MR imaging of degenerative disc disease

Neuroinflammation and nociception in intervertebral disc degeneration: a review of precision medicine perspective

Intervertebral disc (IVD) degeneration is a major cause of low back pain (LBP), which results in disability worldwide. However, the pathogenesis of IVD degeneration mediating LBP remains unclear. Current conservative treatments and surgical interventions are both to relieve the symptoms and minimise pain; nevertheless, they are unable to reverse the degeneration. Previous studies have shown that inflammation and nociception markers are important indicators of pain mechanisms in IVD degeneration underlying LBP. As such, multiomics profiling allows the discovery of these target markers to understand the key pathological mechanisms mediating IVD degeneration underpinnings of LBP. This article provides insights into a precision medicine approach for identifying and understanding the pathophysiology of IVD degeneration associated with LPB based on the severity of the disease from early and mild to severe degenerative stages. Molecular profiling of key markers in degenerative IVDs based on patient stratification at early, mild, and severe stages will contribute to the identification of target markers associated with signalling pathways in mediating neuroinflammation, innervation, and nociception underlying painful IVD degeneration. This approach will offer an understanding of establishing personalised clinical strategies tailored to the severity of IVD degeneration for the treatment of LBP.

Development and application of AI assisted automatic reconstruction of axial lumbar disc CT images and diagnosis of lumbar disc herniation

RATIONALE AND OBJECTIVES

To evaluate the value of artificial intelligence (AI) assisted diagnostic system in reconstructing axial lumbar disc CT images and diagnosing lumbar disc herniation.

MATERIALS AND METHODS

440 patients with lumbar disc herniation were included, with 400 cases of spiral data (320 training, 40 validations, and 40 testing) and 40 cases of axial data (testing). V-Net was used to reconstruct the axial lumbar disc images. U-Net was used to segment the herniated discs and perform MSU classification. The Dice coefficient was used to evaluate the accuracy of AI in lumbar vertebras and discs segmentation. The quality of axial CT images reconstructed by AI and radiology technician was compared. The diagnostic accuracy of AI, radiologist, and AI + radiologist for the MSU classification of lumbar disc herniation in spiral and axial data was evaluated.

RESULTS

The Dice coefficients of AI for segmenting the sacral, lumbar, and lumbar discs were 0.953, 0.940, and 0.926, respectively. The quality of the axial CT images reconstructed by AI and radiographer had non-significant difference (P＞0.05). In both the spiral and axial data, the accuracy of AI, radiologist, and AI + radiologist in diagnosing the MSU classification was significantly different (P < 0.01). The diagnostic accuracy of the AI system in MSU classification was higher in the spiral data than that of the axial data (P = 0.003).

CONCLUSION

The AI system is feasible and satisfactory for segmentation of lumbar CT image, reconstruction of axial lumbar disc CT images, and diagnosis of lumbar disc herniation.

The advancement and utility of multimodal imaging in the diagnosis of degenerative disc disease

Degenerative disc disease (DDD) is a common spinal condition characterized by the deterioration of intervertebral discs, leading to chronic back pain and reduced mobility. While magnetic resonance imaging (MRI) has long been the standard for late-stage DDD diagnosis, its limitations in early-stage detection prompt the exploration of advanced imaging methods. Positron emission tomography/computed tomography (PET/CT) using 18F- fluorodeoxyglucose (FDG) and 18F-sodium fluoride (NaF) has shown promise in identifying metabolic imbalances and age-related spinal degeneration, thereby complementing CT grading of the disease. The novel hybrid imaging modality PET/MRI provides new opportunities and are briefly discussed. The complex pathophysiology of DDD is dissected to highlight the role of genetic predisposition and lifestyle factors such as smoking and obesity. These etiological factors significantly impact the lumbosacral region, manifesting in chronic low back pain (LBP) and potential nerve compression. Traditional grading systems, like the Pfirrmann classification for MRI, are evaluated for their limitations in capturing the full spectrum of DDD. The potential to identify early disease processes and predict patient outcomes by the use of artificial intelligence (AI) is also briefly mentioned. Overall, the manuscript aims to spotlight advancements in imaging technologies for DDD, emphasizing their implications in refining both diagnosis and treatment strategies. The role of ongoing and future research is emphasized to validate these emerging techniques and overcome current limitations for more effective early detection and treatment.

An Automatized Deep Segmentation and Classification Model for Lumbar Disk Degeneration and Clarification of Its Impact on Clinical Decisions

STUDY DESIGN

Cross-sectional database study.

OBJECTIVE

The purpose of this study was to develop a successful, reproducible, and reliable convolutional neural network (CNN) model capable of segmentation and classification for grading intervertebral disc degeneration (IVDD), as well as quantify the network's impact on doctors' clinical decision-making.

METHODS

5685 discs from 1137 patients were graded separately by four experienced doctors according to the Pfirrmann classification. A ground truth (GT) was established for each disc in accordance with the decision of the majority of doctors. The U-net model is used for segmentation. 1815 discs from 363 patients were used to train and test the U-net. The Inception V3 model is employed for classification. All discs were separated into two distinct sets: 90% in a training set and 10% in a test set. The performance metrics of these models were measured. Reliability tests were performed. The impact of CNN assistance on doctors was assessed.

RESULTS

Segmentation accuracy was .9597 with a .8717 Jaccard Index and a .9314 Sorensen Dice coefficient. Classification accuracy is .9346, and the F1 score is .9355. The intraclass correlation coefficient (ICC) and kappa values between CNN and GT were .95-.97. With CNN's assistance, the success rates of doctors increased by 7.9% to 22%.

CONCLUSIONS

The fully automated network outperformed doctors markedly in terms of accuracy and reliability. The results of CNN were comparable to those of other recent studies in the literature. It was determined that CNN's assistance had a substantial positive effect on the doctor's decision.

Sodium MRI of the Lumbar Intervertebral Discs of the Human Spine: An Ex Vivo Study

BACKGROUND

Lower back pain affects 75%-85% of people at some point in their lives. The detection of biochemical changes with sodium (23Na) MRI has potential to enable an earlier and more accurate diagnosis.

PURPOSE

To measure 23Na relaxation times and apparent tissue sodium concentration (aTSC) in ex-vivo intervertebral discs (IVDs), and to investigate the relationship between aTSC and histological Thompson grade.

STUDY TYPE

Ex-vivo.

SPECIMEN

Thirty IVDs from the lumbar spines of 11 human body donors (4 female, 7 male, mean age 86 ± 8 years).

FIELD STRENGTH/SEQUENCE

3 T; density-adapted 3D radial sequence (DA-3D-RAD).

ASSESSMENT

IVD 23Na longitudinal (T1), short and long transverse (T2s* and T2l*) relaxation times and the proportion of the short transverse relaxation (ps) were calculated for one IVD per spine sample (11 IVDs). Furthermore, aTSCs were calculated for all IVDs. The degradation of the IVDs was assessed via histological Thompson grading.

STATISTICAL TESTS

A Kendall Tau correlation (τ) test was performed between the aTSCs and the Thompson grades. The significance level was set to P < 0.05.

RESULTS

Mean 23Na relaxation parameters of a subset of 11 IVDs were T1 = 9.8 ± 1.3 msec, T2s* = 0.7 ± 0.1 msec, T2l* = 7.3 ± 1.1 msec, and ps = 32.7 ± 4.0%. A total of 30 IVDs were examined, of which 3 had Thompson grade 1, 4 had grade 2, 5 had grade 3, 5 had grade 4, and 13 had grade 5. The aTSC decreased with increasing degradation, being 274.6 ± 18.9 mM for Thompson grade 1 and 190.5 ± 29.5 mM for Thompson grade 5. The correlation between whole IVD aTSC and Thompson grade was significant and strongly negative (τ = -0.56).

DATA CONCLUSION

This study showed a significant correlation between aTSC and degenerative IVD changes. Consequently, aTSC has potential to be useful as an indicator of degenerative spinal changes.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 1.

Role of Platelet-Rich Plasma (PRP) in the Management of Stage III and IV Degenerative Disc Disease

Degenerative disc disease is a common disorder that can significantly impact patients' quality of life, leading to chronic pain and disability. Platelet-rich plasma (PRP) therapy is emerging as a potential treatment for degenerative disc disease. The purpose of this review is to summarize the role of PRP in the management of degenerative disc disease types III and IV. This is a scoping literature review. The online database PUBMED was used, and papers were searched using the keywords: ("PRP" OR "platelet-rich plasma") AND ("degenerative disk disease" OR "disk degeneration" OR "intradiscal injection" OR "discogenic pain" OR "intervertebral disc degeneration" OR "degenerative disk disease" OR "intervertebral disc disease"). Clinical studies evaluating the role of PRP in the management of stage III and IV degenerative disc disease were included in the study. Systematic reviews, animal studies, in vitro studies, case reports, study designs, case reports, and studies in languages other than English were excluded. The present study includes 14 studies. PRP has been found to promote tissue regeneration and modulate inflammatory response in degenerated discs. PRP can be administered mostly intradiscally but also epidurally. The benefits of PRP use include pain reduction, improvement of functionality, and low risk of adverse events. The effect of intradiscal PRP injections is similar to steroid injections. A higher concentration of platelets is associated with enhanced clinical outcomes. PRP therapy represents a promising avenue for tissue healing and regeneration across degenerative disc disease. While the evidence supporting its efficacy is encouraging, further research is needed to elucidate its mechanisms of action, optimize treatment protocols, and expand its clinical applications.

Relationship between a Radiographic Grading Scale of Degenerative Lumbar Disease and Quality of Life

Objective  To evaluate the correlation between a radiographic scale of lumbar degenerative disease and the Oswestry Disability Index (ODI). Methods  A cross-sectional study in which the ODI quality of life questionnaire and the radiographic parameters for the classification of lumbar degenerative disease into different grades were compared to try to establish a relationship between them. Results  The relationship between the radiographic parameters and quality of life indicators does not behave homogeneously, considering the different grades of the lumbar grading scale. Grade-2 lumbar degenerative disease showed a statistically significant relationship with the worsening of the ODI quality of life score. Conclusion  The lumbar degenerative disease grading scale used in the present study showed a relevant clinical potential, as it presented a significant relationship with the quality of life measured by the ODI score in part of the groups evaluated.

Artificial Intelligence Classification for Detecting and Grading Lumbar Intervertebral Disc Degeneration

Introduction

Intervertebral disc degeneration (IDD) is a primary cause of chronic back pain and disability, highlighting the need for precise detection and grading for effective treatment. This study focuses on developing and validating a convolutional neural network (CNN) with a You Only Look Once (YOLO) architecture model using the Pfirrmann grading system to classify and grade lumbar intervertebral disc degeneration based on magnetic resonance imaging (MRI) scans.

Methods

We developed a deep learning model trained on a dataset of anonymized MRI studies of patients with symptomatic back pain. MRI images were segmented and annotated by radiologists according to the Pfirrmann grading for the datasets. The segmentation MRI-disc image dataset was prepared for three groups: a training set (1,000), a testing set (500), and an external validation set (500) to assess model generalizability without overlapping images. The model's performance was evaluated using accuracy, sensitivity, specificity, F1 score, prediction error, and ROC-AUC.

Results

The AI model showed high performance across all metrics. For Grade I IDD, the model achieved an accuracy of 97%, 95%, and 92% in the training, testing, and external validation sets, respectively. For Grade II, the sensitivity was 100% in both training and testing sets and 98% in the validation set. For Grade III, the specificity was 95.4% in the training set and 94% in both testing and validation sets. For Grade IV, the F1 score was 97.77% in the training set and 95% in both testing and validation sets. For Grade V, the prediction error was 2.3%, 2%, and 2.5% in the training, testing, and validation sets, respectively. The overall ROC-AUC was 97%, 92%, and 95% in the training, testing, and validation sets, respectively.

Conclusions

The AI-based classification model exhibits high accuracy, sensitivity, and specificity in detecting and grading lumbar IDD using the Pfirrmann grading. AI has significantly enhanced diagnostic precision and reliability, providing a powerful tool for clinicians in managing IDD. The potential impact is substantial, although further clinical validation is necessary before integrating this model into routine practice.

Role of Artificial intelligence model in prediction of low back pain using T2 weighted MRI of Lumbar spine

Background

Low back pain (LBP), the primary cause of disability, is the most common musculoskeletal disorder globally and the primary cause of disability. Magnetic resonance imaging (MRI) studies are inconclusive and less sensitive for identifying and classifying patients with LBP. Hence, this study aimed to investigate the role of artificial intelligence (AI) models in the prediction of LBP using T2 weighted MRI image of the lumbar spine.

Methods

This was a prospective case-control study. A total of 200 MRI patients (100 cases and controls each) referred for lumbar spine and whole spine screening were included. The scans were performed using 3.0 Tesla MRI (United Imaging Healthcare). T2 weighted images of the lumbar spine were segmented to extract radiomic features. Machine learning (ML) models, such as random forest, decision tree, logistic regression, K-nearest neighbors, adaboost, and deep learning methods (DL), such as ResNet and GoogleNet, were used, and performance measures were calculated.

Results

Our study showed that Random forest and AdaBoost are the most reliable ML models for predicting LBP. Random forest showed high performance with area under curve (AUC) values from 0.83 to 0.88 across all lumbar vertebrae and L2-L3, L3-L4, and L4-L5 intervertebral discs (IVDs), with AUCs of 0.88 the highest at L5-S1 IVD (0.92). Adaboost demonstrated high performance at the L2-L5 vertebrae with AUC values of 0.82 to 0.90, with the highest AUC (0.97) at the L5-S1 IVD. Among the DL models, GoogleNet outperformed the other models at 30 epochs with an accuracy of 0.85, followed by ResNet 18 (30 epochs) with an accuracy of 0.84.

Conclusion

The study demonstrated that ML and DL models can effectively predict LBP from MRI T2 weighted image of the lumbar spine. ML and DL models could also enhance the diagnostic accuracy of LBP, potentially leading to better patient management and outcomes.

Impact of Preoperative Intervertebral Disc Degeneration on Patient-Reported Outcome Measures After Lumbar Fusion

OBJECTIVE

The Pfirrmann scoring system classifies lumbosacral disc degeneration based on magnetic resonance imaging signal intensity. The relationship between pre-existing disc degeneration and patient-reported outcome measures (PROMs) after one-level lumbar fusion is not well documented. The purpose of this study was to investigate the relationship between the severity of preoperative intervertebral disc degeneration and preoperative and postoperative PROMs in patients undergoing one-level lumbar fusion.

METHODS

All adult patients who underwent posterior lumbar decompression and fusion or transforaminal lumbar interbody fusion between 2014 and 2022 were included. Patient demographics and comorbidities were extracted from medical records. Lumbar intervertebral discs on sagittal magnetic resonance imaging T2-weighted images were assessed by 2 independent graders utilizing Pfirrmann criteria. Grades I-III were categorized as low-grade disc degeneration, while IV-V were considered high grade. Multivariable linear regression assessed the impact of disc degeneration on PROMs.

RESULTS

A total of 150 patients were included, of which 69 (46%) had low-grade disc degeneration, while 81 (54%) had high-grade degeneration. Patients with high-grade degeneration had increased preoperative visual analog scale (VAS)-Leg scores (6.10 vs. 4.54, P = 0.005) and displayed greater 1-year postoperative improvements in VAS-Back scores (-2.11 vs. -0.66, P = 0.002). Multivariable regression demonstrated Pfirrmann scores as independent predictors for both preoperative VAS-Leg scores (P = 0.004) and postoperative VAS-Back improvement (P = 0.005).

CONCLUSIONS

In patients undergoing one-level lumbar fusion, higher Pfirmann scores were associated with increased preoperative leg pain and greater 1-year postoperative improvement in back pain. Further studies into the relationship of preoperative disc degeneration and their impact on postoperative outcomes may help guide clinical decision-making and patient expectations.

Assessment of thoracic disc degeneration using dual-energy CT-based collagen maps

BACKGROUND

We evaluated the role of dual-energy computed tomography (DECT)-based collagen maps in assessing thoracic disc degeneration.

METHODS

We performed a retrospective analysis of patients who underwent DECT and magnetic resonance imaging (MRI) of the thoracic spine within a 2-week period from July 2019 to October 2022. Thoracic disc degeneration was classified by three blinded radiologists into three Pfirrmann categories: no/mild (grade 1-2), moderate (grade 3-4), and severe (grade 5). The DECT performance was determined using MRI as a reference standard. Interreader reliability was assessed using intraclass correlation coefficient (ICC). Five-point Likert scales were used to assess diagnostic confidence and image quality.

RESULTS

In total, 612 intervertebral discs across 51 patients aged 68 ± 16 years (mean ± standard deviation), 28 males and 23 females, were assessed. MRI revealed 135 no/mildly degenerated discs (22.1%), 470 moderately degenerated discs (76.8%), and 7 severely degenerated discs (1.1%). DECT collagen maps achieved an overall accuracy of 1,483/1,838 (80.8%) for thoracic disc degeneration. Overall recall (sensitivity) was 331/405 (81.7%) for detecting no/mild degeneration, 1,134/1,410 (80.4%) for moderate degeneration, and 18/21 (85.7%) for severe degeneration. Interrater agreement was good (ICC = 0.89). Assessment of DECT-based collagen maps demonstrated high diagnostic confidence (median 4; interquartile range 3-4) and good image quality (median 4; interquartile range 4-4).

CONCLUSION

DECT showed an overall 81% accuracy for disc degeneration by visualizing differences in the collagen content of thoracic discs.

RELEVANCE STATEMENT

Utilizing DECT-based collagen maps to distinguish various stages of thoracic disc degeneration could be clinically relevant for early detection of disc-related conditions. This approach may be particularly beneficial when MRI is contraindicated.

KEY POINTS

A total of 612 intervertebral discs across 51 patients were retrospectively assessed with DECT, using MRI as a reference standard. DECT-based collagen maps allowed thoracic disc degeneration assessment achieving an overall 81% accuracy with good interrater agreement (ICC = 0.89). DECT-based collagen maps could be a good alternative in the case of contraindications to MRI.

Finite element analysis of a three-dimensional cervical spine model with muscles based on CT scan data

BACKGROUND

The incidence of cervical spondylosis is increasing, gradually affecting people's normal lives. Establishing a finite element model of the cervical spine is one of the methods for studying cervical spondylosis. MRI (Magnetic Resonance Imaging) still has certain difficulties in transitioning from human imaging to establishing muscle models suitable for finite element analysis. Medical software provides specific morphologies and can generate muscle finite element models. Additionally, there is little research on the static analysis of cervical spine finite element models with solid muscle.

PURPOSE

A new method is proposed for establishing a finite element model of the cervical spine based on CT (Computed Tomography) data and medical software, and the model's effectiveness is validated. Human movement characteristics based on the force distribution in various parts are analyzed and predicted.

METHODS

The muscle model is reconstructed in medical software and a three-dimensional finite element model of the entire cervical spine (C0-C7) is established by combining muscle models with CT vertebral data models. 1.5 Nm of load is applied to the finite element model to simulate the cervical spine movement.

RESULTS

The finite element model was successfully established, and effectiveness was verified. Stress variations in various parts under six movements were obtained. The effectiveness of the model was basically verified.

CONCLUSION

The finite element model of the cervical spine for mechanical analysis can be successfully established by using medical software and CT data. In daily life, the C2-3, C3-4, C4-C5 intervertebral discs, rectus capitis posterior major, longus colli, and obliquus capitis inferior are more prone to injury.

Magnetic Resonance Elastography for Mechanical Modeling of the Human Lumbar Intervertebral Disc

Magnetic Resonance Elastography (MRE) is a phase-contrast imaging technique that allows for determination of mechanical properties of tissue in-vivo. Due to physiological and morphological changes leading to changes in tissue mechanical properties, MRE may be a promising imaging tool for detection of intervertebral disc degeneration. We therefore performed a preliminary study to determine the frequency dependent mechanical properties of the lumbar intervertebral discs. Six healthy volunteers underwent multifrequency MRE (50, 80, and 100 Hz) to measure the mechanical properties of the intervertebral discs between the L3 and L4, and L4 and L5 vertebrae. Frequency-independent disc mechanical properties and best-fit mechanical model were determined from the frequency-dependent disc data by comparing four different linear viscoelastic material models (Maxwell, Kelvin-Voigt, Springpot, and Zener). A seventh individual with a history of a discectomy on the disc between the L4 and L5 vertebrae was also scanned to provide a preliminary analysis about how degeneration impacts disc mechanical properties. Our findings show that the Zener model may best represent the disc's frequency-dependent mechanical response. Additionally, we observed a significantly lower complex shear modulus in the degenerated disc than the healthy discs at each frequency, demonstrating the potential for MRE to detect early signs of degeneration and pinpoint the cause of chronic back pain.

A novel quantitative method to evaluate lumbar disc degeneration: MRI histogram analysis

PURPOSE

This study aimed to use MRI histogram analysis to routine MRI sequences to evaluate lumbar disc degeneration (LDD), illustrate the correlation between this novel method and the traditional Pfirrmann classification method, and more importantly, perform comprehensive agreement analysis of MRI histogram analysis in various situations to evaluate its objectivity and stability.

METHODS

Lumbar MRI images from 133 subjects were included in this study. LDD was classified into grades by Pfirrmann classification and was measured as peak separation value by MRI histogram analysis. Correlation analysis between the two methods was performed and cutoff values were determined. In addition, the agreement analysis of peak separation value was performed by intraclass correlation coefficient (ICC) in four scenarios, including inter-resolution, inter-observer, inter-regions of interest (ROI) and inter-slice.

RESULTS

Peak separation values were strongly correlated with Pfirrmann grades (r = - 0.847). The inter-resolution agreements of peak separation value between original image resolution of 2304 × 2304 and compressed image resolutions (1152 × 1152, 576 × 576, 288 × 288) were good to excellent (ICCs were 0.916, 0.876 and 0.822), except 144 × 144 was moderate (ICC = 533). The agreements of inter-observer (ICC = 0.982) and inter-ROI (ICC = 0.915) were excellent. Compared with the mid-sagittal slice, the inter-slice agreements were good for the first adjacent slices (ICCs were 0.826 and 0.844), and moderate to good for the second adjacent slices (ICC = 0.733 and 0.753).

CONCLUSION

MRI histogram analysis, used in routine MRI sequences, demonstrated a strong correlation with Pfirrmann classification and good agreements in various scenarios, expanding the range of application and providing an effective, objective and quantitative tool to evaluate LDD.

A fully automatic MRI-guided decision support system for lumbar disc herniation using machine learning

Background

Normalized decision support system for lumbar disc herniation (LDH) will improve reproducibility compared with subjective clinical diagnosis and treatment. Magnetic resonance imaging (MRI) plays an essential role in the evaluation of LDH. This study aimed to develop an MRI-based decision support system for LDH, which evaluates lumbar discs in a reproducible, consistent, and reliable manner.

Methods

The research team proposed a system based on machine learning that was trained and tested by a large, manually labeled data set comprising 217 patients' MRI scans (3255 lumbar discs). The system analyzes the radiological features of identified discs to diagnose herniation and classifies discs by Pfirrmann grade and MSU classification. Based on the assessment, the system provides clinical advice.

Results

Eventually, the accuracy of the diagnosis process reached 95.83%. An 83.5% agreement was observed between the system's prediction and the ground-truth in the Pfirrmann grade. In the case of MSU classification, 95.0% precision was achieved. With the assistance of this system, the accuracy, interpretation efficiency and interrater agreement among surgeons were improved substantially.

Conclusion

This system showed considerable accuracy and efficiency, and therefore could serve as an objective reference for the diagnosis and treatment procedure in clinical practice.

MRI radiomics-based decision support tool for a personalized classification of cervical disc degeneration: a two-center study

Objectives: To develop and validate an MRI radiomics-based decision support tool for the automated grading of cervical disc degeneration. Methods: The retrospective study included 2,610 cervical disc samples of 435 patients from two hospitals. The cervical magnetic resonance imaging (MRI) analysis of patients confirmed cervical disc degeneration grades using the Pfirrmann grading system. A training set (1,830 samples of 305 patients) and an independent test set (780 samples of 130 patients) were divided for the construction and validation of the machine learning model, respectively. We provided a fine-tuned MedSAM model for automated cervical disc segmentation. Then, we extracted 924 radiomic features from each segmented disc in T1 and T2 MRI modalities. All features were processed and selected using minimum redundancy maximum relevance (mRMR) and multiple machine learning algorithms. Meanwhile, the radiomics models of various machine learning algorithms and MRI images were constructed and compared. Finally, the combined radiomics model was constructed in the training set and validated in the test set. Radiomic feature mapping was provided for auxiliary diagnosis. Results: Of the 2,610 cervical disc samples, 794 (30.4%) were classified as low grade and 1,816 (69.6%) were classified as high grade. The fine-tuned MedSAM model achieved good segmentation performance, with the mean Dice coefficient of 0.93. Higher-order texture features contributed to the dominant force in the diagnostic task (80%). Among various machine learning models, random forest performed better than the other algorithms (p < 0.01), and the T2 MRI radiomics model showed better results than T1 MRI in the diagnostic performance (p < 0.05). The final combined radiomics model had an area under the receiver operating characteristic curve (AUC) of 0.95, an accuracy of 89.51%, a precision of 87.07%, a recall of 98.83%, and an F1 score of 0.93 in the test set, which were all better than those of other models (p < 0.05). Conclusion: The radiomics-based decision support tool using T1 and T2 MRI modalities can be used for cervical disc degeneration grading, facilitating individualized management.

SPECT/CT Scan: A New Diagnostic Tool in Pain Medicine

PURPOSE OF REVIEW

The purpose of this review is to evaluate the role of SPECT/CT in identifying facet joint arthropathy and the outcomes of interventions with SPECT/CT as an adjunct.

RECENT FINDINGS

A positive finding of facet arthropathy on SPECT/CT is associated with a higher likelihood of a unilateral procedure and a significantly more effective intervention compared with those performed on patients with facet arthropathy diagnosed only by clinical and/or radiologic examination. Surgical treatment of SPECT/CT-positive findings appears to have a good effect; however, due to limitations in the available studies, no strong conclusion can be drawn. SPECT/CT has a good correlation identifying pain generators in chronic neck and back pain. SPECT/CT-targeted facet interventions demonstrate a higher success rate, but SPECT/CT is not recommended as a first-line diagnostic tool prior to diagnostic facet interventions. More robust studies are needed to confirm the higher success of surgical treatment for SPECT/CT-positive facet arthropathy.

Abdominal aortic calcification is independently associated with lumbar endplate degeneration

BACKGROUND

Abdominal aortic calcification (AAC) is associated with lower back pain, reduced bone mineral density of the spine. Vascular changes could also affect the already sparsely perfused intervertebral endplate and intervertebral disc.

METHODS

Lumbar MRIs and lateral radiographs of patients with lower back pain were retrospectively analyzed. AAC was assessed on lateral lumbar radiographs according to the Kauppila score, with a maximum score of 24. Patients were grouped into no (AAC = 0), moderate (AAC 1 to ≤ 4), and severe AAC (AAC ≥ 5). Endplate and disc degeneration were classified according to the total endplate score (TEPS) and Pfirrmann classification. The associations between AAC and degenerative changes was analyzed with a generalized mixed model and was adjusted for age, sex, body mass index as well as diabetes mellitus, and smoking status.

RESULTS

A total of 217 patients (47.9% female) were included in the analysis, totaling 1085 intervertebral levels. Of those, 45 (20.7%) patients had moderate, and 39 (18%) had severe AAC. The results of the generalized mixed model showed no significant association between AAC and disc degeneration (p > 0.05). In contrast, a significant positive association between AAC and the severity of TEPS (β: 0.51, 95% CI: 1.92-2.12, p = 0.004) was observed in the multivariable analysis.

CONCLUSIONS

This study demonstrates an independent association between AAC and endplate degeneration. These findings expand our knowledge about the degenerative cascade of the lumbar spine and suggest that AAC might be a modifiable risk factor for endplate changes.

Machine Learning Assisting the Prediction of Clinical Outcomes following Nucleoplasty for Lumbar Degenerative Disc Disease

BACKGROUND

Lumbar degenerative disc disease (LDDD) is a leading cause of chronic lower back pain; however, a lack of clear diagnostic criteria and solid LDDD interventional therapies have made predicting the benefits of therapeutic strategies challenging. Our goal is to develop machine learning (ML)-based radiomic models based on pre-treatment imaging for predicting the outcomes of lumbar nucleoplasty (LNP), which is one of the interventional therapies for LDDD.

METHODS

The input data included general patient characteristics, perioperative medical and surgical details, and pre-operative magnetic resonance imaging (MRI) results from 181 LDDD patients receiving lumbar nucleoplasty. Post-treatment pain improvements were categorized as clinically significant (defined as a ≥80% decrease in the visual analog scale) or non-significant. To develop the ML models, T2-weighted MRI images were subjected to radiomic feature extraction, which was combined with physiological clinical parameters. After data processing, we developed five ML models: support vector machine, light gradient boosting machine, extreme gradient boosting, extreme gradient boosting random forest, and improved random forest. Model performance was measured by evaluating indicators, such as the confusion matrix, accuracy, sensitivity, specificity, F1 score, and area under the receiver operating characteristic curve (AUC), which were acquired using an 8:2 allocation of training to testing sequences.

RESULTS

Among the five ML models, the improved random forest algorithm had the best performance, with an accuracy of 0.76, a sensitivity of 0.69, a specificity of 0.83, an F1 score of 0.73, and an AUC of 0.77. The most influential clinical features included in the ML models were pre-operative VAS and age. In contrast, the most influential radiomic features had the correlation coefficient and gray-scale co-occurrence matrix.

CONCLUSIONS

We developed an ML-based model for predicting pain improvement after LNP for patients with LDDD. We hope this tool will provide both doctors and patients with better information for therapeutic planning and decision-making.

Role of Single-Photon Emission Computed Tomography Imaging in the Diagnosis and Treatment of Chronic Neck or Back Pain Caused by Spinal Degeneration: A Systematic Review

BACKGROUND

Chronic neck or back pain is a common clinical problem. The most likely cause is degenerative change, whereas other causes are relatively rare. There is increasing evidence on using hybrid single-photon emission computed tomography (SPECT) to identify the pain generator in spine degeneration. This systematic review explores the diagnostic and therapeutic evidence on chronic neck or back pain examined by SPECT.

METHODS

This review is reported in accordance with the PRISMA guidelines. In October 2022, we searched the following sources: MEDLINE, Embase, CINAHL, SCOPUS, and 3 other sources. Titles and abstracts were screened and classified into diagnostic studies, facet block studies, and surgical studies. We synthesized the results narratively.

RESULTS

The search yielded 2347 records. We identified 10 diagnostic studies comparing SPECT or SPECT/computed tomography (CT) with magnetic resonance imaging, CT, scintigraphy, or clinical examination. Furthermore, we found 8 studies comparing the effect of facet block intervention in SPECT-positive and SPECT-negative patients with cervicogenic headache, neck pain, and lower back pain. Five surgical studies describing the effect of fusion for facet arthropathy in the craniocervical junction, subaxial cervical spine, or the lumbar spine were identified.

CONCLUSIONS

According to the available literature, a positive finding on SPECT in facet arthropathy is associated with a significantly higher facet blockade effect. Surgical treatment of positive findings has a good effect, but this has not been confirmed by controlled studies. SPECT/CT might therefore be a useful method in the evaluation of patients with neck or back pain, especially in cases of unclear findings or multiple degenerative changes.

The current state of radiodiagnostics of degenerative changes in the lumbar spine (literature review)

Examination of the spine using radiological methods remains the most frequently conducted study in the outpatient practice of almost any radiologist. In most cases, changes in the spine are degenerative and dystrophic in nature. These changes in the spine are the leading cause of loss of activity among adults and the elderly, and cover a wide range of age-related structural changes. It is of great importance to understand the possibilities and limitations of radiological methods of diagnostics. The description of morphological changes observed in degenerative and dystrophic changes requires the use of unified terminology and classifications among clinicians and radiologists.The aim. To present modern concepts in the assessment of degenerative changes of the spine using radiological methods. A description of the standardized international nomenclature of intervertebral disc pathology and current classifications of spinal canal stenosis are presented.Material and methods. For literature search, we used electronic databases MEDLINE (PubMed), eLibrary, EMBASE and Cochrane Library with a selection of sources published from 2000 to 2021. We analyzed the works devoted to the diagnosis of degenerative changes in lumbar spine and to degenerative stenosis.Conclusion. The key to productive communication between physicians is the uniformity or standardization of terminology and definitions used. It is important that the protocol of description, its terms, semantic expressions be uniform and understandable to specialists who are involved in the diagnosis and treatment of the spine. Magnetic resonance imaging is a valuable method in the diagnosis of degenerative changes of the spinal column, but it has its limitations.

The role of nerve fibers and their neurotransmitters in regulating intervertebral disc degeneration

Intervertebral disc degeneration (IVDD) has been the major contributor to chronic lower back pain (LBP). Abnormal apoptosis, senescence, and pyroptosis of IVD cells, extracellular matrix (ECM) degradation, and infiltration of immune cells are the major molecular alternations during IVDD. Changes at tissue level frequently occur at advanced IVD tissue. Ectopic ingrowth of nerves within inner annulus fibrosus (AF) and nucleus pulposus (NP) tissue has been considered as the primary cause for LBP. Innervation at IVD tissue mainly included sensory and sympathetic nerves, and many markers for these two types of nerves have been detected since 1940. In fact, in osteoarthritis (OA), beyond pain transmission, the direct regulation of neuropeptides on functions of chondrocytes have attracted researchers' great attention recently. Many physical and pathological similarities between joint and IVD have shed us the light on the neurogenic mechanism involved in IVDD. Here, an overview of the advances in the nervous system within IVD tissue will be performed, with a discussion on in the role of nerve fibers and their neurotransmitters in regulating IVDD. We hope this review can attract more research interest to address neuromodulation and IVDD itself, which will enhance our understanding of the contribution of neuromodulation to the structural changes within IVD tissue and inflammatory responses and will help identify novel therapeutic targets and enable the effective treatment of IVDD disease.

Radiographic analysis of dynamic lumbar motion during the five-repetition sit-to-stand test in degenerative lumbar spondylolisthesis

Background

To investigate the mechanisms of low back pain triggered by the five-repetition sit-to-stand test (5R-STS test) in degenerative lumbar spondylolisthesis (DLS) from radiographic perspective, as well as to determine the most useful diagnostic modalities in the evaluation of segmental instability.

Methods

We retrospectively performed a study of 78 patients (23 men and 55 women) with symptomatic DLS at L4/5 in our institution between April 2020 and December 2021. Each patient was assessed by using the 5R-STS test and received a series of radiographs including the upright standing, normal sitting, standing flexion–extension radiographs, and supine sagittal MR images. Enrolled patients were divided into two groups based on the 5R-STS test score: severe group and mild group. Translational and angular motion was determined by comparing normal sitting radiograph (N) with upright standing radiograph (U) (Combined, NU), flexion/extension radiographs (FE) as well as normal sitting radiograph (N) with a supine sagittal MR image (sMR) (Combined, N-sMR).

Results

Overall, 78 patients were enrolled, and there were 31(39.7%) patients in group S and 47(60.3%) patients in group M, with an average age of 60.7 ± 8.4 years. The normal sitting radiograph demonstrated the maximum slip percentage (SP) and the highest kyphotic angle both in group S and group M. Compared with group M, group S revealed significantly higher SP in the normal sitting position (24.1 vs 19.6; p = 0.002). The lumbar slip angular in group S with a sitting position was significantly higher than that in group M (-5.2 vs -1.3; p < 0.001). All patients in group S had objective functional impairment (OFI) and 28 patients of them were diagnosed with lumbar instability by using the combination of normal sitting radiograph (N) and supine sagittal MR image (sMR) (Combined, N-sMR).

Conclusion

DLS patients with positive sign of the 5R-STS test is a distinct subgroup associated with lumbar instability. The modality of the combination of normal sitting radiograph (N) and supine sagittal MR image (sMR) had a significant advantage in terms of the ability to identify segmental instability.

Lumbar Intervertebral Disc and Discovertebral Segment, Part 1: An Imaging Review of Normal Anatomy

The intervertebral disc is designated the most important cartilaginous articulation of the vertebral column that functions to withstand compressive biomechanical forces and confer strength and flexibility to the spine. A thorough study of the complex fine structure and anatomic relationships of the intervertebral disc is essential for the characterization of the integrity of each individual structure in the discovertebral segment. This elaborate work in human cadavers explores the sophisticated internal structure of the normal intervertebral disc and the discovertebral segment, providing detailed data derived from the dissection of specimens through imaging and close anatomic-histologic correlation. Familiarity with the normal appearances and basic functional properties of the lumbar intervertebral disc and discovertebral segment is fundamental for the recognition of aberrations that may have important clinical implications in patients with low back pain. In Part I of this article, the anatomic structure and features of the discovertebral complex in adults will be described.

Traumatic vertebra and endplate fractures promote adjacent disc degeneration: evidence from a clinical MR follow-up study

OBJECTIVES

The integrity of endplate is important for maintaining the health of adjacent disc and trabeculae. Yet, pathological impacts of traumatic vertebra and endplate fractures were less studied using clinical approaches. This study aims to investigate their effects on the development of adjacent disc degeneration, segmental kyphosis, Modic changes (MCs), and high-intensity zones (HIZs).

MATERIALS AND METHODS

Magnetic resonance (MR) images of patients with acute traumatic vertebral compression fractures (T11-L5) were studied. On MR images, endplate fractures were evaluated as present or absent. Disc signal, height, bulging area, sagittal Cobb angle, MCs, and HIZs were measured on baseline and follow-up MR images to study the changes of the disc in relation to vertebra fractures and endplate fractures.

RESULTS

Ninety-seven patients were followed up for 15.4 ± 14.0 months. There were 123 fractured vertebrae, including 79 (64.2%) with endplate fractures and 44 (35.8%) without. Both the adjacent and control discs decreased in signal and height over time (p < 0.001), and the disc adjacent to vertebral fractures had greater signal and height loss than the control disc (p < 0.05). In the presence of endplate fractures, the adjacent discs had greater signal decrease in follow-up (p < 0.05), as compared to those without endplate fractures. Sagittal Cobb angle significantly increased in segments with endplate fractures (p < 0.05). Vertebra fractures were associated with new occurrence of MCs in the fractured vertebra (p < 0.001) but not HIZs in the adjacent disc.

CONCLUSIONS

Traumatic vertebral fractures were associated with accelerated adjacent disc degeneration, which appears to be further promoted by concomitant endplate fractures. Endplate fractures were associated with progression of segmental kyphosis.

Comprehensive assessment of in vivo lumbar spine intervertebral discs using a 3D adiabatic T1ρ prepared ultrashort echo time (UTE-Adiab-T1ρ) pulse sequence

BACKGROUND

T_1ρ has been extensively reported as a sensitive biomarker of biochemical changes in the nucleus pulposus (NP) and annulus fibrosis of intervertebral discs (IVDs). However, no T_1ρ study of cartilaginous endplates (CEPs) has yet been reported because the relatively long echo times (TEs) of conventional clinical T_1ρ sequences cannot effectively capture the fast-decaying magnetic resonance signals of CEPs, which have very short T₂/T₂*s. This can be overcome by using ultrashort echo time (UTE) T_1ρ acquisitions.

METHODS

Seventeen subjects underwent UTE with adiabatic T_1ρ preparation (UTE-Adiab-T_1ρ) and T₂-weighted fast spin echo imaging of their lumbar spines. Each IVD was manually segmented into seven regions (i.e., outer anterior annulus fibrosis, inner anterior annulus fibrosis, outer posterior annulus fibrosis, inner posterior annulus fibrosis, superior CEP, inferior CEP, and NP). T_1ρ values of these sub-regions were correlated with IVD modified Pfirrmann grades and subjects' ages. In addition, T_1ρ values were compared in subjects with and without low back pain (LBP).

RESULTS

Correlations of T_1ρ values of the outer posterior annulus fibrosis, superior CEP, inferior CEP, and NP with modified Pfirrmann grades were significant (P<0.05) with R values of 0.51, 0.36, 0.38, and -0.94, respectively. Correlations of T_1ρ values of the outer anterior annulus fibrosis, outer posterior annulus fibrosis, and NP with ages were significant with R equal to 0.52, 0.71, and -0.76, respectively. T_1ρ differences of the outer posterior annulus fibrosis, inferior CEP, and NP between the subjects with and without LBP were significant (P=0.005, 0.020, and 0.000, respectively).

CONCLUSIONS

The UTE-Adiab-T_1ρ sequence can quantify T_1ρ of whole IVDs including CEPs. This is an advance, and of value for comprehensive assessment of IVD degeneration.

Fundamentals of Intervertebral Disc Degeneration

Lumbar disc degeneration is one of the leading causes of chronic low back pain. The degenerative cascade is often initiated by an imbalance between catabolic and anabolic processes in the intervertebral discs. As a consequence of extracellular matrix degradation, neoinnervation and neovascularization take place. Ultimately, this degenerative process results in disc bulging and loss of nucleus pulposus and water content and subsequent loss of disc height. Most patients respond to conservative management and surgical interventions well initially, yet a significant number of patients continue to suffer from chronic low back pain. Because of the high prevalence of long-term discogenic pain, regenerative biological therapies, including gene therapies, growth factors, cellular-based injections, and tissue-engineered constructs, have attracted significant attention in light of their potential to directly address the degenerative process. Understanding the pathophysiology of degenerative disc disease is important in both refining existing technologies and developing innovative techniques to reverse the degenerative processes in the discs. In this review, we aimed to cover the underlying pathophysiology of degenerative disc disease as well as its associated risk factors and give a comprehensive summary about the developmental, structural, radiological, and biomechanical properties of human intervertebral discs.

Associations between high-intensity zones, endplate, and Modic changes and their effect on T2-mapping with and without spinal load

The purpose was to investigate if high intensity zones (HIZ), Modic (MC), and endplate changes (EPC) display different behaviors measured with quantitative magnetic resonance imaging (MRI) with and without loading of the spine and if there is a simultaneous presence of these features in the same motion segment. 130 motion segments in patients with chronic low back pain (n = 26, 25-69 year, mean 38 year, 11 males) were examined. HIZs, MCs, and EPCs (i.e., structural findings, reflecting calcifications, erosions, and fissures) were determined with standardized MRI. Different T2-values with and without loading for these features were then determined with the quantitative MRI method T2-mapping. Significantly different behaviors were found in the spinal tissues with associated HIZs, MC, and EPC (p < 0.004). HIZ (62% of patients, 1-2/patient) was associated with EPC (100% of patients, 1-7/patient) (p = 0.0003 and 0.0004 for upper and lower EPs), with an occurrence of 91% for upper and 71% for lower endplates adjacent to discs with HIZ. MC (81% of patients, 1-3/patient) were associated with EPC (p < 0.0001) with an occurrence of 87% for endplates adjacent to vertebrae with MC. The occurrence of both HIZ and MC was 43% (p = 0.0001) for upper and 29% (p = 0.003) for lower vertebrae. HIZ was associated with simultaneous presence of both MC and EPC in the same motion segment. T2-mapping was found to objectively reflect changes in the spinal tissues associated with HIZs, MC, and EPC.

Lumbar spine abnormalities in patients with obstructive sleep apnoea

Previous studies suggested cervical spondylosis as a risk factor for development of obstructive sleep apnoea (OSA). We aimed to assess lumbar disc degeneration in patients with OSA and correlate the findings with symptoms and disease severity. Twenty-seven patients with OSA and 29 non-OSA controls underwent sleep studies and lumbar magnetic resonance imaging (MRI), and completed the Epworth Sleepiness Scale and the 24-item Roland-Morris Disability Questionnaire (RMDQ) questionnaires. Plasma klotho was determined with enzyme-linked immunosorbent assay. Patients with OSA had higher number of disc bulges (4.6 ± 3.7 vs. 1.7 ± 2.5, p < 0.01) and anterior spondylophytes (2.7 ± 4.2 vs. 0.8 ± 2.1, p < 0.01), increased disc degeneration (total Pfirrmann score 16.7 ± 4.7 vs. 13.2 ± 4.1, p < 0.01) and vertebral fatty degeneration (7.8 ± 4.7 vs. 3.8 ± 3.7, p < 0.01). There was no difference in the RMDQ score (0/0-3.5/ vs. 0/0-1/, p > 0.05). Markers of OSA severity, including the oxygen desaturation index and percentage of total sleep time spent with saturation < 90% as well as plasma levels of klotho were correlated with the number of disc bulges and anterior spondylophytes (all p < 0.05). OSA is associated with lumbar spondylosis. Our study highlights the importance of lumbar imaging in patients with OSA reporting lower back pain.

Spine MRI: A Review of Commonly Encountered Emergent Conditions

Over the last 2 decades, the proliferation of magnetic resonance imaging (MRI) availability and continuous improvements in acquisition speeds have led to significantly increased MRI utilization across the health care system, and MRI studies are increasingly ordered in the emergent setting. Depending on the clinical presentation, MRI can yield vital diagnostic information not detectable with other imaging modalities. The aim of this text is to report on the up-to-date indications for MRI of the spine in the ED, and review the various MRI appearances of commonly encountered acute spine pathology, including traumatic injuries, acute non traumatic myelopathy, infection, neoplasia, degenerative disc disease, and postoperative complications. Imaging review will focus on the aspects of the disease process that are not readily resolved with other modalities.

Incidental Finding Prevalences in 3-Tesla Brain and Spine MRI of Military Pilot Applicants

INTRODUCTION: Incidental findings in brain and spine MRI are common. In aerospace medicine, pilot selection may be affected by improved sensitivity of modern MRI devices. We investigated the occurrence of medically unfit rates caused by incidental findings in military pilot applicants using a 3-Tesla scanner as compared to the outcomes of a lower field strength 1-Tesla device based on similar screening protocols.METHODS: A total of 3315 military pilot applicants were assessed by a standardized German Air Force Imaging Screening Protocol and retrospectively subdivided into two cohorts, one of which was assessed by 1-Tesla MRI (2012-2015; N 1782), while in the second cohort (2016-2019; N 1808), a 3-Tesla MRI was used. Cohorts were statistically analyzed relating to three entities of incidental findings: 1) intervertebral disc displacements, 2) intracerebral vessel malformations, and 3) other abnormal findings in the brain.RESULTS: Pooled prevalences of incidental findings in medically unfit applicants significantly increased by use of 3-Tesla MRI as compared to lower resolution 1-Tesla MRI. Regarding the spine, prevalences more than doubled (1.46 vs. 4.99%; P < 0.05) for intervertebral disc displacements. Similarly, prevalences of cerebral vessel malformations as well as other abnormal CNS incidental findings considerably increased by use of 3-Tesla MRI (0.28 vs. 1.67%; P < 0.05, and 5.12 vs. 9.80%; P < 0.05). Effect sizes and correlations were substantial in all conditions analyzed (Cohens d > 0.8; Pearsons r > 0.75).CONCLUSIONS: Our data suggest a strong dependency of incidental cerebrospinal findings on image resolution and sensitivity of MRI devices used for screening, which is enhanced by refined imaging protocols and followed by increased medical unfit rates in prospective aviators. Adjusted strategies in the assessment of such lesions are needed to redefine their natural history and physiological impact, and to optimize screening protocols for future pilot selection.Snksen S-E, Khn SR, Nobl H-J, Knopf H, Ehling J, Jakobs FM, Frischmuth J, Weber F. Incidental finding prevalences in 3-Tesla brain and spine MRI of military pilot applicants. Aerosp Med Hum Perform. 2021; 92(3):146152.

Total spine magnetic resonance imaging for detection of multifocal infection in pyogenic spondylodiscitis: a retrospective observational study

BACKGROUND

Due to the unspecific symptoms of spondylodiscitis (SpD), an early radiological examination is necessary. However, controversially discussed is the need for magnetic resonance imaging of the entire spine to exclude multisegmental infections and to determine the required surgical interventions. The aims of this study were to assess the incidence of multilevel non-contiguous pyogenic SpD and compare comorbidities, pain symptoms, and subsequent surgical strategies between unifocal (uSpD) and multifocal (mSpD) SpD.

METHODS

We retrospectively evaluated the data of patients with confirmed, surgically treated, pyogenic SpD who had received a total spine MRI in a single spine center between 2016 and 2018. MRI findings were classified according to Pola-classification and demographics, duration of clinical symptoms (pain and neurology) and Charlson Comorbidity-Index (CCI) results were compared between uSpD und mSpD groups. Surgical therapy was evaluated in patients with mSpD.

RESULTS

uSpD was detected by MRI in 69 of 79 patients (87%). Of these, mSpD was detected in 10 patients (13%) with 21 infected segments (cervical and/ or thoracic and/ or lumbar region). Age and CCI were similar between uSpD and mSpD and 24 of all SpD regions were clinically unapparent. All patients with uSpD were treated operatively. In seven patients with mSpD, all infected levels of the spine were treated surgically in a one-stage procedure; one patient had a two-stage procedure and one patient had surgery at the lumbar spine, and an additional infected segment of the upper thoracic spine was treated conservatively. One patient died before a planned two-stage procedure was performed.

CONCLUSIONS

Due to mSpD being found in approximately 13% of SpD cases, and considering the risk of overlooking an mSpD case, MRI imaging of the total spine is recommended. The detection of multiple infection levels can have an impact on the therapeutic strategy chosen.

Differentiating epidural fibrosis from disc herniation on contrast-enhanced and unenhanced MRI in the postoperative lumbar spine

OBJECTIVE

To determine diagnostic confidence and inter-observer/intra-observer agreement in differentiating epidural fibrosis from disc herniation and lumbar spinal stenosis parameters on magnetic resonance images (MRI) in postoperative lumbar spines with (Gad-MRI) and without (unenhanced MRI) intravenous gadolinium-based contrast agent.

SUBJECTS AND METHODS

N = 124 lumbar spine MRI examinations of four groups were included: 1-6 months, 7-18 months, 19-36 months, more than 37 months between lumbar spine surgery and imaging. Two radiologists evaluated Gad-MRI and unenhanced MRI: diagnostic confidence was determined as confident or unconfident. Inter-observer and intra-observer agreement were assessed in differentiating epidural fibrosis from disc herniation and for lumbar spinal stenosis parameters on MRI. Fisher's exact test and Cohen's kappa served for statistics.

RESULTS

Diagnostic confidence in differentiating epidural fibrosis from disc herniation was significantly higher on Gad-MR images compared with unenhanced MRI at 1-18 months for observer 1 and at 1-6 months postoperatively for observer 2 (p values: 0.01-0.025). Inter-observer agreement at 1-6 months postoperatively for identification of epidural fibrosis was higher on Gad-MRI (kappa values: 0.53 versus 0.24). Inter-observer and intra-observer agreement for identification of disc herniation and for assessment of lumbar spinal stenosis parameters revealed inconsistent data, without a trend for higher inter-observer or intra-observer agreement on Gad-MRI compared with unenhanced MRI (kappa values: 0.17-0.75).

CONCLUSION

Gad-MR images compared with unenhanced MRI improved diagnostic confidence and agreement in differentiating epidural fibrosis from disc herniation for both observers in the first 6 months and for one observer in the first 18 months after lumbar spine surgery. After 18 months, Gad-MR images compared with unenhanced MRI did neither improve confidence nor agreement.

Imaging of the degenerative spine using a sagittal T2-weighted DIXON turbo spin-echo sequence

PURPOSE

To evaluate the diagnostic performance of a sagittal T2-weighted DIXON turbo spin-echo (TSE) sequence and to assess whether fat-only images could replace dedicated sagittal T1-weighted sequences for magnetic resonance imaging (MRI) of the degenerative spine.

METHOD

35 patients (56.5 ± 19.8 years, 62.9 % males) with lumbar back pain (LBP) who underwent MRI of the lumbar spine including a sagittal T2-weighted DIXON sequence (acquisition time: 3:25 min) and T1-weighted sequence (acquisition time: 3:03 min) were included. Two image layouts (layout 1: fat-only AND water-only AND in-phase images of the DIXON sequence; layout 2: water-only AND in-phase images of the DIXON sequence AND T1-weighted images) were evaluated by two readers (R1 and R2) concerning degenerative changes including diagnostic confidence (1 - low, 2 - intermediate, and 3 - high) and signal changes of vertebral bone marrow (BM). Results were compared between readers and layouts.

RESULTS

No differences were observed in the number of detected pathologies on a segment-wise level, nor in the number of segments affected by degenerative changes when comparing evaluations of layout 1 and layout 2 for each reader. Diagnostic confidence was high without a statistically significant difference between the readings of both layouts (R1: layout 1: 2.79 ± 0.41, layout 2: 2.81 ± 0.39, p = 0.53; R2: layout 1: 2.99 ± 0.07, layout 2: 2.99 ± 0.07, p = 0.99).

CONCLUSIONS

In patients with LBP, MRI using a sagittal T2-weighted DIXON sequence and no separate T1-weighted sequence might be sufficient to accurately detect common degenerative changes with high diagnostic confidence. Sparing dedicated T1-weighted sequences can considerably reduce overall scan time.

Refractory lower urinary tract symptoms in patients with lumbar disc hernia relieved by non-surgical treatment

PURPOSE

Refractory lower urinary tract symptoms (LUTS) coexisting with lumbar disc hernia (LDH) have been shown to resolve following LDH surgery, implying that LDH causes these LUTS. The purpose of this study was to report outcomes in patients with refractory LUTS and LDH following non-surgical treatment targeting LDH.

METHODS

A retrospective cohort study was conducted using outpatient data collected at Tongji Hospital, China, between 2016 and 2018. This study included 131 adult patients with refractory LUTS and LDH. Patients were stratified into two groups. Group A underwent non-surgical treatment for LDH plus pharmacological treatment for LUTS. Group B underwent only pharmacological treatment for LUTS. The International Prostate Symptom Score (IPSS), the IPSS quality of life (QoL) score, and uroflowmetry were used to evaluate outcomes.

RESULTS

In group A, following treatment, the maximum flow rate (Qmax) increased by 3.92 ml/s (p < 0.001), the IPSS reduced by 5.99 points (p < 0.001), and the QoL score decreased by 1.51 points (p < 0.001). In group B, the Qmax increased by 0.09 ml/s (p = 0.833), the IPSS reduced by 0.72 points (p = 0.163), and the QoL score decreased by 0.07 points (p = 0.784).

CONCLUSIONS

LUTS can be relieved by a combination of pharmacological treatment for LUTS and non-surgical treatment for LDH in some refractory LUTS patients with LDH. MRI is recommended for these patients.

Changes of the end plate cartilage are associated with intervertebral disc degeneration: A quantitative magnetic resonance imaging study in rhesus monkeys and humans

Background

The end plate plays an important role in intervertebral disc degeneration progression. The aim of the study was to examine the compositional and structural changes of the end plate with age and to investigate the correlation between end plate and disc degeneration by T1ρ and T2 map magnetic resonance imaging.

Methods

There were 12 young monkeys (6-7 years old), 20 aged monkeys (14-17 years old) and 12 human participants (30-50 years old) in this study. T1ρ or T2 map values of the nucleus pulposus and end plate cartilage were analyzed according to Pfirrmann grades and age. Afterwards, micro computed tomography and histological analysis were used to confirm the end plate changes in monkeys. Pearson’s correlation was performed to investigate the relationship between end plate and disc degeneration.

Results

In monkeys, T1ρ (r=-0.794, P<0.001) and T2 map values (r=-0.8, P<0.001) of the nucleus pulposus were negatively associated with Pfirrmann grades. Moreover, the T2 map was more suitable than T1ρ for the evaluation of end plate degeneration. Age was an important influence factor of end plate and disc degeneration, which was confirmed by microcomputed tomography, Safranin O/fast green staining, and collagen II staining. The T2 map value of lower end plate degeneration positively correlated with that of the intervertebral discs in monkeys (R²=0.3133, P<0.001) and humans (R²=0.2092, P<0.001).

Conclusion

This study suggests that the compositional and structural changes of the end plate can be quantitatively evaluated by T2 map. Furthermore, cartilage end plate degeneration is associated with disc degeneration during ageing.

The translational potential of this article

A better understanding of how the cartilage end plate affects disc degeneration is needed, which may propose a new clinical application using T2 map to evaluate end plate degeneration.

Challenges in the clinical diagnosis of psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic heterogeneous inflammatory musculoskeletal disease. The non-specific and often subtle manifestations make early diagnosis and subsequent treatment challenging. In the absence of diagnostic criteria and biomarkers, the diagnosis is often delayed leading to poor long-term outcomes. In addition, the differential diagnosis of a patient presenting with arthritis in the setting of skin psoriasis is wide due to symptom overlap with many other diseases. Peripheral arthritis, dactylitis, enthesitis and axial arthritis are the 4 domains of musculoskeletal involvement in PsA and careful examination of each domain by a rheumatologist is the first step for a correct diagnosis. Other extra-musculoskeletal features such as the presence of uveitis, inflammatory bowel disease, nail psoriasis and elevated acute phase reactants aid in the diagnosis of PsA. Screening patients with skin psoriasis using validated questionnaires might help in early diagnosis especially when coupled with imaging.

The impact of degenerative disc disease on regional volumetric bone mineral density (vBMD) measured by quantitative computed tomography

BACKGROUND CONTEXT

It has been reported that degenerative disc disease (DDD) is associated with higher spinal bone mineral density (BMD) based on previous studies that used dual X-ray absorptiometry (DXA). However, DDD is often associated with proliferative bone changes and can lead to an overestimation of BMD measured with DXA. Trabecular volumetric BMD (vBMD) in the vertebral body measured with quantitative computed tomography (QCT) is less affected by those changes and can be a favorable alternative to DXA for patients with degenerative spinal changes.

PURPOSE

The purpose of this study is to investigate the effect of DDD on regional trabecular vBMDs in the vertebral body measured by QCT.

STUDY DESIGN/SETTING

Cross-sectional observational study at a single academic institution.

PATIENTS SAMPLE

Consecutive patients undergoing posterior lumbar spinal fusion between 2014 and 2017 who had a routine preoperative CT scan and magnetic resonance imaging (MRI) within a 90-day interval.

OUTCOME MEASURES

Regional trabecular vBMDs in the vertebral body by QCT.

METHODS

QCT measurements were conducted in L1-S1 vertebral trabecular bone. Any apparent sclerotic lesions that might affect vBMD values were excluded from the region of interest. The vBMDs of each level were defined as the average vBMD of the upper and lower vertebrae. To evaluate DDD, Pfirrmann grade, Modic grade, total end plate score, and vacuum phenomenon were documented. Univariate regression analysis and multivariate analyses with a linear mixed model adjusted with individual variability of segmental vBMDs were conducted with vBMD as the response variable.

RESULTS

Of 143 patients and 715 disc levels, 125 patients and 596 discs met our inclusion criteria. Mean vBMD (±standard deviation [SD]) of all levels was 119.0±39.6 mg/cm³. After adjusting for all covariates, Pfirrmann grade was not an independent contributor to vBMD, but the presence of any Modic change (type 1, β=6.8, p≤.001; type 2, β=6.7, p<.001; type 3, β=43.6, p<.001), high TEPS (score 10-12, β=14.2, p<.001), or vacuum phenomenon (β=9.0, p<.001) was shown to be independent contributors to vBMD.

CONCLUSIONS

Our results showed that the presence of certain end plate lesions (Modic changes and high TEPS) on MRI was significantly associated with increased regional QCT-vBMDs in the vertebral body, but no significant association was observed with disc nucleus pathology, unless it was associated with a vacuum phenomenon. When end plate lesions with Modic changes and high TEPS are present at the measuring level, care must be taken to interpret vBMD values, which might be overestimations even if the trabecular area appears normal.

Comparison of MRI cross-sectional area and functions of core muscles among asymptomatic individuals with and without lumbar intervertebral disc degeneration

BACKGROUND

Previous studies suggested that patients with symptomatic intervertebral disc degeneration (IDD) of lumbar spine have reduced cross-sectional area (CSA) and functions of core muscles. However, reduced CSA and functions of core muscles have been observed not only in patients with symptomatic IDD but also in patients with other subgroups of low back pain (LBP). Thus, it is uncertain whether reduced CSA and functions of core muscles lead to IDD and LBP, or pain leads to reduced CSA and functions of core muscles in patients with symptomatic IDD. Therefore, this study aimed to compare the CSA and functions of core muscles between asymptomatic participants with and without IDD in magnetic resonance imaging (MRI).

METHODS

Twenty asymptomatic participants (12 men and 8 women) participated in this study. Ten participants had asymptomatic IDD at L4-5. The others were healthy controls (without IDD at all levels of lumbar spine). The CSA of core muscles was measured using MRI. Maximal isometric trunk flexor strength and side bridge strength were measured by a Smart KEMA strength sensor. Trunk flexor endurance test, side bridge endurance test and plank endurance test were used to measure core endurance. Double legs loading test was used to measure core stability. Mann-Whitney U test was used to compare the differences between two groups.

RESULTS

There were no significant differences in core muscle functions between the two groups (p > 0.05). Moreover, there was no significant difference in CSA between the two groups (p > 0.05).

CONCLUSIONS

There was no significant difference in CSA and core muscle functions between asymptomatic participants with and without IDD. These findings indicate that a degenerative or bulging disc in asymptomatic individuals has little effect on CSA and functions of core muscles, especially in young age. Therefore, the general core endurance test or strength test could not differentiate asymptomatic people with and without IDD of lumbar spine.

TRIAL REGISTRATION NUMBER

Clinical Research information Service. KCT0004061. Registered 13 June 2019. retrospectively registered.

Risk Factors of Secondary Lumbar Discectomy of a Herniated Lumbar Disc after Lumbar Discectomy

Objective

To study risk factors of secondary lumbar discectomy (LD) for recurrent herniated lumbar disc (HLD) and identify methods to lower the rate of recurrence.

Methods

Data from 160 patients who underwent primary LD were collected retrospectively. Demographic features, radiologic findings including Pfirrmann disc degeneration, and surgical information were analyzed to compare risks between revision and non-revision patients.

Results

The revision rate was 15% (24 patients), and the mean follow-up was 28.3 months. HLD recurrence was not related to any demographic characteristics. Primary and secondary LD were most common at the L4–5 level, but the level of operation was not significantly associated with revision. Primary LD most commonly had a Pfirrmann disc degeneration grade of 3, followed by 4. For recurrent HLD, Pfirrmann grade 4 was most common and was statistically significant (p<0.05). A body mass index (BMI) over 30 was considered obese and was significantly related with HLD revision (p<0.05).

Conclusion

Patients with high BMI or severe disc degeneration should be informed of HLD revision.

Novel Application of the Pfirrmann Disc Degeneration Grading System to 9.4T MRI: Higher Reliability Compared to 3T MRI

STUDY DESIGN

Reliability study.

OBJECTIVE

To evaluate the applicability and reliability of 9.4T magnetic resonance imaging (MRI) in the assessment of degenerative disc disease compared with 3T MRI.

SUMMARY OF BACKGROUND DATA

MRI is a reliable indicator of biochemical changes in the intervertebral disc (IVD) including hydration status, proteoglycan content, and disc degeneration compared with anatomical and histological studies. High-field 9.4T MRI has been shown to provide superior resolution and anatomical detail. However, it has not been tested against current standard MRI techniques.

METHODS

Disc degeneration was initiated in 36 skeletally mature ewes 6 months prior to necropsy via validated surgical IVD injury models using either scalpel injury or drill-bit injury techniques at lumbar spine levels L2/3 and L3/4 with L1/2, L4/5, and L5/6 serving as control discs. All ex vivo IVDs were examined with 9.4T MRI and 3T MRI. All scans were analyzed using the Pfirrmann grading system by four independent observers. Intra- and interobserver reliability was assessed using kappa statistics and Spearman correlation.

RESULTS

Inter- and intraobserver agreement for 9.4T MRI was excellent, both at κ 0.91 (P < 0.001). Comparatively, 3T interobserver reliability demonstrated substantial agreement at κ 0.61 (P < 0.001). Complete agreement was obtained in 92.7% to 100% of discs at 9.4T compared with 69.7% to 83.1% at 3T. A difference of one grade or more occurred in 6.7% at 9.4T and 39.3% at 3T. 9.4T MRI scored 97.3% of discs as grade 1 to 2 compared with 71.3% at 3T. 3T MRI tended to over-score the extent of disc degeneration with 28.6% of discs scored as grade 3 or higher compared with 2.7% at 9.4T MRI.

CONCLUSION

9.4T MRI study of IVD degeneration using the Pfirrmann grading system demonstrated excellent inter- and intraobserver reliability. Comparatively, 3T MRI demonstrated a tendency to over score the extent of disc degeneration. This improved reliability of 9.4T MRI holds great potential for its clinical applications.

LEVEL OF EVIDENCE

3.

Five-year development of lumbar disc degeneration-a prospective study

OBJECTIVE

To examine the impact of demographic, clinical, and genetic factors as well as herniated discs on 5-year development of disc degeneration in the lumbar spine, and to investigate associations between changes in lumbar degenerative findings and pain.

MATERIALS AND METHODS

In 144 patients with lumbar radicular pain or low back pain, we scored disc degeneration, herniated discs, and high-intensity zones in the posterior annulus fibrosus on lumbar magnetic resonance imaging (MRI) at baseline and 5-year follow-up. Genotyping (TaqMan assay) was performed for genes encoding vitamin D receptor (VDR), collagen XIα (COL11A), matrix metalloproteinase 1/9 (MMP1/MMP9), and interleukin 1α/1RN (IL-1α/IL-1RN). Associations were analyzed using multivariate linear regression adjusted for age, sex, smoking, body mass index, and baseline scores for degenerated discs and herniated discs (when analyzing impact of baseline factors) or for pain (when analyzing associations with pain).

RESULTS

Progression of disc degeneration over 5 years was significantly (p < 0.001) related to higher age and less disc degeneration at baseline, but not to sex, smoking, body mass index, herniated discs, or variants in the studied genes. No associations were identified between changes in disc degeneration or high-intensity zones and pain at 5-year follow-up. However, increased number of herniated discs over 5 years was associated with pain at rest (p = 0.019).

CONCLUSIONS

Age and disc degeneration at baseline, rather than genetic factors, influenced the 5-year development of disc degeneration in patients with lumbar radicular pain or low back pain. Development of herniated discs was related to pain at rest.

Magnetic resonance imaging analysis of work-related chronic low back pain: comparisons of different lumbar disc patterns

Background

Currently, there is a lack of comparative research about different lumbar disc patterns in patients with work-related chronic low back pain (CLBP) based on magnetic resonance imaging (MRI) analysis. Therefore, this study, on different patterns of lumbar disc degeneration or herniation in patients with CLBP, is valuable. In this study, we retrospectively investigated lumbar degenerative changes in patients with CLBP by using MRI analysis.

Materials and methods

Two hundred and eighty-three patients (110 women and 173 men) with work-related CLBP were enrolled and divided into four groups based on intervertebral disc morphology from MRI analysis, including normal discs (ND) group, degenerative discs (DD) group, bulging discs (BD) group, and herniated discs (HD) group. Demographic characteristics, occupational information, Visual Analog Scale (VAS) scores, and Oswestry Disability Index (ODI) scores were analyzed. Moreover, multiple parameters were investigated in the MRI analysis.

Results

The mean age of all 283 patients was 41.8±12.0 years (range, 18-80) and the mean duration of CLBP for all patients was 24.5±24.9 months. There were no significant differences in the patients' BMI, history of smoking, and education level (P>0.05). The three most common occupational types were manual worker, desk worker, and technician. The VAS and ODI scores of patients with CLBP in the DD, BD, and HD groups were significantly higher than those of patients in the ND group (P<0.05). The degrees of degeneration of L4/5 and L5/S1 were significantly higher than those of other intervertebral discs (P<0.05). The disc heights of L4/5 in the BD and HD groups were significantly lower than those of the ND group (P<0.05) and the disc height of L5/S1 in the HD group was significantly lower than that of the ND group (P<0.05). At the neutral position, the distances of L3/4, L4/5, and L5/S1 discs' bulge/herniation in the BD and HD groups were significantly higher than those in the ND and DD groups (P<0.05).

Conclusion

In summary, more severe degenerative changes of lower lumbar discs (L4/5 and L5/S1) such as higher degree of degeneration of disc, lower disc height, and significant displacement of disc were found in patients with work-related CLBP based on MRI analysis.

Severity of foraminal lumbar stenosis and the relation to clinical symptoms and response to periradicular infiltration-introduction of the "melting sign"

BACKGROUND CONTEXT

Nerve root compression causing symptomatic radiculopathy can occur within the intervertebral foramen. Sagittal magnetic resonance imaging (MRI) sequences are reliable in detection of nerve root contact to intraforaminal disc material, but a clinically relevant classification of degree of contact is lacking.

PURPOSE

This study aimed to investigate a potential relation of amount of contact between intraforaminal disc material and nerve root to clinical findings and response after periradicular corticosteroid infiltration.

STUDY DESIGN

A post hoc analysis of a prospective cohort was carried out.

PATIENT SAMPLE

Patients who underwent computed tomography (CT)-guided periradicular corticosteroid infiltration (L1-L5) at our institution (January 2014 to May 2016) were included.

OUTCOME MEASURES

The medical records and radiographic imaging were reviewed.

METHODS

T2-weighted MRI of the lumbar spine of patients with single-level symptomatic radiculopathy with (responders, n=28) or without (non-responders, n=14) pain relief after periradicular infiltration with corticosteroids were measured and compared by two independent readers to determine the amount of intraforaminal nerve root contact with the intervertebral disc ("melting" of the T2-hypointense signal). Pain relief was defined with a pain level decrease of >50% on a visual analogue scale and lack of pain relief with a pain level decrease of <25%, respectively. The amount of T2-hypointensity melting of disc and nerve root was categorized to 0%, 1%-25%, and over 25%.

RESULTS

Reader one identified 0% T2-melting in none of the responders, 1%-25% melting in 13 patients (46.4%), 26%-50% in 15 of the 28 patients (53.6%) with pain relief after periradicular corticosteroid infiltration (responders), with a mean amount of T2-melting of 5.9±2.1 mm, whereas the non-responder group had 0% T2-melting in 2 patients (14.3%), 1%-25% T2-melting in 11 patients (78.6%), and 26%-50% in 1 patient (7.1%), with a mean amount of T2-melting of 2.6±1.9 mm (p<.05). Reader two identified 0% T2-melting in none, 1%-25% T2-melting in 15 (53.6%) patients, and 26%-50% in 13 of the 28 responders (46.4%), with mean amount of 6.3±1.9 mm. In the non-responder group 0% T2-melting was seen in 3 patients (21.4%), 1%-25% T2-melting in 10 patients (71.4%), and 26%-50% in 1 patient (7.1%), with a mean amount of T2-melting of 2.7±1.9 mm (p<.05). None of the MRI showed T2-melting in over 50% of the circumference of the intraforaminal nerve root. A T2-melting of >25% had a high specificity of 93% but a sensitivity of 50%, thus a positive likelihood ratio of 7.5, to identify those with a pain relief of more than 50% after infiltration.

CONCLUSION

The amount of T2-melting of disc material and nerve root on sagittal MRI (>25%) predicts the amount of pain relief by periradicular infiltration in patients with intraforaminal nerve root irritation.

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.

Is it appropriate to measure age-related lumbar disc degeneration on the mid-sagittal MR image? A quantitative image study

PURPOSE

Even though phenotypes of disc degeneration vary on different sagittal magnetic resonance images (MRI), measurements typically are acquired on the mid-sagittal MRI. This study investigated the appropriateness of using the mid-sagittal MRI to measure various phenotypes of age-related disc degeneration.

METHODS

Lumbar spine MRIs of 66 subjects (mean age 50.3 years, standard deviation 16.5 years, range 22-84 years) were studied. An image analysis program Spine Explorer was used to obtain quantitative measurements for disc height, bulging, and signal on para- and mid-sagittal T2-weighted MRIs. Measurements on para- and mid-sagittal MRIs and their associations with age were compared.

RESULTS

Measurements of disc height, signal, and posterior disc bulging acquired on the mid-sagittal MRI were greater than those on the para-sagittal MRIs. Disc height measurements were not linearly associated with age. Greater age was correlated with greater anterior (r = 0.45, P < 0.001) and posterior (r = 0.33, P < 0.01) bulging on para-sagittal MRIs, but not posterior disc bulging on the mid-sagittal MRI (r = - 0.10, P > 0.05). Disc signal intensity measurements on the mid-sagittal MRI had stronger correlations with age than those on para-sagittal MRIs. Mean and standard deviation of disc signal intensity acquired on the mid-sagittal MRI had the strongest correlations with age among all measures of disc degeneration studied (r = - 0.50, - 0.67, respectively, P < 0.001 for both).

CONCLUSIONS

Disc signal measurements acquired on the mid-sagittal MRI were reliable and had strong correlations with age and thus can be used as an appropriate measure of disc degeneration. Disc bulging had better be measured on para-sagittal MRIs. Although severe disc narrowing clearly is a sign of severe disc degeneration, disc height was not linearly associated with age.

Quantitative Pfirrmann Disc Degeneration Grading System to Overcome the Limitation of Pfirrmann Disc Degeneration Grade

Objective

Pfirrmann disc degeneration grade is one of morphologic disc degeneration grading system and it was reliable on routine T2-weighted magnetic resonance (MR) images. The purpose of this study was to evaluate the agreement of Pfirrmann disc degeneration grade, and check the alternative technique of disc degeneration grading system.

Methods

Fifteen volunteers (4 medical doctors related to spinal disease, 2 medical doctors not related to spinal disease, 6 nurses in spinal hospital, and 3 para-medicines) were included in this study. Three different digitalized MR images were provided all volunteers, and they checked Pfirrmann disc degeneration grade of each disc levels after careful listening to explanation. Indeed, all volunteers checked the signal intensity of disc degeneration at the points of nucleus pulposus (NP), disc membrane, ligaments, fat, and air to modify the quantitative Pfirrmann disc degeneration grade.

Results

Total 225 grade results of Pfirrmann disc degeneration grade and 405 signal intensity results of quantitative Pfirrmann disc degeneration grade were analyzed. Average interobserver agreement was "moderate (mean±standard deviation, 0.575±0.251)" from poor to excellent. Completely agreed levels of Pfirrmann disc degeneration grade were only 4 levels (26.67%), and the disagreement levels were observed in 11 levels; two different grades in 8 levels (53.33%) and three different grades in 3 levels (20%). Quantitative Pfirrmann disc degeneration showed relatively cluster distribution with the interobserver deviations of 0.41-1.56 at the ratio of NP and disc membrane, and it showed relatively good cluster and distribution indicating that the proposed grading system has good discrimination ability.

Conclusion

Pfirrmann disc degeneration grade showed the limitation of different interobserver results, but this limitation could be overcome by using quantitative techniques of MR signal intensity. Further evaluation is needed to access its advantage and reliabilities.