Imaging the intervertebral disk: age-related changes, herniations, and radicular pain

Examination of annulus fibrosus and nucleus pulposus in cervical and lumbar intervertebral disc herniation patients by scanning acoustic microscopy, scanning electron microscopy and energy dispersive spectroscopy

Intervertebral disc herniation (IVDH) is observed in humans as a result of the alteration of annulus fibrous (AF) and nucleus pulposus (NP) tissue compositions in intervertebral discs. In this study, we studied the feasibility of scanning acoustic microscopy (SAM), scanning electron microscopy (SEM) and energy dispersive spectroscopy (EDS) in characterizing the herniated segments of AF and NP tissues from male and female patients. SAM determined the acoustic property variations in AF and NP tissues by calculating the acoustic impedance values of samples of 15 patients. SEM obtained higher resolution images and EDS made elemental analysis of the specimen. Consequently, we suggest that these techniques have the potential to be combined for the investigation and removal of the disrupted AF and NP tissues with micrometer resolution in clinics.

The Relationship Between Bone Mineral Density and Lumbar Disc Herniation in Postmenopausal Women

INTRODUCTION

In previous studies, the relationship between BMD (bone mineral density) and LDH (lumbar disc herniation) has been investigated in young people, except for postmenopausal women. The aim of this study was to evaluate this association in postmenopausal women.

METHODS

A cross-sectional analysis of 545 consecutive postmenopausal women was performed at a single center. The study included patients aged 45 to 85 with low back pain. Age, weight, height, L1-L4 BMD, L1-L4 T-score, L1-L4 Z-score, femoral neck BMD, femoral neck T-score, and femoral neck Z-score of patients were collected. MRI scans were assessed for the diagnosis of LDH. To explore the impact of the number of herniated segments, patients with LDH were further divided into single-level and multi-level LDH groups.

RESULTS

Five hundred and thirteen postmenopausal women were included in the final analysis. The mean age of the patients was 61.3±8.6 years in the LDH group and 58.4±7.8 years in the non-LDH group (p=0.001). The LDH group had higher lumbar (p<0.001) and femoral neck (p<0.05) BMD, T, and Z-scores than the non-LDH group. In binary logistic regression analysis, age, lumbar, and femoral neck BMD were significantly associated with LDH (p<0.001, p=0.03, and p=0.040, respectively). Patients with multi-level herniation had significantly higher rates of obesity (BMI ≥30) compared to patients with single-level herniation (58.0% vs. 47.0%; p=0.031). However, in terms of obesity rates, the LDH group and the non-LDH group were statistically similar (53.9% vs. 54.2%; p=0.961). There was no association between the single and multi-level herniation groups in terms of L1-4 and femoral neck BMD (p=0.760 and 0.435, respectively).

CONCLUSION

Higher lumbar bone mineral density and higher femoral neck bone mineral densities were found to be associated with lumber disc herniation in postmenopausal women with low back pain. These results suggest that bone mineral density assessment may be useful in clinical practice to determine which patients are at higher risk of lumbar disc herniation.

Deep Learning Model to Classify and Monitor Idiopathic Scoliosis in Adolescents Using a Single Smartphone Photograph

Importance

Adolescent idiopathic scoliosis (AIS) is the most common pediatric spinal disorder. Routine physical examinations by trained personnel are critical to diagnose severity and monitor curve progression in AIS. In the presence of concerning malformation, radiographs are necessary for diagnosis or follow-up, guiding further management, such as bracing correction for moderate malformation and spine surgery for severe malformation. If left unattended, progressive deterioration occurs in two-thirds of patients, leading to significant health concerns for growing children.

Objective

To assess the ability of an open platform application (app) using a validated deep learning model to classify AIS severity and curve type, as well as identify progression.

Design, Setting, and Participants

This diagnostic study was performed with data from radiographs and smartphone photographs of the backs of adolescent patients at spine clinics. The ScolioNets deep learning model was developed and validated in a prospective training cohort, then incorporated and tested in the AlignProCARE open platform app in 2022. Ground truths (GTs) included severity, curve type, and progression as manually annotated by 2 experienced spine specialists based on the radiographic examinations of the participants' spines. The GTs and app results were blindly compared with another 2 spine surgeons' assessments of unclothed back appearance. Data were analyzed from October 2022 to February 2023.

Exposure

Acquisitions of unclothed back photographs using a mobile app.

Main Outcomes and Measures

Outcomes of interest were classification of AIS severity and progression. Quantitative statistical analyses were performed to assess the performance of the deep learning model in classifying the deformity as well as in distinguishing progression during 6-month follow-up.

Results

The training data set consisted of 1780 patients (1295 [72.8%] female; mean [SD] age, 14.3 [3.3] years), and the prospective testing data sets consisted of 378 patients (279 [73.8%] female; mean [SD] age, 14.3 [3.8] years) and 376 follow-ups (294 [78.2%] female; mean [SD] age, 15.6 [2.9] years). The model recommended follow-up with an area under receiver operating characteristic curve (AUC) of 0.839 (95% CI, 0.789-0.882) and considering surgery with an AUC of 0.902 (95% CI, 0.859-0.936), while showing good ability to distinguish among thoracic (AUC, 0.777 [95% CI, 0.745-0.808]), thoracolumbar or lumbar (AUC, 0.760 [95% CI, 0.727-0.791]), or mixed (AUC, 0.860 [95% CI, 0.834-0.887]) curve types. For follow-ups, the model distinguished participants with or without curve progression with an AUC of 0.757 (95% CI, 0.630-0.858). Compared with both surgeons, the model could recognize severities and curve types with a higher sensitivity (eg, sensitivity for recommending follow-up: model, 84.88% [95% CI, 75.54%-91.70%]; senior surgeon, 44.19%; junior surgeon, 62.79%) and negative predictive values (NPVs; eg, NPV for recommending follow-up: model, 89.22% [95% CI, 84.25%-93.70%]; senior surgeon, 71.76%; junior surgeon, 79.35%). For distinguishing curve progression, the sensitivity and NPV were comparable with the senior surgeons (sensitivity, 63.33% [95% CI, 43.86%-80.87%] vs 77.42%; NPV, 68.57% [95% CI, 56.78%-78.37%] vs 72.00%). The junior surgeon reported an inability to identify curve types and progression by observing the unclothed back alone.

Conclusions

This diagnostic study of adolescent patients screened for AIS found that the deep learning app had the potential for out-of-hospital accessible and radiation-free management of children with scoliosis, with comparable performance as spine surgeons experienced in AIS management.

Imaging features of the aging spine

Among many degenerative abnormalities commonly found in spine imaging, not all are associated with the patient's symptoms. We aimed to assess features of the standard, asymptomatic aging process of the spine. In this narrative review, we emphasize studies that describe imaging features of the spine in asymptomatic populations of different age groups. Degeneration of the intervertebral discs, bulging, and facet joint arthropathy have been documented in almost 90% of asymptomatic patients over 60 years of age. After the age of 40 years, nearly all patients have anterior and lateral vertebral osteophytes, whereas posterior osteophytes are found in a minority of them. There is a gradual increase in vertebral bone marrow fat composition with age with the acceleration of this process in women after menopause. The prevalence of these findings is common in asymptomatic populations and varies depending on the patient's age. It is essential to differentiate likely natural and age-related findings from pathological abnormalities to make an accurate diagnosis.

The Association of Lumbar Disc Herniation with Lumbar Volumetric Bone Mineral Density in a Cross-Sectional Chinese Study

Little is known about the effect of lumbar intervertebral disc herniation (LDH) on lumbar bone mineral density (BMD), and few previous studies have used quantitative computed tomography (QCT) to assess whether the staging of LDH correlates with lumbar vertebral trabecular volumetric bone mineral density (Trab.vBMD). To explore the relationship between lumbar Trab.vBMD and LDH, seven hundred and fifty-four healthy participants aged 20–60 years were enrolled in the study from an ongoing study on the degeneration of the spine and knee between June 2014 and 2017. QCT was used to measure L2–4 Trab.vBMD and lumbar spine magnetic resonance images (MRI) were performed to assess the incidence of disc herniation. After 9 exclusions, a total of 322 men and 423 women remained. The men and women were divided into younger (age 20–39 years) and older (age 40–60 years) groups and further into those without LDH, with a single LDH segment, and with ≥2 segments. Covariance analysis was used to adjust for the effects of age, BMI, waistline, and hipline on the relationship between Trab.vBMD and LDH. Forty-one younger men (25.0%) and 59 older men (37.3%) had at least one LDH segment. Amongst the women, the numbers were 46 (22.5%) and 80 (36.4%), respectively. Although there were differences in the characteristics data between men and women, the difference in Trab.vBMD between those without LDH and those with single and ≥2 segments was not statistically significant (p > 0.05). These results remained not statistically significant after further adjusting for covariates (p > 0.05). No associations between lumbar disc herniation and vertebral trabecular volumetric bone mineral density were observed in either men or women.

Traction Therapy for Cervical Radicular Syndrome is Statistically Significant but not Clinically Relevant for Pain Relief. A Systematic Literature Review with Meta-Analysis and Trial Sequential Analysis

Aim: We aimed to investigate the effectiveness of traction therapy in reducing pain by performing a systematic review with meta-analysis. We also explore the best modality for administering traction to patients with cervical radicular syndrome (CRS). Methods: We searched the Medline, Physiotherapy Evidence Database (PEDro), Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic databases. Two reviewers independently selected randomized controlled trials (RCTs) that compared traction in addition to other treatments versus the effectiveness of other treatments alone for pain outcome. We calculated the mean differences (MDs) and 95% confidence intervals (CIs). We used Cochrane’s tool to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to evaluate the quality of evidence and summarize the study conclusions. Results: A total of seven studies (589 patients), one with low risk of bias, were evaluated. An overall estimate of treatment modalities showed low evidence that adding traction to other treatments is statistically significant (MD −5.93 [95% CI, −11.81 to −0.04] P = 0.05 and I² = 57%) compared to other treatments alone. The subgroup analyses were still statistically significant only for mechanical and continuous modalities. Conclusions: Overall analysis showed that, compared to controls, reduction in pain intensity after traction therapy was achieved in patients with cervical radiculopathy. However, the quality of evidence was generally low and none of these effects were clinically meaningful.

The value of contrast-enhanced three-dimensional isotropic T2-weighted turbo spin-echo SPACE sequence in the diagnosis of patients with lumbosacral nerve root compression

PURPOSE

To investigate the diagnostic value of contrast-enhanced three-dimensional (3D) T2-weighted turbo spin-echo SPACE (T2-SPACE) sequence in LNRC.

METHODS

A total of 90 surgically confirmed LNRC patients with 165 explored nerve roots were enrolled in this study. Diagnostic values were quantified using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy. The consistency between 2D MRI and 3D T2-SPACE MRI was quantified using kappa test. The compression of specific branch in nerve root was evaluated on 2D MRI, 3D T2-SPACE MRI, and surgical findings. The pedicle height, vertebral body height (VH), proximal tilting angle of nerve root (PTA) were measured on MR images.

RESULTS

The sensitivity, specificity, PPV, NPV, and accuracy by 2D MRI were 78.3%, 72.7%, 94.9%, 34.0%, and 77.6%, respectively. For 3D T2-SPACE MRI imaging, the sensitivity, specificity, PPV, NPV, and accuracy were 91.6%, 86.4%, 97.8%, 61.3%, and 90.9%, respectively. 2D MRI and 3D T2-SPACE MRI for detection of intra-foramen and extra-foramen nerve compression showed poor homogeneity (Kappa = 0.333, Kappa = 0.276, respectively). Smaller VHs and larger PTAs could be indicators for the diagnosis of foraminal nerve root compression.

CONCLUSIONS

3D T2-SPACE MRI had a higher sensitivity, specificity, PPV, NPV, and accuracy than 2D MRI for detecting LNRC. The 3D T2-SPACE scan could be a good substitute to routine 2D MRI in LNRC diagnosis, especially for foraminal nerve root compression patients.

LEVEL OF EVIDENCE

III.

Radiological and clinical outcomes in patients undergoing anterior cervical discectomy and fusion: Comparing titanium and PEEK (polyetheretherketone) cages

Objectives:

To study clinical and radiological outcomes in patients who had undergone the procedure of anterior cervical discectomy and fusion with titanium or PEEK (polyetheretherketone) cages for cervical disc prolapse.

Methods:

This is a retrospective/non-randomized study which was conducted at the Combined Military Hospital Peshawar. Study interval was four years from 1st October, 2010 to 31st September, 2014. Total number of included patients were 149. All of the patients had undergone the procedure of anterior cervical discectomy and fusion with titanium or PEEK (polyetheretherketone) cages. All of the patients had plain MRI cervical spine done for diagnosis of anterior cervical disc prolapse.

Results:

Most of the patients had stenosis at the C5 / C6 (PEEK cage group 63% and titanium cage group 47.6%) and C6 / C7 (PEEK cage group 15.38% and titanium cage group 19.04%) cervical level. Bi-level involvement was also seen. In the patients who complained of brachialgia, total resolution of symptoms was seen after the operation. Three (2.01%) of the patients in titanium cage group, who presented with axial neck pain, continued to complain of pain after the operation. Four (2.6%) of the patients in PEEK (polyetheretherketone) cage group and 2 (1.3%) in titanium cage group complained of pain at the donor site (iliac crest). Fusion rate was 100% with both titanium and PEEK (polyetheretherketone) cages at one year.

Conclusion:

Results with titanium and PEEK (polyetheretherketone) cages are excellent. There was no significant difference in clinical and radiological outcome between two groups of patients (p > 0.05). Fusion rate was 100% at one year with both cages.

Age-related changes in shock absorption capacity of the human spinal column

Background

The spinal column possesses shock absorption properties, mainly provided by the intervertebral discs. However, with the process of senescence, all structures of the spine, including the discs, undergo degenerative changes. It may lead to alteration of the mechanical properties of the spinal motion segment and diminished capacity for vibration attenuation.

Objective

The objective of this study was to investigate the age-related changes in shock absorption properties of the spine.

Patients and methods

A total of 112 individuals divided into three groups according to age (third, fifth, and seventh decades of life) were enrolled in this study. The transmissibility of vibrations through the spine was measured in a standing position on a vibration platform by accelerometers mounted at the levels of S2 and C0. Registered signals were described using four parameters: VMS (variability), peak-to-peak amplitude (PPA), and spectral activity in two bands F2 (0.7–5 Hz) and F20 (15–25 Hz).

Results

In all age groups, signals registered at C0 were characterized by significantly lower values of VMS, PPA, and F20, when compared to level S2. Simultaneously, the parameter F20 significantly differed among all age groups when C0 vibrations were analyzed: 2.43±1.93, 5.02±3.61, and 10.84±5.12 for the third, fifth, and seventh decades of life, respectively.

Conclusion

The human spinal column provides vibration attenuation; however, this property gradually declines with the aging process.

Interleukin 6 (IL-6) and IL-10 Promoter Region Polymorphisms Are Associated with Risk of Lumbar Disc Herniation in a Northern Chinese Han Population

AIM

This study assessed the association of single-nucleotide polymorphisms (SNPs) in the proinflammatory cytokines interleukin 6 (IL-6) and IL-10 with the risk of lumbar disc herniation in a Chinese Han population.

METHODS

We collected blood samples from 267 patients with lumbar disc herniation (case group) and 300 normals (control group) and performed analyses of the IL-6 572C/G and 174G/C SNPs as well as the IL-10 592A/C and 1082G/A SNPs using TaqMan technology.

RESULTS

The frequencies of the IL-6-572 GG, GC, and CC genotypes were 5.99%, 42.3%, and 51.6%, respectively, in the case group, and 1.6%, 24%, and 64.3%, respectively, in the control group. Thus, the relative risk of the IL-6-572 G genotype (GG plus GC) was 1.69-fold higher for developing lumbar disc herniation compared to the CC genotype (95% confidence interval: 1.16-2.39, p < 0.01). The risks associated with the IL-6-572 CG and GG genotypes were 1.55- and 4.48-fold higher, respectively, versus the CC genotype for developing lumbar disc herniation (p < 0.01). The IL-10-1082 AG genotype was significantly higher in the case group (26.22%) versus the control group (11.67%); whereas the AA genotype was lower in the case group (73.78%) versus the control group (88.33%; p < 0.05). The IL-10-1082 G allele frequency was significantly higher in the case group (13.11%) versus the control group (5.83%; p < 0.05).

CONCLUSION

This study demonstrates that genetic variants in the promoter regions of the IL-6 and IL-10 genes are associated with lumbar disc herniation risk in this Northern Chinese Han population.

The incidence of cervical spondylosis decreases with aging in the elderly, and increases with aging in the young and adult population: a hospital-based clinical analysis

Background and purpose

Cervical spondylosis is well accepted as a common degenerative change in the cervical spine. Compelling evidence has shown that the incidence of cervical spondylosis increases with age. However, the relationship between age and the incidence of cervical spondylosis remains obscure. It is essential to note the relationship between age and the incidence of cervical spondylosis through more and more clinical data.

Methods

In the case-controlled study reported here, retrospective clinical analysis of 1,276 cases of cervical spondylosis has been conducted. We analyzed the general clinical data, the relationship between age and the incidence of cervical spondylosis, and the relationship between age-related risk factors and the incidence of cervical spondylosis. A chi-square test was used to analyze the associations between different variables. Statistical significance was defined as a P-value of less than 0.05.

Results

The imaging examination demonstrated the most prominent characteristic features of cervical spondylosis: bulge or herniation at C3-C4, C4-C5, and C5-C6. The incidence of cervical spondylosis increased with aging before age 50 years and decreased with aging after age 50 years, especially in the elderly after 60 years old. The occurrence rate of bulge or herniation at C3-C4, C4-C5, C5-C6, and C6-C7 increased with aging before age 50 years and decreased with aging after age 50 years, especially after 60 years. Moreover, the incidence of hyperosteogeny and spinal stenosis increased with aging before age 60 years and decreased with aging after age 60 years, although there was no obvious change in calcification. The age-related risk factors, such as hypertension, hyperlipidemia, diabetes, cerebral infarct, cardiovascular diseases, smoking, and drinking, have no relationship with the incidence of cervical spondylosis.

Conclusion

A decreasing proportion of cervical spondylosis with aging occurs in the elderly, while the proportion of cervical spondylosis increases with aging in the young and the adults. This investigation implicates that aging is not only a contributor to the clinical performance of cervical spondylosis in the elderly, although the incidence of cervical spondylosis is proportional to the progress of age.

T1ρ and T2 mapping of the intervertebral disk: comparison of different methods of segmentation

BACKGROUND AND PURPOSE

Intervertebral disk biochemical composition could be accessed in vivo by T1ρ and T2 relaxometry. We found no studies in the literature comparing different segmentation methods for data extraction using these techniques. Our aim was to compare different manual segmentation methods used to extract T1ρ and T2 relaxation times of intervertebral disks from MR imaging. Seven different methods of partial-disk segmentation techniques were compared with whole-disk segmentation as the reference standard.

MATERIALS AND METHODS

Sagittal T1ρ and T2 maps were generated by using a 1.5T MR imaging scanner in 57 asymptomatic volunteers 20-40 years of age. Two hundred eighty-five lumbar disks were separated into 2 groups: nondegenerated disk (Pfirrmann I and II) and degenerated disk (Pfirrmann III and IV). In whole-disk segmentation, the disk was segmented in its entirety on all sections. Partial-disk segmentation methods included segmentation of the disk into 6, 5, 4, 3, and 1 sagittal sections. Circular ROIs positioned in the nucleus pulposus and annulus fibrosus were also used to extract T1ρ and T2, and data were compared with whole-disk segmentation

RESULTS

In the nondegenerated group, segmentation of ≥5 sagittal sections showed no statistical difference with whole-disk segmentation. All the remaining partial-disk segmentation methods and circular ROIs showed different results from whole-disk segmentation (P < .001). In the degenerated disk group, all methods were statistically similar to whole-disk segmentation. All partial-segmentation methods, including circular ROIs, showed strong linear correlation with whole-disk segmentation in both the degenerated and nondegenerated disk groups.

CONCLUSIONS

Manual segmentation showed strong reproducibility for T1ρ and T2 and strong linear correlation between partial- and whole-disk segmentation. Absolute T1ρ and T2 values extracted from different segmentation techniques were statistically different in disks with Pfirrmann grades I and II.

Analysis of the clinical picture in patients with osteoarthritis of the spine depending on the type and severity of lesions on magnetic resonance imaging

OBJECTIVES

Spondyloarthritis is the most common pathological change in the spine. In a significant number of cases, it leads to compression of the nervous structures of the spinal canal, causing pain and neurological symptoms. Intervertebral disc pathology is a common cause of root deficits in neurological examination of all types of degenerative changes of the spine structures. Disc herniation is pathologically divided into 4 stages of herniated nucleus pulposus: 1) bulging, 2) protrusion, 3) extrusion, 4) sequestration. The aim of this study is to analyze the correlation between the type and severity of degenerative changes in the spine and the incidence of neurological deficits.

MATERIAL AND METHODS

The study included 100 patients: 74 men and 26 women aged 50.2 ±10.43 years with pain of the spine in the cervical and/or lumbosacral segments and with degenerative changes in the plain radiographs. The mean value of body mass index (BMI) was 27.8 ±3.95 kg/m(2). Each patient underwent neurological examinations and 1.5 T magnetic resonance imaging MRI of the cervical and/or lumbar spine.

RESULTS

Every patient was diagnosed with herniated nucleus pulposus affecting on average 4 ±2 segments of the spine. The most frequently observed degree of severity of disc herniation was the second (protrusion, 71.9% of all disc disease in 89 patients). Much less frequently found was the third degree (extrusion, 45 patients, 20.1% slipped disc), the first (bulging, 14 patients, 6.3% slipped disc), and least often only a small percentage of fourth degree (sequestration, 4 patients, 1.7% slipped disc). Neurological symptoms (deficits) were observed in 34 patients. They were accompanied by disc herniations in 23.7% of patients. In remaining patients with neurological deficits there was spinal stenosis. No correlation was observed between neurological deficits and stage 1 of disc herniation.

CONCLUSIONS

The incidence rate of neurological deficits is correlated with the degree of changes in the spine, as visualized by MRI.

Neuroradiology in women of childbearing age

PURPOSE OF REVIEW

This review summarizes safety concerns associated with diagnostic neuroimaging in patients who are of childbearing age, focusing on diagnostic modalities and radiologic features of neurologic conditions encountered by pregnant women.

RECENT FINDINGS

During pregnancy, women experience a range of physiologic changes that can affect neurologic function. These include endocrine, hemodynamic, endothelial, immunologic, and coagulopathic changes that can alter susceptibility to stroke, subarachnoid hemorrhage, demyelination, venous thrombosis, and other neurologic conditions. Unique safety concerns are associated with imaging procedures performed to diagnose neurologic conditions that occur during pregnancy.

SUMMARY

This review discusses the use of diagnostic neuroimaging, including administration of IV contrast, in pregnant women and in nonpregnant women of childbearing age.