Vertebral Endplate Defects Induced Mechanical Alterations and Disc Calcification.

STUDY DESIGN: Cross sectional comparative study. OBJECTIVES: The current study aims to explore the calcification potential (BMP2 expression) of intervertebral discs and its association with the presence of vertebral endplate defects visible on MRI. METHODS: Forty-seven herniated lumbar disc samples obtained from patients aged 20-76 (31 M/16F) undergoing surgery. Five-µm thin sections were stained with H&E in order to assign a histological degeneration score (HDS) from 0-15 on the basis of cell density (0-5), structural alterations (0-4), granular changes (0-3) and mucus degeneration (0-3). Sections were immuno-stained with anti BMP-2 antibodies to observe the calcification potential in these discs. In addition, pre-operativeT2-T1 W MRI images of the lumbar spine were analyzed for the presence and type (typical or atypical) of vertebral endplate defects, grade of disc degeneration (Pfirrmann grade I-V), presence of high intensity zones (HIZ), and Modic changes at the operated level. RESULTS: Vertebral endplate defects, Modic changes & HIZ were observed in 81%, 29% and 21% of patients respectively. Mean HDS & BMP-2 expression was 9 ± 2 and mean 71 ± 36 spots/mm2 respectively. Discs with adjacent vertebral endplate defects showed increased cell density (P = .004), mucus degeneration (P = .002), HDS (P = .01) and BMP-2 expression (P = .01). Discs with HIZ also had increased HDS, but significance was seen with increased BMP2 expression (P = .006). HDS showed a positive correlation with BMP 2 expression (r = .30, P = .04). CONCLUSION: These findings suggest that the altered mechanical environment of discs is strongly associated with BMP-2 expression which is an important marker of intervertebral disc calcification.

MRI phenotypes of herniated discs associated with adjacent disc degeneration.

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.

Vertebral Endplate Changes Correlate with Presence of Cartilaginous Endplate in the Herniated Disc Tissue: Factor Predicting Failure of Conservative Treatment.

STUDY DESIGN: Cross-sectional comparative. PURPOSE: To characterize the scores of disc degeneration, inflammation, and nerve density in herniated disc samples and associate findings with the presence of vertebral endplate (VEP) changes on magnetic resonance imaging (MRI). OVERVIEW OF LITERATURE: Considering the role of disc composition in spontaneous regression and persistence of pain during conservative management, it is important to identify the influencing factors. VEP changes are highly associated with disc degeneration, but their correlation with herniated disc composition has not yet been reported. METHODS: Fifty-one discs were obtained from patients undergoing surgery for herniated disc. Their ages ranged from 19-65 years, and 31/51 were male. Pre-surgical T1 and T2 weighted lumbar-spine MRIs were analyzed to observe Pfirrmann grade, VEP defects, herniation type, Modic changes, and high-intensity zones (HIZ) at the affected level. Five-micron thick sections were stained with hematoxylin and eosin, Alcian blue periodic acid-Schiff stain; examined for histological degeneration scores (HDS; 0-15), inflammation (0 [absence]-3 [severe]), and presence of cartilaginous endplate (CEP). Three-micron thick sections were stained with protein-gene-product 9.5 and expression was counted/mm2. Data was analyzed, and p<0.05 was considered to indicate statistical significance. RESULTS: VEP defects, Modic changes, and HIZ were respectively observed in 30/51, 16/51, and 6/51 of the samples. CEP was observed in 26/51 samples and in 23/51 with endplate defects. Discs with adjacent VEP defects showed increased HDS (p<0.001) and inflammation (p<0.001). Discs with adjacent Modic changes also revealed increased HDS (p=0.01). Histological sections with CEP showed increased HDS (p<0.001) and inflammation (p<0.001), and nerve density was significantly positively correlated with HDS (r=0.27, p=0.02). CONCLUSIONS: VEP changes can modulate degeneration and inflammation of herniated discs. Presence of these changes is highly predictive of the occurrence of CEP in herniated discs, which leads to slow resorption and persistent clinical symptoms.

Increased frequency of fibromyalgia among patients with chronic pain presenting to internal medicine clinics of a tertiary care hospital: A cross sectional study.

OBJECTIVE: To estimate fibromyalgia frequency among patients presenting with complaints of chronic fatigue and or generalised body pain for at least six weeks. METHODS: The cross-sectional study was conducted at the Department of Internal Medicine, Indus Hospital, Karachi, between December 2016 and March 2018, and comprised patients of either gender presenting with complaints of chronic fatigue and or generalised body pain for at least six weeks. They were assessed for fibromyalgia according to the 2010 Fibromyalgia Diagnostic criteria questionnaire. The Data was analysed using SPSS 21. RESULTS: Of the 267 patients, 197(73.8%) were females and 70(26.2%) were males. Fibromyalgia was detected in 149(55.80%) patients. The mean age of patients with fibromyalgia was 42.3±14.6 years and it was 38.9±13.7 years in patients without fibromyalgia (p<0.05). No significant association was found between gender and fibromyalgia (p>0.05). CONCLUSIONS: All patients with generalised pain should be evaluated for fibromyalgia and a diagnosis made to reduce the cost of further referrals and investigations, and delay in the management of this debilitating disorder.