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Heggli I, Mengis T, Laux C, Opitz L, Herger N, Menghini D, Schuepbach R, Farshad-Amacker N, Brunner F, Fields A, Farshad M, Distler O, Dudli S. Low back pain patients with Modic type 1 changes exhibit distinct bacterial and non-bacterial subtypes. OSTEOARTHRITIS AND CARTILAGE OPEN 2024; 6:100434. [PMID: 38322145 PMCID: PMC10844677 DOI: 10.1016/j.ocarto.2024.100434] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/13/2023] [Accepted: 01/08/2024] [Indexed: 02/08/2024] Open
Abstract
Objectives Modic type 1 changes (MC1) are vertebral endplate bone marrow (BM) lesions observed on magnetic resonance images in sub-populations of chronic low back pain (CLBP) patients. The etiopathogenesis remains unknown and treatments that modify the underlying pathomechanisms do not exist. We hypothesized that two biological MC1 subtypes exist: a bacterial and a non-bacterial. This would have important implications for developing treatments targeting the underlying pathomechanisms. Methods Intervertebral disc (IVD) samples adjacent to MC1 (n = 34) and control (n = 11) vertebrae were collected from patients undergoing spinal fusion. Cutibacterium acnes (C.acnes) genome copy numbers (GCNs) were quantified in IVD tissues with 16S qPCR, transcriptomic signatures and cytokine profiles were determined in MC1 and control BM by RNA sequencing and immunoassay. Finally, we assessed if C.acnes GCNs are associated with blood plasma cytokines. Results IVD tissues from control levels had <870 C.acnes GCNs/gram IVD. MC1-adjacent IVDs had either "low" (<870) or "high" (>870) C.acnes GCNs. MC1 patients with "high" C.acnes GCNs had upregulated innate immune cell signatures (neutrophil, macrophage/monocyte) and pro-inflammatory cytokines related to neutrophil and macrophage/monocyte function in the BM, consistent with a host defense against bacterium. MC1 patients with "low" C.acnes GCNs had increased adaptive immune cell signatures (T-and B-cell) in the BM and elevated IL-13 blood plasma levels. Conclusion Our study provides the first evidence for the existence of bacterial (C.acnes "high") and non-bacterial (C.acnes "low") subtypes in MC1 patients with CLBP. This supports the need for different treatment strategies.
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Affiliation(s)
- I. Heggli
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - T. Mengis
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - C.J. Laux
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - L. Opitz
- Functional Genomics Center Zurich, University and ETH Zurich, Zurich, Zurich, Switzerland
| | - N. Herger
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - D. Menghini
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - R. Schuepbach
- Unit of Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - N.A. Farshad-Amacker
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - F. Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - A.J. Fields
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - M. Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - O. Distler
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
| | - S. Dudli
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Balgrist Campus, University of Zurich, Zurich, Switzerland
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Heggli I, Teixeira GQ, Iatridis JC, Neidlinger‐Wilke C, Dudli S. The role of the complement system in disc degeneration and Modic changes. JOR Spine 2024; 7:e1312. [PMID: 38312949 PMCID: PMC10835744 DOI: 10.1002/jsp2.1312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 12/15/2023] [Accepted: 01/04/2024] [Indexed: 02/06/2024] Open
Abstract
Disc degeneration and vertebral endplate bone marrow lesions called Modic changes are prevalent spinal pathologies found in chronic low back pain patients. Their pathomechanisms are complex and not fully understood. Recent studies have revealed that complement system proteins and interactors are dysregulated in disc degeneration and Modic changes. The complement system is part of the innate immune system and plays a critical role in tissue homeostasis. However, its dysregulation has also been associated with various pathological conditions such as rheumatoid arthritis and osteoarthritis. Here, we review the evidence for the involvement of the complement system in intervertebral disc degeneration and Modic changes. We found that only a handful of studies reported on complement factors in Modic changes and disc degeneration. Therefore, the level of evidence for the involvement of the complement system is currently low. Nevertheless, the complement system is tightly intertwined with processes known to occur during disc degeneration and Modic changes, such as increased cell death, autoantibody production, bacterial defense processes, neutrophil activation, and osteoclast formation, indicating a contribution of the complement system to these spinal pathologies. Based on these mechanisms, we propose a model how the complement system could contribute to the vicious cycle of tissue damage and chronic inflammation in disc degeneration and Modic changes. With this review, we aim to highlight a currently understudied but potentially important inflammatory pathomechanism of disc degeneration and Modic changes that may be a novel therapeutic target.
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Affiliation(s)
- Irina Heggli
- Center of Experimental Rheumatology, Department of RheumatologyUniversity Hospital Zurich, University of ZurichZurichSwitzerland
- Department of Physical Medicine and RheumatologyBalgrist University Hospital, Balgrist Campus, University of ZurichZurichSwitzerland
- Leni and Peter W. May Department of OrthopaedicsIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Graciosa Q. Teixeira
- Institute of Orthopedic Research and Biomechanics, Trauma Research Centre, Ulm UniversityUlmGermany
| | - James C. Iatridis
- Leni and Peter W. May Department of OrthopaedicsIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | | | - Stefan Dudli
- Center of Experimental Rheumatology, Department of RheumatologyUniversity Hospital Zurich, University of ZurichZurichSwitzerland
- Department of Physical Medicine and RheumatologyBalgrist University Hospital, Balgrist Campus, University of ZurichZurichSwitzerland
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Rajasekaran S, Bt P, Murugan C, Mengesha MG, Easwaran M, Naik AS, Ks SVA, Kanna RM, Shetty AP. The disc-endplate-bone-marrow complex classification: progress in our understanding of Modic vertebral endplate changes and their clinical relevance. Spine J 2024; 24:34-45. [PMID: 37690481 DOI: 10.1016/j.spinee.2023.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 08/29/2023] [Accepted: 09/02/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND CONTEXT The disc, endplate (EP), and bone marrow region of the spine form a single anatomical and functional interdependent unit; isolated degeneration of any one structure is rare. Modic changes (MC), however, are restricted to the subchondral bone alone and based on only T1 and T2 sequences of MRI. This results in poor reliability in differentiating fat from edema and hence may give a false impression of disease inactivity. PURPOSE To study the changes in disc, endplate, and bone marrow as a whole in degeneration and propose a classification based on the activity status of this complex with the addition of STIR MRI sequences. STUDY DESIGN Observational cohort. PATIENT SAMPLE Patients with isolated brain, cervical, or thoracic spine injury and patients with low back pain (LBP) who underwent MRI formed the control and study groups, respectively. OUTCOME MEASURES Demographic data, the prevalence of MC and disc-endplate-bone marrow classification (DEBC) changes, EPs undergoing reclassification based on DEBC, and comparison of the prevalence of MC, DEBC, H+modifier and DEBC with H+concordance between control and LBP group. The study determined the risk of LBP patients undergoing surgery as well as the incidence of postoperative infection based on DEBC changes. Significance was calculated by binomial test and chi-square test with the effect size of 0.3 to 0.5. Prevalence and association of outcome were calculated by Altman's odds ratio with the 95% CI and the scoring of z statistics. Logistic expression was plotted for independent variables associated with each class of both Modic and DEBC against dependent variables surgery and nonsurgery. METHODS Lumbar segments in both groups were assessed for MC types. The DEBC classification was developed with the addition of STIR images and studying the interdependent complex as a whole: type-A: acute inflammation; type-B: chronic persistence; type-C: latent and type-D: inactive. Modifier H+ was added if there was disc herniation. The classification was compared with MC and correlated to clinical outcomes. RESULTS A total of 3,560 EPs of 445 controls and 8,680 EPs in 1,085 patients with LBP were assessed. Four nonMC, 560 MC-II, and 22 MC-III EPs were found to have previously undetected edema in STIR (n=542) or hyperintensity in discs (n=44) needing reclassification. The formerly undescribed type-B of DEBC, representing a chronic persistent activity state was the most common (51.8%) type. The difference between the control and LBP of H+(12% vs 28.8%) and its co-occurrence with DEBC type 1.1% vs 23.3%) was significant (p<.0001). The odds ratio for the need for surgery was highest (OR=5.2) when H+ and DEBC type change co-occurred. Postoperative deep infection (as determined by CDC criteria) was 0.47% in nonDEBC, compared with 2.4% in patients with DEBC (p=.002), with maximum occurrence in type-B. CONCLUSION Classification based on the classic MC was found to need a reclassification in 586 EPs showing the shortcomings of results of previous studies. Considering the DEBC allowed better classification and better predictability for the need for surgical intervention and incidence of postoperative infection rate than MC.
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Affiliation(s)
| | - Pushpa Bt
- Department of Radiodiagnosis, Ganga hospital, 313. Mettupalayam Rd, Coimbatore, Tamil Nadu, India
| | - Chandhan Murugan
- Department of Spine Surgery, Ganga Hospital, 313. Mettupalayam Rd, Coimbatore, Tamil Nadu, India
| | - Mengistu G Mengesha
- Department of Spine Surgery, Ganga Hospital, 313. Mettupalayam Rd, Coimbatore, Tamil Nadu, India
| | - Murugesh Easwaran
- Ganga Research Centre, 187. Mettupalayam Rd, Koundampalayam, Coimbatore, Tamil Nadu, India
| | - Ashish Shankar Naik
- Department of Spine Surgery, Ganga Hospital, 313. Mettupalayam Rd, Coimbatore, Tamil Nadu, India
| | - Sri Vijay Anand Ks
- Department of Spine Surgery, Ganga Hospital, 313. Mettupalayam Rd, Coimbatore, Tamil Nadu, India
| | - Rishi Mugesh Kanna
- Department of Spine Surgery, Ganga Hospital, 313. Mettupalayam Rd, Coimbatore, Tamil Nadu, India
| | - Ajoy Prasad Shetty
- Department of Spine Surgery, Ganga Hospital, 313. Mettupalayam Rd, Coimbatore, Tamil Nadu, India
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Crump KB, Alminnawi A, Bermudez‐Lekerika P, Compte R, Gualdi F, McSweeney T, Muñoz‐Moya E, Nüesch A, Geris L, Dudli S, Karppinen J, Noailly J, Le Maitre C, Gantenbein B. Cartilaginous endplates: A comprehensive review on a neglected structure in intervertebral disc research. JOR Spine 2023; 6:e1294. [PMID: 38156054 PMCID: PMC10751983 DOI: 10.1002/jsp2.1294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 09/15/2023] [Accepted: 09/26/2023] [Indexed: 12/30/2023] Open
Abstract
The cartilaginous endplates (CEP) are key components of the intervertebral disc (IVD) necessary for sustaining the nutrition of the disc while distributing mechanical loads and preventing the disc from bulging into the adjacent vertebral body. The size, shape, and composition of the CEP are essential in maintaining its function, and degeneration of the CEP is considered a contributor to early IVD degeneration. In addition, the CEP is implicated in Modic changes, which are often associated with low back pain. This review aims to tackle the current knowledge of the CEP regarding its structure, composition, permeability, and mechanical role in a healthy disc, how they change with degeneration, and how they connect to IVD degeneration and low back pain. Additionally, the authors suggest a standardized naming convention regarding the CEP and bony endplate and suggest avoiding the term vertebral endplate. Currently, there is limited data on the CEP itself as reported data is often a combination of CEP and bony endplate, or the CEP is considered as articular cartilage. However, it is clear the CEP is a unique tissue type that differs from articular cartilage, bony endplate, and other IVD tissues. Thus, future research should investigate the CEP separately to fully understand its role in healthy and degenerated IVDs. Further, most IVD regeneration therapies in development failed to address, or even considered the CEP, despite its key role in nutrition and mechanical stability within the IVD. Thus, the CEP should be considered and potentially targeted for future sustainable treatments.
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Affiliation(s)
- Katherine B. Crump
- Tissue Engineering for Orthopaedics & Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical FacultyUniversity of BernBernSwitzerland
- Department of Orthopaedic Surgery and Traumatology, InselspitalBern University Hospital, Medical Faculty, University of BernBernSwitzerland
- Graduate School for Cellular and Biomedical Sciences (GCB)University of BernBernSwitzerland
| | - Ahmad Alminnawi
- GIGA In Silico MedicineUniversity of LiègeLiègeBelgium
- Skeletal Biology and Engineering Research Center, KU LeuvenLeuvenBelgium
- Biomechanics Research Unit, KU LeuvenLeuvenBelgium
| | - Paola Bermudez‐Lekerika
- Tissue Engineering for Orthopaedics & Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical FacultyUniversity of BernBernSwitzerland
- Department of Orthopaedic Surgery and Traumatology, InselspitalBern University Hospital, Medical Faculty, University of BernBernSwitzerland
- Graduate School for Cellular and Biomedical Sciences (GCB)University of BernBernSwitzerland
| | - Roger Compte
- Twin Research & Genetic EpidemiologySt. Thomas' Hospital, King's College LondonLondonUK
| | - Francesco Gualdi
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM)BarcelonaSpain
| | - Terence McSweeney
- Research Unit of Health Sciences and TechnologyUniversity of OuluOuluFinland
| | - Estefano Muñoz‐Moya
- BCN MedTech, Department of Information and Communication TechnologiesUniversitat Pompeu FabraBarcelonaSpain
| | - Andrea Nüesch
- Division of Clinical Medicine, School of Medicine and Population HealthUniversity of SheffieldSheffieldUK
| | - Liesbet Geris
- GIGA In Silico MedicineUniversity of LiègeLiègeBelgium
- Skeletal Biology and Engineering Research Center, KU LeuvenLeuvenBelgium
- Biomechanics Research Unit, KU LeuvenLeuvenBelgium
| | - Stefan Dudli
- Center of Experimental RheumatologyDepartment of Rheumatology, University Hospital Zurich, University of ZurichZurichSwitzerland
- Department of Physical Medicine and RheumatologyBalgrist University Hospital, Balgrist Campus, University of ZurichZurichSwitzerland
| | - Jaro Karppinen
- Research Unit of Health Sciences and TechnologyUniversity of OuluOuluFinland
- Finnish Institute of Occupational HealthOuluFinland
- Rehabilitation Services of South Karelia Social and Health Care DistrictLappeenrantaFinland
| | - Jérôme Noailly
- BCN MedTech, Department of Information and Communication TechnologiesUniversitat Pompeu FabraBarcelonaSpain
| | - Christine Le Maitre
- Division of Clinical Medicine, School of Medicine and Population HealthUniversity of SheffieldSheffieldUK
| | - Benjamin Gantenbein
- Tissue Engineering for Orthopaedics & Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical FacultyUniversity of BernBernSwitzerland
- Department of Orthopaedic Surgery and Traumatology, InselspitalBern University Hospital, Medical Faculty, University of BernBernSwitzerland
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Mengis T, Herger N, Heggli I, Devan J, Spirig JM, Laux CJ, Brunner F, Farshad M, Distler O, Dudli S. Bone marrow stromal cells in Modic type 1 changes promote neurite outgrowth. Front Cell Dev Biol 2023; 11:1286280. [PMID: 37965581 PMCID: PMC10641389 DOI: 10.3389/fcell.2023.1286280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/10/2023] [Indexed: 11/16/2023] Open
Abstract
The pain in patients with Modic type 1 changes (MC1) is often due to vertebral body endplate pain, which is linked to abnormal neurite outgrowth in the vertebral body and adjacent endplate. The aim of this study was to understand the role of MC1 bone marrow stromal cells (BMSCs) in neurite outgrowth. BMSCs can produce neurotrophic factors, which have been shown to be pro-fibrotic in MC1, and expand in the perivascular space where sensory vertebral nerves are located. The study involved the exploration of the BMSC transcriptome in MC1, co-culture of MC1 BMSCs with the neuroblastoma cell line SH-SY5Y, analysis of supernatant cytokines, and analysis of gene expression changes in co-cultured SH-SY5Y. Transcriptomic analysis revealed upregulated brain-derived neurotrophic factor (BDNF) signaling-related pathways. Co-cultures of MC1 BMSCs with SH-SY5Y cells resulted in increased neurite sprouting compared to co-cultures with control BMSCs. The concentration of BDNF and other cytokines supporting neuron growth was increased in MC1 vs. control BMSC co-culture supernatants. Taken together, these findings show that MC1 BMSCs provide strong pro-neurotrophic cues to nearby neurons and could be a relevant disease-modifying treatment target.
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Affiliation(s)
- Tamara Mengis
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Nick Herger
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Irina Heggli
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Jan Devan
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - José Miguel Spirig
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Christoph J. Laux
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Florian Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Oliver Distler
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Stefan Dudli
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
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Beukers M, Grinwis GCM, Vernooij JCM, van der Hoek L, Tellegen AR, Meij BP, Veraa S, Samartzis D, Tryfonidou MA, Bach FC. Epidemiology of Modic changes in dogs: Prevalence, possible risk factors, and association with spinal phenotypes. JOR Spine 2023; 6:e1273. [PMID: 37780831 PMCID: PMC10540828 DOI: 10.1002/jsp2.1273] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 05/18/2023] [Accepted: 06/25/2023] [Indexed: 10/03/2023] Open
Abstract
Background Chronic low back pain, a leading contributor to disease burden worldwide, is often caused by intervertebral disc (IVD) degeneration. Modic changes (MCs) are MRI signal intensity changes due to lesions in vertebral bone marrow adjacent to degenerated IVDs. Only a few studies described the histopathological changes associated with MC to date. MC type 1 is suggested to be associated with bone marrow infiltration of fibrovascular tissue, type 2 with fatty infiltration, and type 3 with bone sclerosis in humans. Methods This study investigated whether the dog can be a valuable animal model to research MCs, by examining the prevalence, imaging, and histological characteristics of lumbar MCs in dogs (340 dogs, 2496 spinal segments). Results Logistic regression analysis indicated that the presence of lumbosacral MCs was associated with age and disc herniation (annulus fibrosis protrusion and/or nucleus pulposus extrusion). According to MRI analysis, MCs were mostly detected at the lumbosacral junction in dogs. Most signal intensity changes represented MC type 3, while previous spinal surgery seemed to predispose for the development of MC type 1 and 2. Histological analysis (16 dogs, 39 spinal segments) indicated that IVDs with MCs showed more histopathological abnormalities in the endplate and vertebral bone marrow than IVDs without MCs. Mostly chondroid proliferation in the bone marrow was encountered, while the histologic anomalies described in humans associated with MCs, such as fibrovascular or fatty infiltration, were scarcely detected. Conclusions Dogs spontaneously develop MCs, but may exhibit other pathological processes or more chronic bone marrow pathologies than humans with MCs. Therefore, more research is needed to determine the translatability of the MCs encountered in dog low-back-pain patients.
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Affiliation(s)
- Martijn Beukers
- Department of Clinical Sciences, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Guy C. M. Grinwis
- Department of Biomolecular Health Sciences, Pathology Division, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Johannes C. M. Vernooij
- Department of Population Health Sciences, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Lisanne van der Hoek
- Department of Clinical Sciences, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Anna R. Tellegen
- Department of Clinical Sciences, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Björn P. Meij
- Department of Clinical Sciences, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Stefanie Veraa
- Department of Clinical Sciences, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Dino Samartzis
- Department of Orthopaedic Surgery, Rush Medical CollegeRush University Medical CenterChicagoIllinoisUSA
| | - Marianna A. Tryfonidou
- Department of Clinical Sciences, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Frances C. Bach
- Department of Clinical Sciences, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
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Wang D, Lai A, Gansau J, Seifert AC, Munitz J, Zaheer K, Bhadouria N, Lee Y, Nasser P, Laudier DM, Holguin N, Hecht AC, Iatridis JC. Lumbar endplate microfracture injury induces Modic-like changes, intervertebral disc degeneration and spinal cord sensitization - an in vivo rat model. Spine J 2023; 23:1375-1388. [PMID: 37086976 PMCID: PMC10524828 DOI: 10.1016/j.spinee.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 04/05/2023] [Accepted: 04/18/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND CONTEXT Endplate (EP) injury plays critical roles in painful IVD degeneration since Modic changes (MCs) are highly associated with pain. Models of EP microfracture that progress to painful conditions are needed to better understand pathophysiological mechanisms and screen therapeutics. PURPOSE Establish in vivo rat lumbar EP microfracture model and assess crosstalk between IVD, vertebra and spinal cord. STUDY DESIGN/SETTING In vivo rat EP microfracture injury model with characterization of IVD degeneration, vertebral remodeling, spinal cord substance P (SubP), and pain-related behaviors. METHODS EP-injury was induced in 5 month-old male Sprague-Dawley rats L4-5 and L5-6 IVDs by puncturing through the cephalad vertebral body and EP into the NP of the IVDs followed by intradiscal injections of TNFα (n=7) or PBS (n=6), compared with Sham (surgery without EP-injury, n=6). The EP-injury model was assessed for IVD height, histological degeneration, pain-like behaviors (hindpaw von Frey and forepaw grip test), lumbar spine MRI and μCT, and spinal cord SubP. RESULTS Surgically-induced EP microfracture with PBS and TNFα injection induced IVD degeneration with decreased IVD height and MRI T2 signal, vertebral remodeling, and secondary damage to cartilage EP adjacent to the injury. Both EP injury groups showed MC-like changes around defects with hypointensity on T1-weighted and hyperintensity on T2-weighted MRI, suggestive of MC type 1. EP injuries caused significantly decreased paw withdrawal threshold, reduced axial grip, and increased spinal cord SubP, suggesting axial spinal discomfort and mechanical hypersensitivity and with spinal cord sensitization. CONCLUSIONS Surgically-induced EP microfracture can cause crosstalk between IVD, vertebra, and spinal cord with chronic pain-like conditions. CLINICAL SIGNIFICANCE This rat EP microfracture model was validated to induce broad spinal degenerative changes that may be useful to improve understanding of MC-like changes and for therapeutic screening.
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Affiliation(s)
- Dalin Wang
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1188, New York, NY 10029 USA; Department of Orthopaedics, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, Jiangsu 210006, China; Department of Orthopedic Surgery, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| | - Alon Lai
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1188, New York, NY 10029 USA
| | - Jennifer Gansau
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1188, New York, NY 10029 USA
| | - Alan C Seifert
- Department of Radiology, Icahn School of Medicine at Mount Sinai, Leon and Norma Hess Center for Science and Medicine, 1470 Madison Avenue, 1st Floor, New York, NY 10029, USA
| | - Jazz Munitz
- Department of Radiology, Icahn School of Medicine at Mount Sinai, Leon and Norma Hess Center for Science and Medicine, 1470 Madison Avenue, 1st Floor, New York, NY 10029, USA
| | - Kashaf Zaheer
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1188, New York, NY 10029 USA
| | - Neharika Bhadouria
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1188, New York, NY 10029 USA; School of Mechanical Engineering, Purdue University, 610 Purdue Mall, West Lafayette, IN 47907, USA
| | - Yunsoo Lee
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1188, New York, NY 10029 USA
| | - Philip Nasser
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1188, New York, NY 10029 USA
| | - Damien M Laudier
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1188, New York, NY 10029 USA
| | - Nilsson Holguin
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1188, New York, NY 10029 USA
| | - Andrew C Hecht
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1188, New York, NY 10029 USA
| | - James C Iatridis
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1188, New York, NY 10029 USA.
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8
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Dudli S, Heggli I, Laux CJ, Spirig JM, Wanivenhaus F, Betz M, Germann C, Farshad-Amacker NA, Herger N, Mengis T, Brunner F, Farshad M, Distler O. Role of C-reactive protein in the bone marrow of Modic type 1 changes. J Orthop Res 2023; 41:1115-1122. [PMID: 36062874 PMCID: PMC9985669 DOI: 10.1002/jor.25437] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/19/2022] [Accepted: 08/29/2022] [Indexed: 02/04/2023]
Abstract
Modic type 1 changes (MC1) are vertebral bone marrow lesions and associate with low back pain. Increased serum C-reactive protein (CRP) has inconsistently been associated with MC1. We aimed to provide evidence for the role of CRP in the tissue pathophysiology of MC1 bone marrow. From 13 MC1 patients undergoing spinal fusion at MC1 levels, vertebral bone marrow aspirates from MC1 and intrapatient control bone marrow were taken. Bone marrow CRP, interleukin (IL)-1, and IL-6 were measured with enzyme-linked immunosorbent assays; lactate dehydrogenase (LDH) was measured with a colorimetric assay. CRP, IL-1, and IL-6 were compared between MC1 and control bone marrow. Bone marrow CRP was correlated with blood CRP and with bone marrow IL-1, IL-6, and LDH. CRP expression by marrow cells was measured with a polymerase chain reaction. Increased CRP in MC1 bone marrow (mean difference: +0.22 mg CRP/g, 95% confidence interval [CI] [-0.04, 0.47], p = 0.088) correlated with blood CRP (r = 0.69, p = 0.018), with bone marrow IL-1β (ρ = 0.52, p = 0.029) and IL-6 (ρ = 0.51, p = 0.031). Marrow cells did not express CRP. Increased LDH in MC1 bone marrow (143.1%, 95% CI [110.7%, 175.4%], p = 0.014) indicated necrosis. A blood CRP threshold of 3.2 mg/L detected with 100% accuracy increased CRP in MC1 bone marrow. In conclusion, the association of CRP with inflammatory and necrotic changes in MC1 bone marrow provides evidence for a pathophysiological role of CRP in MC1 bone marrow.
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Affiliation(s)
- Stefan Dudli
- Department of Rheumatology, Center of Experimental Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Center for Applied Biotechnology and Molecular Medicine, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Irina Heggli
- Department of Rheumatology, Center of Experimental Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christoph J. Laux
- Department of Orthopeadics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - José M. Spirig
- Department of Orthopeadics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Florian Wanivenhaus
- Department of Orthopeadics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Michael Betz
- Department of Orthopeadics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christoph Germann
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Nadja A. Farshad-Amacker
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Nick Herger
- Department of Rheumatology, Center of Experimental Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Tamara Mengis
- Department of Rheumatology, Center of Experimental Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Florian Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopeadics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Oliver Distler
- Department of Rheumatology, Center of Experimental Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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9
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Heggli I, Laux CJ, Mengis T, Karol A, Cornaz F, Herger N, Aradi‐Vegh B, Widmer J, Burkhard MD, Farshad‐Amacker NA, Pfammatter S, Wolski WE, Brunner F, Distler O, Farshad M, Dudli S. Modic type 2 changes are fibroinflammatory changes with complement system involvement adjacent to degenerated vertebral endplates. JOR Spine 2022; 6:e1237. [PMID: 36994463 PMCID: PMC10041382 DOI: 10.1002/jsp2.1237] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 11/04/2022] [Accepted: 12/02/2022] [Indexed: 12/25/2022] Open
Abstract
Background Vertebral endplate signal intensity changes visualized by magnetic resonance imaging termed Modic changes (MC) are highly prevalent in low back pain patients. Interconvertibility between the three MC subtypes (MC1, MC2, MC3) suggests different pathological stages. Histologically, granulation tissue, fibrosis, and bone marrow edema are signs of inflammation in MC1 and MC2. However, different inflammatory infiltrates and amount of fatty marrow suggest distinct inflammatory processes in MC2. Aims The aims of this study were to investigate (i) the degree of bony (BEP) and cartilage endplate (CEP) degeneration in MC2, (ii) to identify inflammatory MC2 pathomechanisms, and (iii) to show that these marrow changes correlate with severity of endplate degeneration. Methods Pairs of axial biopsies (n = 58) spanning the entire vertebral body including both CEPs were collected from human cadaveric vertebrae with MC2. From one biopsy, the bone marrow directly adjacent to the CEP was analyzed with mass spectrometry. Differentially expressed proteins (DEPs) between MC2 and control were identified and bioinformatic enrichment analysis was performed. The other biopsy was processed for paraffin histology and BEP/CEP degenerations were scored. Endplate scores were correlated with DEPs. Results Endplates from MC2 were significantly more degenerated. Proteomic analysis revealed an activated complement system, increased expression of extracellular matrix proteins, angiogenic, and neurogenic factors in MC2 marrow. Endplate scores correlated with upregulated complement and neurogenic proteins. Discussion The inflammatory pathomechanisms in MC2 comprises activation of the complement system. Concurrent inflammation, fibrosis, angiogenesis, and neurogenesis indicate that MC2 is a chronic inflammation. Correlation of endplate damage with complement and neurogenic proteins suggest that complement system activation and neoinnervation may be linked to endplate damage. The endplate-near marrow is the pathomechanistic site, because MC2 occur at locations with more endplate degeneration. Conclusion MC2 are fibroinflammatory changes with complement system involvement which occur adjacent to damaged endplates.
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Affiliation(s)
- Irina Heggli
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of Zurich Zurich Switzerland
| | - Christoph J. Laux
- Department of Orthopedics, Balgrist University Hospital University of Zurich Zurich Switzerland
| | - Tamara Mengis
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of Zurich Zurich Switzerland
| | - Agnieszka Karol
- Department of Molecular Mechanisms of Disease University of Zurich Zurich Switzerland
| | - Frédéric Cornaz
- Department of Orthopedics, Balgrist University Hospital University of Zurich Zurich Switzerland
| | - Nick Herger
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of Zurich Zurich Switzerland
| | - Borbala Aradi‐Vegh
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of Zurich Zurich Switzerland
| | - Jonas Widmer
- Department of Orthopedics, Balgrist University Hospital University of Zurich Zurich Switzerland
| | - Marco D. Burkhard
- Department of Orthopedics, Balgrist University Hospital University of Zurich Zurich Switzerland
| | | | - Sibylle Pfammatter
- Functional Genomics Center Zurich, University and ETH Zurich Zurich Switzerland
| | - Witold E. Wolski
- Functional Genomics Center Zurich, University and ETH Zurich Zurich Switzerland
- Swiss Institute of Bioinformatics Lausanne Switzerland
| | - Florian Brunner
- Department of Physical Medicine and Rheumatology Balgrist University Hospital, University of Zurich Zurich Switzerland
| | - Oliver Distler
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of Zurich Zurich Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital University of Zurich Zurich Switzerland
| | - Stefan Dudli
- Center of Experimental Rheumatology, Balgrist Campus, University Hospital Zurich and Balgrist University Hospital, University of Zurich Zurich Switzerland
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