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This study aimed to characterize the mechanical properties of native human ligamentum flavum (LF) and correlate them with histopathological changes. Mechanical property gradients across the cranial, medial, and caudal regions of LF were mapped and compared with histological sections. We also compared lumbar spinal stenosis (LSS) samples with disc herniation (DH) samples as reference material to identify differences in mechanical properties and histopathological features. Our results revealed significant heterogeneity in LF mechanical properties, with local variations correlating with specific histopathological changes such as chondroid metaplasia and loss of elastic fibers. These findings underscore the importance of considering LF heterogeneity in mechanical characterization and provide insights into its behavior under pathological conditions., (Creative Commons Attribution license.)

Background: To analyze the characteristics of an unnamed interlaminar ligaments(ILL) through magnetic resonance image (MRI), endoscopy and pathological examination., Method: A retrospective study was conducted to analyze the clinical data of patients who underwent posterior endoscopic surgery for lumbar disc herniation or lumbar spinal stenosis from January 2021 to February 2022 at our medical center. The height, width and cross-sectional thickness of the ligament was analyzed using T2 weighted MRI. Meanwhile, the morphological and pathological characteristics were also compared with those of the ligamentum flavum to highlight the differences between above mentioned ligaments., Result: Forty-three patients were included in this study, including 27 males and 16 females, with an average age of 46.6 ± 12.1y. There were 20 cases of lumbar disc herniation and 23 cases of lumbar spinal stenosis. The width, length, thickness of the ILL, the thickness of LF and surgical time in the lumbar disc group were 17.7 ± 3.5 mm, 4.3 ± 1.3 mm, 18.3 ± 3.5 mm, 5.3 ± 1.9 mm, 53.2 ± 14.5 min, respectively. In the lumbar spinal stenosis group, the corresponding parameters were 16.0 ± 3.1 mm, 4.1 ± 1.6 mm, 17.6 ± 4.8 mm, 6.3 ± 0.8 mm, 61.8 ± 12.4 min, respectively. The intergroup difference in thickness of the ligamentum flavum was statistically significant (P = 0.02). The difference in surgical time was also established(P = 0.04). Endoscopic differences were identified as to the location of the anchor points and appearances among the two ligaments. Significant differences in the density and direction of fibrous structures were also observed under biopsy. Under endoscopy, significant difference as to the grade of ILL thickness was established when compared regarding disease spectrum (P = 0.09.) CONCLUSION: The interlaminar ligament is a structure that has not yet been officially named, which has significant structural differences from those of the ligamentum flavum. For posterior endoscopic procedure, its clinical significance lies in its ability to serve as the endpoint of soft tissue channel establishment. The thickness of the ligamentum flavum in MRI and the thickness of ILL under endoscopy vary according to the disease spectrum., (© 2024. The Author(s).)

Spontaneous regression of lumbar disc herniation refers to shrinkage or disappearance of herniated nucleus pulposus without invasive surgical treatments. This phenomenon has been reported and is supported by improved clinical symptoms and radiographic after conservative treatment, but the underlying mechanism remains unclear. This article reports 4 cases of disc reabsorption and reviews the distribution of several clinical and radiographic factors of disc herniation reabsorption of total 46 patients, including the four from our study, gathered from 28 recent publications. Some of these factors are present with anomalous distributions. But some factors have similar deviations in patients with lumbar disc herniation. Therefore, more research is needed to explore the correlation between those factors and disc reabsorption.

Background Context: Vertebral endplate defects are often implicated in degenerative disc disorders, yet their connection to patient-reported symptoms remains unclear. COX-2 and PGE-2 are known for their roles in inflammation and pain, with EP-4 receptor involvement in pain signaling. Examining their expression in vertebral endplate tissues may provide insights into pathomechanism of low back pain., Purpose: To investigate the association between endplate defects and patient-reported symptoms and to further clarify the role of the COX-2/PGE-2/EP-4 axis in the pathogenesis of chronic low back pain., Study Design/setting: Retrospective study., Patient Sample: A total of 71 patients who had undergone single-level L4/5 or L5/S1 modified laminectomy decompression preserving proximal upper laminae and transforaminal lumbar interbody fusion surgery were included in this study, including 18 patients diagnosed with lumbar disc herniation, 19 with lumbar disc herniation accompanied by degenerative lumbar spinal stenosis, and 34 with degenerative spondylolisthesis., Outcome Measures: Demographic data, Pfirrmann grade, Modic changes, endplate defect score, visual analog scale (VAS) for back and leg pain, and Oswestry Disability Index (ODI) before surgery, 3-month and 6-month follow-up, and the percentage of immune-positive cells (COX-2, PGE-2, and EP-4) in endplate tissue sections., Methods: Patients were divided into defect and nondefect groups according to endplate morphology on lumbar MR. All intraoperative endplate specimens were immediately fixed in 10% formaldehyde, and then embedded in paraffin 3 days later for tissue sections. The outcome measures were compared between the defect group and nondefect group. Data were analyzed using independent t-tests and χ² tests. Pearson's rank correlation test was used to assess correlations between patient-reported symptoms and the percentage of immune-positive cells in the groups. Multivariable logistic regression models using the forward stepwise likelihood ratio method were used to identify the factors that were independently associated with endplate defects., Results: The age of Defect group was significantly higher than that of nondefect group (52.5±7.7 vs 57.2±9.1. p=.024). There were no significant differences in gender, diagnosis, BMI, comorbidities, or surgical level between the two groups. Modic changes (Type Ⅱ/Type Ⅲ) were more common in patients of Defect group than nondefect group (38.5% vs 11.1%, p<.001), and so was disc degeneration (Pfirrmann grade Ⅳ/Ⅴ) (69.2% vs 33.3%, p<.001). Defect group had significantly higher VAS-Back (6.5±2.0 vs 4.9±1.6, p<.001) and ODI scores (62.9±10.7 vs 45.2±14.8, p<.001) than nondefect group, while there was no significant differences between the two groups during the 3 and 6-month follow-up after surgery. Histologically, Defect group was characterized by upregulation of COX-2, PGE-2, and EP-4 in endplate tissue sections. Both in defect and nondefect groups, VAS-Back showed moderate positive correlations with the expressions of COX-2 (r=0.643; r=0.558, p both<.001), PGE-2 (r=0.611; r=0.640, p both<.001), and EP-4 (r=0.643; r=0.563, p both<.001). Multivariate regression analyses reveled that percentage of COX-2-positive cells was associated with endplate defects (OR=1.509, 95%CI [1.048-2.171], p=.027), as well as percentage of PGE-2-positive (OR=1.291, 95%CI [1.106-1.508], p=.001) and EP-4-positive cells (OR=1.284, 95%CI [1.048∼2.171], p=.003)., Conclusions: Patients with endplate defects had worse quality of life, more severe disc degeneration and Modic changes, and up-regulated COX-2/PGE-2/EP-4 axis expression in cartilage endplates in patients with defected endplates. Inflammatory factors may significantly contribute to the onset and progression of chronic low back pain in patients with endplate defects, consequently impacting patient-reported symptoms., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To determine the occurrence of degenerative changes affecting the vertebral column in cats, assess their clinical significance, and determine the occurrence in cats with intervertebral disk herniation compared to other spinal diseases., Animals: 114 client-owned cats., Methods: Hospital records were retrospectively reviewed for cats with suspected myelopathy that had undergone spinal MRI. Signalment; history; neurological examination; neurolocalization; primary diagnosis; presence, type, and location of intervertebral disk herniation; and presence and location of other degenerative spinal changes (intervertebral disk degeneration [IVDD], spondylosis deformans [SD], end plate changes, dorsal compressions [DC], and foraminal stenosis [FS]) were recorded., Results: 70% of cats showed at least 1 spinal degenerative change. The most common change was IVDD, followed by SD and intervertebral disk protrusion (IVDP), while intervertebral disk extrusion (IVDE), end plate changes, DC, and FS were uncommon to rare. Primary complaint was attributed to a degenerative condition in 22% of cats, including 100% with IVDE, 9% with IVDP, and 43% with degenerative lumbosacral stenosis (DLSS). The occurrence of degenerative spinal changes and number of intervertebral disks affected by IVDD significantly increased with age and body weight. Age was positively correlated with the occurrence of SD and DLSS. Intervertebral disk degeneration, IVDP, SD, DC, and FS were more prevalent in the lumbosacral junction. Cats with IVDD were significantly more likely to show IVDE and IVDP., Clinical Relevance: This study revealed that in a population of cats presenting for signs of myelopathy, IVDE was always responsible for the clinical presentation, DLSS was commonly considered incidental, and IVDP was infrequently related to neurological signs.

Purpose: MIXTURE is a simultaneous morphological and quantitative imaging sequence developed by Philips that provides high-resolution T2 maps from the imaged series. We aimed to compare the T2 maps of MIXTURE and SHINKEI-Quant (S-Q) in the cervical spine and to examine their usefulness in the functional diagnosis of cervical radiculopathy., Methods: Seven healthy male volunteers (mean age: 31 ± 8.0 years) and one patient with cervical disc herniation (44 years old, male) underwent cervical spine magnetic resonance imaging (MRI), and T2-mapping of each was performed simultaneously using MIXTURE and S-Q in consecutive sequences in one imaging session. The standard deviation (SD) of the T2 relaxation times and T2 relaxation times of the bilateral C6 and C7 dorsal root ganglia (DRG) and C5/6 level cervical cord on the same slice in the 3D T2-map of the cervical spine coronal section were measured and compared between MIXTURE and S-Q., Results: T2 relaxation times were significantly shorter in MIXTURE than in S-Q for all C6, C7 DRG, and C5/6 spinal cord measurements. The SD values of the T2 relaxation times were significantly lower for MIXTURE in the C5/6 spinal cord and C7 DRG. In cervical disc herniation, MRI showed multiple intervertebral compression lesions with spinal canal stenosis at C5/6 and disc herniation at C6/7., Conclusion: MIXTURE is useful for preoperative functional diagnosis. T2-mapping using MIXTURE can quantify cervical nerve roots more accurately than the S-Q method and is expected to be clinically applicable to cervical radiculopathy., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Objective: Degenerative Disc Disease (DDD) is a common health problem in the population. There are recent studies focusing on relationship between DDD and immunological factors. However, there is still a lack of data on the role of apoptosis in DDD pathophysiology. Therefore, we aimed to investigate the relationship between Modic-type changes and the apoptosis in DDD., Materials and Methods: Ninety adult male patients who presented with low back and/or radicular pain and were operated on due to lumbar disc herniation were included. Three groups were formed based on Modic type degeneration observed on magnetic resonance imaging. Specific parameters involved in the intrinsic and extrinsic pathways of apoptosis were assessed in excised disc materials using the enzyme-linked immunosorbent assay method., Results: All three groups formed according to Modic degeneration types were homogenous in all variances. Cytochrome-C was significantly decreased only in the Modic type-3 group, whereas Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand Receptor-1, B-Cell Lymphoma-2 (Bcl-2) Homologous Antagonist Killer-1, Direct Inhibitor of Apoptosis-Binding Protein with Low Pi, and Bcl-2 Associated X Apoptosis Regulator levels were significantly different in both Modic type-2 and -3 groups. However, BH3 interacting domain death agonist and Bcl-2 levels were similar across all groups., Conclusions: In conclusion, this study suggests that Direct Inhibitor of Apoptosis-Binding Protein with Low Pi, cytochrome - c, Bcl-2 Associated X Apoptosis Regulator, Bcl-2 Homologous Antagonist Killer-1, and Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand Receptor-1proteins play important roles in the development and progression of DDD and are correlated with Modic types. Further studies are needed to explore the potential therapeutic role of inhibiting these apoptotic proteins in DDD., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Study Design: Retrospective study., Objection: There can be a relationship between degenerative diseases in the spine and hip., Summary of Background Data : Degenerative diseases in the spine and hip may occur concomitantly. This study was done to investigate the cross-sectional area of psoas muscle size and incidence of lumbar disc herniation after unilateral hip arthroplasty., Methods: The data files of patients who were operated on for unilateral hip arthroplasty between January 2014- and 15 May 2021 at the Recep Tayyip Erdogan University Hospital were retrospectively analysed for the relationship between the psoas muscle volume and the incidence of lumbar disc herniation. The patients were divided according to their operated sides., Results: The data files of 48 patients were retrospectively analysed. The patients were divided into two groups according to the operated side of their hip joints. Gender and age differences were not significant, and the mean ages were 68,68 years old in the right hip arthroplasty group, and 69,39 in the left hip arthroplasty group., Conclusions: A complex interaction between the development of lumbar disc herniations and increased contralateral cross-sectional area of the psoas muscle at the L4-5 level was observed in patients operated for unilateral hip arthroplasty. This interaction can be a compensatory mechanism to counteract the spinal imbalance.

Adjacent segment degeneration is commonly observed in patients after fusion surgery. Among the associated risk factors is the preoperative presence of adjacent disc degeneration (ADD). The risk factors and other spine phenotypes associated with preoperative ADD is critical to understand the pathological process and better prognosis postsurgery. Current study aims to assess and compare the magnetic resonance imaging (MRI) spinal phenotype of herniated level with and without ADD. Preoperative T2W sagittal lumbar MRI images of 155 lumbar disc herniated patients were analyzed for the presence of ADD (Pfirrmann grade III and above). The herniated disc level was assessed for the presence and absence of vertebral endplate (VEP) defects, Modic changes, and high intensity zone (HIZ). Mean age of patients was 38 ± 2 years, almost 62% were males. ADD was found in 57%, VEP defects were seen in 62% of the herniated level, 24.5% showed Modic changes, 3.8% showed spondylolishthesis, and 15.5% revealed HIZ. Age and other demographic factors did not have any significant effect on the presence of ADD, the patients with extruded and sequestered discs had more ADD (p = 0.02). VEP defects were significantly higher in levels with ADD (p = 0.02). Patients with ADD had significantly VEP defect scores (p = 0.01), Modic score (p = 0.002), HIZ score (0.02), and posterior bulge score (p < 0.001). Findings suggest that affected levels with VEP defects and severe grade of disc herniation have the greater likelihood of having ADD. Once developed this ADD may also affect the other spinal levels, and also can affect postoperative prognosis., (© 2023 Orthopaedic Research Society.)

Objectives: This study aimed to investigate differences in vertebral fat distribution and bone density between patients with and without Modic changes (MCs) using a magnetic resonance imaging (MRI)-based vertebral bone quality (VBQ) scoring system., Patients and Methods: In this retrospective study, 189 patients (95 males, 94 females; mean age: 54±2.2 years; range, 18 to 82 years) with primary single-level disk herniation were reviewed between June 2021 and June 2022. The patients were divided into the MC group (n=99) and the non-MC (NMC) group (n=90). The subcutaneous fat tissue thickness and bone mineral density were determined. The system consisted of two scores: the VBQ score, which reflected the fatty infiltration within the vertebral body, and the endplate bone quality (EBQ) score, which reflected the signal intensity (SI) of the upper and lower endplates. The EBQ score is a novel measurement that we introduced in this study. The VBQ and EBQ were measured and scored using MRI scans. The mean SI of the upper and lower endplates (endplate SI)/the bone marrow SI (marrow SI) was measured., Results: There was a considerable difference in subcutaneous fat tissue thickness between the MC and NMC groups (1.40 vs. 1.16 cm, p=0.01). The EBQ scores of the L4 and L5 vertebrae and endplate SI/marrow SI of all vertebral body levels were significantly higher in the MC group., Conclusion: The occurrence of MCs in the lumbar spine may be associated with abnormal fat distribution. The distribution of vertebral fat in patients with MCs is distributed earlier in the upper and lower endplates of the vertebral body, and this trend is not observed in patients without MC. The thickness of subcutaneous fat tissue is a key factor in the occurrence of MCs.

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and, optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electromagnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the spine, including lower back pain, with or without numbness and/or dysfunction in the lower extremities, disc herniation, spinal stenosis, and spondylolisthesis. Promising and established treatment modalities include repair of the annulus fibrosis, injection of expanded or nonexpanded autologous or allogenic cells that are chondrogenic or from a stem cell lineage used to promote matrix tissue regeneration of the intervertebral disc, including nucleus pulpous cells and mesenchymal stem cells isolated from bone marrow, umbilical cord blood, or adipose tissue; and injection of platelet-rich plasma, platelet-rich fibrin, or fibrin sealant. Early clinical studies show promise for pain reduction and functional recovery. LEVEL OF EVIDENCE: Level V, expert opinion., Competing Interests: Disclosure The authors report the following potential conflicts of interest or sources of funding: J.D.K. reports other from OnPoint Surgical, outside the submitted work. All other authors (S.M., G.V.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Full ICMJE author disclosure forms are available for this article online, as supplementary material., (Copyright © 2024. Published by Elsevier Inc.)

Background: Lumbar disc herniation (LDH) is the main clinical cause of low back pain. The pathogenesis of lumbar disc herniation is still uncertain, while it is often accompanied by disc rupture. In order to explore relationship between loading rate and failure mechanics that may lead to lumbar disc herniation, the failure mechanical properties of the intervertebral disc under high rates of loading were analyzed., Method: Bend the lumbar motion segment of a healthy sheep by 5° and compress it to the ultimate strength point at a strain rate of 0.008/s, making a damaged sample. Within the normal strain range, the sample is subjected to quasi-static loading and high loading rate at different strain rates., Results: For healthy samples, the stress-strain curve appears collapsed only at high rates of compression; for damaged samples, the stress-strain curves collapse both at quasi-static and high-rate compression. For damaged samples, the strengthening stage becomes significantly shorter as the strain rate increases, indicating that its ability to prevent the destruction is significantly reduced. For damaged intervertebral disc, when subjected to quasi-static or high rates loading until failure, the phenomenon of nucleus pulposus (NP) prolapse occurs, indicating the occurrence of herniation. When subjected to quasi-static loading, the AF moves away from the NP, and inner AF has the greatest displacement; when subjected to high rates loading, the AF moves closer to the NP, and outer AF has the greatest displacement. The Zhu-Wang-Tang (ZWT) nonlinear viscoelastic constitutive model was used to describe the mechanical behavior of the intervertebral disc, and the fitting results were in good agreement with the experimental curve., Conclusion: Experimental results show that, both damage and strain rate have a significant effect on the mechanical behavior of the disc fracture. The research work in this article has important theoretical guiding significance for preventing LDH in daily life., (© 2023. The Author(s).)

Lumbar disc herniation (LDH) is a clinically common degenerative disease of the spine, and spinal-pelvic sagittal balance and paravertebral muscle degeneration have been a research focus in recent years. To explore the relationship between the degeneration of paravertebral muscle and the changes in the spinal-pelvic sagittal parameters in LDH patients, 105 LDH patients (experimental group) and 63 healthy volunteers (control group) hospitalized in Ordos Central Hospital from January 2020 and January 2023 were included as study subjects. All the patients underwent lumbar magnetic resonance imaging and spinal X-ray using uniform criteria. The correlation between the paravertebral muscle and sagittal-pelvic sagittal parameters of the patients with LDH was obtained from two imaging examinations, and the data were organized and grouped to explore the correlation between these parameters. No significant difference in general data existed between the groups (P > 0.05). In the L4/5 LDH patients group, the ratio of fat infiltration (FIR) in the healthy side [multifidus (MF) and erector spinae (ES)] was negatively correlated with the lumbar lordosis (LL) (r = -0.461, r = -0.486, P < 0.05). The relative cross-sectional area (RCSA) of the bilateral MF was positively correlated with the pelvic tilt (r = 0.549, r = 0.515, P < 0.05). The bilateral ES RCSA was negatively correlated with the sagittal vertical axis (r = -0.579, r = -0.621, P < 0.05). A positive correlation existed between the RCSA and thoracic kyphosis in the healthy side ES (r = 0.614, P < 0.05). In the L5/S1 LDH patients group, a negative correlation existed between the FIR and LL in the healthy side ES (r = -0.579, P < 0.05). Thus, the paravertebral muscle parameters were correlated with the spinal-pelvic sagittal parameters in the patients with LDH., (© 2024. The Author(s).)

Purpose: Degenerative spinal conditions, including disc degeneration (DD), Schmorl nodes (SN), and endplate signal changes (ESC), are pervasive age-associated phenomena that critically affect spinal health. Despite their prevalence, a comprehensive exploration of their distribution and correlations is lacking. This study examined the prevalence, distribution, and correlation of DD, SN, and ESC across the entire spine in a population-based cohort., Methods: The Wakayama Spine Study included 975 participants (324 men, mean age 67.2 years; 651 women, mean age 66.0 years). Magnetic resonance imaging (MRI) was used to evaluate the intervertebral space from C2/3 to L5/S1. DD was classified using Pfirrmann's system, ESC was identified by diffuse high-intensity signal changes on the endplates, and SN was defined as a herniation pit with a hypointense signal. We assessed the prevalence and distribution of SN, ESC, and DD across the entire spine. The correlations among these factors were examined., Results: Prevalence of ≥ 1 SN over the entire spine was 71% in men and 77% in women, while prevalence of ≥ 1 ESC was 57.9% in men and 56.3% in women. The prevalence of ESC and SN in the thoracic region was the highest among the three regions in both sexes. Positive linear correlations were observed between the number of SN and DD (r = 0.41, p < 0.001) and the number of ESC and DD (r = 0.40, p < 0.001), but weak correlations were found between the number of SN and ESC (r = 0.29, p < 0.001)., Conclusion: The prevalence and distribution of SN and ESC over the entire spine were observed, and correlations between SN, ESC, and DD were established. This population-based cohort study provides a comprehensive analysis of these factors., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Aim: To determine the impact of ethanol gel chemonucleolysis (EGCh) on the radiological picture of the treated intervertebral disc, the relationship between the initial radiological status and the clinical status of the patient after EGCh treatment, and the optimal radiographic criteria for qualifying a patient for EGCh treatment., Materials and Methods: The study involved a group of 45 patients (25 men and 20 women) aged 23-68 years (46 ± 11) who underwent an EGCh procedure after qualification, radiography, and clinical questionnaire evaluation., Results: The results showed a decrease in the size of the protrusion and Gadolinium-Enhanced (GI) zone in the treated intervertebral disc. The presence of a high-intensity zone (HIZ) on baseline magnetic resonance imaging was found to be a good predictor of the timing and outcome of treatment, and an increase in disc height was observed in adjacent segments., Conclusion: These findings suggest that EGCh is a promising treatment for spine diseases, and the HIZ on baseline magnetic resonance imaging can be used as a qualification criterion for this procedure., (Copyright © 2023. Published by Elsevier Ltd.)

Lumbar disc herniation (LDH) is rare in juveniles. LDH occurring at age 20 years or younger is referred to as juvenile disc herniation (JDH). While adult LDH is regarded as an advanced stage of disc degeneration, it remains unclear why intervertebral discs rupture in youth. This study aimed to characterize magnetic resonance imaging (MRI) findings of JDH and investigate possible etiological factors. From 2013 to 2020, JDH patients and controls were identified and interviewed to assess demographics, general lifestyles, and family histories. MRIs were evaluated for disc degeneration, epiphyseal ring separation, Modic changes and endplate lesions. The relationships between JDH and suspected risk factors were examined. A total of 297 JDH patients (199 boys and 98 girls, age 17.3 ± 2.1 years) and 185 controls (age 17.1 ± 2.4 years) were studied. Age, body mass index, exposures to daily physical labor, regular exercise, and daily sitting time were similar between JDH cases and controls. A family medical history of serious back pain was more common in JDH patients than in controls (59.4% vs. 26.5%, p < 0.001), as well as family history of clinically established LDH (45.0% vs. 12.4%, p < 0.001). Epiphyseal ring separation was identified in 102 (29.2%) herniated discs in 91 (36.4%) JDH patients, while occurring in only 5 (1.4%) control participants (p < 0.001). Overall, severe disc degeneration was not a prominent finding in JDH patients. In conclusion, epiphyseal ring separation was a common magnetic resonance feature in JDH. Findings suggest a genetically mediated developmental model of JDH, rather than a model of premature disc degeneration., (© 2023 Orthopaedic Research Society.)

Objective: To investigate the effect of protrusion amount on pain, lumbar mobility, physical dysfunction, and the cross-sectional area of the multifidus muscle in patients with lumbar disc herniation., Methods: 54 male patients aged 20 to 50 years were included in this study in 2 groups. The control group (n = 18) consisted of patients with disc herniation without nerve root compression, and the study group (n = 36) consisted of patients with lumbar disc herniation and nerve root compression in 3 subgroups according to the amount of protrusion. The multifidus muscle cross-sectional area and the amount of protrusion were measured using Magnetic Resonance Imaging. Pain intensity was measured using the Visual Pain Scale, physical dysfunction was measured using the Oswestry Disability Index, flexion-extension was measured with TiltMeter, and trunk rotation was measured with smartphone applications called iPhone Compass., Results: There were no differences in pain levels (P > .05), mean trunk rotation movements of the affected and unaffected sides (P = .001, P = .001, P = .983, and P = .954, respectively), Oswestry Disability Index results (P = .967), or cross-sectional area sizes of the multifidus muscle (P = .866, P = .552, P = .787, respectively). There was a difference between the groups in terms of the mean trunk flexion and extension movement values (P = .001). The regression analysis indicated that there was no significant correlation between the binary variables, and the models exhibited a low explanatory rate for the dependent variable., Conclusion: A relationship has been identified between lumbar disc herniation and low back pain, lumbar movement limitation, and physical functionality. Nevertheless, subsequent to the regression analysis, it became evident that the binary variables did not exhibit a noteworthy relationship, leading to a decrease in the explanatory capacity of the models for the dependent variable. In forthcoming studies, it is advisable to contemplate the augmentation of the subject pool or the incorporation of multiple independent variables into the regression analysis as potential strategies to enhance the model capability in elucidating variations in the dependent variable., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Low back pain is the leading contributor to disability burden globally. It is commonly due to degeneration of the lumbar intervertebral discs (LDD). Magnetic resonance imaging (MRI) is the current best tool to visualize and diagnose LDD, but places high time demands on clinical radiologists. Automated reading of spine MRIs could improve speed, accuracy, reliability and cost effectiveness in radiology departments. The aim of this review and meta-analysis was to determine if current machine learning algorithms perform well identifying disc degeneration, herniation, bulge and Modic change compared to radiologists., Methods: A PRISMA systematic review protocol was developed and four electronic databases and reference lists were searched. Strict inclusion and exclusion criteria were defined. A PROBAST risk of bias and applicability analysis was performed., Results: 1350 articles were extracted. Duplicates were removed and title and abstract searching identified original research articles that used machine learning (ML) algorithms to identify disc degeneration, herniation, bulge and Modic change from MRIs. 27 studies were included in the review; 25 and 14 studies were included multi-variate and bivariate meta-analysis, respectively. Studies used machine learning algorithms to assess LDD, disc herniation, bulge and Modic change. Models using deep learning, support vector machine, k-nearest neighbors, random forest and naïve Bayes algorithms were included. Meta-analyses found no differences in algorithm or classification performance. When algorithms were tested in replication or external validation studies, they did not perform as well as when assessed in developmental studies. Data augmentation improved algorithm performance when compared to models used with smaller datasets, there were no performance differences between augmented data and large datasets., Discussion: This review highlights several shortcomings of current approaches, including few validation attempts or use of large sample sizes. To the best of the authors' knowledge, this is the first systematic review to explore this topic. We suggest the utilization of deep learning coupled with semi- or unsupervised learning approaches. Use of all information contained in MRI data will improve accuracy. Clear and complete reporting of study design, statistics and results will improve the reliability and quality of published literature., (© 2023. Crown.)

Background: The simplified 3-grade system for measuring fat infiltration in the paraspinal muscles is widely utilized. In comparing our proposed 4-grade system to the existing 3-grade system, we evaluated its impact on results and particularly its ability to predict disc herniation, ultimately highlighting deficiencies in the latter. The objective of this investigation was to validate the efficacy of our newly proposed semi-quantitative simplified 4-grade system for assessing fat infiltration, as compared to the existing literature-based simplified 3-grade system, in terms of their predictive value for lumbar disc herniation., Methods: Infiltration of the right and left lumbar multifidus and erector spinae muscles were assessed using a semi-quantitative 3- and 4-grade fat infiltration system on axial magnetic resonance imaging sections at the L3-S1 level in all subjects, with comparison of results between groups. The correlation between these grading systems and lumbar disc herniation was investigated., Results: The simplified 3-degree system for measuring fat infiltration was not effective in predicting lumbar disc herniation (p > 0.05), while the 4-degree system proved to be useful in predicting it (p < 0.05). In both grading systems, females were found to have a higher risk of lumbar disc herniation than males (p < 0.05), and the risk increased with age and body mass index (BMI) (p < 0.001)., Conclusions: It was observed that using the 4-grade fat infiltration system to determine the level of fat infiltration in the paraspinal muscles is more effective in predicting lumbar disc herniation compared to the 3-grade system. The 4-grade fat infiltration grading system proves to be an efficient semi-quantitative method that can replace the simplified 3-grade system., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Low back pain (LBP) is one of the most frequent reasons for medical consultation. Most of the patients will have nonspecific LBP, which usually are self-limited episodes. It is unclear which of the diagnostic imaging pathways is most effective and costeffective and how the imaging impacts on patient treatment. Imaging techniques are usually indicated if symptoms remain after 6 weeks. Magnetic resonance imaging (MRI) is the diagnostic imaging examination of choice in lumbar spine evaluation of low back pain; however, availability of MRI is limited., Objectives: To evaluate the diagnostic accuracy of computed tomography (CT) with MRI (as standard of reference) in the evaluation of chronic low back pain (LBP) without red flags symptoms. To compare the results obtained by two radiologists with different grades of experience., Materials and Methods: Patients with chronic low back pain without red flags symptoms were retrospectively reviewed by two observers with different level of experience. Patients included had undergone a lumbar or abdominal CT and an MRI within a year. Once the radiological information was collected, it was then statistically reviewed. The aim of the statistical analysis is to identify the equivalence between both diagnostic techniques. To this end, sensitivity, specificity and validity index were calculated. In addition, intra and inter-observer reliability were measured by Cohen's kappa values and also using the McNemar test., Results: 340 lumbar levels were evaluated from 68 adult patients with chronic low back pain or sciatica. 63.2% of them were women, with an average age of 60.3 years (SD 14.7). CT shows high values of sensitivity and specificity (>80%) in most of the items evaluated, but sensitivity was low for the evaluation of density of the disc (40%) and for the detection of disc herniation (55%). Moreover, agreement between MRI and CT in most of these items was substantial or almost perfect (Cohen's kappa-coefficient > 0'8), excluding Modic changes (kappa = 0.497), degenerative changes (kappa0.688), signal of the disc (kappa = 0.327) and disc herniation (kappa = 0.639). Finally, agreement between both observers is mostly high (kappa > 0.8). Foraminal stenosis, canal stenosis and the grade of the canal stenosis were overdiagnosed by the inexperienced observer in the evaluation of CT images., Conclusions and Significance: CT is as sensitive as lumbar MRI in the evaluation of most of the items analysed, excluding Modic changes, degenerative changes, signal of the disc and disc herniation. In addition, these results are obtained regardless the experience of the radiologist. The rising use of diagnostic medical imaging and the improvement of image quality brings the opportunity of making a second look of abdominal CT in search of causes of LBP. Thereby, inappropriate medical imaging could be avoided (2). In addition, it would allow to reduce MRI waiting list and prioritize other patients with more severe pathology than LBP., (Copyright © 2023 SERAM. Published by Elsevier España, S.L.U. All rights reserved.)

Objective: To compare if the degenerative findings from MRI differ between the sciatica patients classified as centralizers (CEN) and non-centralizers (Non-CEN) according to the McKenzie Method of mechanical diagnosis and therapy., Study Design: A cross-sectional study., Methods: Patients ( N  = 100) referred to a spine clinic of a single tertiary hospital for specialist consultation for sciatica. The McKenzie-based assessment was performed by the mechanical diagnosis and therapy-trained physiotherapists. Clinical data and prevalence of lumbar MRI findings were compared between the groups., Results: There was no significant difference in leg pain intensity between the groups. The Non-CEN had significantly more intense back pain, mean 56 (SD 30) and were more disabled 44 (SD 15) compared to the CEN mean 41 (SD 25) and mean 31 (11), measured with a visual analogue scale (0-100), and the Oswestry Disability Index (0-100), respectively. The CEN had more severe degenerative findings on MRI than the Non-CEN: vertebral end-plate changes were 63% and 43%; mean Pfirrmann's disc degeneration lumbar summary score was 12.8, and 10.6; and severity score of total damage was 12.0 and 10.1, respectively. There were differences neither in disc contour changes nor nerve root stenosis on MRI., Conclusions: Sciatica patients classified as non-centralizers had significantly more severe back pain, and were significantly more disabled than centralizers, who instead had more severe degenerative findings on MRI. Thus, classification to non-centralizers by the McKenzie method seems not predict higher incidence of degenerative findings on MRI compared to centralizers.

Background: Previous studies have shown that the Valsalva maneuver (VM) causes spinal canal object movements. We hypothesized that this occurs because of cerebrospinal fluid (CSF) flow generated from intradural space reduction. Previous studies using myelograms reported lumbar CSF space changes during inspiration. However, no similar studies have been conducted using modern MRI. Therefore, this study analyzed intradural space reduction during the VM using cine magnetic resonance imaging (MRI)., Methods: The participant was a 39-year-old, healthy, male volunteer. Cine MRI involved fast imaging employing steady-state acquisition cine sequence during three resting and VM sets for 60 s each. The axial plane was at the intervertebral disc and vertebral body levels between Th12 and S1 during cine MRI. This examination was performed on 3 separate days; hence, data from nine resting and VM sets were available. Additionally, two-dimensional myelography was performed during rest and the VM., Results: Intradural space reduction was observed during the VM using cine MRI and myelography. The intradural space cross-sectional area during the VM (mean: 129.3 mm 2 ; standard deviation [SD]: 27.4 mm 2 ) was significantly lower than that during the resting period (mean: 169.8; SD: 24.8; Wilcoxon signed-rank test, P < 0.001). The reduction rate of the vertebral body level (mean: 26.7%; SD: 9.4%) was larger than that of the disc level (mean: 21.4%; SD: 9.5%; Wilcoxon rank sum test, P = 0.0014). Furthermore, the reduction was mainly observed on the ventral and bilateral intervertebral foramina sides at the vertebral body and intervertebral disc levels, respectively., Conclusion: The intradural space was reduced during the VM, possibly because of venous dilatation. This phenomenon may be associated with CSF flow, intradural object movement, and nerve compression, potentially leading to back pain., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Abstract: A 44-year-old healthy volunteer received an 18F-FAPI-04 scan for a normal biodistribution and dosimetry study. An incidental finding of an increased uptake of the radiotracer at the L4/5 subarticular disc herniation was noted, and a subsequent MRI scan confirmed the degenerative nature of the lesion., Competing Interests: Conflicts of interest and sources of funding: This work was supported by the fund from the National Natural Science Foundation of China (81971645), Guangdong Provincial People's Hospital (KY0120211130), and Guangdong Provincial Key Laboratory of Artificial Intelligence inMedical Image Analysis and Application (2022B1212010011). The authors have no conflicts of interest to report., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Although spinal surgery can offer pain relief and functional improvements in daily life, it is often associated with various perioperative complications. The incidence of cardiac complications associated with spinal surgery is relatively low. We evaluated frequency and causes for bradycardia incidents in posterior thorocolumbar spinal surgeries., Methods: We retrospectively evaluated posterior thoracolumbar spinal surgeries between 2018-2022 for bradycardic events in our tertiary general hospital. Patients operated for degenerative changes or disk herniations are included, other cases for tumors, trauma, arteriovenous (AV) fistulae or previously operated are excluded., Results: The study reached 6 eligible patients (4 female and 2 male) aged between 45-75 years (mean: 63.3) among 550 patients operated between 2018-2022. The rate of bradycardia was 1.09%. Of these, 5 patients (lumbar discectomy: one; posterior stabilization:4) exhibited it following L2 and L3 root manipulation and one presented it following L4-5 discectomy. In each of these cases, bradycardia occurred during surgical manipulation and ceased upon removal of the insult. None of the cases exhibited accompanying hypotension. The patient's heart rates were seen to drop to lowest the of 30 beats/min, and all patients exhibited favorable outcomes and no postoperative cardiac complications over a mean follow-up period of 20 months (range: 10-40 months)., Conclusions: The current study examines the occurrence of unexpected bradycardia events associated with thoracolumbar spinal surgery during surgical handling of the dura mater. Awareness of such incidents among surgeons and anesthesiologists can help prevent catastrophic outcomes caused by adverse cardiac events., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Although both disc- or osseous-associated forms of cervical spondylomyelopathy (CSM) are observed in the same dogs, this combined form has not been thoroughly evaluated., Objectives: To describe imaging characteristics of dogs with concurrent disc- and osseous CSM and investigate an association between findings on neurological examination and imaging., Animals: Sixty dogs with disc and osseous-associated CSM from 232 CSM-affected dogs., Methods: Retrospective study. Dogs diagnosed via high-field MRI with a combination of intervertebral disc (IVD) protrusion and osseous proliferation of articular processes, dorsal lamina, or both were identified. Large and giant breed dogs were grouped according to whether combined compressions were at the same site or different sites. Statistical methods were used to investigate the association and relationship between variables., Results: Thirty-five out of 60 (58%) were large breeds and 22/60 (37%) were giant breeds. Mean and median age was 6.6 and 7 years respectively (range, 0.75-11 years). Forty of the 60 dogs (67%) had concurrent osseous and disc-associated spinal cord compression in the same location. This was considered the main compression site in 32/40 (80%) dogs. Dogs with osseous- and disc-associated compressions at the same site were more likely to have a higher neurologic grade (P = .04)., Conclusions and Clinical Importance: A substantial percentage of dogs with CSM present with concomitant IVD protrusion and osseous proliferations, most at the same site. Characterizing this combined form is important in the management of dogs with CSM because it could affect treatment choices., (© 2023 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals LLC on behalf of American College of Veterinary Internal Medicine.)

Intervertebral disc degeneration (IVDD) has become a serious public health problem, placing a heavy burden on society and the healthcare system. Its pathogenesis is not completely clear and may be closely related to mechanical damage, inflammatory factors, oxidative stress and death of nucleus pulposus cells (NPCs). The treatment of IVDD mainly includes conservative treatment and surgery. Conservative treatment is based on hormonal and anti-inflammatory drugs and massage techniques, which can relieve the pain symptoms to a certain extent, but cannot solve the problem from the root cause. Surgical treatment is mainly by removing the herniated nucleus pulposus, but it is more traumatic for IVDD patients, expensive and not suitable for all patients. Therefore, it is extremely important to clarify the pathogenesis of IVDD, to find an effective and convenient treatment and to further elaborate its mechanism of action. The effectiveness of traditional Chinese medicine in the treatment of IVDD has been well demonstrated in clinical medical research. We have been working on the Chinese herbal formula Duhuo Jisheng Decoction, which is a common formula for the treatment of degenerative disc disease. Not only does it have significant clinical effects, but it also has few adverse effects. At present, we found that its mechanism of action mainly involves regulation of inflammatory factors, reduction of apoptosis and pyroptosis of NPCs, inhibition of extracellular matrix degradation, improvement of intestinal flora, etc. However, a few relevant articles have yet comprehensively and systematically summarized the mechanisms by which they exert their effect. Therefore, this paper will comprehensively and systematically explain on it. This is of great clinical significance and social value for elucidating the pathogenesis of IVDD and improving the symptoms of patients, and will provide a theoretical basis and scientific basis for the treatment of IVDD with traditional Chinese medicine., (© 2023. The Author(s).)

Study Design: Prospective observational study., Objective: To determine the prevalence of isolated thoracic degeneration on magnetic resonance imaging (MRI), demographic factors and imaging features, as well as the patient-reported quality of life outcomes associated with this condition., Summary of Background Data: Thoracic intervertebral discs are least susceptible to disc degeneration (DD) and may represent a manifestation of "dysgeneration." These discs may never be hydrated from the beginning and seem hypointense on MRI., Patients and Methods: A population-based MRI study of 2007 volunteers was conducted. Each disc from C2/3 to L5/S1 was measured by Pfirrmann and Schneiderman grading. Disc herniation, Schmorl node (SN), high-intensity zones (HIZ), and Modic changes were studied. DD was defined by Pfirrmann 4 or 5. patient-reported quality of life scores, including a 36-item short-form questionnaire and visual analog scale for low back pain, were recorded. Subjects were divided into "isolated thoracic degeneration" (only thoracic segment) and "tandem thoracic degeneration" (thoracic with other segments). The association between imaging findings and isolated thoracic degeneration was determined using multivariate logistic regression., Results: The mean age of the subjects was 50.0 ± 0.5 and 61.4% were females (n = 1232). Isolated thoracic degeneration was identified in 2.3% of the cohort. Factors associated with isolated thoracic degeneration included lower age, C6/7 HIZ, T8/9 HIZ, and T8/9 SN. Factors associated with tandem thoracic degeneration included L4/5 posterior bulging. The thoracic and lumbar tandem degeneration group demonstrated higher bodily pain, despite a lower visual analog scale, and a higher physical component score of the 36-item short form., Conclusions: Isolated thoracic degeneration demonstrated an earlier age of onset, mostly involving the mid-thoracic region (T5/6-T8/9), and in association with findings such as SN. Subjects with tandem thoracolumbar degeneration had less severe lumbar DD and low back pain as compared with those with isolated lumbar degeneration. This paints the picture of "dysgeneration" occurring in the thoracic and lumbar spine., Level of Evidence: 1., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Macrophage infiltration and polarization during lumbar intervertebral disc herniation (LDH) have attracted increased attention but their role remains unclear. To explore macrophage polarization in herniated nucleus pulposus (NP) tissue of patients with LDH and investigate the association between cell frequency and different clinical characteristics or symptoms, we conducted a retrospective study by analyzing NP tissue samples from 79 patients. Clinical features and symptoms, using the visual analog scale (VAS) and Oswestry disability index (ODI), were collected. The macrophage markers CD68, CCR7, CD163, and CD206; pro-inflammatory cytokine TNF-α; and anti-inflammatory factor IL-4 were analyzed by immunohistochemistry. The frequency of polarized macrophages and positivity rate of pro- and anti-inflammatory cytokines showed significant differences in some of clinical characteristics. Specifically, higher CCR7 + and TNF-α + proportions were identified in the high-intensity zone (HIZ) and the type of extrusion and sequestration NP tissue than in non-HIZ and protrude NP tissue. Higher CD206 + and IL-4+ proportion were detected in Modic changes. However, no differences in gender, age, smoking status, Pfirrmann grade, analgesic use, leg pain duration, and segments were found between groups. CD68 + , CCR7 + , and CD206 + cell proportions, and TNF-α and IL-4 showed positive associations with VAS scores preoperation. Associations between ODI and the macrophages markers were weak/insignificant. Our results indicated that macrophage polarization or macrophage-like cells contribute to LDH pathological features. Macrophage populations displaying significant associations with VAS score reflected continuous M1/M2 transition contributing to pain during LDH. These findings may contribute to enhanced/personalized pharmacological interventions for patients with LDH considering pain heterogeneity., (© 2022 Orthopaedic Research Society. Published by Wiley Periodicals LLC.)

Cauda equina syndrome (CES) is a rare and severe type of spinal stenosis, where all the nerves in the lower back suddenly become severely compressed. It is a serious medical emergency, and compression of the nerves in the lower portion of the spinal canal can lead to permanent loss of bowel and bladder control, paraesthesia, and paralysis of the legs if left untreated. Causes of CES include: trauma, spinal stenosis, herniated discs, spinal tumour, cancerous tumour, inflammatory and infectious conditions or due to an accidental medical intervention. CES patients typically present with symptoms of: saddle anaesthesia, pain, incontinence and numbness. Any of these are red flag symptoms and require immediate investigation and treatment.

Background: Non-traumatic spinal cord hemorrhage (NTSH) is an uncommon cause of myelopathy in dogs., Objectives: Describe the clinical characteristics, concurrent medical conditions and underlying causes, magnetic resonance imaging (MRI) findings and outcome in dogs with NTSH., Animals: Dogs diagnosed with NTSH using gradient echo T2-weighted (GRE) sequences with or without histopathological confirmation of hemorrhage were included. Dogs with a traumatic cause were excluded, including those with compressive intervertebral disc extrusion., Methods: Retrospective descriptive study; the databases of 2 referral hospitals were searched between 2013 and 2021., Results: Twenty-three dogs met inclusion criteria. The onset of signs was acute and progressive in 70% of cases; spinal hyperesthesia was variable (48%). Hemorrhage was identified in the thoracolumbar spinal segments in 65% of dogs. An underlying cause was identified in 65% of cases. Angiostrongylus vasorum represented 18% of the total cohort, followed by steroid-responsive meningitis arteritis (SRMA; 13%). Overall, 64% of dogs had a good or excellent outcome, regardless of cause; which was increased to 100% for SRMA, 75% for A. vasorum and 75% for idiopathic NTSH. Outcome was not associated with neurological severity. Recovery rate was 67% and 50% for nociception-intact and nociception-negative dogs, respectively., Conclusions: Larger prospective studies would be required to define prognostic factors for dogs with NTSH, but outcome appeared to be most influenced by the underlying cause, as opposed to neurological severity at presentation., (© 2023 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals LLC on behalf of American College of Veterinary Internal Medicine.)

Background: Lumbar vertebral endplates lesions (LEPLs), one of the etiologies of low back pain (LBP), are one of the most prevalent causes of health-care costs. Despite progressively becoming the focus in recent years, almost all studies have concentrated on symptomatic patients rather than general populations. As a result, our study was designed to determine the prevalence and distribution patterns of LEPLs in a middle-young general population, as well as their associations with lumbar disc herniation (LDH), lumbar disc degeneration (LDD), and lumbar vertebral volumetric bone mineral density (vBMD)., Methods: Seven hundred fifty-four participants aged 20-60 years were recruited from the subjects enrolled in a 10-year longitudinal study of degeneration of the spine and knee being conducted at the Beijing Jishuitan Hospital and 4 of them were excluded due to the missing of MRIs. In this observational study, a lumbar quantitative computed tomography (QCT) and MRI scan were performed among participants within 48 h. T2-weighted sagittal lumbar MRI images for all included subjects were identified for LEPLs by two independent observers based on morphological and local characteristics. Lumbar vertebral vBMD was measured with QCT. The age, BMI, waistline, hipline, lumbar vBMD, LDD, and LDH were measured to investigate their associations with LEPLs., Results: The prevalence of LEPLs was higher among the male subjects. 80% of endplates were recognition as no lesions with a substantial disparity between female (75.6%) and male subjects (83.4%) (p < 0.001). The most common lesions were "wavy/irregular" and "notched", and "fracture" is most involved in L3-4 inferior endplate both in two genders. LEPLs were found to be associated with LDH (≥ 2 levels: OR = 6.859, P < 0.001; 1 level: OR = 2.328, P = 0.002 in men. OR = 5.004, P < 0.001; OR = 1.805, P = 0.014 in women) reference for non-LDH, and hipline in men (OR = 1.123, P < 0.001)., Conclusions: LEPLs are the common findings on lumbar MRIs in general population, particularly in men. The presence of these lesions and advance from slightly to severely could be mainly attributed to LDH and men's higher hipline., (© 2023. The Author(s).)

Background: Skeletal muscle atrophy is a common condition without a pharmacologic therapy. AGGF1 encodes an angiogenic factor that regulates cell differentiation, proliferation, migration, apoptosis, autophagy and endoplasmic reticulum stress, promotes vasculogenesis and angiogenesis and successfully treats cardiovascular diseases. Here, we report the important role of AGGF1 in the pathogenesis of skeletal muscle atrophy and attenuation of muscle atrophy by AGGF1., Methods: In vivo studies were carried out in impaired leg muscles from patients with lumbar disc herniation, two mouse models for skeletal muscle atrophy (denervation and cancer cachexia) and heterozygous Aggf1 +/- mice. Mouse muscle atrophy phenotypes were characterized by body weight and myotube cross-sectional areas (CSA) using H&E staining and immunostaining for dystrophin. Molecular mechanistic studies include co-immunoprecipitation (Co-IP), western blotting, quantitative real-time PCR analysis and immunostaining analysis., Results: Heterozygous Aggf1 +/- mice showed exacerbated phenotypes of reduced muscle mass, myotube CSA, MyHC (myosin heavy chain) and α-actin, increased inflammation (macrophage infiltration), apoptosis and fibrosis after denervation and cachexia. Intramuscular and intraperitoneal injection of recombinant AGGF1 protein attenuates atrophy phenotypes in mice with denervation (gastrocnemius weight 81.3 ± 5.7 mg vs. 67.3 ± 5.1 mg for AGGF1 vs. buffer; P < 0.05) and cachexia (133.7 ± 4.7 vs. 124.3 ± 3.2; P < 0.05). AGGF1 expression undergoes remodelling and is up-regulated in gastrocnemius and soleus muscles from atrophy mice and impaired leg muscles from patients with lumbar disc herniation by 50-60% (P < 0.01). Mechanistically, AGGF1 interacts with TWEAK (tumour necrosis factor-like weak inducer of apoptosis), which reduces interaction between TWEAK and its receptor Fn14 (fibroblast growth factor-inducing protein 14). This leads to inhibition of Fn14-induced NF-kappa B (NF-κB) p65 phosphorylation, which reduces expression of muscle-specific E3 ubiquitin ligase MuRF1 (muscle RING finger 1), resulting in increased MyHC and α-actin and partial reversal of atrophy phenotypes. Autophagy is reduced in Aggf1 +/- mice due to inhibition of JNK (c-Jun N-terminal kinase) activation in denervated and cachectic muscles, and AGGF1 treatment enhances autophagy in two atrophy models by activating JNK. In impaired leg muscles of patients with lumbar disc herniation, MuRF1 is up-regulated and MyHC and α-actin are down-regulated; these effects are reversed by AGGF1 by 50% (P < 0.01)., Conclusions: These results indicate that AGGF1 is a novel regulator for the pathogenesis of skeletal muscle atrophy and attenuates skeletal muscle atrophy by promoting autophagy and inhibiting MuRF1 expression through a molecular signalling pathway of AGGF1-TWEAK/Fn14-NF-κB. More importantly, the results indicate that AGGF1 protein therapy may be a novel approach to treat patients with skeletal muscle atrophy., (© 2023 The Authors. Journal of Cachexia, Sarcopenia and Muscle published by John Wiley & Sons Ltd on behalf of Society on Sarcopenia, Cachexia and Wasting Disorders.)

Background: A nerve root anomaly, typified by a conjoined nerve root, is a rare finding. Conjoined nerve root anomalies are easily missed even in preoperative advanced imaging modalities, which can be potentially troublesome during and after surgery. In this report, we present a case of conjoined right L5-S1 nerve root in a patient with lumbar disc herniation, accompanied by spina bifida occulta, which was undiagnosed on preoperative imaging studies., Case Report: A 55-year-old Asian (Japanese) woman presented with low back pain and right leg radiating pain due to lumbar disc herniation at the right L5/S1. Physical examination revealed a positive Lasègue sign and the range of the straight leg raising test was 20° on the right side. The right patellar tendon reflex was normal; however, the right ankle jerk reflex disappeared. Although no obvious hypoesthesia was noted, mild muscle weakness (4/5) was observed in the right leg on the manual muscle test. We planned the lumbar discectomy under a microscope. During surgery, the conjoined right L5-S1 nerve root, which was compressed by herniated nucleus pulposus, was encountered. Although it was very thick and less mobile, some pieces of herniated nucleus pulposus could be removed piece by piece from the axillary part. After sequential decompressive procedures, the tightness of the conjoined right L5-S1 nerve root decreased but its mobility did not improve much. The laterality of the thickness and exit angle of the conjoined right L5-S1 nerve root was retrospectively confirmed on T2 coronal magnetic resonance images and magnetic resonance neurography. Postoperatively, right leg pain was immediately alleviated and complete improvement of muscle weakness was achieved 1 week later (5/5)., Conclusions: Magnetic resonance neurography is extremely useful for the accurate diagnosis of anomalous nerve roots because of clear visualization of the neural tissue. Discectomy under a microscope, which enables magnified three-dimensional observation of the surgical field, must provide a valid and safe procedure to achieve not only secure resection of herniated discs but also adequate exposure of anomalous nerve roots., (© 2023. The Author(s).)

Objective: To investigate the effect of midazolam on pain in lumbar disc herniation model rats based on p38 MAPK signaling pathway., Methods: Fifty SPF-grade Sprague-Dawley healthy rats, half male and half female, were selected and randomly divided into normal group, model group, and low-dose, medium-dose, high-dose groups. Model group and low-dose, medium-dose, high-dose groups were initially modeled for lumbar disc herniation. Intraperitoneal injection of saline was performed in rats of normal and model groups; and in the low-dose, medium-dose, and high-dose groups, intraperitoneal injection of midazolam was performed with doses of 30, 60, and 90 mg/kg, respectively. Interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α), 5-hydroxytryptamine (5-HT), β-endorphin (β-EP), substance P (SP), neuropeptide Y (NPY) were detected in the serum of rats by enzyme-linked immunoassay. The expression of p38 MAPK and matrix metalloproteinase-3(MMP-3) protein were detected by Western blot in the tissues of rats of each group., Results: The levels of TNF-α, IL-1β and β-EP were higher and the level of 5-HT was lower in the model group than in the normal group( P <0.05);the levels of TNF-α, IL-1β and β-EP were lower and the level of 5-HT was higher in the low-dose, medium-dose and high-dose groups than in the model group( P <0.05). The levels of SP and NPY increased in the model group compared with the normal group ( P <0.05) and the levels of SP and NPY decreased in the low-dose, medium-dose and high-dose groups compared with the model group ( P <0.05). The expression of p38 MAPK and MMP-3 increased in the model group compared with the normal group ( P <0.05); the expression of p38 MAPK and MMP-3 decreased in the low-dose, medium-dose and high-dose compared with the model group( P <0.05)., Conclusion: Midazolam may ameliorate the immune inflammatory response in rats with a model of lumbar disc herniation, possibly regulated through the p38MAPK signaling pathway.

Introduction: Resorption after lumbar disk herniation is a common yet unpredictable finding. It is hypothesized that nearly 70% of lumbar herniated nucleus pulposus (HNP) undergo the resorption to a significant degree after acute herniation, which has led to nonoperative management before surgical planning., Methods: This narrative review on the literature from 4 databases (MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Cochrane) examines historical and recent advancements related to disk resorption. Studies were appraised for their description of the predictive factor (e.g., imaging or morphologic factors), pathophysiology, and treatment recommendations., Observations: We reviewed 68 articles considering the possibility of resorption of lumbar HNP. Recent literature has proposed various mechanisms (inflammation and neovascularization, dehydration, and mechanical traction) of lumbar disk resorption; however, consensus has yet to be established. Current factors that increase the likelihood of resorption include the initial size of the herniation, sequestration, percentage of rim enhancement on initial gadolinium-based magnetic resonance imaging (MRI), composition of inflammatory mediators, and involvement of the posterior longitudinal ligament., Conclusion: Heterogeneity in imaging and morphologic factors has led to uncertainty in the identification of which lumbar herniations will resorb. Current factors that increase the likelihood of disk resorption include the initial size of the herniation, sequestration, percentage of rim enhancement on initial MRI, composition of cellular and inflammatory mediators present, and involvement of the posterior longitudinal ligament. This review article highlights the role of disk resorption after herniation without surgical intervention and questions the role of traditional noninflammatory medications after acute herniation. Further research is warranted to refine the ideal patient profile for disk resorption to ultimately avoid unnecessary treatment, thus individualizing patient care., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A886)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: This study aims to find out if there is any relationship between disc pathology and spinopelvic morphology, respectively., Methods: A total of 152 patients who complained about low back pain were assessed retrospectively. Patients were divided into three groups based on the presence of disc pathology: non-degenerative (ND) (n=34), degenerative disc disease (DDD) (n=80), and lumbar disc herniation (LDH) (n=38). Spinopelvic parameters were measured on the lateral standing radiographs using Surgimap® Software. The degree of degeneration of each disc was evaluated using T2-weighted images according to the Pfirmann classification. Correlation analyses were performed., Results: No significant difference was observed between the three groups in terms of sagittal spinal and pelvic parameters. Age and BMI were positively correlated with DDD and LDH. PI and proximal lombar lordosis (PLL) were the only effective variables in predicting DDD. PT and distal lumbar lordosis (DLL) were found to be effective variables in predicting LDH. PI and PT values in patients with L1, L2, and L3 DDD were statistically significantly higher than those without degeneration (P<0.05). Although there were no statistical differences between PI and PT values (P>0.05), DLL values in L4 and L5 DDD patients were significantly lower than those without degeneration (P=0.041; P=0.046; P<0.05)., Conclusions: The sagittal morphology of the spine directly influences the extent of lumbar disc degeneration. As the values of PI and PT increase, disc degeneration tends to occur at higher levels (L1-2-3). Disc degeneration at lower levels (L4-5) was associated with low DLL levels., Level of Evidence: Level III, retrospective study., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

The objective of this study was to assess degenerative changes (DCs) on magnetic resonance imaging (MRI) of lumbar spine in axial spondyloarthritis (axSpA) and non-specific mechanical low back pain (mLBP). Patients were consecutively recruited and all underwent MRI of the lumbar spine in this cross-sectional study. Disk degeneration (DD, Pfirrmann classification), endplate changes (Modic, types 1, 2, and 3), annular fissure, disk bulging, and protrusion or extrusion at each lumbar spinal level were assessed using anonymized images. Patients with axSpA were assessed for disease activity, functioning, and quality of life. Univariate and subsequent multivariate logistic regression analyses with adjustments of various covariates were used to assess association between MRI findings and clinical variables. One hundred twenty-three patients had non-radiographic (nr-axSpA) and 144 had radiographic axSpA/ankylosing spondylitis (AS). Degenerative changes were more prevalent in patients with mLBP (n = 105) than axSpA. Disk degeneration was the most prevalent MRI finding, followed by annular fissure, disk herniation (protrusion or extrusion), and Modic changes (MCs) in axSpA. Disk herniation was more prevalent in patients with nr-axSpA compared to AS. Modic changes (OR = 6.455), lumbar disk herniation (OR = 2.278), annular fissure (OR = 2.842), conventional synthetic or biologic disease-modifying antirheumatic drugs (csDMARDs) non-users (OR = 2.225), and advanced age (OR = 31.556) were factors associated with an increased risk of DD in axSpA. Coexisting DD increased the burden of disease in axSpA. A considerable proportion of patients with axSpA had DD at the lumbar spine. These degenerative changes might explain some of the complaints and should not been overlooked in patients with axSpA. Key Points • Lumbar herniated nucleus pulposus (LHNP) is more frequent in nr-axSpA while MC is more frequent in AS. • DD may cause an increase in BASFI and BASMI scores in axSpA. • Spinal DCs might be an alternative explanation for low back complaints and should not been overlooked in patients with axSpA., (© 2022. The Author(s), under exclusive licence to International League of Associations for Rheumatology (ILAR).)

Background: The determination of muscle pathologies in lumbar disc herniation (LDH) and other conditions with low back pain is important for understanding low back problems and determining appropriate treatment methods. In patients with lumbar disc herniation with radiculopathy, elucidating the effect of root compression on the severity of muscle degeneration may predict the importance of alleviating root compression. For this purpose, magnetic resonance imaging (MRI) was used to compare the degeneration and asymmetries of the lumbar musculus multifidus (MF) and lumbar musculus erector spinae (ES) muscles in patients with lumbar discopathy without root compression (radiculopathy) and in patients with lumbar discopathy with root compression (radiculopathy)., Methods: The patients were examined in two groups: 56 patients with lumbar discopathy and no radiculopathy (Non-rad group) and 51 patients with lumbar discopathy and radiculopathy (Rad group). On axial MRI sections passing through the centre of the disc at the L3-S1 level, the asymmetry, cross-sectional area (CSA), fat infiltration, and total CSA (TCSA = MF + ES) of the MF and ES muscles were measured and compared., Results: No difference was seen between the groups with respect to the CSA values of the right and left MF and left ES, but a significant difference was found in the right ES CSA (p = 0.021). The CSA and TCSA of the MF and ES showed no asymmetry according to group. Severe fat infiltration of > 50% in the right and left MF and left ES was found in the Rad group at a higher rate than in the Non-rad group. Fat infiltration was significantly positively correlated with age, body mass index, and the duration of pain (p < 0.001, p < 0.001, p = 0.004, respectively)., Conclusions: The study results showed a correlation between LDH and paraspinal muscle degeneration, while no correlation was found with asymmetry. Severe (> 50%) fat infiltration is associated with root compression, and the severity of fat filtration increases in the presence of root compression. The development of more severe degeneration due to denervation associated with root compression plays a role in the emergence of this situation. Therefore, in patients with lumbar disc herniation with radiculopathy, it can be foreseen that to stop and correct severe fat infiltration and muscle degeneration, first, nerve root compression should be corrected with appropriate medical treatment methods, and in patients in whom there is no response, the pressure should be alleviated with appropriate surgical methods., (© 2022. The Author(s).)

Introduction: We aimed to identify imaging-based findings that can differentiate between spinal subchondral bone metastasis with focal pathologic endplate fracture and oedematous Schmorl's nodes that have been histopathologically confirmed., Methods: Between March 2010 and April 2016, 11 patients who had undergone spinal magnetic resonance (MR) imaging or computed tomography (CT) with final radiologic reports that included 'subchondral bone metastasis with focal pathologic endplate fracture' or 'edematous Schmorl's node' and had also undergone percutaneous imaging-guided spinal biopsies were included. Two radiologists retrospectively evaluated the following imaging features in consensus: size, location, presence of sclerotic margin, presence of intralesional or perilesional enhancement and opposite endplate enhancement of the involved disc, presence of disc height loss and presence of metabolic uptake at a corresponding lesion on nuclear medicine imaging., Results: A total of 11 patients, including six patients with spinal subchondral bone metastasis with focal pathologic endplate fracture and five patients with oedematous Schmorl's nodes, were included in this study (median age, 58 years; range, 50-63 years; six men). Sclerotic margin (P = 0.002) and enhancement on the opposite endplate of the involved disc (P = 0.047) were significantly different between oedematous Schmorl's node and subchondral bone metastasis with focal pathologic endplate fracture., Conclusion: Sclerotic margin and enhancement on the opposite endplate of the involved disc suggest oedematous Schmorl's node rather than subchondral bone metastasis with focal pathologic endplate fracture. Decreased disc height is likely to be an oedematous Schmorl's node rather than subchondral bone metastasis with focal pathologic endplate fracture., (© 2021 The Royal Australian and New Zealand College of Radiologists.)

Objective: To assess and compare the pathological and radiological outcomes of multifidus degeneration in scoliosis and lumbar disc herniation patients., Methods: We performed a retrospective review on 24 patients with scoliosis and 26 patients with lumbar disc herniation (LDH) in the Third Hospital of Hebei Medical University from January 2017 to March2021. The patients were divided into scoliosis group and LDH group according to the treatment. The MRI fatty infiltration rate (FIR) of multifidus and strength of back muscle were calculated to evaluate muscle condition. Multifidus biopsy samples were obtained during surgery in the affected side at L4 or L5 segment in LDH group and on the concavity side of apical vertebrae in scoliosis group. The biopsy fatty infiltration degree (FID) and FIR in two groups, the FIR of affected and unaffected side in LDH group, and the FIR of concavity and convexity side in scoliosis group were compared. The correlation between concavity-convexity FIR difference and cobb angle in scoliosis group, back muscle strength and FIR in LDH group, FID and FIR in both groups was calculated respectively., Results: The FIR was higher in scoliosis group than in LDH group, higher in concavity side than convexity side in scoliosis group (both P < 0.05). The FID was higher in scoliosis group than in LDH group (P < 0.05). No significant difference was found between affected and unaffected side in LDH group (P > 0.05). There was a positive correlation between concavity-convexity FIR difference and cobb angle, FIR and FID (both P < 0.01). There was a negative correlation between back muscle strength and FIR (P < 0.01). The biopsy staining results showed that both two groups were found the existence of rimmed vacuoles, nuclear aggregation, and abnormal enzyme activity, indicating that the scoliosis and LDH may be associated with myogenic diseases., Conclusion: The scoliosis patients showed more serious fatty infiltration than LDH patients and rare pathological findings were found in both diseases., (© 2022. The Author(s).)

The present study aimed to observe the content difference of macrophage migration inhibitory factor [MIF; novoprotein recombinant human MIF (n‑6his) (ch33)], TGFβ1 and MMP13 in patients with and without ligamentum flavum (LF) hypertrophy and investigate the roles of MIF in LF hypertrophy. The concentration of MIF, TGFβ1 and MMP13 in LF were detected by ELISA in a lumbar spinal stenosis (LSS) group and a lumbar disc herniation (LDH) group. Culture of primary LFs and identification were performed for the subsequent study. Cell treatments and cell proliferation assay by CCK‑8 was performed. Western blot and quantitative PCR analysis were used to detect the expression of TGFβ1, MMP13, type I collagen (COL‑1) and type III collagen (COL‑3) and Src which were promoted by MIF. The concentration of MIF, TGFβ1 and MMP13 were higher in the LSS group compared with the LDH group. Culture of primary LFs and identification were performed. Significant difference in LFs proliferation occurred with treatment by MIF at a concentration of 40 nM for 48 h (P<0.05). The gene and protein expression of TGFβ1, MMP13, COL‑1, COL‑3 and Src were promoted by MIF (P<0.05). Proliferation of LFs was induced by MIF and MIF‑induced proliferation of LFs was inhibited by PP1 (a Src inhibitor). MIF may promote the proliferation of LFs through the Src kinase signaling pathway and can promote extracellular matrix changes by its pro‑inflammatory effect. MIF and its mediated inflammatory reaction are driving factors of LF hypertrophy.

Objective: There are currently no standard criteria for evaluating the risk of recurrent disk herniation after surgical repair. This study investigated the predictive values of 5 presurgical imaging parameters: paraspinal muscle quality, annular tear size, Modic changes, modified Phirrmann disk degeneration grade, and presence of sacralization or fusion., Methods: Between 2015 and 2018, 188 patients (89 female, 99 male, median age 50) receiving first corrective surgery for lumbar disk herniation were enrolled. Microdiskectomy was performed in 161 of these patients, and endoscopic translaminar diskectomy approach was performed in 27 patients. Clinical status was evaluated before surgery and 4, 12, and 24 months post surgery using a visual analog scale, Oswestry Disability Index, and Short Form 36., Results: Recurrent disk herniation was observed in 21 of 188 patients. Seventeen of the recurrent disk herniations were seen in those who underwent microdiskectomy and 4 in those who underwent endoscopic translaminar diskectomy. There were significant differences in visual analog scale, Oswestry Disability Index, and Short Form 36 scores at 4, 12, and 24 months between patients with recurrence and the 167 no-recurrence patients. The median annular tear length was significantly greater in patients with recurrence than without recurrence. In addition, there were significant differences in recurrence rate according to Modic change type distribution, sacralization or fusion presence, Pfirmann disk; degeneration grade distribution, dichotomized annular tear size, dichotomized Modic change; and type and simplified 3-tier muscle degeneration classification distribution., Conclusions: Patients with poor clinical scores and recurrence exhibited additional radiologic abnormalities before surgery, such as poor paraspinal muscle quality, longer annular tears, higher Modic change type, higher modified Phirrmann disk degeneration grade, and sacralization or fusion. This risk evaluation protocol may prove valuable for patient selection, surgical planning, and choice of postoperative recovery regimen., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: There is conflicting data on the risk factors for recurrent lumbar disc herniation (rLDH). Most of the predictors for rLDH identified so far are acquired risk factors or radiological factors at the level of the herniation. Whole lumbar spine (WLS) morphometry has not been evaluated as a possible predictor of rLDH., Objectives: We aimed to evaluate if preoperative spinal morphometry can predict the occurrence of rLDH requiring revision surgery., Methods: This retrospective case-control study on 250 patients included 45 patients operated for rLDH, 180 controls without rLDH who had previously undergone microdiscectomy for a single level lumbar disc prolapse, and a holdout validation set of 25 patients. Morphometric variables related to the WLS were recorded in addition to previously identified predictors of rLDH. Logistic regression (LR) analysis was performed to identify independent predictors of rLDH., Results: LR yielded four predictors of which two were WLS morphometric variables. While increasing age and smoking positively predicted rLDH, increasing WLS interfacet distance and WLS dural-sac circumference negatively predicted rLDH. The LR model was statistically significant, χ 2 (4) =15.98, P = 0.003, and correctly classified 80.3% of cases. On validation, the model demonstrated a fair accuracy in predicting rLDH (accuracy: 0.80, AUC: 0.70)., Conclusions: Larger mean lumbar bony canals and dural sacs protect from the occurrence of symptomatic rLDH. These WLS morphometric variables should be included in future risk stratification algorithms for lumbar disc disease. In addition to the previously recognized risk factors, our study points to an underlying developmental predisposition for rLDH., Competing Interests: None

Purpose: It is suggested that non-specific low back pain (LBP) can be related to nerve ingrowth along granulation tissue in disc fissures, extending into the outer layers of the annulus fibrosus. Present study aimed to investigate if machine-learning modelling of magnetic resonance imaging (MRI) data can classify such fissures as well as pain, provoked by discography, with plausible accuracy and precision., Methods: The study was based on previously collected data from 30 LBP patients (age = 26-64 years, 11 males). Pressure-controlled discography was performed in 86 discs with pain-positive discograms, categorized as concordant pain-response at a pressure ≤ 50 psi and for each patient one negative control disc. The CT-discograms were used for categorization of fissures. MRI values and standard deviations were extracted from the midsagittal part and from 5 different sub-regions of the discs. Machine-learning algorithms were trained on the extracted MRI markers to classify discs with fissures extending into the outer annulus or not, as well as to classify discs as painful or non-painful., Results: Discs with outer annular fissures were classified in MRI with very high precision (mean of 10 repeated testings: 99%) and accuracy (mean: 97%) using machine-learning modelling, but the pain model only demonstrated moderate diagnostic accuracy (mean accuracy: 69%; precision: 71%)., Conclusion: The present study showed that machine-learning modelling based on MRI can classify outer annular fissures with very high diagnostic accuracy and, hence, enable individualized diagnostics. However, the model only demonstrated moderate diagnostic accuracy regarding pain that could be assigned to either a non-sufficient model or the used pain reference., (© 2021. The Author(s).)

Objectives: To study the resorption of the herniated lumbar disc (RHLD) and its mechanism in the SD rats of lumbar intervertebral disc herniation treated with Hui medicine moxibustion (HMM)., Methods: Forty SD rats were randomly divided into four groups, normal group, lumbar disc herniation (LDH) group, HMM group, and antagonist (HMM+Met12) group, with 10 rats in each group. The rat model of LDH was prepared with the method of lumbar epidural emplacement of the caudal intervertebral disc. In the HMM group and HMM+Met12 groups, 4 weeks after modeling, HMM therapy was performed in the lumbar spine for 3 months with 1 time per day and 20 min each time, the samples were collected 8 weeks after the treatment. The histological degeneration was observed through HE staining, and the neovascularization of intervertebral disc tissues was detected by the expression of CD34 and vascular endothelial growth factor (VEGF). The apoptosis of nucleus pulpous cells was detected by TUNEL assay, and the activity of caspase-3, -8, and -9 and extracellular matrix enzymes was detected by western blotting., Results: HMM treatment significantly improved the behavioral ability of rats with LDH surgery. The morphological structure was obviously destroyed in the LDH group, but disc structure was significantly repaired in the HMM group, and mild structure alterations were observed in the HMM+Met12 group. Higher levels of CD34 and VEGF were detected in the HMM group indicating that neovascularization is formed. The expression level of FasL was significantly increased in the HMM group. The protein expression levels of cleaved-caspase-3, cleaved-caspase-8, and cleaved-caspase-9 in nucleus pulposus (NP) tissues were also elevated when treated with HMM, and the TUNEL staining showed the same results. The protein expression levels of matrix metalloproteinases- (MMP-) 1, MMP-2, MMP-3, MMP-13, and ADAMTS-4 were markedly promoted in the HMM group. Met12, a small peptide antagonist of FasL, significantly reduced the effects of HMM., Conclusion: HMM can promote the formation of neovascularization of lumbar intervertebral disc, support the apoptosis of NP cells through Fas/FasL signaling, and regulate the degradation of extracellular matrix enzyme, which then accelerates the absorption of lumbar intervertebral disc herniation and the recovery of motor function in rats., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2022 Jianfeng Xu et al.)

Background: The contribution of Cutibacterium acnes (C. acnes) infection to intervertebral disc degeneration (IDD) and the antibiotic therapy has evoked several controversies in recent years. While some microbiology studies report bacterial disc infection within IDD patients, others attribute the positive results to contamination during prolonged cultures. In addition to the clinical controversy, little was known about the mechanism of C. acnes-caused Modic changes (MCs) if C. acnes was the pathogenic factor., Objectives: This study aimed to investigate the inflammatory mechanism of MCs induced by different phylotypes of C. acnes in patients with IDD., Methods: Specimens from sixty patients undergoing microdiscectomy for disc herniation were included, C. acnes were identified by anaerobic culture, followed by biochemical and PCR-based methods. The identified species of C. acnes were respectively inoculated into the intervertebral discs of rabbits. MRI and histological change were observed. Additionally, we detected MMP expression in the rabbit model using reverse transcription-quantitative polymerase chain reaction (RT-qPCR)., Results: Of the 60 cases, 18 (30%) specimens were positive for C. acnes, and we identified 4 of 6 defined phylogroups: IA, IB, II and III. The rabbits that received Type IB or II strains of C. acnes showed significantly decreased T1WI and higher T2WI at eighth weeks, while strain III C. acnes resulted in hypointense signals on both T1WI and T2WI. Histological examination results showed that all of the three types of C. acnes could cause disc degeneration and endplates rupture. Moreover, endplate degeneration induced by type IB or II strains of C. acnes is related with MMP13 expression. Meanwhile, strain III C. acnes might upregulated the level of MMP3., Conclusion: This study suggested that C. acnes is widespread in herniated disc tissues. Different types of C. acnes could induce different MCs by increasing MMP expression., Competing Interests: The authors have declared that no competing interests exist.

Intervertebral disc degeneration (IDD) causes a variety of signs and symptoms, such as low back pain (LBP), intervertebral disc herniation, and spinal stenosis, which contribute to high social and economic costs. IDD results from many factors, including genetic factors, aging, mechanical injury, malnutrition, and so on. The pathological changes of IDD are mainly composed of the senescence and apoptosis of nucleus pulposus cells (NPCs), the progressive degeneration of extracellular matrix (ECM), the fibrosis of annulus fibrosus (AF), and the inflammatory response. At present, IDD can be treated by conservative treatment and surgical treatment based on patients' symptoms. However, all of these can only release the pain but cannot reverse IDD and reconstruct the mechanical function of the spine. The latest research is moving towards the field of biotherapy. Mesenchymal stem cells (MSCs) are regard as the potential therapy of IDD because of their ability to self-renew and differentiate into a variety of tissues. Moreover, the non-coding RNAs (ncRNAs) are found to regulate many vital processes in IDD. There have been many successes in the in vitro and animal studies of using biotherapy to treat IDD, but how to transform the experimental data to real therapy which can apply to humans is still a challenge. This article mainly reviews the treatment strategies and research progress of IDD and indicates that there are many problems that need to be solved if the new biotherapy is to be applied to clinical treatment of IDD. This will provide reference and guidance for clinical treatment and research direction of IDD., (© 2022 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

The study was conducted to establish the association of Schmorl's nodes and osteoporosis in a Middle Eastern cohort. The prevalence of SN in this sample was 41.1%. It was most frequent in the lumbar spine typically solitary central lesions. Over 88% Schmorl's node cases were osteoporotic/osteopenic and only 11.6% normal., Introduction: This study aims to identify the prevalence of Schmorl's nodes (SNs) in a cohort of Omani nationals, and also to determine any relation between osteoporosis and Schmorl's nodes., Methods: This retrospective observational study was conducted on Omani nationals. One thousand three hundred and forty-eight DEXA scan patients were included. Of these, 545 patients had complete X-rays and MRI scans that would help determine the SN status. The X-rays and sagittal, coronal, and axial T2-weighted MR images were used to identify the presence and exact location of the Schmorl nodes by one orthopedic trainee and confirmed by the senior author. The correlation of each parameter with the presence of SN was analyzed by the independent-samples T test and one-way ANOVA., Results: The overall prevalence of SN in this population sample appeared to be 41.1%. Over 88% of the SN-positive cases were either osteopenic or frankly osteoporotic by the WHO definition. Vast majority of SNs (87.1%) occurred in the lumbar spine and were central in location and mostly solitary. Statistical analysis of the data revealed significant correlation between osteopenia or osteoporosis and the presence of SNs., Conclusions: The prevalence of SN in the sample of Omanis studied was 41.1% and was most frequently seen in older men in the lumbar spine. It is strongly associated with osteoporosis/osteopenia (88.4%) and frequently presents as solitary central lesions., (© 2022. International Osteoporosis Foundation and National Osteoporosis Foundation.)

AbstractParaspinal (erector spinae and multifidus) and psoas muscles contribute to spinal stability, but no study has yet examined the relationship between muscle mass and recurrent lumbar disc herniation (rLDH). The purpose of this study was to investigate the effect of psoas and paraspinal muscle mass on recurrent Lumbar disc herniation (LDH). This retrospective study included 49 patients with LDH (22 men, 27 women; mean age: 59.9 years; range 32-80) who underwent discectomy and partial laminectomy without fusion and underwent both pre- and postoperative magnetic resonance imaging. The presence of rLDH was determined using medical records and postoperative magnetic resonance imagings. Patients were divided into an rLDH group (26 patients) and a without-rLDH group (23 patients). Clinical characteristics, segmental motion, and paraspinal and psoas muscle mass were compared between the groups. Using ImageJ software, the cross-sectional area (CSA), lean muscle mass (LMM), and skeletal muscle index (SMI) were measured on T2 axial preoperative magnetic resonance images at L2-L3, L3-L4, and L4-L5 disc levels to represent muscle mass. Univariate and multivariate logistic regression analyses were performed. In the rLDH group, patients were younger (52.6 years vs 68.2 years; P = .001), segmental instability was more common (50.0% vs 4.3%; P = .001), and the CSA, LMM, CSASMI, and LMMSMI of psoas muscles were larger (5851.59 mm2 vs 4264.93 mm2, 5456.59 mm2 vs 4044.77 mm2, 18.77 cm2/m2 vs 13.86 cm2/m2, and 17.52 cm2/m2 vs 12.98 cm2/m2; P < .01 for all 4 variables). On multivariate logistic regression, age and segmental instability were independent risk factors for rLDH (odds ratio 0.886 and 18.527; P = .01 and P = .02, respectively). In middle-aged and elderly patients with lumbar disc herniation, relatively younger age, segmental instability, and greater psoas muscle mass may be risk factors for recurrence., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)