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Hornung AL, Rudisill SS, Barajas JN, Harada G, Fitch AA, Leonard SF, Roberts AC, An HS, Albert HB, Tkachev A, Samartzis D. How Does Resorption Differ Among Single-Level and Multilevel Lumbar Disc Herniations? A Prospective Multi-Imaging and Clinical Phenotype Study. Spine (Phila Pa 1976) 2024; 49:763-771. [PMID: 38343165 DOI: 10.1097/brs.0000000000004955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 12/23/2023] [Indexed: 05/09/2024]
Abstract
STUDY DESIGN Prospective, case series. OBJECTIVE To identify and characterize any differences in specific patient factors, MRI findings, features of spontaneous disc resorption, and outcomes between patients with single-level and multilevel LDH. BACKGROUND Lumbar disc herniation (LDH) is one of the most common spinal pathologies worldwide. Though many cases of LDH resolve by spontaneous resorption, the mechanism underlying this "self-healing" phenomenon remains poorly understood, particularly in the context of multilevel herniations. METHODS A one-year prospective study was conducted of patients presenting with acute symptomatic LDH between 2017 and 2019. Baseline demographics, herniation characteristics, and MRI phenotypes were recorded before treatment, which consisted of gabapentin, acupuncture, and the avoidance of inflammatory-modulating medications. MRIs were performed approximately every three months after the initial evaluation to determine any differences between patients with single-level and multilevel LDH. RESULTS Ninety patients were included, 17 demonstrated multilevel LDH. Body mass index was higher among patients with multilevel LDH ( P <0.001). Patients with multilevel LDH were more likely to exhibit L3/L4 inferior endplate defects ( P =0.001), L4/L5 superior endplate defects ( P =0.012), and L4/L5 inferior endplate defects ( P =0.020) on MRI. No other differences in MRI phenotypes ( e.g. Modic changes, osteophytes, etc .) existed between groups. Resorption rate and time to resolution did not differ between those with single-level and multilevel LDH. CONCLUSIONS Resorption rates were similar between single-level and multilevel LDH at various time points throughout one prospective assessment, providing insights that disc healing may have unique programmed signatures. Compared with those with single-level LDH, patients with multilevel herniations were more likely to have a higher BMI, lesser initial axial and sagittal disc measurements, and endplate defects at specific lumbar levels. In addition, our findings support the use of conservative management in patients with LDH, regardless of the number of levels affected. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Alexander L Hornung
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
- The International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL
| | - Samuel S Rudisill
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
- The International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL
| | - J Nicolas Barajas
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
- The International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL
| | - Garrett Harada
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
- The International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL
| | - Ashlyn A Fitch
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
- The International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL
| | - Skylar F Leonard
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
- The International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL
| | - Ashley C Roberts
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
- The International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL
| | - Howard S An
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
- The International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL
| | | | - Alexander Tkachev
- The International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL
| | - Dino Samartzis
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
- The International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL
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Zhao Z, Qi H, Wang C, Zhao A, Zu F, Zhang J, He M, Yuan H, Yang A, Wang C, Zhang D. Investigating the impact of cartilaginous endplate herniation on recovery from percutaneous endoscopic lumbar discectomy. J Orthop Surg Res 2024; 19:264. [PMID: 38664852 PMCID: PMC11044348 DOI: 10.1186/s13018-024-04746-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
OBJECTIVE This study aimed to evaluate the influence of herniation of cartilaginous endplates on postoperative pain and functional recovery in patients undergoing percutaneous endoscopic lumbar discectomy (PELD) for lumbar disc herniation (LDH). METHODS A retrospective analysis was conducted on 126 patients with LDH treated with PELD at the Third Hospital of Hebei Medical University from January 2021 to January 2022. Whether cartilaginous endplates had herniated was identified by analyzing these specific findings from MRI scans: posterior marginal nodes, posterior osteophytes, mid endplate irregularities, heterogeneous low signal intensity of extruded material, and Modic changes in posterior corners and mid endplates. Patients were assessed for postoperative pain using the Visual Analogue Scale (VAS) and functional recovery using the Oswestry Disability Index (ODI) and Modified MacNab criteria. Statistical analyses compared outcomes based on the presence of herniation of cartilaginous endplates. RESULTS Patients with herniation of cartilaginous endplates experienced higher pain scores early postoperatively but showed significant improvement in pain and functional status over the long term. The back pain VAS scores showed significant differences between the groups with and without herniation of cartilaginous endplates on postoperative day 1 and 1 month (P < 0.05). Leg pain VAS scores showed significant differences on postoperative day 1 (P < 0.05). Modic changes were significantly associated with variations in postoperative recovery, highlighting their importance in predicting patient outcomes. In patients with herniation of cartilaginous endplates, there were statistically significant differences in the back pain VAS scores at 1 month postoperatively and the ODI functional scores on postoperative day 1 between the groups with and without Modic changes (P < 0.05). There were no significant differences in the surgical outcomes between patients with and without these conditions regarding the Modified MacNab criteria (P > 0.05). CONCLUSION Herniation of cartilaginous endplates significantly affect early postoperative pain and functional recovery in LDH patients undergoing PELD. These findings emphasize the need for clinical consideration of these imaging features in the preoperative planning and postoperative management to enhance patient outcomes and satisfaction.
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Affiliation(s)
- Zenghui Zhao
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Hao Qi
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Chenchen Wang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Anqi Zhao
- Hebei Medical University School of Basic Medical Sciences, Shijiazhuang, China
| | - Feiyu Zu
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Jianzhou Zhang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Mengzi He
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Hongru Yuan
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Ao Yang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Chenxi Wang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Di Zhang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China.
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Li X, Luo S, Fan W, Jiang C, Wang W, Chen J, Chen Y, Zhang Z, Qiu Z, Tan D, Huang C, Wang M, Bai X. Influence of macrophage polarization in herniated nucleus pulposus tissue on clinical efficacy after lumbar discectomy. JOR Spine 2023. [DOI: 10.1002/jsp2.1249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Xiao‐Chuan Li
- Department of Cell Biology, School of Basic Medical Sciences Southern Medical University Guangzhou Guangdong China
- Postdoctoral Innovation Practice Base of Gaozhou People's Hospital Maoming Guangdong China
- Department of Orthopaedic Surgery, Gaozhou People's Hospital Maoming Guangdong China
| | - Shao‐Jian Luo
- Department of Orthopaedic Surgery, Gaozhou People's Hospital Maoming Guangdong China
| | - Wu Fan
- Department of Orthopaedic Surgery, Gaozhou People's Hospital Maoming Guangdong China
| | - Cheng Jiang
- Graduate School of Guangdong Medical University Zhanjiang Guangdong China
| | - Wei Wang
- Graduate School of Guangdong Medical University Zhanjiang Guangdong China
| | - Jiong‐Hui Chen
- Graduate School of Guangdong Medical University Zhanjiang Guangdong China
| | - Yong‐Long Chen
- Graduate School of Guangdong Medical University Zhanjiang Guangdong China
| | - Zhen‐Wu Zhang
- Graduate School of Guangdong Medical University Zhanjiang Guangdong China
| | - Zhen‐Hua Qiu
- Postdoctoral Innovation Practice Base of Gaozhou People's Hospital Maoming Guangdong China
| | - Dan‐Qin Tan
- Department of Orthopaedic Surgery, Gaozhou People's Hospital Maoming Guangdong China
| | - Chun‐Ming Huang
- Postdoctoral Innovation Practice Base of Gaozhou People's Hospital Maoming Guangdong China
- Department of Orthopaedic Surgery, Gaozhou People's Hospital Maoming Guangdong China
| | - Mao‐Sheng Wang
- Postdoctoral Innovation Practice Base of Gaozhou People's Hospital Maoming Guangdong China
| | - Xiao‐Chun Bai
- Department of Cell Biology, School of Basic Medical Sciences Southern Medical University Guangzhou Guangdong China
- Postdoctoral Innovation Practice Base of Gaozhou People's Hospital Maoming Guangdong China
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Feng P, Che Y, Gao C, Zhu L, Gao J, Vo NV. Immune exposure: how macrophages interact with the nucleus pulposus. Front Immunol 2023; 14:1155746. [PMID: 37122738 PMCID: PMC10140429 DOI: 10.3389/fimmu.2023.1155746] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/31/2023] [Indexed: 05/02/2023] Open
Abstract
Intervertebral disc degeneration (IDD) is a primary contributor to low back pain. Immune cells play an extremely important role in modulating the progression of IDD by interacting with disc nucleus pulposus (NP) cells and extracellular matrix (ECM). Encased within the annulus fibrosus, healthy NP is an avascular and immune-privileged tissue that does not normally interact with macrophages. However, under pathological conditions in which neovascularization is established in the damaged disc, NP establishes extensive crosstalk with macrophages, leading to different outcomes depending on the different microenvironmental stimuli. M1 macrophages are a class of immune cells that are predominantly pro-inflammatory and promote inflammation and ECM degradation in the NP, creating a vicious cycle of matrix catabolism that drives IDD. In contrast, NP cells interacting with M2 macrophages promote disc tissue ECM remodeling and repair as M2 macrophages are primarily involved in anti-inflammatory cellular responses. Hence, depending on the crosstalk between NP and the type of immune cells (M1 vs. M2), the overall effects on IDD could be detrimental or regenerative. Drug or surgical treatment of IDD can modulate this crosstalk and hence the different treatment outcomes. This review comprehensively summarizes the interaction between macrophages and NP, aiming to highlight the important role of immunology in disc degeneration.
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Affiliation(s)
- Peng Feng
- School of Medicine, China Academy of Chinese Medical Sciences, Beijing, China
- Department of Spine, Wangjing Hospital Affiliated to China Academy of Chinese Medical Sciences, Beijing, China
| | - Ying Che
- School of Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Chunyu Gao
- Department of Spine, Wangjing Hospital Affiliated to China Academy of Chinese Medical Sciences, Beijing, China
| | - Liguo Zhu
- Department of Spine, Wangjing Hospital Affiliated to China Academy of Chinese Medical Sciences, Beijing, China
- Beijing Key Laboratory of Bone Setting Technology of Traditional Chinese Medicine, Wangjing Hospital Affiliated to China Academy of Chinese Medical Sciences, Beijing, China
| | - Jinghua Gao
- Department of Spine, Wangjing Hospital Affiliated to China Academy of Chinese Medical Sciences, Beijing, China
- *Correspondence: Jinghua Gao, ; Nam V. Vo,
| | - Nam V. Vo
- Ferguson Laboratory for Orthopedic and Spine Research, Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, PA, United States
- *Correspondence: Jinghua Gao, ; Nam V. Vo,
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Hornung AL, Baker JD, Mallow GM, Sayari AJ, Albert HB, Tkachev A, An HS, Samartzis D. Resorption of Lumbar Disk Herniation: Mechanisms, Clinical Predictors, and Future Directions. JBJS Rev 2023; 11:01874474-202301000-00001. [PMID: 36722839 DOI: 10.2106/jbjs.rvw.22.00148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Resorption after lumbar disk herniation is a common yet unpredictable finding. It is hypothesized that nearly 70% of lumbar herniated nucleus pulposus (HNP) undergo the resorption to a significant degree after acute herniation, which has led to nonoperative management before surgical planning. METHODS This narrative review on the literature from 4 databases (MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Cochrane) examines historical and recent advancements related to disk resorption. Studies were appraised for their description of the predictive factor (e.g., imaging or morphologic factors), pathophysiology, and treatment recommendations. OBSERVATIONS We reviewed 68 articles considering the possibility of resorption of lumbar HNP. Recent literature has proposed various mechanisms (inflammation and neovascularization, dehydration, and mechanical traction) of lumbar disk resorption; however, consensus has yet to be established. Current factors that increase the likelihood of resorption include the initial size of the herniation, sequestration, percentage of rim enhancement on initial gadolinium-based magnetic resonance imaging (MRI), composition of inflammatory mediators, and involvement of the posterior longitudinal ligament. CONCLUSION Heterogeneity in imaging and morphologic factors has led to uncertainty in the identification of which lumbar herniations will resorb. Current factors that increase the likelihood of disk resorption include the initial size of the herniation, sequestration, percentage of rim enhancement on initial MRI, composition of cellular and inflammatory mediators present, and involvement of the posterior longitudinal ligament. This review article highlights the role of disk resorption after herniation without surgical intervention and questions the role of traditional noninflammatory medications after acute herniation. Further research is warranted to refine the ideal patient profile for disk resorption to ultimately avoid unnecessary treatment, thus individualizing patient care.
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Affiliation(s)
| | - James D Baker
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago
| | - G Michael Mallow
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago
| | - Arash J Sayari
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago
| | | | - Alexander Tkachev
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago
| | - Howard S An
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago
| | - Dino Samartzis
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago
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Yu P, Mao F, Chen J, Ma X, Dai Y, Liu G, Dai F, Liu J. Characteristics and mechanisms of resorption in lumbar disc herniation. Arthritis Res Ther 2022; 24:205. [PMID: 35999644 PMCID: PMC9396855 DOI: 10.1186/s13075-022-02894-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 07/26/2022] [Indexed: 12/12/2022] Open
Abstract
Lumbar disc herniation (LDH) can be spontaneously absorbed without surgical treatment. However, the pathogenesis and physiological indications for predicting protrusion reabsorption are still unclear, which prevents clinicians from preferentially choosing conservative treatment options for LDH patients with reabsorption effects. The purpose of this review was to summarize previous reports on LDH reabsorption and to discuss the clinical and imaging features that favor natural absorption. We highlighted the biological mechanisms involved in the phenomenon of LDH reabsorption, including macrophage infiltration, inflammatory responses, matrix remodeling, and neovascularization. In addition, we summarized and discussed potential clinical treatments for promoting reabsorption. Current evidence suggests that macrophage regulation of inflammatory mediators, matrix metalloproteinases, and specific cytokines in intervertebral disc is essential for the spontaneous reabsorption of LDH.
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Affiliation(s)
- Pengfei Yu
- Department of Orthopaedic Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, 215009, People's Republic of China
| | - Feng Mao
- Department of Orthopaedic Surgery, Kunshan Integrated TCM and Western Medicine Hospital, Suzhou, 215332, People's Republic of China
| | - Jingyun Chen
- State Key Laboratory of Bioreactor Engineering & Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai, 200237, People's Republic of China
| | - Xiaoying Ma
- State Key Laboratory of Bioreactor Engineering & Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai, 200237, People's Republic of China
| | - Yuxiang Dai
- Department of Orthopaedic Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, 215009, People's Republic of China
| | - Guanhong Liu
- Department of Orthopaedic Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, 215009, People's Republic of China
| | - Feng Dai
- Department of Orthopaedic Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, 215009, People's Republic of China
| | - Jingtao Liu
- Department of Orthopaedic Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, 215009, People's Republic of China.
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Djuric N, Rajasekaran S, Tangavel C, Raveendran M, Soundararajan DCR, Nayagam SM, Matchado MS, Anand KSSV, Shetty AP, Kanna RM. Influence of endplate avulsion and Modic changes on the inflammation profile of herniated discs: a proteomic and bioinformatic approach. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 31:389-399. [PMID: 34611718 DOI: 10.1007/s00586-021-06989-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 08/23/2021] [Accepted: 09/05/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of this observational radiographic and proteomic study is to explore the influence of both Modic change (MC) and endplate avulsion (EPA) on the inflammation profile of herniated discs using a proteomic and bioinformatics approach. METHODS Fifteen nucleus pulposus (NP) harvested from surgery underwent LC-MS/MC analysis, the proteome was subsequently scanned for inflammatory pathways using a bioinformatics approach. All proteins that were identified in inflammatory pathways and Gene Ontology and present in > 7 samples were integrated in a multiple regression analysis with MC and EPA as predictors. Significant proteins were imputed in an interaction and pathway analysis. RESULTS Compared to annulus fibrosus tear (AFT), six proteins were significantly altered in EPA: catalase, Fibrinogen beta chain, protein disulfide-isomerase, pigment epithelium-derived factor, osteoprotegerin and lower expression of antithrombin-III, all of which corresponded to an upregulation of pathways involved in coagulation and detoxification of reactive oxygen species (ROS). Moreover, the presence of MC resulted in a significant alteration of nine proteins compared to patients without MC. Patients with MC showed a significantly higher expression of clusterin and lumican, and lower expression of catalase, complement factor B, Fibrinogen beta chain, protein disulfide-isomerase, periostin, Alpha-1-antitrypsin and pigment epithelium-derived factor. Together these altered protein expressions resulted in a downregulation of pathways involved in detoxification of ROS, complement system and immune system. Results were verified by Immunohistochemistry with CD68 cell counts. CONCLUSION Both EPA and MC status significantly influence disc inflammation. The beneficial inflammatory signature of EPA illustrates that endplate pathology does not necessarily have to worsen the outcome, but the pathological inflammatory state is dependent on the presence of MC.
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Affiliation(s)
- Niek Djuric
- Ganga Research Centre, No 91, Mettupalayam Road, Coimbatore, 641030, India.,Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Shanmuganathan Rajasekaran
- Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, 641043, India. .,Department of Orthopaedics and Spine Surgery, Ganga Hospital, 313, Mettupalayam road, Coimbatore, India.
| | - Chitra Tangavel
- Ganga Research Centre, No 91, Mettupalayam Road, Coimbatore, 641030, India
| | - Muthurajan Raveendran
- Department of Plant Biotechnology, Tamil Nadu Agricultural University, Coimbatore, 641003, India
| | | | | | | | - K S Sri Vijay Anand
- Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, 641043, India
| | - Ajoy Prasad Shetty
- Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, 641043, India
| | - Rishi Mugesh Kanna
- Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, 641043, India
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Latif R, Imran S, Ahmad I, Ilyas MS, Aziz A, Zehra U. Vertebral Endplate Changes Correlate with Presence of Cartilaginous Endplate in the Herniated Disc Tissue: Factor Predicting Failure of Conservative Treatment. Asian Spine J 2021; 16:212-220. [PMID: 34461689 PMCID: PMC9066261 DOI: 10.31616/asj.2021.0106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/02/2021] [Indexed: 12/28/2022] Open
Abstract
Study Design Cross-sectional comparative. Purpose To characterize the scores of disc degeneration, inflammation, and nerve density in herniated disc samples and associate findings with the presence of vertebral endplate (VEP) changes on magnetic resonance imaging (MRI). Overview of Literature Considering the role of disc composition in spontaneous regression and persistence of pain during conservative management, it is important to identify the influencing factors. VEP changes are highly associated with disc degeneration, but their correlation with herniated disc composition has not yet been reported. Methods Fifty-one discs were obtained from patients undergoing surgery for herniated disc. Their ages ranged from 19–65 years, and 31/51 were male. Pre-surgical T1 and T2 weighted lumbar-spine MRIs were analyzed to observe Pfirrmann grade, VEP defects, herniation type, Modic changes, and high-intensity zones (HIZ) at the affected level. Five-micron thick sections were stained with hematoxylin and eosin, Alcian blue periodic acid–Schiff stain; examined for histological degeneration scores (HDS; 0–15), inflammation (0 [absence]–3 [severe]), and presence of cartilaginous endplate (CEP). Three-micron thick sections were stained with protein-gene-product 9.5 and expression was counted/mm2. Data was analyzed, and p<0.05 was considered to indicate statistical significance. Results VEP defects, Modic changes, and HIZ were respectively observed in 30/51, 16/51, and 6/51 of the samples. CEP was observed in 26/51 samples and in 23/51 with endplate defects. Discs with adjacent VEP defects showed increased HDS (p<0.001) and inflammation (p<0.001). Discs with adjacent Modic changes also revealed increased HDS (p=0.01). Histological sections with CEP showed increased HDS (p<0.001) and inflammation (p<0.001), and nerve density was significantly positively correlated with HDS (r=0.27, p=0.02). Conclusions VEP changes can modulate degeneration and inflammation of herniated discs. Presence of these changes is highly predictive of the occurrence of CEP in herniated discs, which leads to slow resorption and persistent clinical symptoms.
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Affiliation(s)
- Rabia Latif
- Department of Anatomy, University of Health Sciences Lahore, Lahore, Pakistan
| | - Sumera Imran
- Department of Anatomy, University of Health Sciences Lahore, Lahore, Pakistan
| | - Ijaz Ahmad
- Department of Orthopedics & Spine Surgery, Ghurki Trust Teaching Hospital, Lahore, Pakistan
| | - Muhammad Saad Ilyas
- Department of Orthopedics & Spine Surgery, Ghurki Trust Teaching Hospital, Lahore, Pakistan
| | - Amer Aziz
- Department of Orthopedics & Spine Surgery, Ghurki Trust Teaching Hospital, Lahore, Pakistan
| | - Uruj Zehra
- Department of Anatomy, University of Health Sciences Lahore, Lahore, Pakistan
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Din RU, Cheng X, Yang H. Diagnostic Role of Magnetic Resonance Imaging in Low Back Pain Caused by Vertebral Endplate Degeneration. J Magn Reson Imaging 2021; 55:755-771. [PMID: 34309129 DOI: 10.1002/jmri.27858] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 12/25/2022] Open
Abstract
Low back pain (LBP) is a common health issue worldwide with a huge economic burden on healthcare systems. In the United States alone, the cost is estimated to be $100 billion each year. Intervertebral disc degeneration is considered one of the primary causes of LBP. Moreover, the critical role of the vertebral endplates in disc degeneration and LBP is becoming apparent. Endplate abnormalities are closely correlated with disc degeneration and pain in the lumbar spine. Imaging modalities such as plain film radiography, computed tomography, and fluoroscopy are helpful but not very effective in detecting the causes behind LBP. Magnetic resonance imaging (MRI) can be used to acquire high-quality three-dimensional images of the lumbar spine without using ionizing radiation. Therefore, it is increasingly being used to diagnose spinal disorders. However, according to the American College of Radiology, current referral and justification guidelines for MRI are not sufficiently clear to guide clinical practice. This review aimed to evaluate the role of MRI in diagnosing LBP by considering the correlative contributions of vertebral endplates. The findings of the review indicate that MRI allows for fine evaluations of endplate morphology, endplate defects, diffusion and perfusion properties of the endplate, and Modic changes. Changes in these characteristics of the endplate were found to be closely correlated with disc degeneration and LBP. The collective evidence from the literature suggests that MRI may be the imaging modality of choice for patients suffering from LBP. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 3.
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Affiliation(s)
- Rahman Ud Din
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | | | - Haisheng Yang
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
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Cartilaginous endplate avulsion is associated with modic changes and endplate defects, and residual back and leg pain following lumbar discectomy. Osteoarthritis Cartilage 2021; 29:707-717. [PMID: 33609694 DOI: 10.1016/j.joca.2021.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 01/04/2021] [Accepted: 01/18/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE While cartilaginous endplate (CEP) avulsion is a common finding in discectomy due to lumbar disc herniation, its roles in residual back and leg pain, associations with Modic changes (MCs) and endplate defects (EPD) remain unknown. DESIGN Patients with a single-level lumbar disc herniation who underwent endoscopic discectomy were studied. On MR images, the adjacent endplates of the herniated disc were assessed for MCs and EPD. The presence of CEP avulsion was examined under endoscopic and visualized inspection. Back and leg pain were evaluated by a numeric rating scale (NRS) and the Oswestry Disability Index. Associations of CEP avulsion with adjacent MCs, EPD, and residual back and leg pain were examined. In addition, histological features of avulsed CEP were determined using gross staining and immunohistochemical methods. RESULTS A total of 386 patients were included. CEP avulsion was found in 166 (43%) patients, and adjacent MCs and EPD were observed in 117 (30.3%) and 139 (36%) patients. The presence of CEP avulsion was associated with greater age, adjacent MCs (OR = 2.60, 95%CI [1.61-4.19]) and EPD (OR = 1.63, 95%CI [1.03-2.57]). Among the 187 patients with ≥2 years follow-up, CEP avulsion was associated with residual back pain (OR = 2.49, 95%CI [1.29-4.82]) and leg pain (OR = 2.25, 95%CI [1.04-4.84]). Histologically, the avulsed CEP was characterized by multiple defects, apparent inflammation, and nucleus invasion, as well as the upregulation of IL-1β, caspase-1, and NLRP3 inflammasome. CONCLUSION CEP avulsion was associated with MCs, EPD, and residual back and leg pain after discectomy, which may be attributed to NLRP3 inflammasome related inflammations.
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Morozumi N, Aizawa T, Sasaki M, Koizumi Y, Kokubun S. Spontaneous Resorption of Intradural Lumbar Disc Herniation: A Rare Case Report. Spine Surg Relat Res 2020; 4:277-279. [PMID: 32864497 PMCID: PMC7447335 DOI: 10.22603/ssrr.2019-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/10/2019] [Indexed: 11/05/2022] Open
Affiliation(s)
- Naoki Morozumi
- Department of Orthopaedic Surgery, National Hospital Organization Sendai-Nishitaga Hospital, Sendai, Japan
| | - Toshimi Aizawa
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Morichika Sasaki
- Department of Orthopaedic Surgery, National Hospital Organization Sendai-Nishitaga Hospital, Sendai, Japan
| | - Yutaka Koizumi
- Department of Orthopaedic Surgery, National Hospital Organization Sendai-Nishitaga Hospital, Sendai, Japan
| | - Shoichi Kokubun
- Department of Orthopaedic Surgery, National Hospital Organization Sendai-Nishitaga Hospital, Sendai, Japan
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12
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New insights link low-virulent disc infections to the etiology of severe disc degeneration and Modic changes. Future Sci OA 2019. [DOI: 10.4155/fsoa-2019-0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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Manniche C, O'Neill S. New insights link low-virulent disc infections to the etiology of severe disc degeneration and Modic changes. Future Sci OA 2019; 5:FSO389. [PMID: 31245043 PMCID: PMC6554696 DOI: 10.2144/fsoa-2019-0022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 03/05/2019] [Indexed: 12/24/2022] Open
Abstract
Within the last 5 years, international research collaborations including those of several research groups skilled in microbiology, immunology and pathophysiology, have identified a low-virulent intradiscal infection with the ability to provoke gradual and progressive disc degeneration, end-plate disruption, Modic changes and persistent clinical lower-back pain. Certain strains of the Propionibacterium acne bacterium seem able to invade, colonize and develop a protective biofilm inside the disc. The interaction of P. acne, disc tissues and mononuclear cells of the bone marrow are shown to trigger a relevant immunological response and an ensuing destructive inflammation of the disc and adjacent vertebrae. This process presents on MRI as Modic changes. Recent proof-of-concept data provide compelling evidence for this bacterial disc infection hypothesis.
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Affiliation(s)
- Claus Manniche
- Department of Occupational & Environmental Medicine, Odense University Hospital & Institute of Clinical Research, University of Southern Denmark, 5230 Odense M, Denmark.,Department of Occupational & Environmental Medicine, Odense University Hospital & Institute of Clinical Research, University of Southern Denmark, 5230 Odense M, Denmark
| | - Søren O'Neill
- Spinecenter of Southern Denmark, Lillebaelt Hospital, Institute of Regional Health Research, University of Southern Denmark, 5230 Odense M, Denmark.,Spinecenter of Southern Denmark, Lillebaelt Hospital, Institute of Regional Health Research, University of Southern Denmark, 5230 Odense M, Denmark
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