

CONCLUSION

This "proof-of-concept" study is the first to identify specific and significantly circulating blood biomarkers associated with symptomatic patients with lumbar MC, independent of disc alterations of degeneration and/or bulges/herniations. Specifically, differences in CCL5 and MIF protein levels were significantly noted in MC patients compared to those without MC.

The Success of Deep Learning Modalities in Evaluating Modic Changes

BACKGROUND

Modic changes are pathologies that are common in the population and cause low back pain. The aim of the study is to analyze the modic changes detected in magnetic resonance imaging (MRI) using deep learning modalities.

METHODS

The sagittal T1, sagittal and axial T2-weighted lumbar MRI images of 307 patients, of which 125 were female and 182 were male, aged 19-86 years, who underwent MRI examination between 2016-2021 were analyzed. Modic changes (MC) were categorized and marked according to signal changes. Our study consists of 2 independent stages: classification and segmentation. The categorized data were first classified using convolutional neural network (CNN) architectures such as DenseNet-121, DenseNet-169, and VGG-19. In the next stage, masks were removed by segmentation using U-Net, which is the CNN architecture, with image processing programs on the marked images.

RESULTS

During the classification stage, the success rates for modic type 1, type 2, and type 3 changes were 98%, 96%, 100% in DenseNet-121, 100%, 94%, 100% in DenseNet-169, and 98%, 92%, 97% in VGG-19, respectively. At the segmentation phase, the success rate was 71% with the U-Net architecture.

CONCLUSIONS

Evaluation of MRI findings of MC in the etiology of lower back pain with deep learning architectures can significantly reduce the workload of the radiologist by providing ease of diagnosis.

Modic changes in the lumbar vertebral column of chondrodystrophic and non-chondrodystrophic dogs with intervertebral disc disease

Introduction

Modic changes (MC) are signs of vertebral pathology visible on magnetic resonance (MR) images that have been associated with low back pain (LBP) and disc degeneration in people. Multiple breeds of dogs also develop MCs and coincident back pain. However, the association between breed, MC, and spinal pathologies has yet to be fully elucidated. This study aimed to identify the prevalence of MC that occur spontaneously in the lumbar vertebral column of dogs diagnosed with intervertebral disc disease (IVDD) and examine their association with demographic criteria and the disc width index (DWI).

Methods

Medical records and lumbar vertebral column MR images were examined from 104 dogs (831 intervertebral disc spaces and adjacent vertebrae), which were divided into three groups: chondrodystrophic dogs (CD; n =54) and non-chondrodystrophic dogs (NCD; n =30) with IVDD as the primary diagnosis, and control dogs (n =20) with other spinal diseases as their primary diagnosis.

Results

Increasing age and a diagnosis of IVDD were significantly associated with MC in dogs (p <  0.001 and p = 0.0062, respectively). In CD dogs with IVDD, Type 2 MC were most prevalent, whereas, in NCD dogs, Type 3 MC were the most prevalent type. Type 2 MC were distributed nearly equally across the lumbar vertebral column, while Type 3 MC were primarily detected at the level of L7-S1.

Discussion

This study demonstrated that MC developed spontaneously in dogs, are common in dogs diagnosed with IVDD, and the type observed varies by breed. Further research is needed to understand the pathogenesis of MC; however, the increased presence of Type 2 MC in CD dogs, similar to what is found in people with disc degeneration, suggests that CD dogs could serve as models for MC in people.