European Radiology

, Volume 27, Issue 6, pp 2507–2520 | Cite as

The intervertebral disc, the endplates and the vertebral bone marrow as a unit in the process of degeneration

  • Nadja A. Farshad-Amacker
  • Alexander Hughes
  • Richard J. Herzog
  • Burkhardt Seifert
  • Mazda Farshad



The association of disc degeneration (DD) and vertebral endplate degeneration (EPD) is still not well understood. This study aimed to find segmental predictive risk factors for DD and EPD and to illuminate associations of the disc, endplate and bone marrow changes in the process of degeneration.


After institutional review board approval, 450 lumbar levels, followed up with MRI for at least 4 years, were retrospectively graded for DD according to Pfirrmann (PFG), for EPD according to the endplate score (EPS) and according to the presence, extension and type of Modic changes (MC). Clustered logistic regression and multivariate analysis was applied in nested, matched case-control subgroups to evaluate potential local risk factors for progression.


An EPS score of  ≥4 was identified as an independent risk factor for progression of DD (OR = 2.32, 95%CI:1.07–5.01,p = 0.03) and MC (OR = 5.49,95%CI:2.30–13.10,p < 0.001). Progression of DD was significantly accompanied by progression or evolution of MC (OR = 12.25,95%CI:1.49–100.6,p = 0.02) and with progression of EPS (OR = 1.71, 95%CI:1.00–1.05, p = 0.01). Once advanced DD has occurred, it becomes a risk factor for progression in EPS (OR = 2.24,95%CI:1.23–4.12,p < 0.01).


The degenerative processes in the disc, endplate and bone marrow are highly associated. An EPS ≥ 4 is an independent risk factor for DD and MC progression in a population with low back pain.

Key Points

The degenerative processes in the disc, endplate and bone marrow are associated.

An endplate score ≥4 is a risk factor for DD and MC progression.

Modic changes are last to occur in the development of segmental intervertebral degeneration.

A new segmental grading system is suggested.


Spine degeneration Segmental degeneration Intervertebral disc Endplate changes Vertebral bone marrow 



The scientific guarantor of this publication is Mazda Farshad. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

This study has received funding by: Grant Support: Department fund of the MRI Department, Hospital for Special Surgery, USA and individual funding of Swiss National Foundation (N.F. PBZHP3_143674). Burkhardt Seifert kindly provided statistical advice for this manuscript. Institutional review board approval was obtained.

Written informed consent was waived by the Institutional Review Board.

Some study subjects or cohorts have been previously reported in:

1. Farshad-Amacker NA, Hughes AP, Aichmair A, Herzog RJ, Farshad M. Determinants of evolution of endplate and disc degeneration in the lumbar spine: a multifactorial perspective. European Spine Journal. 2014 Jun 5.

2. Farshad-Amacker NA, Hughes AP, Aichmair A, Herzog RJ, Farshad M. Is an annular tear a predictor for accelerated disc degeneration? European Spine Journal. 2014 Mar 13.

Methodology: retrospective, case-control study, performed at one institution.


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Copyright information

© European Society of Radiology 2016

Authors and Affiliations

  • Nadja A. Farshad-Amacker
    • 1
    • 2
  • Alexander Hughes
    • 3
  • Richard J. Herzog
    • 4
  • Burkhardt Seifert
    • 5
  • Mazda Farshad
    • 6
  1. 1.MRI, Radiology DepartmentHospital for Special SurgeryNew YorkUSA
  2. 2.Institute of Diagnostic and Interventional RadiologyUniversity Hospital of ZurichZurichSwitzerland
  3. 3.Spine SurgeryHospital for Special SurgeryNew YorkUSA
  4. 4.Spinal ImagingHospital for Special SurgeryNew YorkUSA
  5. 5.Departement of Biostatistics, Epidemiology, Biostatistics and Prevention InstituteUniversity of ZurichZurichSwitzerland
  6. 6.Spine DivisionBalgrist University HospitalZurichSwitzerland

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