Lumbar disc degeneration progression in young women in their 20's: A prospective ten-year follow up

Biglycan fragment modulates TGF-β activity in intervertebral disc via an eIF6-coupled intracellular path

Biglycan, a pericellular small leucine-rich proteoglycan, is crucial in skeletal development and regeneration. Intervertebral disc degeneration (IDD) contributes to back pain and disability. Previous studies have shown that biglycan promotes hypoxic survival of disc progenitor cells, while its depletion accelerates IDD. An association of pathological tissue remodeling with a biglycan fragment 344YWEVQPATFR, termed Bgm1, has been reported, however its role is yet to be defined. Using a custom antibody, we detected Bgm1 in human and mouse nucleus pulposus, with prominent intracellular expression in notochordal cells. Proteomic analysis revealed that Bgm1 interacts with eukaryotic translation initiation factor 6 (eIF6), a key player in ribosome biogenesis. Bgm1 dysregulates eIF6 localization in notochordal cells, affecting nucleocytoplasmic transport. Induced IDD in mice showed elevated nuclear eIF6 expression and reduced Bgm1 in degenerating nucleus pulposus. Transcriptome analysis suggests that Bgm1 regulates fatty acid metabolism and glycolysis in a transforming growth factor-β-dependent manner, highlighting its potential role in metabolic control in spinal joint homeostasis.

Comparison of Disc Degeneration between Pyogenic Spondylitis and Noninfected Lumbar Spondylosis: A Multicenter Retrospective Study with Propensity Score Matching

Introduction

Disc degeneration is a risk factor of pyogenic spondylitis. However, its degree in patients with pyogenic spondylitis is unknown. This study aimed to determine differences in disc degeneration between patients with pyogenic spondylitis and those with noninfectious lumbar spondylosis.

Methods

A total of 85 patients with lumbar pyogenic spondylitis (the infected group) and 156 with lumbar spondylosis who underwent posterior lumbar interbody fusion (the noninfected group) were retrospectively evaluated. Patients with a previous history of spinal fusion, tuberculous spondylitis, and multilevel infection and those receiving dialysis were excluded. Magnetic resonance imaging of the lumbar spine was conducted. Each disc at the L1/2-L5/S levels was graded. The total score of the four discs, excluding the affected disc, was used as the modified disc degenerative disease (DDD) score. Propensity score matching was performed using independent variables such as age, sex, diabetes mellitus, cancer, and steroid use. The modified DDD scores at all and each disc level were compared between the two matched groups.

Results

After matching, 48 patients in the infected group and 88 in the noninfected group were finally included in the study. The mean modified DDD scores of the infected and noninfected groups were 7.63 and 5.40, respectively. The modified DDD scores at all and each disc level were higher in the infected group than in the noninfected group.

Conclusions

The incidence of disc degeneration at all and each disc level was higher in patients with pyogenic spondylitis than in those with noninfectious lumbar spondylosis.

Assessing the risk of lumbar degenerative disc disease associated with swimming: A systematic review

OBJECTIVE

The purpose of the current study is to synthesize the outcomes of investigations reporting the odds of lumbar degenerative disc disease (DDD) in competitive swimmers compared to controls.

LITERATURE SURVEY

PubMed, Embase, and Web of Science databases were searched according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines from inception until March 2023 to identify relevant studies evaluating the risk for lumbar DDD associated with swimming.

METHODS

Data in the current literature were synthesized for positive imaging findings of DDD at one or more lumbar level in swimmers compared to nonswimmers. Additionally, data regarding prevalence of lumbar disc degeneration and back pain in competitive swimmers were synthesized.

SYNTHESIS

Four studies were included in the final analysis. Study quality and risk of bias were deemed adequate. There was significant heterogeneity among studies (I2 = 0.74) regarding data collected, population of swimmers, sample size, and methods. Therefore, a meta-analysis was not conducted. Three of the four studies included in this review reported that swimmers have increased odds of developing lumbar DDD. Additionally, secondary outcome analysis indicated that swimmers have a higher probability of developing moderate-to-severe back pain.

CONCLUSION

Competitive swimming appears to be associated with the presence of DDD on advanced imaging and moderate-to-severe back pain. These findings are limited by significant differences in study methodology in the included studies. Although swimming is conventionally considered a low-impact sport, elite swimmers risk developing lower back pain and disc pathology, possibly because training involves unique biomechanics with repetitive rotational and hyperextension/flexion of the spine. Further research investigating risk factors involving biomechanics of swimming on the spine may have important implications for stroke technique, injury prevention, and rehabilitation for swimmers.

Relationship of disc degeneration after pubertal growth spurt to future low back pain: a longitudinal cohort study

PURPOSE

In this longitudinal cohort study, we investigated the relationship of disc degeneration (DD) after pubertal growth spurt to future low back pain (LBP).

METHODS

A group of healthy volunteers underwent a semi-structured interview about LBP without trauma and a 1.5T lumbar MRI at ages 18 and 34. A Pfirrmann Summary Score (PSS) was calculated by adding up the Pfirrmann grades of the three lowest lumbar discs of each subject (range 3-15). The relationship of PSS at age 18 to LBP at age 34 was analyzed.

RESULTS

Forty-one participants had full data at both time points. Mean PSS at age 18 was 6.8 (SD 1.1) and 5.6 (SD 1.2) for participants with or without LBP at age 34, respectively (p = 0.009). The OR (95% CI) of PSS at age 18 for LBP at age 34 was 5.46 (1.22 to 24.47) when adjusted for sex, BMI, smoking and physical activity. All participants but one with PSS greater than 6 at age 18 reported LBP at age 34.

CONCLUSION

This is the first study to suggest that DD may be associated with future LBP and the critical time frame seems to be the pubertal growth spurt. Every 1-point increase in Pfirrmann grade at age 18 increased the risk of LBP 5.5-fold at age 34 when adjusted for sex, BMI, smoking and physical activity at age 34. All participants but one with at least one disc with Pfirrmann grade 3 or higher at age 18 reported LBP at age 34.

Fibrin glue delivery system containing rhein ameliorates intervertebral disc degeneration by anti-inflammatory efficacy

PURPOSE

To construct an injectable, sustained-release fibrin gel containing rhein to solve the problem of low bioavailability of rhein, and observe its efficacy in the treatment of intervertebral disc degeneration.

METHODS

The fibrin gel containing rhein was first synthesized in advance. Subsequently, the materials were characterized by various experimental methods. Secondly, the degenerative cell model was constructed by stimulating nucleus pulposus cells with lipopolysaccharide (LPS), and the corresponding intervention treatment was carried out to observe the effect in vitro. Finally, the rat tail intervertebral disc was acupunctured by needles to establish the intervertebral disc degeneration model, and the effect of the material was observed through intradiscal injection.

RESULTS

The fibrin glue containing rhein (rhein@FG) showed good injectability, sustained release and biocompatibility. Rhein@FG can improve the LPS-induced inflammatory microenvironment, regulate ECM metabolic disorders of nucleus pulposus cells and aggregation of the NLRP3 inflammasome in vitro, and inhibit cell pyroptosis. Furthermore, in vivo experiments, rhein@FG effectively prevented needle puncture-induced intervertebral disc degeneration in rats.

CONCLUSIONS

Rhein@FG has better efficacy than rhein or FG alone due to its slow release and mechanical properties, which can be used as a potential replacement therapy for intervertebral disc degeneration.

ISSLS prize in clinical science 2022: accelerated disc degeneration after pubertal growth spurt differentiates adults with low back pain from their asymptomatic peers

PURPOSE

In this prospective observational cohort study, the development of lumbar intervertebral discs (LIVD) on magnetic resonance imaging (MRI) was investigated from childhood to adulthood with emphasis on the possible association of disc degeneration (DD) to low back pain (LBP).

METHODS

In 2021, 89 subjects who were enrolled in 1994 in a longitudinal study with lumbar spine MRI at ages 8, 11 and 18 were invited to participate in a long-term follow-up comprising a clinical examination, selected patient-reported outcome measures and a lumbar spine MRI. We assessed all MRIs (three lowest LIVDs) with the Pfirrmann summary score, and the ratio of signal intensity of nucleus pulposus to signal intensity of cerebrospinal fluid (SINDL). We further analyzed whether disc changes at any age were associated with self-reported LBP at age 34.

RESULTS

Of the 48 subjects in the follow-up, 35 reported LBP at age 34. The Pfirrmann summary score significantly increased with age (p < 0.001). Subjects reporting LBP at age 34 demonstrated statistically significantly higher summary scores at age 18 and 34 compared to asymptomatic subjects (p = 0.004 at age 18, and p = 0.039 at age 34). SINDL significantly decreased with age (p < 0.001 for all levels separately), but no significant differences between subjects with or without LBP at age 34 were noticed.

CONCLUSION

Subjects with LBP at age 34 had more widespread or severe DD already at age 18 compared to those without LBP.

Is There Any Association between the Severity of Disc Degeneration and Low Back Pain?

Objective  To access the possibility that higher degrees of disc degeneration lead to higher levels of pain and dysfunction. Methods  Magnetic resonance imaging (MRI) scans of 85 patients with low back pain lasting for more than 12 weeks were evaluated, and the degree of disc degeneration was quantified according to the Pfirrmann grading system. The Pfirrmann degree in each disc space from L1-L2 to L5-S1, the maximum degree of Pfirrmann (Pfirrmann-max) between the lumbar discs, and the sum of Pfirrmann (Pfirrmann-sum) degrees were correlated (through the Spearman test) with the Oswestry Disability Index (ODI) and the Visual Analogical Scale (VAS) for pain. Results  In total, 87% of the patients had moderate to severe lumbar disc degeneration measured by Pfirrmann-max, and the most degenerated discs were L4-L5 and L5-S1. There was a week to moderate correlation regarding the Pfirrmann-max (r = 0,330; p  = 0.002) and the Pfirrmann-sum (r = 0,266; p  = 0,037) and the ODI, and the Pfirrmann scores in L1-L2 were correlated with the ODI and the VAS. Conclusion  Patients with chronic idiopathic low back pain frequently have moderate to severe lumbar disc degeneration, which has a negative impact on the quality of life of the patients. Low degrees of degeneration in L1-L2 might be related with higher degrees of pain and of functional disability.

The Upregulation of COX2 in Human Degenerated Nucleus Pulposus: The Association of Inflammation with Intervertebral Disc Degeneration

Intervertebral disc degeneration (IVDD) is an important risk factor of low back pain. We previously found upregulated markers of fibrosis, the late stage of chronic inflammation, in degenerated IVD with a small number of clinical specimens. Here, we aimed to study on a larger scale the association of cyclooxygenase 2 (COX2), an inflammation and/or pain marker, with IVDD. This study involved 107 LBP participants. The IVD degeneration level was graded on a 1–5 scale according to the Pfirrmann classification system. Discs at grades 1-3 were further grouped as white discs with grades 4-5 as black discs. We recorded baseline information about age, gender, body mass index (BMI), diabetes history, smoking history, and magnetic resonance imaging (MRI). Their association with IVDD was statistically analyzed. The expression level of COX2 was investigated by immunohistochemistry. The total integrated COX2 optical density (IOD), number of COX2-positive cells, and total cell number of each image were counted and analyzed by Image-Pro Plus software. The IOD and number of COX2-positive cells were divided by the total cell number to obtain COX2 expression density (IOD/cell) and COX2 positivity (cell+/cell). As a result, among the baseline information investigated, only age was found to have a significant association with IVDD. The IOD/cell was found to be significantly increased from grade 2 to grade 5, as well as in black discs compared to white discs. The cell+/cell displayed the same trend that it increased in highly degenerative discs compared to their counterparts. In conclusion, the expression of COX2 is associated with IVDD, which highlights COX2 as a biomarker for IVD degeneration and indicates the involvement of inflammation and pain signaling in IVDD.

Disc Degeneration of Young Low Back Pain Patients: A Prospective 30-year Follow-up MRI Study

STUDY DESIGN

A prospective follow-up study.

OBJECTIVE

The aim of this study was to investigate whether early lumbar disc degeneration (DD) in young low back pain (LBP) patients predicts progression of degenerative changes, pain, or disability in a 30-year follow-up.

SUMMARY OF BACKGROUND DATA

MRI is an accurate method for studying degenerative changes in intervertebral discs. Decreased signal intensity (SI) can be used as indication of decreased water content. Long-term prognosis of early DD remains unclear.

METHODS

In an earlier study, 75 conscripts aged 20 years with LBP had their lumbar spine examined by MRI. At a follow-up of 30 years, the subjects were contacted; 35 of 69 filled a pain and disability questionnaire, and 26 of 35 were also reexamined clinically and by MRI. The images were evaluated for decreased SI and other degenerative changes. Association between decreased SI of a disc at baseline and the presence of more severe degenerative changes in the same disc space at follow-up was analyzed using Fisher exact test. Association between decreased baseline SI and pain/disability scores from the questionnaire was analyzed with Kruskal-Wallis H test.

RESULTS

The total number of lumbar discs with decreased SI increased from 23 of 130 (18%) to 92 of 130 (71%)-from 0.9 to 3.5 per subject during the follow-up. Distribution of DD changed from being mostly in L4-L5 and L5-S1 discs to being almost even between the four lowermost discs. Discs that had even slightly decreased SI at baseline were more likely to have severely decreased SI at follow-up, compared to healthy discs (57% vs. 11%, P < 0.001). Other degenerative changes were also more common in these discs. Severity of DD at baseline did not have a significant association with current pain or disability.

CONCLUSION

In young LBP patients, early degeneration in lumbar discs predicts progressive degenerative changes in the respective discs, but not pain, disability, or clinical symptoms.

LEVEL OF EVIDENCE

4.

Intervertebral Disc Disease of the Lumbar Spine in Health Personnel with Occupational Exposure to Patient Handling-A Systematic Literature Review and Meta-Analysis

Lifting or carrying loads or working while the trunk is in a bent position are well established risk factors for the development of disc disease of the lumbar spine (LDD). Patient handling is associated with certain hazardous activities, which can result in exposure to heavy loads and high pressure for the discs of the lumbar spine of the nurses performing these tasks. The purpose of this review was to examine the occurrence of work-related LDD among health personnel (HP) with occupational exposure to patient handling activities in comparison to un-exposed workers. A systematic literature search was conducted using the following databases: PubMed, CINAHL, Scopus, and Web of Science. A meta-analysis of odds ratios (OR) was conducted by stratifying for various factors. Five studies reported a higher prevalence for LDD among nurses and geriatric nurses (11.3-96.3%) compared to all controls (3.78-76.47%). Results of the meta-analysis showed a significantly increased OR for LDD among HP compared to all controls (OR 2.45; 95% confidence interval (CI) 1.41, 4.26). In particular, the results of this review suggest that nurses have a higher probability of developing disc herniation than office workers.

Thermosensitive hydrogels loaded with human‐induced pluripotent stem cells overexpressing growth differentiation factor‐5 ameliorate intervertebral disc degeneration in rats

To evaluate the effects of thermosensitive hydrogels loaded with human‐induced pluripotent stem cells transfected with the growth differentiation factor‐5 (GDF5‐hiPSCs) on rat intervertebral disc regeneration. GDF5‐hiPSCs were cocultured with rat nucleus pulposus (NP) cells in vitro. Real‐time PCR and western blot were used to determine the differentiation of hiPSCs. Rat caudal intervertebral discs were punctured using a needle under X‐ray, and groups of coccygeal (Co) discs were subject to various treatments: Puncture group (Co6/7, punctured without treatment); Hydrogel group (Co7/8, 2 μl of hydrogel injected without cells); GDF5‐hiPSCs + Hydrogel group (Co8/9, 2 μl of GDF5‐hiPSCs‐loaded hydrogel injected); and Normal control (Co5/6). X‐ray, MRI, and histological evaluations were performed at 1, 2, and 3 months after cell transplantation and relative changes in the disc height index (DHI%) and voxel count were calculated and compared. GDF5‐hiPSCs were successfully differentiated to a chondrogenic linage after cocultured with rat NP cells. In terms of X‐ray, MRI, and HE staining scores, the GDF5‐hiPSCs + Hydrogel group was significantly superior to the Puncture and Hydrogel groups (p < .05). Compared with the Normal group, the MRI‐based voxel count of the GDF5‐hiPSCs + Hydrogel group was significantly lower at 1, 2, and 3 months after cell transplantation (p < .05). However, there were no significant differences in histological scores at 1 and 2 months after cell transplantation compared with the Normal group (p > .05). In conclusion, thermosensitive hydrogel‐encapsulated hiPSCs overexpressing the GDF5 gene ameliorated intervertebral disc degeneration.

Lumbar Intervertebral Disc Degeneration as a Common Incidental Finding in Young Pregnant Women as Observed on Prenatal Magnetic Resonance Imaging

Background: Obstetric imaging, subserving fetal evaluation, may yield incidental maternal findings. Based on prenatal magnetic resonance (MR) imaging, this study aims to investigate incidental intervertebral disc degeneration and displacement in young, pregnant women. Methods: This retrospective study included the sagittal 1.5 Tesla, T2-weighted lumbar spine images of 943 pregnant Central Europeans (age range, 18-47 years), who initially had undergone MR imaging because of sonographically suspected fetal abnormalities. Qualitatively, 4715 lumbar intervertebral discs were evaluated for degeneration using a modified Pfirrmann MR classification (nondegenerated, low-grade, moderate, and high-grade degeneration), as well as for displacement. In addition to descriptive statistics, an ordinal regression analysis was performed to analyze the relationship between degeneration and the women's age, and body weight. Results: With regard to the highest degree of degeneration in each woman, 578 (61.3%) showed low-grade, 211 (22.4%) moderate, and 154 (16.3%) high-grade degeneration, and no woman had entirely nondegenerated discs. For the span from 18 to 47 years of age, moderate and high-grade degeneration increased from 6.7% to 36.7% and from 13.3% to 22.4%, respectively. Of 943 women, 57 (6%) had disc displacements, of which 97% were in conjunction with high-grade degeneration. There was a statistically significant relationship (p < 0.001) between degeneration and age, and between degeneration and body weight. Conclusions: In young pregnant women, lumbar intervertebral disc degeneration is a ubiquitous, incidental finding, increasing from the late second decade of life onward, which may be part of physiological aging, as opposed to a small percentage of incidental disc displacements.

Association between parity and lumbar spine degenerative disorders in young women

Introduction: Estrogen helps to maintain the health of collagen-containing tissues including the intervertebral disc. Estrogen deficiency after menopause negatively affects the quality of vertebral end plates and induces development of degenerative disc disease (DDD). However, there is no study examining the relationship between parity and spinal degeneration in young women. The aim of this study was to define the relationship between parity and development of vertebral endplate signal changes and DDD in young premenopausal women.Materials and methods: This case-control case study included 224 patients aged 20-40 years with a history of low back pain for at least 3 months. Pfirrmann's grade, Modic changes (MCs), and Schmorl's nodes (SNs) were graded based on magnetic resonance images. Patients' parity, demographics, body mass index, physical activity level, and disability scores were assessed using a questionnaire.Results: The prevalence of abnormal total Pfirrmann's score (>10) and MCs was higher in primiparous patients than multiparous and grand-multiparous; however, it was not statistically significant. The presence of SN was statistically significantly associated with low parity. According to multivariate logistic regression analysis, it was found that the number of births increases by 1 unit, the abnormality in Pfirrmann's score decreases by 1.36 times.Conclusions: This cross-sectional study shows that parity is associated with DDD and vertebral end plate changes. SNs were significantly associated with parity. Modic changes and DDD were less common in grand multipara and multipara young women than in primipara women. These results indicate that low parity may possibly be associated with the development of spinal degeneration.

Prognostic factors in the progression of intervertebral disc degeneration: Which patient should be targeted with regenerative therapies?

OBJECTIVE

Possible regenerative treatments for lumbar intervertebral disc degeneration (DD) are rapidly emerging. There is consensus that the patient that would benefit most has early-stage DD, with a predicted deterioration in the near future. To identify this patient, the aim of this study was to identify prognostic factors for progression of DD.

STUDY DESIGN

Systematic review.

METHODS

A systematic search was performed on studies evaluating one or more prognostic factor(s) in the progression of DD. The criteria for inclusion were (a) patients diagnosed with DD on MRI, (b) progression of DD at follow-up, and (c) reporting of one or more prognostic factor(s) in progression of DD. Two authors independently assessed the methodological quality of the included studies. Due to heterogeneity in DD determinants and outcomes, only a best-evidence synthesis could be conducted.

RESULTS

The search generated 3165 references, of which 16 studies met our inclusion criteria, involving 2.423 patients. Within these, a total of 23 clinical and environmental and 12 imaging factors were identified. There was strong evidence that disc herniation at baseline is associated with progression of DD at follow-up. There is limited evidence that IL6 rs1800795 genotype G/C male was associated with no progression of DD. Some clinical or environmental factors such as BMI, occupation and smoking were not associated with progression.

CONCLUSIONS

Disc herniation is strongly associated with the progression of DD. Surprisingly, there was strong evidence that smoking, occupation, and several other factors were not associated with the progression of DD. Only one genetic variant may have a protective effect on progression, otherwise there was conflicting or only limited evidence for most prognostic factors. Future research into these prognostic factors with conflicting and limited evidence is not only needed to determine which patients should be targeted by regenerative therapies, but will also contribute to spinal phenotyping.

A selective inhibition of c-Fos/activator protein-1 as a potential therapeutic target for intervertebral disc degeneration and associated pain

Intervertebral disc (IVD) degeneration is a major cause of low back pain. The transcription factor c-Fos/Activator Protein-1 (AP-1) controls the expression of inflammatory cytokines and matrix metalloproteinases (MMPs) that contribute to the pathogenesis IVD degeneration. We investigated the effects of inhibition of c-Fos/AP-1 on IVD degeneration and associated pain. A selective inhibitor, T-5224, significantly suppressed the interleukin-1β-induced up-regulation of Mmp-3, Mmp-13 and Adamts-5 transcription in human nucleus pulposus cells and in a mouse explant culture model of IVD degeneration. We used a tail disc percutaneous needle puncture method to further assess the effects of oral administration of T-5224 on IVD degeneration. Analysis of disc height, T2-magnetic resonance imaging (MRI) findings, and histology revealed that IVD degeneration was significantly mitigated by T-5224. Further, oral administration of T-5224 ameliorated pain as indicated by the extended tail-flick latency in response to heat stimulation of rats with needle-puncture-induced IVD degeneration. These findings suggest that the inhibition of c-Fos/AP-1 prevents disc degeneration and its associated pain and that T-5224 may serve as a drug for the prevention of IVD degeneration.