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To clarify the current state of knowledge on the association of endplate structural defects and back pain. Five databases were searched for studies reporting on the association between endplate structural defects and back pain. Covidence and comprehensive meta-analysis software were used for article screening and selection and pooling of extracted data. Overall quality of evidence was assessed using GRADE. Twenty-six studies comprised of 11,027 subjects met inclusion criteria. The presence of moderate heterogeneity (I2 = 73%; p = 0.001) prevented the pooling of estimates across all studies. However, it was possible to pool studies of specific endplate defect phenotypes, such as erosion (OR: 2.69; 95% CI: 1.35–5.50) and sclerosis (OR: 1.97; 95% CI: 1.50–2.58), which yielded significant associations with back pain. Schmorl’s nodes were also associated with most individual back pain phenotypes (OR: 1.53–1326, I2 = 0–7.5%) and back pain overall (OR: 1.63, 95% CI: 1.37–1.94, I2 = 26%) in general population samples. The pooling of data from all studies of specific back pain phenotypes, such as frequent back pain (OR: 2.83; 95% CI: 1.77–4.52) and back pain incidence (OR: 1.65; 95% CI: 1.30–2.10), each yielded significant association with endplate structural defects and was supported by low heterogeneity (I2 =

Objective This retrospective study aimed to compare vertebral endplate cyst formation (VECF), an early predictor for pseudoarthrosis, in different types of interbody cages. Methods We reviewed 84 cases treated with single-level posterior/transforaminal lumbar interbody fusion. We utilized a polyetheretherketone cage in 20 cases (group P), a titanium cage in 16 cases (group Ti), a titanium-coating polyetheretherketone cage in 13 cases (group TiP) and a porous tantalum cage in 35 cases (group Tn). VECF was evaluated comparing the computed tomography scans taken at day 0 and 6-month postoperation. We defined VECF (+) as enlargement of a pre-existing cyst or de novo formation of a cyst with the diameter over 2 mm. We calculated the adjusted odds ratio (OR) and 95% confidence intervals (CIs) as an indicator of association between different types of cages and VECF using a logistic regression model. Results VECF was observed in 13 (65%), 7 (44%), 9 (69%), and 8 (23%) cases in groups P, Ti, TiP and Tn, respectively. VECF correlated with the type of cage (p = 0.04). In comparison with group P, the proportion of VECF (+) cases was lower in group Tn (OR, 0.16; 95% CI, 0.04-0.60) but not different in group Ti (OR, 0.47; 95% CI, 0.10-2.20) and group TiP (OR, 1.06; 95% CI, 0.21-5.28). No patient underwent additional surgery for the fused spinal level during the follow-up periods (average, 37.9 months; range, 6-76 months). Conclusion VECF was the least in the porous Tn cage, suggesting its potential superiority for initial stability.

Background Endplate defects are commonly seen in patients with lumbar degenerative disease. However, little is known about the presence of endplate defects in patients with degenerative spondylolisthesis (DS). In the present study, we have introduced a classification system for endplate defects in patients with DS using routine magnetic resonance imaging findings and explored the correlative factors. Methods Endplate defects were classified into 3 major categories (rim defects, focal defects, and erosive defects) and 5 subtypes (anterior type, posterior type, arc type at the anterior rim, notch type, and Schmorl's nodes). The incidence rates of the endplate defects were compared between the slippage and nonslippage levels. The correlations between the endplate defects and age, sex, disc degeneration, Modic changes (MCs), body mass index, slippage segment, and slippage degree were analyzed. Results Endplate defects were present in 47.43% of the endplates in DS. The most common endplate defects were rim defects. The occurrence of endplate defects, especially anterior defects, was more common at the slippage levels. Endplate defects were associated with age and closely related to MCs and the severity of disc degeneration. The slippage degree, slippage segment, body mass index, and sex differences were not associated with endplate defects in our study. The results obtained using this novel classification system were stable and consistent. Conclusions The results from the present study have shown that the novel radiological classification system of endplate defects is reliable. Endplate defects were associated with slippage but not with the slippage degree or slippage segment differences in DS. The correlation between endplate defects and age and between MCs and disc degeneration were important features on the magnetic resonance imaging scans of patients with DS.

Background. The importance of identifying osteoporotic vertebral endplate or/and cortex fracture (ECF), which primarily includes endplate fracture (EPF) and vertebral anterior cortex buckling, has been recognized. However, some old traumatic ECFs with healing process in the elderly may be mistaken as osteoporotic. This study analyzes the radiological features of traumatic EPF. Methods. This was a retrospective analysis of 194 spine trauma patients with 263 vertebral fractures (mean age: 42.11 ± 9.82 years, 118 males and 76 females). All patients had traumatic EPF identified by X-ray/CT/MRI. Results. The involved vertebra was mostly L1 (29.7%), followed by T12 and L2. Except EPFs involved both superior and inferior endplates (12.6%), only 1.9% involved inferior endplate alone, with the majority involved superior endplate. If each endplate was divided into five segments of equal lengths (from anterior to posterior: a1, a2, m, p2, p1), the most depressed point of superior EPFs was mostly at segment-a2 (approximately 45%), followed by segment-a1 (approximately 20%) or segment-m (approximately 20%), and very rarely at segment-p1. The upper 1/3 of anterior vertebral wall was more likely to fracture, followed by middle 1/3 of anterior wall. For posterior vertebral wall fracture, 68.5% broke the bony wall surrounding the basivertebral vain. 58.6%, 30.0%, and 11.4% of vertebral fractures had 1/3 vertebral body height loss. As the extent of vertebral height loss increased, the chance of having both superior and inferior EPFs also increased; however, the chance of having inferior EPF alone did not increase. Conclusion. Traumatic EPF features are characterized, which may help the differentiation of traumatic and osteoporotic EPFs.

Objective To evaluate whether vertebral endplate signal changes (VESCs) influence the prognosis of patients submitted to conservative or surgical treatment for low back pain and lumbosciatica. Methods Study with 241 patients who underwent conservative treatment, infiltration or surgery with 12 months of follow-up. They were evaluated for pain by the Visual Analog Scale for Pain (VAS), for function by the Roland Morris questionnaire and for quality of life by the EuroQoI5 (EQ-5D). Results The VESCs did not have a significant effect on the treatment responses for the VAS (F = 0.03; P = 0.97), Roland Morris (F = 0.51; P = 0.60) and EQ-5D (F = 2.67; P = 0.07) variables, nor was there any interaction between VESC and treatment for VAS (F = 2.15; P = 0.08), Roland Morris (F = 1.55; P = 0.19) and EQ-5D (F = 2.15; P = 0.08). There was a significant effect for all treatments, however, the effect of the surgical procedure was superior when compared to the others (P

Adisa Kuršumović,1 Gerrit Joan Bouma,2 Larry E Miller,3 Richard Assaker,4 Erik Van de Kelft,5 Robert Hes,6 Jenny C Kienzler7 1Department of Neurosurgery, Donauisar Klinikum Deggendorf, Deggendorf, Germany; 2Department of Neurosurgery, OLVG-West and Academic Medical Center, Amsterdam, the Netherlands; 3Miller Scientific, Johnson City, TN, USA; 4Department of Neurosurgery, Centre Hospitalier Régional Universitaire de Lille, Lille, France; 5Department of Neurosurgery, AZ Nikolaas, Sint-Niklaas and University of Antwerp, Antwerpen, Belgium; 6Department of Neurosurgery, AZ Klina, Brasschaat, Belgium; 7Department of Neurosurgery, Kantonsspital Aarau, Aarau, SwitzerlandCorrespondence: Adisa KuršumovićDepartment of Neurosurgery, Donauisar Klinikum Deggendorf, Deggendorf, GermanyEmail kursumovic@hotmail.comObjective: Vertebral endplate disruptions (VEPD) are common findings on imaging after lumbar surgery. The objective of this study was to explore the clinical implications of VEPD development following lumbar discectomy with or without implant with a bone-anchored annular closure device (ACD).Methods: This was a multicenter randomized controlled trial of patients with large postsurgical annular defects after limited lumbar discectomy who were randomized to additionally receive an ACD or no additional treatment. VEPD were identified on computed tomography and confirmed by an imaging core laboratory. Clinical outcomes included recurrent herniation, reoperation, Oswestry Disability Index, leg pain, and back pain. Patient follow-up in this study was 3 years.Results: In the ACD group (n=272), the risk of reoperation was lower in patients with vs without VEPD (8% vs 24%, p< 0.01), but no other clinical outcomes differed when stratified by VEPD prevalence or size. In the Control group (n=278), the risk of symptomatic reherniation was higher in patients with VEPD (41% vs 23%, p< 0.01) and patients with the largest VEPD had the highest reoperation rates. Patient-reported outcomes were not associated with VEPD prevalence or size in the Control group.Conclusion: VEPD had no significant influence on patient-reported outcomes at 3 years after lumbar discectomy. VEPD increased the risk of recurrence in patients treated with lumbar discectomy only, but had no negative influence in patients treated with the ACD.Keywords: annular closure, disc herniation, lumbar discectomy, randomized controlled trial, sciatica, vertebral endplate &nbsp

Background Cervical fusion and arthroplasty are common surgical procedures where devices are inserted into cervical interbody spaces. These spaces are defined superiorly and inferiorly by adjacent vertebral body endplates. Having sufficient data on cervical endplate shape and size contributes to superior device designs associated with better functional outcomes and less postoperative complications. This study presents a systematic review of current literature on cervical endplate morphology and variation with age, gender and spinal level. Methods A systematic review was conducted on 4 electronic databases using combinations of search terms (“endplate”, “cervical”, “cervical spine”, “morphology” and “anatomy”). Relevant articles (n = 10) were selected with additional studies identified through their citations (n = 2). Results Current literature on cervical endplate morphology is limited. Most studies reported that cervical endplate diameters and surface area (SA) increased with descending vertebral level. Only two studies investigated the relationship between age and cervical endplate diameters, with conflicting results. Females generally had smaller cervical endplate diameters and inferior vertebral endplates were more concave than superior counterparts. Relationships between gender, age and cervical endplate SA, concavity and concavity apex location were not well reported. Conclusions Literature on three-dimensional (3D) cervical endplate and interbody space morphology is limited. Existing studies are based on linear and area parameters measured from two-dimensional (2D) imaging modalities (computed tomography (CT) and X-rays) in specific planes or 3D reconstructions of scanned spines (living or cadaveric). These 2D parameters do not capture the 3D shape of cervical endplates and studies differ on how they define these parameters, making data difficult to compare. Further studies utilising methods that better capture the 3D shape of cervical endplates would benefit our understanding of vertebral endplates and, thereby, cervical interbody space shape. In turn, greater morphological knowledge of cervical interbody spaces could aid in the design of new generation devices.

Background In 1927, Schmorl described a focal herniation of disc material into the adjacent vertebral body through a defect in the endplate, named as Schmorl’s node (SN). The aim of the study is to reveal the prevalence and distribution of Schmorl’s nodes (SNs) in the lumbar spine and their relation to disc degeneration disease in Kirkuk city population. Results A cross-sectional analytic study was done for 324 adults (206 females and 118 males) with lower back pain evaluated as physician requests by lumbosacral MRI at the Azadi Teaching Hospital, Kirkuk city, Iraq. The demographic criteria of the study sample were 20–71 years old, 56–120 kg weight, and 150–181 cm height. SNs were seen in 72 patients (22%). Males were affected significantly more than the females (28.8% vs. 18.8%, P = 0.03). SNs were most significantly affecting older age groups. L1–L2 was the most affected disc level (23.6%) and the least was L5–S1 (8.3%). There was neither a significant relationship between SN and different disc degeneration scores (P = 0.76) nor with disc herniation (P = 0.62, OR = 1.4), but there was a significant relation (P = 0.00001, OR = 7.9) with MC. Conclusion SN is a frequent finding in adults’ lumbar spine MRI, especially in males; it is related to vertebral endplate bony pathology rather than discal pathology.

Background Destabilization of the vertebral column – as seen in trauma and metastatic spine disease – often requires corpectomy and anterior column reconstruction. Stresses applied to the implant can lead to subsidence, ultimately requiring in surgical revision. Here we report a cadaveric investigation of a novel expandable corpectomy cage with a self-adjusting, multiaxial end cap. Methods Four cadaveric T11-sacrum spines (mean 67.3 yr; 75% female) were treated with L2 corpectomy and T12-L4 pedicle screw fusion. Pressure sensors were applied to the L1 and L3 endplates and anterior column reconstruction was performed with either a standard expandable corpectomy cage (T2A), an expandable corpectomy cage with a self-adjusting, multiaxial end cap (T2S), or the latter cage with oblong, extended end caps (T2S + EE). Total contact area was compared pre- and post-reduction using ANOVA general linear model. Results Pre-reduction, the T2S constructs had a trend of higher surface contact than the conventional T2A constructs, though the results were not significant (p = 0.068); however, T2S + EE constructs did produce significantly larger contact with vertebral endplates (p = 0.04). The difference was also significant for both conditions following compression (p Conclusions The use of an expandable corpectomy cage with a self-adjusting, multiaxial end cap produces significant increases in vertebral endplate contact area. These in vitro data suggest that the self-adjusting, multiaxial end cap may serve to decrease the risk of subsidence in patients undergoing anterior column resection and reconstruction. Clinical data would be required to confirm the relationship between endplate contact area and risk of subsidence.

The positive association between low back pain and MRI evidence of vertebral endplate bone marrow lesions, often called Modic changes (MC), offers the exciting prospect of diagnosing a specific phenotype of chronic low back pain (LBP). However, imprecision in the reporting of MC has introduced substantial challenges, as variations in both imaging equipment and scanning parameters can impact conspicuity of MC. This review discusses key methodological factors that impact MC classification and recommends guidelines for more consistent MC reporting that will allow for better integration of research into this LBP phenotype. Non-systematic literature review. The high diagnostic specificity of MC classification for a painful level contributes to the significant association observed between MC and LBP, whereas low and variable sensitivity underlies the between- and within-study variability in observed associations. Poor sensitivity may be owing to the presence of other pain generators, to the limited MRI resolution, and to the imperfect reliability of MC classification, which lowers diagnostic sensitivity and thus influences the association between MC and LBP. Importantly, magnetic field strength and pulse sequence parameters also impact detection of MC. Advances in pulse sequences may improve reliability and prove valuable for quantifying lesion severity. Comparison of MC data between studies can be problematic. Various methodological factors impact detection and classification of MC, and the lack of reporting guidelines hinders interpretation and comparison of findings. Thus, it is critical to adopt imaging and reporting standards that codify acceptable methodological criteria. These slides can be retrieved under Electronic Supplementary Material.

The aim of the current study was to investigate the multi-dimensional characteristics of lumbar endplate defects in humans in relation to disc degeneration and other MRI phenotypes as well as their role with pain and disability. A total of 108 subjects were recruited and underwent 3T MRI of the lumbar spine. Structural endplate defects were identified and their dimensions were measured in terms of maximum width and depth, and were then standardized to the actual width of the endplate and depth of the vertebral body, respectively. Both width and depth of all endplate defects in each subject were added separately and scores were assigned on the basis of size from 1 to 3. Combining both scores provided "cumulative endplate defect scores." Disc degeneration scores, Modic changes, disc displacement, HIZ, and facet joint changes were assessed. Subject demographics, pain profile, and Oswestry Disability Index (ODI) were also obtained. Endplate defects were observed in 67.5% of the subjects and in 13.5% of the endplates. All dimensions of endplate defects showed significance with disc degenerative scores, Modic changes, and posterior disc displacement (p < 0.05). Maximum width (p = 0.009) and its standardized value (p = 0.02), and cumulative endplate defect scores (p = 0.004) increased with narrow facet joints. Cumulative endplate defect scores showed a strong positive association with ODI (p < 0.05) compared to disc degenerative scores. Large size endplate defects were strongly associated with degenerative spine changes and more back-related disability. Findings from this study stress the need to assess endplate findings from a multi-dimensional perspective, whose role may have clinical utility. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

BACKGROUND CONTEXT The cartilaginous and bony material that can be present in herniated tissue suggests that failure can involve both cartilaginous and vertebral-endplates. How structural integration is achieved across the junction between these two distinct tissue regions via its fibril and mineral components is clearly relevant to the modes of endplate failure that occur. PURPOSE To understand how structural integration is achieved across the cartilaginous-vertebral endplate junction. STUDY DESIGN A micro- and fibril-level structural analysis of the cartilage-vertebral endplate region was carried out using healthy, mature ovine motion segments. METHODS Oblique vertebra-annulus-vertebra samples were prepared such that alternate layers of lamellar fibers extended from vertebra to vertebra. The endplate region of each sample was then decalcified in a targeted manner before being loaded in tension along the fiber direction to achieve incomplete rupture within the region of the endplate. The failure regions were then analyzed with differential interference contrast microscopy and scanning electron microscopy. RESULTS Microstructural analysis revealed that failure within the endplate region was not confined to the cement line. Instead, rupture continued into the underlying vertebral endplate with bony material still attached to the now unanchored annular bundles. Ultrastructural analysis of the partially ruptured regions of the cement line revealed clear evidence of blending/interweaving relationships between the fibrils of the annular bundles, the calcified cartilage and the bone with no one pattern of association appearing dominant. These findings suggest that fibril-based structural cohesion exists across the cement line at the site of annular insertion, with strengthening via a mechanism somewhat analogous to steel-reinforced concrete. The fibrils are brought into a close intermingling association with interfibril forces mediated via the mineral component. CONCLUSIONS This study provides clear evidence of structural connectivity across the cartilaginous-vertebral endplate junction by the intermingling of their fibrillar components and mediated by the mineral phase. This is consistent with the clinical observation that in some disc herniations bony material can be still attached to the extruded soft tissue.

Space travel has grown during the past 2 decades, and is expected to surge in the future with the establishment of an American Space Force, businesses specializing in commercial space travel, and National Aeronautics and Space Administration’s planned sustained presence on the moon. Accompanying this rise, treating physicians are bracing for a concomitant increase in space-related medical problems, including back pain. Back pain is highly prevalent in astronauts and space travelers, with most cases being transient and self-limiting (space adaptation back pain). Pathophysiologic changes that affect the spine occur during space travel and may be attributed to microgravity, rapid acceleration and deceleration, and increased radiation. These include a loss of spinal curvature, spinal muscle atrophy, a higher rate of disc herniation, decreased proteoglycan and collagen content in intervertebral discs, and a reduction in bone density that may predispose people to vertebral endplate fractures. In this article, the authors discuss epidemiology, pathophysiology, prevention, treatment, and future research.

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 pppp=0.01). Histological sections with CEP showed increased HDS (ppr=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.

Objectives To evaluate the changes of Hounsfield units (HU) value in different types of Modic changes (MCs) and to analyze the correlation between the change of HU value and area ratio of MCs region, bone mineral density (BMD), and degree of intervertebral disc degeneration. Methods One hundred fifty-eight endplates with MCs were included and analyzed. HU values of MCs regions and adjacent vertebral corresponding regions without MCs were measured. The area ratio of MCs region was defined as the area of MCs divided by the area of endplate or the vertebral sagittal plane. BMD was measured by Dual-energy x-ray absorptiometry (DXA). Degree of intervertebral disc degeneration was evaluated based on Pfirrmann classification. According to the types of variables, descriptive statistics, Kolmogorove-Smirnov test, paired t-test, Wilcoxon signed-rank test, Independent-Samples T Test, and Pearson correlation analysis were used. Results The HU values in any types of MCs are significantly higher than that of adjacent vertebral corresponding regions without MCs (P Conclusions HU values of the vertebral endplate and bone marrow were increased in most MCs regions with all types of MCs. HU value of endplates had a significantly positive correlation with BMD. Higher area ratio of MCs region is associated with more severe intervertebral disc degeneration.

Lumbar back pain during aging is a major clinical problem, the origins and underlying mechanisms of which are challenging to study. Degenerative changes occur in various parts of the functional spinal unit, such the vertebral endplate and intervertebral disc. The homeostasis of these structural components is regulated by signaling molecules, such as transforming growth factor-β and parathyroid hormone. Previous efforts to understand sources of lumbar back pain focused on sensory innervation in the degenerative intervertebral disc, but intervertebral disc degeneration is frequently asymptomatic. An in vivo mouse model of lumbar spine aging and degeneration, combined with genetic technology, has identified endplate innervation as a major source of lumbar back pain and a potential therapeutic target. In this review, we consider how each structural component of the functional spinal unit contributes to lumbar back pain, how the homeostasis of each component is regulated, and how these findings can be used to develop potential therapies.

Background An annular closure device (ACD) could potentially prevent recurrent herniation by blocking larger annular defects after limited microdiscectomy (LMD). The purpose of this study was to analyze the incidence of endplate changes (EPC) and outcome after LMD with additional implantation of an ACD to prevent reherniation. Methods This analysis includes data from a) RCT study-arm of patients undergoing LMD with ACD implantation and b) additional patients undergoing ACD implantation at our institution. Clinical findings (VAS, ODI), radiological outcome (reherniation, implant integrity, volume of EPC) and risk factors for EPC were assessed. Results Seventy-two patients (37 men, 47 ± 11.63yo) underwent LMD and ACD implantation between 2013–2016. A total of 71 (99%) patients presented with some degree of EPC during the follow-up period (14.67 ± 4.77 months). In the multivariate regression analysis, localization of the anchor was the only significant predictor of EPC (p = 0.038). The largest EPC measured 4.2 cm3. Reherniation was documented in 17 (24%) patients (symptomatic: n = 10; asymptomatic: n = 7). Six (8.3%) patients with symptomatic reherniation underwent rediscectomy. Implant failure was documented in 19 (26.4%) patients including anchor head breakage (n = 1, 1.3%), dislocation of the whole device (n = 5, 6.9%), and mesh dislocation into the spinal canal (n = 13, 18%). Mesh subsidence within the EPC was documented in 15 (20.8%) patients. Seven (9.7%) patients underwent explantation of the entire, or parts of the device. Conclusion Clinical improvement after LMD and ACD implantation was proven in our study. High incidence and volume of EPC did not correlate with clinical outcome. The ACD might prevent disc reherniation despite implant failure rates. Mechanical friction of the polymer mesh with the endplate is most likely the cause of EPC after ACD., BMC Surgery, 21 (1)

Purpose Vertebral endplate bone marrow lesions (“Modic changes”, MC) are associated with chronic low back pain (CLBP). Bone marrow composition in MC is poorly understood. The goals of this study were to: (1) measure bone marrow fat fraction (BMF) in CLBP patients with MC using water–fat MRI and (2) assess the relationship between BMF measurements and patient-reported clinical characteristics. Methods In this cross-sectional study, 42 CLBP patients (men, n = 21; age, 48 ± 12.4 years) and 18 asymptomatic controls (men, n = 10; 42.7 ± 12.8 years) underwent 3 T MRI between January 2016 and July 2018. Imaging consisted of T1- and T2-weighted sequences to evaluate MC and spoiled gradient-recalled echo sequence with asymmetric echoes and least-squares fitting to measure BMF. BMF was compared between vertebrae with and without MC using mixed effects models. The relationship between the BMF measurements and patient-reported disability scores was examined using regression. Results Twenty-seven subjects (26 CLBP, 1 control) had MC, and MC presence coincided with significantly altered BMF. In MC 1, BMF was lower than endplates without MC (absolute difference −22.3%; p p p = 0.029–0.032) and were not associated with pain (p = 0.49–0.83). Conclusion BMF is significantly altered in MC. Water–fat MRI enables BMF measurements that may eventually form the basis for quantitative assessments of MC severity and progression.

This paper aims to provide a comprehensive review of the changing role of hepatocyte growth factor (HGF) signaling in the healthy and diseased synovial joint and spine. HGF is a multifunctional growth factor that, like its specific receptor c-Met, is widely expressed in several bone and joint tissues. HGF has profound effects on cell survival and proliferation, matrix metabolism, inflammatory response, and neurotrophic action. HGF plays an important role in normal bone and cartilage turnover. Changes in HGF/c-Met have also been linked to pathophysiological changes in degenerative joint diseases, such as osteoarthritis (OA) and intervertebral disc degeneration (IDD). A therapeutic role of HGF has been proposed in the regeneration of osteoarticular tissues. HGF also influences bone remodeling and peripheral nerve activity. Studies aimed at elucidating the changing role of HGF/c-Met signaling in OA and IDD at different pathophysiological stages, and their specific molecular mechanisms are needed. Such studies will contribute to safe and effective HGF/c-Met signaling-based treatments for OA and IDD.

This paper describes a minimally invasive technique of percutaneous intervertebral bridging cementoplasty (PIBC) to augment the fractured vertebrae and immobilize the intervertebral space with endplate-disc complex injury simultaneously. Thirty-two patients with adjacent multilevel osteoporotic thoracolumbar fractures (AMOTLFs) and vertebral endplate-disc complex injury (EDCI) treated by PIBC were retrospectively reviewed. The PIBC technique was a combination of puncture, balloon expansion and bridging cementoplasty. The clinical and radiological assessments were reviewed. The operation time was 82.8 ± 32.5 min, and blood loss was 76.9 ± 31.7 mL. A cement bridge was connected between the two fractured vertebrae across the injured intervertebral space. VAS at three time points including pre-operation, post-operation 1 day and final follow-up was 6.9 ± 0.9, 2.9 ± 0.8 and 1.7 ± 0.8, respectively; ODI at three time points was (71.1 ± 7.8)%, (18.4 ± 5.7)%, and (10.3 ± 5.7)%, respectively; Cobb angle at three time points was 46.0° ± 10.4°, 25.9° ± 8.5°, and 27.5° ± 7.1°, respectively. Compared with pre-operation, VAS, ODI and Cobb angle were significantly improved at post-operation 1 day and final follow-up (P

On magnetic resonance (MR) imaging, Modic type 1 (MT1) endplate changes and infectious spondylodiscitis share similar findings. Therefore, this study investigated vertebral bone marrow and endplate changes to enable their differentiation. The lumbar spine MR examinations of 91 adult patients were retrospectively included: 39 with MT1, 19 with early spondylodiscitis without abscess, and 33 with advanced spondylodiscitis with abscess. The assessment included percentage of bone marrow edema on sagittal short tau inversion recovery images, and the signal ratio of edema to unaffected bone and endplate contour (normal, irregular, yet intact, blurred, destructive) on sagittal unenhanced T1-weighted images. Differences were tested for statistical significance by Chi-square test and mixed model analysis of variance. The MR diagnostic accuracy in differentiating MT1 and spondylodiscitis was assessed by cross-tabulation and receiver-operating characteristic analysis. The endplate contours, edema extents, and T1-signal ratios of MT1 (extent, 31.96%, ratio, 0.83) were significantly different (p &lt, 0.001) from early spondylodiscitis (56.42%, 0.60), and advanced spondylodiscitis (91.84%, 0.61). The highest diagnostic accuracy (sensitivity, 94.87%, specificity, 94.23%, accuracy, 94.51%) in identifying MT1 was provided by an irregular, yet intact endplate contour. This may be a useful MR feature for the differentiation between MT1 and spondylodiscitis, particularly in its early stage.

Melatonin is reportedly associated with intervertebral disc degeneration (IDD). Endplate cartilage is vitally important to intervertebral discs in physiological and pathological conditions. However, the effects and mechanism of melatonin on endplate chondrocytes (EPCs) are still unclear. Herein, we studied the effects of melatonin on EPC apoptosis and calcification and elucidated the underlying mechanism. Our study revealed that melatonin treatment decreases the incidence of apoptosis and inhibits EPC calcification in a dose‐dependent manner. We also found that melatonin upregulates Sirt1 expression and activity and promotes autophagy in EPCs. Autophagy inhibition by 3‐methyladenine reversed the protective effect of melatonin on apoptosis and calcification, while the Sirt1 inhibitor EX‐527 suppressed melatonin‐induced autophagy and the protective effects of melatonin against apoptosis and calcification, indicating that the beneficial effects of melatonin in EPCs are mediated through the Sirt1‐autophagy pathway. Furthermore, melatonin may ameliorate IDD in vivo in rats. Collectively, this study revealed that melatonin reduces EPC apoptosis and calcification and that the underlying mechanism may be related to Sirt1‐autophagy pathway regulation, which may help us better understand the association between melatonin and IDD.

A cross-sectional magnetic resonance (MR) imaging study.To classify and characterize endplate defects using routine lumbar MR images and to determine associations of endplate defects with Modic changes (MCs) and disc degeneration.Previously, a cadaveric study revealed that endplate lesions were common and associated with back pain history. New in vivo approaches appropriate for clinical studies are needed to further this potentially important line of research on the clinical significance of endplate lesions, including their relation with MCs, disc degeneration, and back pain.Using a MRI archive, 1564 endplates of 133 subjects (59 men and 74 women, mean age 58.9 ± 11.9 years) with the presence of MCs were retrospectively collected from April of 2014 to June of 2015. On the basis of morphological characteristics, a protocol was proposed to identify three distinct types of endplate defects, including focal, corner, and erosive defects. The location, size, and distribution patterns of various endplate lesions were characterized. MCs and disc degeneration were measured to examine their associations with endplate defects.Endplate defects were observed in 27.8% of endplates studied. Greater age was associated with the presence of endplate defects. Focal defects were the most common (13.5%), followed by erosive defects (11.1%) and corner defects (3.2%). Defect types also differed in size and distribution patterns. Endplate defects and MCs had similar distribution patterns in the lumbar spine. The presence of endplate defects were associated with the presence of MCs (odds ratio = 4.29, P 0.001), and associated with less disc signal intensity and disc height, and greater disc bulging (P 0.05).The three endplate defects identified on routine MR images appear to represent different pathologies and may play a key role in the pathogenesis of MCs. This classification system may facilitate clinical studies on endplate defects.4.

Osteoporosis is the most common metabolic bone disease, and vertebral fractures (VFs) are the most common osteoporotic fracture. A single atraumatic VF may lead to the diagnosis of osteoporosis. Prevalent VFs increase the risk of future vertebral and non-vertebral osteoporotic fracture independent of bone mineral density (BMD). The accurate and clear reporting of VF is essential to ensure patients with osteoporosis receive appropriate treatment. Radiologist has a vital role in the diagnosis of this disease. Several morphometrical and radiological methods for detecting osteoporotic VF have been proposed, but there is no consensus regarding the definition of osteoporotic VF. A vertebra may fracture yet not ever result in measurable changes in radiographic height or area. To overcome these difficulties, algorithm-based qualitative approach (ABQ) was developed with a focus on the identification of change in the vertebral endplate. Evidence of endplate fracture (rather than variation in vertebral shape) is the primary indicator of osteoporotic fracture according to ABQ criteria. Other changes that may mimic osteoporotic fractures should be systemically excluded. It is also possible that vertebral cortex fracture may not initially occur in endplate. Particularly, vertebral cortex fracture can occur in anterior vertebral cortex without gross vertebral deformity (VD), or fractures deform the anterior vertebral cortex without endplate disruption. This article aims to serve as a teaching material for physicians or researchers to identify vertebral endplate/cortex fracture (ECF). Emphasis is particularly dedicated to identifying ECF which may not be associated apparent vertebral body collapse. We believe a combined approach based on standardized radiologic evaluation by experts and morphometry measurement is the most appropriate approach to detect and classify VFs.

OBJECTIVE. In the 29 years since the initial description of Modic type 1 vertebral endplate changes there has been ongoing debate regarding their cause. Studies have attributed Modic type 1 vertebral endplate changes to traumatic injury to the vertebral endplate, localized action of proinflammatory mediators, and more recently low-grade bacterial infection. Can we reconcile these conflicting data about the underlying cause of Modic type 1 vertebral endplate changes? Are we now in a position to conclude whether Modic type 1 vertebral endplate changes are secondary to injury, inflammation, or infection? CONCLUSION. We argue that the processes are not disparate but are in fact closely linked, each potentially instigating a chain of events leading to the MRI findings of Modic type 1 vertebral endplate change. A method of delineating which process is predominantly at play in an individual patient is required so that tailored treatment options can be offered with huge potential benefit to individuals and societ...

To examine monosegmental lordosis after posterior lumbar interbody fusion (PLIF) surgery and relate lordosis to cage size, shape, and placement. Eighty-three consecutive patients underwent single-level PLIF with paired identical lordotic cages involving a wide decompression and bilateral facetectomies. Cage parameters relating to size (height, lordosis, and length) and placement (expressed as a ratio relative to the length of the inferior vertebral endplate) were recorded. Centre point ratio (CPR) was the distance to the centre of both cages and indicated mean position of both cages. Posterior gap ratio (PGR) was the distance to the most posterior cage and indicated position and cage length indirectly. Relationships between lordosis and cage parameters were explored. Mean lordosis increased by 5.98° (SD 6.86°). The cages used varied in length from 20 to 27 mm, in lordosis from 10° to 18°, and in anterior cage height from 10 to 17 mm. The mean cage placement as determined by CPR was 0.54 and by PGR was 0.16. The significant correlations were: both CPR and PGR with lordosis gain at surgery (r = 0.597 and 0.537, respectively, p

Study Design: Prospective cohort study. Objective: Endplate lesions though have been implicated in the genesis of lumbar disc herniation (LDH), very little is known regarding their clinical course. Thus, the present study is aimed to investigate the incidence and types of endplate failure (EPF) in LDH and its correlation with the clinical symptoms and prognosis. Methods: Clinical and magnetic resonance imaging (MRI) features of 66 patients with isolated single level LDH were studied. Three-dimensional fast spoiled gradient (3D FSPGR) MRI and computed tomography scans were used to identify the bony and cartilaginous EPF. Twenty-five patients were operated on and 41 patients were treated conservatively. Changes in the pain score, function and neurology were noted at 3, 6, 12, 24, and 36 weeks. Results: Endplate lesions were observed in 64 patients (96.9%), including bony endplate failure (bony failure) in 47 patients (71.2%) and isolated cartilaginous endplate lesions in 17 patients (25.7%). Bony failure group had similar pain and functional scores but more severe neurological deficit at the initial evaluation. Clinical parameters improved in all groups, but the recovery was lesser in conservatively treated bony failure patients. Conclusion: Endplate lesions are commonly associated with symptomatic LDH. Presence of bony failure can increase neurological deficit and reduce the chance of recovery with conservative management. The 3D FSPGR sequence of MRI can be successfully used for detection of the endplate lesions in the herniated disc.

To summarize the scope of nomenclature and measurement methods used to document endplate defects in the health sciences literature. The scoping review followed the York framework and was reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. The databases of PubMed, Scopus, Embase and CINAHL were searched using key terms. Screening and selection were conducted by two independent reviewers. A standardized, pilot-tested form was used for extracting data, which were analyzed descriptively. The review included 211 studies, originating from 29 countries, with the USA (18.8%) and China (12.26%) as leading contributors. Thirty-four different terms for structural endplate defects were reported, but were never defined in most studies (65%). Of the 34 different terms used, some appeared to represent the same phenomenon, while the same terms were occasionally defined differently between studies. Schmorl’s nodes were most commonly investigated (n = 99 studies) and defined similarly across studies, with the main difference relating to whether the indentation (node) was required to have a sclerotic margin. There were also similarities in definitions for endplate sclerosis. However, there was great variability in the definitions of other terms, such as lesions, irregularities, abnormalities, erosions and changes. With the possible exception of Schmorl’s nodes, we lack a common language for effectively communicating structural endplate findings. This review provides a foundation and impetus for standardizing terminology and core measures to improve communication and synthesis of the growing body of endplate research to advance related knowledge. These slides can be retrieved under Electronic Supplementary Material (paragraph). Then process the ppt slide as graphical image.

The anatomical descriptions of the IVD include the nucleus pulposus and annulus fibrosus (classic but not as evident in the young), the vertebral endplate, and the marginal listel (apophyseal ring). The IVD infrastructure consists of proteoglycans, collagen, hyaluronic acid, and water with a hydrophilic role, hydraulic shock absorber, and stress transmission according to a tensegrity model (tensional integrity). MR imaging shows the different types of herniated discs and guides the therapeutic decision. The disc pressure is measured in vivo and the endoscopic approach for radiofrequency of the fissure zone is discussed, superseding blind percutaneous approaches.

Background This study was undertaken to determine the relationship between intervertebral endplate changes and intervertebral disc disease. This study was designed as a cross-sectional, observational study. Two hundred thirteen canine MRI scans performed between 2007 and 2014 were retrieved from a digital image archive. Scans which included any sagittal sections of the vertebral column from C1 to S1 were assessed for morphological changes to the vertebral endplate. Results There was found to be a significant association between vertebral endplate changes and intervertebral disc disease of the adjacent disc (P = 0.021). There was not found to be any significant association between dogs having vertebral endplate changes and having intervertebral disc disease (P = 0.38). There was found to be a highly significant association between discs with vertebral endplate changes on both associated vertebrae (bilateral) and having intervertebral disc disease (P = Conclusions The presence of endplate changes should alert the observer to closely examine the disc, as intervertebral disc disease is mildly more likely to occur adjacent to these changes.

This paper describes a novel automatic system for Modic changes classification of vertebral endplates. Modic changes are classes of vertebral degenerations visible as intensity variations in magnetic resonance images (MRI). The system operates on T1 and T2 MRI. We introduce three main novelties: 1. a vertebrae alignment scheme via precise bounding boxes obtained through corner localisation, 2. vertebral endplate classification in three dimensions, and 3. Modic changes classification. The system was trained and validated using a large dataset of 785 patients, containing MRIs sourced from a wide range of acquisition protocols. The proposed system achieved 87.8 % classification accuracy on our dataset.

Though segmentation of spinal column from medical images have been intensively studied for decade, most of the works were concentrated on the segmentation of the vertebral body and arch, instead of the endplate. Recently, the increasing study on degeneration analysis of vertebra and intervertebral disc (IVD) make endplate segmentation as important as others. While the accurately segmentation of mice endplate from micro computed tomography (CT) images is challenging. The major difficulties include potential high system payload and poor run-time efficiency resulting from high-resolution micro-CT data, highly complicated and variable shape of the vertebra tissues, and the ambiguous segmentation boundary due to the similarity of spongy structures inside both the endplate and its adjacent vertebral body. To solve the problems, the core idea of the proposed method is to identify trabeculae between the endplate and the body through a graph-based strategy. In addition, in order to reduce the data complexity, an endplate-targeted region of interest (ROI) extraction method is introduced according to the analysis of spatial relationship and variety of bone density of vertebra. Furthermore, shape priori of endplate in both two-dimensional and three-dimensional are extracted to assist in the segmentation. Finally, an iterative cutting procedure is implemented to produce the final result. Experiments were carried out which validate the performances of the proposed method in terms of effectiveness and accuracy.

Degenerative disc disease, associated with discrete structural changes in the peripheral annulus and vertebral endplate, is one of the most common pathological triggers of acute and chronic low back pain, significantly depreciating an individual’s quality of life and instigating huge socioeconomic costs. Novel emerging therapeutic techniques are hence of great interest to both research and clinical communities alike. Exogenous crosslinking, such as Genipin, and platelet-rich plasma therapies have been recently demonstrated encouraging results for the repair and regeneration of degenerated discs, but there remains a knowledge gap regarding the quantitative degree of effectiveness and particular influence on the mechanical properties of the disc. This study aimed to investigate and quantify the material properties of intact (N = 8), trypsin-denatured (N = 8), Genipin-treated (N = 8), and platelet-rich plasma–treated (N = 8) discs in 32 porcine thoracic motion segments. A poroelastic finite element model was used to describe the mechanical properties during different treatments, while a meta-model analytical approach was used in combination with ex vivo experiments to extract the poroelastic material properties. The results revealed that both Genipin and platelet-rich plasma are able to recover the mechanical properties of denatured discs, thereby affording promising therapeutic modalities. However, platelet-rich plasma–treated discs fared slightly, but not significantly, better than Genipin in terms of recovering the glycosaminoglycans content, an essential building block for healthy discs. In addition to investigating these particular degenerative disc disease therapies, this study provides a systematic methodology for quantifying the detailed poroelastic mechanical properties of intervertebral disc.

Accurate determination of vertebral endplate surface area and diameters plays an important role in surgical procedures, spinal implant design and sizing. The objective of this study was to contribute with baseline information on the endplate geometrical parameters using subject-based 3D whole-spine computed tomography (CT) models based on myelogram CT images taken of 49 patients with spinal disorders. Superior and inferior bony endplate mesh-models were created from said 3D CT models and endplate geometrical parameters including total polygon-mesh areas, projected areas and antero posterior and transverse diameters of each endplate were measured. The position of each endplate was determined by the cumulative distance along the spinal column with respect to C2. Endplate area and diameters were analyzed by gender, spinal level, age and correlation with spinal position. Males had larger endplates than females at all levels (p

We propose a method for automated grading of the vertebral endplate regions according to the Modic changes scale based on the VGG16 network architecture. We evaluate four variations of the method in a standard 9-fold cross-validation study setup on a heterogeneous dataset of 92 cases. Due to the very weak representation of the Modic Type III in the dataset, we focus on the grading of Modic Type I and Modic Type II. Despite the relatively small size of our dataset, the pipeline demonstrated a performanc1e that is similar to or better than those achieved by the state-of-the-art methods. In particular, the most performant variant achieved an accuracy of 88.0% with an average-per-class accuracy of 77.3%. When the method is used as a binary detector for the presence or not of Modic changes, the achieved average-per-class accuracy is 92.3%. Our evaluation also suggests that the so-called mixup strategy is particularly useful for this type of classification task.

Despite years' research, the radiographic criteria for osteoporotic vertebral fracture and its grading remain debated. The importance of identifying vertebral endplate/cortex fracture (ECF) is being recognised; however, evaluation of osteoporotic ECF requires training and experience. This article aims to serve as a teaching material for radiologists/physicians or researchers to evaluate osteoporotic ECF. Emphasis is particularly dedicated to identifying ECF that may not be associated with apparent vertebral body collapse. We suggest a combined approach based on standardised radiologic evaluation by experts and morphometry measurement is the most appropriate approach to detect and classify osteoporotic vertebral fractures. The translational potential: A good understanding of radiologic anatomy of vertebrae and fracture signs of endplate/cortex are essential for spine fragility fracture assessment. Keywords: Endplate, Normal variants, Osteoporosis, Osteoporotic fractures, Radiograph

A novel morphometric measurement of endplate degradation was compared with qualitative ratings of intervertebral disc degeneration (Pfirrmann Grading) in a double-blinded study to investigate a new, quantitative method for relating disc morphology and bony changes using MR imaging techniques known as the “Concavity Index” (CI). By adding a quantitative measure of vertebral endplate degeneration, the CI could provide further insight into structural changes related to disc breakdown and subsequent low back pain. The continuous nature of the CI may also allow medical professionals to more closely monitor a patient’s low back health. T2-weighted MRI scans of the sagittal profile of the lumbar endplates (L2-S1) were collected from 50 subjects (25 females and 25 males) whose ages ranged from 20–40 years. Three trained examiners independently measured the height and the concavity levels of each lumbar vertebrae (L2-S1) as well as assessed the health of the intervertebral discs using Pfirrmann’s lumbar disc degeneration grading method. Concavity Indices (CIs) were computed by dividing measured concavity level by disc height (CL/DH). A larger CI was hypothesized to be indicative of spinal degradation and subsequent low back pain. Intra- and inter-rater reliabilities were assessed for both the CI measurements and Pfirrmann’s lumbar disc degeneration grades. The categorical intra-observer agreement for Pfirrmann ratings ranged from 26 to 63%. However, the CI, which is a continuous measure, varied by only 2% (average absolute error) among raters. Endplate concavity is indicative of fracturing and damage and is hypothesized to lead to subsequent disc degeneration due to impediment of nutrient flow to the discs themselves. The CI shows promise as a means for potentially quantifying low back health and identifying risk for future low back pain prior to significant disc degeneration.

STUDY DESIGN: Cross-sectional study of spine MR in a population, predominantly female, sample.OBJECTIVE: To determine the relationship between vertebral endplate defect and intervertebral disc degeneration (DD) in general population.SUMMARY OF BACKGROUND DATA: Precise understanding of the mechanisms leading to DD development is lacking. In a degenerating disc, mechanical and structural changes lead to further worsening of disc integrity. Increasing attention has been paid to vertebral endplate defects as having a possible role in the etiopathogenesis of DD.METHODS: The study population comprised 831 twin volunteers from TwinsUK (mean age 54 ± 8 years, 95.8% female). Lumbar T2-weighted magnetic resonance images were coded for endplate defects from 8310 endplates into six grades. Total endplate score (TEP score) was achieved by summing both endplate defect grades from the same disc level. DD was evaluated using two different classifications; Pfirrmann grading, and a quantitative trait for DD based on a 4-point grading systems. Multivariable regression analysis was used to determine relationships between the traits of interest and the known risk factors for DD, age and body mass index (BMI). A receiver operator curve for TEP score predicting DD was generated, and survival analysis paired with Cox proportional hazards models analysis performed.RESULTS: There was statistically significant association between DD and age and BMI. These associations lost significance when TEP score was included as predictor in multivariable model. TEP score was strongly and independently associated at every lumbar disc level with DD (Pfirmann p≤0.001; 4-point grading systems p CONCLUSIONS: Our large, population-based study has shown that endplate defect was strongly and independently associated with DD at every lumbar disc level. These results provide a mechanism by which increasing age and BMI predispose to DD.LEVEL OF EVIDENCE: 2.

Modic changes [vertebral endplate spinal changes (VESC)] have been related to degenerative disk disease, and in past decades it was thought that their presence justified the surgical treatment, in particular spinal fusion.The aim of the present study is to investigate its prevalence and features in a population of young workers suffering from low back pain, and explore the eventual relationship with the treatment applied in each case.We conducted a retrospectively review of 450 magnetic resonance images from our hospital, in patients with low back pain or sciatica and age below 40.Age, sex, symptoms predominance, concurrence with other spine disease, VESC type, evolution, level/s of involvement and placement, affected disk location and extent of the disease, disk height, and status of the endplate were recorded. The applied treatment was divided in groups according to the degree of invasiveness of the procedure.Prevalence of VESC was 13.05% predominant in patients over 30 years, and 100% associated to disk degenerative changes. Most frequent features were: type I (54%), lower lumbar region (98%), along with a decreased disk height (68%), and distortion of the disk endplates (98%, P0.01). The patients with VESC presented a favorable outcome with conservative treatment, but were more frequently associated with invasive treatment, compared with non-VESC patients (P0.024).VESC prevalence increases with age, underlying the degenerative causative etiology. Surgical indication should not be stated on the basis of the VESC findings alone, the main factor for indicating surgery depends more on other associated degenerative spinal changes.

Vertebral endplate abnormalities may be associated with disc degeneration and, perhaps, pain generation. However, consensus definitions for endplate findings on spine MRI do not exist, posing a challenge to compare findings between studies and ethnic groups. The following survey was created to characterize the variability among the global spine community regarding endplate structural findings with respect to nomenclature and etiology. A working group within the International Society for the Study of the Lumbar Spine (ISSLS) Spinal Phenotype Focus Group was established to assess the endplate phenotype. A survey which consisted of 13 T2-weighted sagittal MRIs of the human lumbar spine illustrating the superior and inferior endplates was constructed based on discussion and agreement by the working group. A list of nomenclature and etiological terms with historical precedence was generated. Participants were asked to describe the endplates of each image and select from 14 possible nomenclatures and 10 etiological terms along with the option of free text response. The survey was entered into RedCap and was circulated throughout the ISSLS membership for data capture. Participants’ demographics were also noted. The survey was completed by 55 participants (87% males; 85% above 45 years of age, 39 clinicians, and 16 researchers). Sixty-eight percent of researchers and seventy-four percent of clinicians reported more than 16 and 20 years of research and clinical experience. Considerable variation existed in selection of nomenclature, etiology, and degree of severity of the endplate structural findings (reliability coefficients for single measures in each case were 0.3, 0.08, and 0.2, respectively). Sixty-seven percent regarded Modic changes as being a structural endplate finding. Approximately 84 and 80% of clinicians and researchers, respectively, agreed that a standardized endplate nomenclature and understanding the etiology is clinically important and needed. This study found that variations exist with respect to endplate nomenclature and etiology between clinicians and basic scientists, and paves the way for a consensus process to formalize the definitions.

Epidemiological and biomechanical evidence indicates that the risk of vertebral fracture differs between men and women, and that vertebral fracture frequently involves failure of the endplate region. The goal of this study was to compare the bone microstructure of the endplate region-defined as the (bony) vertebral endplate and underlying subchondral trabecular bone-between sexes and to determine whether any such sex differences are associated with vertebral strength. The bone density (volume fraction, apparent density and tissue mineral density) of the superior-most 2 mm of the vertebra, and the bone density and trabecular architecture of the next 5 mm were quantified using micro-computed tomography in human T8 (12 female, 16 male) and L1 (13 female, 12 male) vertebrae. Average density of the vertebra (integral bone mineral density (BMD)) was determined by quantitative computed tomography and compressive strength by mechanical testing. Few differences were found between male and female vertebrae in the density of the endplate region; none were found in trabecular architecture. However, whereas endplate volume fraction was positively correlated with integral BMD in male vertebrae (r = 0.654, p .001), no correlation was found in the female vertebrae (r = 0.157, p = .455). Accounting for the density of the endplate region improved predictions of vertebral strength (p .034) and eliminated sex-specificity in the strength prediction that was based on integral BMD alone. These results suggest that the density of the endplate region influences vertebral fracture and that non-invasive assessment of this region's density can contribute to predictions of vertebral strength in men and women.

Vertebral end-plate changes/modic changes are the MRI-image of inflammatory vertebral endplate damage, most often related to general disc degeneration. However, in a subgroup of patients disc infection may be the causal factor. In patients with prolonged back pain, the prevalence of modic changes (MC) is 40%. In most cases, nocturnal pain is the rule and MC causes highly localized pain 24/7. There are currently no better diagnostic methods than MRI and case history findings. In persistent back pain after a disc herniation and emerging MC type 1, it is relevant to consider: 'disc infection'. Most commonly, Propionibacterium acnes is involved. Long-term antibiotics may be effective. Vertebral end-plate changes/modic changes are the MRI-image of inflammatory vertebral endplate damage, most often related to general disc degeneration and low back pain. However, in a subgroup of patients disc infection may be the causal factor. In patients with prolonged back pain, the prevalence of modic changes (MC) is 40%. In most cases, nocturnal pain is the rule and MC causes highly localized pain 24/7. There are currently no better diagnostic methods than MRI and case history findings. In persistent back pain after a disc herniation and emerging MC type 1, it is relevant to consider: 'disc infection'. Most commonly, Propionibacterium acnes is involved. Long-term antibiotics may be effective.

BACKGROUND CONTEXT The transforaminal lumbar interbody fusion (TLIF) approach was developed to avoid the risks of the anterior lumbar interbody fusion (ALIF) and posterior lumbar interbody fusion (PLIF) approaches, and their potential for damage to the major vessels and the neurological elements, respectively. Contact between the entire spacer and the adjacent endplates of these various techniques is paramount to providing stability, increasing fusion rates, and reducing subsidence. A novel bilateral-TLIF technique includes reconstruction via a bilateral facetectomy and the placement of two interbody spacers along the lateral margins of the disc space. Bone graft is pre-packed in the graft chamber as well as between spacers. PURPOSE The goal of this study was to assess spacer and graft contact with the endplate of the proposed technique compared to various standard constructs. STUDY DESIGN/SETTING In vitrobiomechanics study. OUTCOME MEASURES Spacer and graft contact percentage was calculated from sagittal images across the entire width of the disc space for each specimen. METHODS Twenty-four fresh frozen cadaveric spines (L3–L4/L5–S1) were divided into four groups with equivalent bone mineral density average scores (n=6). Specimens were instrumented with either (1) one static ALIF spacer; (2) one standard TLIF static oblique spacer (Ob); (3) two static bilateral-TLIF spacers (BiSt); or (4) two expandable bilateral-TLIF spacers (BiEx). Specimens were scanned using the SkyScan-1173 (Bruker microCT, Belgium) with an isotropic resolution of 35um. Quantitative analysis was performed using DataViewer (Bruker microCT) and CTAn software (Bruker microCT). Based on sagittal images, spacer and graft contact percentage was calculated by dividing the contact length of graft and spacer on the endplate, by endplate length. The relative percentage was averaged across the entire width of the disc space for each specimen. Statistical analysis was performed (p RESULTS BiST (27.5%) exhibited the highest spacer and graft contact percentage followed by BiEX (21.4%) > ALIF (19.6%) > Ob (9.9%) (Figure 1). ALIF, BiST, and BiEX groups had significantly higher contact with the vertebral endplate compared to Ob (p=0.005, 0.000, and 0.001, respectively). CONCLUSIONS The proposed bilateral-TLIF technique resulted in relative spacer and graft contact area comparable to ALIF and significantly increased contact with the endplate compared to an oblique spacer. A benefit to the proposed approach is higher graft contact with the endplate due to graft packed between the spacers. It can be suggested that because of higher graft contact, this unique approach may potentially increase fusion rates. FDA DEVICE/DRUG STATUS Interbody spacers (Approved for this indication)

Study design The bone union rate after lumbar interbody fusion (LIF) using titanium (Ti) or polyetheretherketone (PEEK) cages was investigated retrospectively. Objective To assess whether the PEEK cage is superior to the Ti cage in terms of bone union after LIF. Summary of background data We previously reported that the formation of vertebral endplate cysts is useful for predicting nonunion after LIF using Ti cages. Methods We examined 144 levels in 117 patients treated from March 2005 to July 2012 with transforaminal LIF using Ti (93 levels in 77 patients) or PEEK cages (51 levels in 40 patients) with pedicle screw fixation. Using computed tomography, vertebral endplate cyst (cyst sign) was evaluated at 3 months, and bone union status was evaluated at 1 and 2 years postoperatively. The relationship between cyst sign and union status was analyzed statistically. The bone union rate and the accuracy of the cyst sign were compared between the two groups. Results The postoperative bone union rate was 75.2% and 74.5% at 1 year, and 82.8% and 80.4% at 2 years for Ti and PEEK groups, respectively. The rate of positive cyst sign was 17.2% and 13.7%, respectively. The nonunion rate with positive cyst sign was 100% and 100% at 1 year, and 56.2% and 71.4% at 2 years, respectively. Calculated for the cyst sign and union status, the sensitivity was 69.6% and 53.8%, and the specificity was 100% and 100%, respectively. There were no significant differences in bone union rate, rate of positive cyst sign, nonunion rate with positive cyst sign, sensitivity, and specificity between the two groups. Conclusion The cyst sign was useful for predicting nonunion after LIF using PEEK or Ti cages. The bone union rate after LIF did not differ significantly between the two groups. Level of evidence 3.

The aim of this study was to develop a novel method for observing the morphology of the blood vessels in the rabbit endplate. Twenty 6-month-old rabbits were used in this study. The blood vessels in the L5 endplate in Group A were injected with iohexol and Group B with barium sulfate. Group C was the control group with saline. To optimize the study, Group B was divided into two subgroups: Group B-1 was injected with 100% (w/v) barium sulfate and Group B-2 with 50% (w/v). After injection, the L4–L5 vertebral body was excised and the cranial endplate of L5 was scanned using a micro-CT scanner. Models of the vertebral endplate and vessels were reconstructed using the 3D reconstruction software (Mimics 16.0) by calculating a bone threshold value, and then merged these two models to create a superimposed model. The 3D vessel models could not be created in Groups A and C, but they were clearly visualized in Group B. In the 3D model, the blood vessels extended from the subchondral bone to the endplate, and the density of the blood vessels in the area of the nucleus pulposus (NP) was higher than in the annulus fibrosus. The results of this study suggest that the blood vessels in the rabbit endplate can be clearly observed by the method described using barium sulfate [the 50% (w/v) gave better results compared with the 100% (w/v)]. The information from the 3D vessel structure could provide essential data to help us understand the nutrient pathways within the vertebral endplate.

BACKGROUND AND PURPOSE: Data on the association between vertebral endplate changes and low back pain are contradictory. This study was designed to assess whether this association exists among Southern European subjects. MATERIALS AND METHODS: Patients in this study serving as cases were 35–50 years of age with low back pain lasting >90 days, for whom a lumbar MR imaging had been prescribed. Controls were subjects 35–50 years of age, having a cranial MR imaging for headache with normal findings, and no history of clinically relevant LBP. Two hundred forty cases and 64 controls were recruited consecutively in the radiology services across 6 cities in Spain. Imaging findings and subject characteristics were gathered through previously validated instruments. Radiologists who interpreted MRI were blinded to the subject characteristics. A multivariate logistic regression model was developed to assess the association of vertebral endplate changes with LBP, adjusting for sex, age, body mass index, lifetime exposure to smoking, physical activity, disk degeneration, and the interaction between disk degeneration and vertebral endplate changes. RESULTS: Vertebral endplate changes were found in 80.4% of the cases and in 87.5% of the controls. In the regression model, disk degeneration was the only variable showing a confounding effect. Results showed that after adjusting for disk degeneration, the presence of vertebral endplate changes is associated with the absence of chronic LBP (OR for LBP: 0.31; 95% CI, 0.10–0.95). CONCLUSIONS: In Southern European subjects, vertebral endplate changes are not associated with chronic LBP.

Spinal MR images acquired from canine patients over a 7-year period were reviewed for the presence of vertebral endplate changes. Seventy-five dogs with 76 distinct lesions were identified. Presumptive diagnoses fell into five categories: reactive endplate changes (10 dogs/13.2%), discospondylitis (29 dogs/38.2%), vertebral osteochondrosis (7 dogs/9.2%), intravertebral disc herniation (Schmorl's nodes) (4 dogs/5.3%), and fatty infiltration (26 dogs/34.2%). Fatty infiltration occurred significantly more often in small breed dogs (P