ISSLS PRIZE in Clinical Science 2023: comparison of degenerative MRI features of the intervertebral disc between those with and without chronic low back pain. An exploratory study of two large female populations using automated annotation

OBJECTIVES

The relationship of degeneration to symptoms has been questioned. MRI detects apparently similar disc degeneration and degenerative changes in subjects both with and without back pain. We aimed to overcome these problems by re-annotating MRIs from asymptomatic and symptomatics groups onto the same grading system.

METHODS

We analysed disc degeneration in pre-existing large MRI datasets. Their MRIs were all originally annotated on different scales. We re-annotated all MRIs independent of their initial grading system, using a verified, rapid automated MRI annotation system (SpineNet) which reported degeneration on the Pfirrmann (1-5) scale, and other degenerative features (herniation, endplate defects, marrow signs, spinal stenosis) as binary present/absent. We compared prevalence of degenerative features between symptomatics and asymptomatics.

RESULTS

Pfirrmann degeneration grades in relation to age and spinal level were very similar for the two independent groups of symptomatics over all ages and spinal levels. Severe degenerative changes were significantly more prevalent in discs of symptomatics than asymptomatics in the caudal but not the rostral lumbar discs in subjects < 60 years. We found high co-existence of degenerative features in both populations. Degeneration was minimal in around 30% of symptomatics < 50 years.

CONCLUSIONS

We confirmed age and disc level are significant in determining imaging differences between asymptomatic and symptomatic populations and should not be ignored. Automated analysis, by rapidly combining and comparing data from existing groups with MRIs and information on LBP, provides a way in which epidemiological and 'big data' analysis could be advanced without the expense of collecting new groups.

LEVEL OF EVIDENCE I

Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Incidence of serious side effects with intravenous bisphosphonate: a clinical audit

BACKGROUND

Bisphosphonates (BP) have been associated with osteonecrosis of the jaw (ONJ) and atypical femoral fractures (AFF). The prevalence of these side effects in intravenous (IV) BP-treated subjects is not well understood.

AIM

This audit aimed to delineate the prevalence of ONJ, thigh pain and AFF in patients having regular IV BP and its effect on bone mineral density (BMD). Design and

METHODS

Patients attending for IV BP over a 3-month period completed a questionnaire about thigh pain and dental health. Data concerning BMD, treatment indication and treatment history were obtained from medical records.

RESULTS

There were 201 patients between 28 and 94 years (74.1% female) mostly on zoledronate (ZOL) (102) or pamidronate (PAM) (97). Osteoporosis (75.6%) and Paget's disease (16.5%) were the main indications for treatment; median length of IV BP was 4 years (range 0.25-25). One patient had ONJ (0.5%) while oral pain was reported by 6.5% and 12.7% noted tooth loosening. Twenty-seven subjects (13.4%) complained of current thigh pain. AFF occurred in four patients (2%), none of whom had idiopathic osteoporosis. At time of AFF, only one patient had a femoral neck T-score less than -2.5. All four had received pamidronate treatment; median 12.5 years (range 7-22). IV BP treatment significantly increased lumbar spine BMD but not femoral neck BMD.

CONCLUSION

Classical ONJ was rare (0.5%), although tooth loss was more frequent. Thigh pain was frequent while AFF occurred in 2.0% of subjects and was associated with long treatment periods and non-osteoporotic bone.

Combined autologous chondrocyte implantation and allogenic meniscus transplantation: a biological knee replacement

Meniscus deficient knees develop early osteoarthritis in the knee. Autologous Chondrocyte Implantation has provided a new dimension to the treatment of chondral defects in the knee, with 85% good to excellent results and a long-term durable outcome of up-to 11 years. However, it is contraindicated in meniscus deficient knees. Allogenic Meniscus Transplantation gives good symptomatic relief in meniscus deficient knees, with a success rate of 89%. However, it is contraindicated in advanced cartilage degeneration. We hypothesized that combination of these two might be a solution for bone-on-bone arthritis in young individuals. We studied a consecutive series of eight patients, with mean age of 43 years, presenting with large kissing chondral defects, secondary to the previous meniscectomy. All the patients were treated with a combination of Autologous Chondrocyte Implantation and Allogenic Meniscus Transplantation. Mean pre-operative Lysholm score was 49, which rose to mean of 66 at 1 year, an average increase by 16.4 points. Six patients showed significant improvement at one year. MRI scans showed good integration of the menisci with the capsule, without any rejection. Histology confirmed the integration. All the patients could lead an active life-style. Five patients maintained the improvement at a mean follow-up of 3.2 years. We could not find any deleterious effects of the combination of these two techniques. So we conclude that the combination of these two techniques together may act a one step towards a true biological knee replacement.

Symptoms and radiographic osteoarthritis: not as discordant as they are made out to be?

OBJECTIVES

Joint pain and radiographic osteoarthritis are often discordant.

AIM

To investigate this issue more closely by studying the detailed nature of pain and disability, and how this relates to radiographic osteoarthritis.

METHODS

Population-based study of 819 adults aged >or=50 years with knee pain. The severity of knee pain, stiffness and disability was measured using a validated scale (the Western Ontario and McMaster Universities (WOMAC) Score) and pain persistence was recorded. Global severity was measured by the graded chronic pain scale. Three radiographic views of the knees were obtained-weight-bearing posteroanterior metatarsophalangeal, supine skyline and supine lateral.

RESULTS

745 participants with knee pain in the past 6 months were eligible (mean age 65 years, 338 men). Radiographic osteoarthritis was more common in those with a longer history and more persistent symptoms. A strong trend was found of radiographic osteoarthritis being more strongly associated with higher WOMAC scores for pain severity, stiffness and disability (adjusted odds ratio (95% confidence interval (CI)) for highest v lowest WOMAC category: 3.7 (2.0 to 6.7), 3.0 (2.0 to 4.6) and 2.8 (1.6 to 5.0), respectively). Those individual WOMAC items for pain and disability pertaining to weight-bearing mobility were the most strongly associated with radiographic osteoarthritis. Combining pain persistence and global severity, persistent severe pain was associated with a significant increase in the occurrence of radiographic osteoarthritis (2.6 (95% CI 1.5 to 4.7)).

CONCLUSIONS

A consistent association was found between severity of pain, stiffness and physical function and the presence of radiographic osteoarthritis. This study highlights the potential contribution of underlying joint disease to the degree of pain and disability.

The emergency department: an appropriate referral rate for radiography

AIM

To evaluate the hypothesis that where there is good clinical practice in an emergency department (ED), there is a low uptake of plain radiography.

MATERIALS AND METHODS

Emergency notes and radiography records were reviewed over one week in January 1999, to determine the rate of radiography of first time attenders at the North Staffordshire NHS Trust. The clinical appropriateness of the imaging was assessed by pairs of radiology specialist registrars and casualty physicians. They judged the appropriateness of the imaging by the 1998 Royal College of Radiologists (RCR) guidelines and/or their clinical judgement, by consensus. Where there was no consensus or the data appeared incomplete, the radiology and ED consultant reviewed the notes.

RESULTS

A total of 1615 notes were found out of 1643 (98%). Of these, 147 (9%) return attenders were excluded and 32 patients left without being seen. The number of first time attenders was 1436 (87%), of whom 637 (44%) were radiographed; 95% of these radiography examinations were appropriate and 5% were inappropriate. Of the first time attenders who were not radiographed the decision was appropriate in 95% of cases, and inappropriate for 5%, i.e. 5% of those who had no radiography, should have been X-rayed. There were no disagreements between RCR guidelines and the clinical judgements, but in 16% there were no suitable RCR guidelines. Junior doctors were not always able to find the relevant RCR guideline (relevant clinical guideline found in 73% of cases) in the guideline book, compared to the consultants (relevant clinical guideline found in 84% of cases).

CONCLUSION

The application of the RCR guidelines is taken as representing good clinical practice in determining when to refer a patient for radiography. Based on this assumption, a referral rate for radiography of 44% of first time attenders was found to be appropriate. This referral rate can be taken as a benchmark. A benchmark is necessary in order to allow departments to make a local assessment as to whether their local referral rate is likely to be too high or too low.

Marginal erosive discovertebral "Romanus" lesions in ankylosing spondylitis demonstrated by contrast enhanced Gd-DTPA magnetic resonance imaging

OBJECTIVE

To assess the value of Gd-DTPA magnetic resonance (MR) imaging in the demonstration of marginal destructive discovertebral Romanus lesions in ankylosing spondylitis.

DESIGN AND PATIENTS

A prospective study of Gd-DTPA MR imaging was performed in 39 patients with a clinical diagnosis of ankylosing spondylitis and typical Romanus lesions seen on radiographs of the thoracolumbar spine. MR morphological appearances and signal intensity changes at the discovertebral junctions were analysed and compared with the radiographic findings.

RESULTS

Ninety-nine discovertebral junctions with Romanus lesions showed low signal intensity on T1-weighted and high signal on T2-weighted and T1-weighted postcontrast images at the vertebral corners consistent with oedematous hyperaemic inflammatory tissue. There were nine discovertebral junctions with similar MR findings but normal radiographs. Fifty-three discovertebral junctions showed syndesmophyte formation with increased signal intensity on both T1- and T2-weighted images with no contrast enhancement. Sixty-five discovertebral junctions showed a mixture of radiographic features and varied high and low signal changes at the vertebral rim on MR imaging with rims of enhancement in the vertebral body following contrast administration.

CONCLUSION

Gd-DTPA MR imaging demonstrates a variable signal pattern and degree of contrast enhancement which may reflect the evolutionary stages of discovertebral enthesitis in ankylosing spondylitis. MR imaging may identify early erosive changes in radiographically normal vertebra. The role of MR imaging needs further investigation.