The intervertebral disc, the endplates and the vertebral bone marrow as a unit in the process of degeneration
- 603 Downloads
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.
• 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.
KeywordsSpine 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.
- 1.Battié MC, Videman T, Kaprio J et al (2009) The Twin Spine Study: contributions to a changing view of disc degeneration. Spine J 47–59Google Scholar
- 3.Miller JA, Schmatz C, Schultz AB (1988) Lumbar disc degeneration: correlation with age, sex, and spine level in 600 autopsy specimens. Spine (Phila Pa 1976) 173–178Google Scholar
- 4.Videman T, Sarna S, Battié MC et al (1995) The long-term effects of physical loading and exercise lifestyles on back-related symptoms, disability, and spinal pathology among men. Spine (Phila Pa 1976) 699–709Google Scholar
- 6.Battié MC, Videman T, Gill K et al (1991) 1991 Volvo Award in clinical sciences. Smoking and lumbar intervertebral disc degeneration: an MRI study of identical twins. Spine (Phila Pa 1976) 1015–1021Google Scholar
- 7.Kauppila LI (2009) Atherosclerosis and disc degeneration/low-back pain--a systematic review. Eur J Vasc Endovasc Surg 661–670Google Scholar
- 8.Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW (1990) Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 403–408Google Scholar
- 9.Powell MC, Wilson M, Szypryt P, Symonds EM, Worthington BS (1986) Prevalence of lumbar disc degeneration observed by magnetic resonance in symptomless women. Lancet 1366–1367Google Scholar
- 10.Wiesel SW, Tsourmas N, Feffer HL, Citrin CM, Patronas N (1984) A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients. Spine (Phila Pa 1976) 549–551Google Scholar
- 11.Nadja AF-A, Alexander PH, Alexander A, Richard JH, Mazda F, (2014) Determinants of evolution of endplate and disc degeneration in the lumbar spine: a multifactorial perspective. European Spine Journal 23(9):1863–1868Google Scholar
- 13.Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N (2001) Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine (Phila Pa 1976) 1873–1878Google Scholar
- 14.Modic MT, Steinberg PM, Ross JS, Masaryk TJ, Carter JR (1988) Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology 193–199Google Scholar
- 15.Rajasekaran S, Venkatadass K, Naresh Babu J, Ganesh K, Shetty AP (2008) Pharmacological enhancement of disc diffusion and differentiation of healthy, ageing and degenerated discs : results from in-vivo serial post-contrast MRI studies in 365 human lumbar discs. Eur Spine J 626–643Google Scholar
- 17.Albert HB, Briggs AM, Kent P, Byrhagen A, Hansen C, Kjaergaard K (2011) The prevalence of MRI-defined spinal pathoanatomies and their association with modic changes in individuals seeking care for low back pain. Eur Spine J 1355–1362Google Scholar
- 19.Vital JM, Gille O, Pointillart V et al (2003) Course of Modic 1 six months after lumbar posterior osteosynthesis. Spine (Phila Pa 1976) 715–720- discussion 721Google Scholar
- 20.Hutton MJ, Bayer JH, Powell JM (2011) Modic vertebral body changes: the natural history as assessed by consecutive magnetic resonance imaging. Spine (Phila Pa 1976) 2304–2307Google Scholar
- 21.Kuisma M, Karppinen J, Niinimäki J et al (2006) A three-year follow-up of lumbar spine endplate (Modic) changes. Spine (Phila Pa 1976) 1714–1718Google Scholar
- 22.Fardon DF, Milette PC, Combined Task Forces of the North American Spine Society ASoSR, and American Society of Neuroradiology (2001) Nomenclature and classification of lumbar disc pathology. Recommendations of the Combined task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine (Phila Pa 1976) E93–E113Google Scholar
- 28.Pfirrmann CW, Resnick D (2001) Schmorl nodes of the thoracic and lumbar spine: radiographic-pathologic study of prevalence, characterization, and correlation with degenerative changes of 1,650 spinal levels in 100 cadavers. Radiology 368–374Google Scholar