Clinical Relationship of Degenerative Changes between the Cervical and Lumbar Spine

Quantitative assessment of cervical disc degeneration using disc signal intensity index

BACKGROUND/CONTEXT

The assessment of disc degeneration remains a significant challenge in clinical research. Pfirrmann grade is a frequently used classification for lumbar disc degeneration on MRI. However, there has been no gold standard for cervical spine disc degeneration. Recently, we introduced the Disc Signal Intensity Index (DSI2) as a quantitative disc assessment for the lumbar spine, which is easily measurable in the cervical spine.

PURPOSE

The aim of this study was to apply DSI2 in the cervical intervertebral disc and investigate the factors associated with the cervical disc degeneration.

STUDY DESIGN/SETTING

Cross-sectional study using retrospectively collected data.

PATIENT SAMPLE

Cervical MRIs from a database of patients undergoing ACDF between 2015 and 2018 were retrospectively reviewed.

OUTCOME MEASURES

Demographic variables included age, sex, body mass index (BMI), race, smoking status, and comorbidities such as diabetes, chronic kidney disease, and coronary artery disease.

METHODS

DSI2 measurements were performed on midsagittal T2-weighted MRI images by determining the intensity within regions of interest (ROI). One ROI was set in the cerebrospinal fluid (CSF) and three ROIs were set per disc at the anterior, middle, and posterior third. The mean of the three measurements per disc was then divided by that of the CSF to calculate the DSI2 score. Multivariable linear regression analyses with mixed model were conducted to determine the potential contributing factors for disc degeneration.

RESULTS

A total of 149 patients and 770 discs were included in the final analysis. Ninety-three patients (37.6%) were female and the mean (SD) age was 55.6 (11.7) years. The distribution of DSI2 scores among the different Pfirrmann grades was as follows: Grade 1: 0.259±NA; Grade 2: 0.226±0.090; Grade 3: 0.175±0.070; Grade 4: 0.136±0.060; Grade 5: 0.131±0.050. Multivariable linear mixed-effect regression analysis, setting with DSI2 as the objective variable, demonstrated that age (β=-0.130, p<.05), BMI (β=-2.06, p<.05), Modic changes (Type1 β= -2.70, p<.01) were independent contributors to disc degeneration. The segments C4/5 and C7/T1 were less prone to disc degeneration (C4/5: β=1.37, p<.001; C7/T1: β=2.63, p<.001) and the history of diabetes (β=5.31, p<.01) was associated with high DSI2.(p<.01).

CONCLUSIONS

The present study provides valuable insights for identifying risk factors in degenerative cervical conditions utilizing the DSI2. The DSI2 method emerges as a promising alternative for future disc research, excelling in the detection of subtle progressions of degeneration and distinguishing itself from the subjective Pfirrmann grading system.

Cross-cultural adaptation, validation, and establishment of the minimal clinicallyimportant change score of the European Portuguese Core Outcome Measures Index in patients with cervical degenerative spine disease

PURPOSE

We aimed to validate and cross-culturally adapt the Core Outcome Measures Index (COMI) neck for use in Portuguese patients with cervical spine degenerative disease and define the minimal clinically important change score (MCIC) for this questionnaire and population.

METHODS

The COMI translation and cross-cultural adaptation was done following published guidelines. Patients awaiting surgery in a neurosurgical centre completed the COMI, Neck Disability Index (NDI) and EQ-5D questionnaires, a pain visual analog scale (VAS) twice within a 5-to-15-day period, and a Global Treatment Outcome (GTO) question evaluating whether a clinical status change had occurred during that period. The MCIC was obtained through an anchor method by analysis of changes in pre- to postoperative total COMI scores and GTO dichotomized answers.

RESULTS

The COMI first assessment was completed by 101 patients and 72 patients completed both assessments. The questionnaire showed good construct validity (n = 72 patients) as predefined hypotheses were confirmed: scores on each COMI domain correlated with a Spearman ρ > 0.4 with scores for the corresponding domain on other questionnaires and COMI total score displayed good correlation with total NDI score (ρ = 0.67) and EQ-5D total score (ρ = 0.55). Test-retest reliability (n = 72 patients) was confirmed through high intraclass correlation coefficients. The MCIC (n = 76 patients) was calculated as 2 points.

CONCLUSION

The COMI (neck) psychometric qualities were confirmed, such that it can be considered a valid and reliable questionnaire to be applied in the European Portuguese population with surgical cervical spine degenerative disease, with an MCIC of 2 points.

Cervical Spondylopathy and Lumbar Intervertebral Disc Herniation Coexist in Free Radical Metabolism and Focus Separation in the Body

Lumbar disc herniation is a common lumbar disease in clinics, which is related to improper use of lumbar vertebrae and osteoporosis. Surgical removal of nucleus pulposus and maintenance of lumbar structural stability are important for the treatment of lumbar disc herniation. At present, in clinical percutaneous intervertebral foramen endoscopic surgery for lumbar disc herniation, interlaminar and intervertebral foramen approaches can be selected. Different approaches have different degrees of difficulty in the treatment of lumbar disc herniation, and the clinical effects that may be obtained are different. In this study, we observed the influencing factors of plasma nitric oxide (NO) and free radical metabolism in patients with lumbar disc herniation and the correlation between the effects of focus separation. The organic combination of local and total illness differentiation and dialectics, conventional acupuncture, and electrical stimulation was highlighted in this study, which linked local acupoints squeezed by nerve roots with distant acupoints along meridians. The use of authoritative quantitative standards and a multifactor assessment of the disease can accurately represent the disease's severity. The patient's condition changes in each period may be expressed more accurately, thoroughly, and objectively through the rise or reduction of the score, making self-evaluation easier for the patient. Electroacupuncture at point may be one of the most important strategies to minimize free radical damage, based on changes in plasma levels.

Cervical spine MRI phenotypes and prediction of pain, disability and adjacent segment degeneration/disease after ACDF

Degenerative spine imaging findings have been extensively studied in the lumbar region and are associated with pain and adverse clinical outcomes after surgery. However, few studies have investigated the significance of these imaging "phenotypes" in the cervical spine. Patients with degenerative cervical spine pathology undergoing anterior cervical discectomy and fusion (ACDF) from 2008 to 2015 were retrospectively and prospectively assessed using preoperative MRI for disc degeneration, narrowing, and displacement, high-intensity zones, endplate abnormalities, Modic changes, and osteophyte formation from C2-T1. Points were assigned for these phenotypes to generate a novel Cervical Phenotype Index (CPI). Demographics were evaluated for association with phenotypes and the CPI using forward stepwise regression. Bootstrap sampling and multiple imputations assessed phenotypes and the CPI in association with patient-reported outcomes (Neck Disability Index [NDI], Visual Analog Scale [VAS]-neck, VAS-arm) and adjacent segment degeneration (ASDeg) and disease (ASDz). Of 861 patients, disc displacement was the most common (99.7%), followed by osteophytes (92.0%) and endplate abnormalities (57.3%). Most findings were associated with age and were identified at similar cervical vertebral levels; at C5-C7. Imaging phenotypes demonstrated both increased and decreased associations with adverse patient-reported outcomes and ASDeg/Dz. However, the CPI consistently predicted worse NDI (P = .012), VAS-neck (P = .007), and VAS-arm (P = .013) scores, in addition to higher odds of ASDeg (P = .002) and ASDz (P = .004). The CPI was significantly predictive of postoperative symptoms of pain/disability and ASDeg/Dz after ACDF, suggesting that the totality of degenerative findings may be more clinically relevant than individual phenotypes and that this tool may help prognosticate outcomes after surgery.

Reciprocal Regulation of TRPS1 and miR-221 in Intervertebral Disc Cells

Intervertebral disc (IVD), a moderately moving joint located between the vertebrae, has a limited capacity for self-repair, and treating injured intervertebral discs remains a major challenge. The development of innovative therapies to reverse IVD degeneration relies primarily on the discovery of key molecules that, occupying critical points of regulatory mechanisms, can be proposed as potential intradiscal injectable biological agents. This study aimed to elucidate the underlying mechanism of the reciprocal regulation of two genes differently involved in IVD homeostasis, the miR-221 microRNA and the TRPS1 transcription factor. Human lumbar IVD tissue samples and IVD primary cells were used to specifically evaluate gene expression and perform functional analysis including the luciferase gene reporter assay, chromatin immunoprecipitation, cell transfection with hTRPS1 overexpression vector and antagomiR-221. A high-level expression of TRPS1 was significantly associated with a lower pathological stage, and TRPS1 overexpression strongly decreased miR-221 expression, while increasing the chondrogenic phenotype and markers of antioxidant defense and stemness. Additionally, TRPS1 was able to repress miR-221 expression by associating with its promoter and miR-221 negatively control TRPS1 expression by targeting the TRPS1-3'UTR gene. As a whole, these results suggest that, in IVD cells, a double-negative feedback loop between a potent chondrogenic differentiation suppressor (miR-221) and a regulator of axial skeleton development (TRPS1) exists. Our hypothesis is that the hostile degenerated IVD microenvironment may be counteracted by regenerative/reparative strategies aimed at maintaining or stimulating high levels of TRPS1 expression through inhibition of one of its negative regulators such as miR-221.

Abnormal performance of cervical stabilizer muscles in individuals with low back pain

Objectives: To compare the performance of cervical stabilizer muscles using the craniocervical flexion test (CCFT) among individuals with subacute, chronic, and asymptomatic low back pain (LBP) conditions. Methods: Individuals with subacute (N = 23) and chronic LBP (N = 23) with their age- and gender-matched controls (N = 30) participated in this study. All recruited participants were required to perform the CCFT. The activation score (AS) and the performance index (PI) were recorded by an assessor who was blinded to the group of participants. Results: Approximately, 74% of subacute LBP participants and 60-65% of chronic LBP participants obtained abnormal AS and PI. AS was significantly lower in participants with subacute (P = 0.0002) and chronic LBP (P = 0.0009) than the control group. Likewise, the PI was significantly lower in participants with subacute (P = 0.0002) and chronic LBP (P = 0.0036) than the control group. Participants in the subacute LBP group showed significantly greater percentages of abnormal responses on the AS (P < 0.0001) and the PI (P = 0.0001) than the control. Discussion: Abnormal performance of cervical stabilizer muscles using the CCFT was demonstrated in a high proportion of participants with LBP. The findings highlight the plausible association in muscle control between cervical and lumbar stabilizers. Level of Evidence: 2b.