Schmorl's nodes could be associated with intervertebral disc degeneration at upper lumbar levels and end-plate disease at lower lumbar level in patients with low back pain.

Schmorl's nodes (SNs) have increasingly been recognized on vertebral end-plates using advanced imaging techniques. Even though vertebral end-plates are the closest structures to discs, their pathologies are underestimated in the etiology of low back pain (LBP). We aimed to detect the prevalence of SNs and other end-plate defects in subjects with/without LBP and to understand whether SNs were associated with LBP and spinal degeneration. Subjects were evaluated in terms of end-plate defects, intervertebral disc degeneration (IVDD), and vertebral end-plate changes (Modic changes) at all lumbar levels on lumbar spine magnetic resonance imagings (MRI). Control subjects were compared to patients with LBP. Higher Pfirrmann scores (OR: 2.696) and higher SN scores (OR: 8.076) were significantly associated with Modic changes at L4-L5 disc level. Patients with higher SN scores at L1-L2 or L2-L3 levels had approximately 7-fold increased risk of severe IVDD at the corresponding levels. The most significant factor associated with presence of SNs was body weight of the patients (OR: 1.417). The most significant factor associated with intensity of LBP was severe IVDD at L5-S1 level (OR: 3.670). Having higher total SN score had an OR of 1.230 (95% CI: 1.003-1.509; p = 0.047) for predicting LBP. Schmorl's nodes were seen in 33.1% of patients and 11.5% of asymptomatic subjects. Body weight was the most significant factor associated with SNs. The most significant factor associated with LBP was severe IVDD at L5-S1 level.

A new radiological index for the assessment of higher body fat status and lumbar spine degeneration.

OBJECTIVE: Obesity has been proposed as a risk factor for low back pain (LBP) and intervertebral disc degeneration (IVDD). Even though body mass index (BMI) is used as a parameter for obesity, it could not represent percentage and distribution of the body fat. Subcutaneous fat tissue thickness (SFTT) was proposed as one of the magnetic resonance imaging (MRI) parameters to evaluate the percentage of the body fat. In this study, we aimed to find out whether SFTT at lower back correlated with LBP and spine degeneration. MATERIALS AND METHODS: We retrospectively reviewed a database of the patients with LBP. Concomitantly, asymptomatic control subjects were retrieved. Patients and control subjects were evaluated in terms of IVDD and Modic changes at all lumbar levels on MRI. SFTT was measured both on MRI and computed tomography (CT) scans, where applicable. RESULTS: SFTT at the lumbar spine had moderate-to-strong correlations with BMI. SFTT at L1-L2 level was significantly associated with severe IVDD at L5-S1 level, and Modic changes at L4-L5 and L5-S1 levels. BMI had no significant association with severe IVDD and Modic changes at lumbar spine. BMI and mean SFTT of all lumbar levels had ORs of 0.735 (95% CI: 0.631-0.857, p < 0.001) and 1.389 (95% CI: 1.266-1.524, p < 0.001) in predicting symptomatic subjects with LBP. CONCLUSION: SFTT at upper lumbar levels could predict severe IVDD and Modic changes better than BMI, specifically in men. SFTT was better than BMI in predicting a symptomatic patient with LBP.

Obesity could be associated with poor paraspinal muscle quality at upper lumbar levels and degenerated spine at lower lumbar levels: Is this a domino effect?

Vertebral end-plate changes and paraspinal muscles are recently getting much more attention, since they could be associated with intervertebral disc degeneration (IVDD) and low back pain (LBP). Even though obesity is known as a risk factor for LBP, the role of obesity in the process of LBP is still controversial. In this study, we aimed to identify whether increased body mass index (BMI) was associated with IVDD, vertebral end-plate changes and paraspinal muscle quality. Consecutive women and men, aged between 20 and 50 years, presented with chronic LBP to the outpatient clinics were included. Patients were evaluated in terms of IVDD, vertebral end-plate changes, fatty infiltration in the paraspinal muscles at all lumbar levels on magnetic resonance imaging. Severe IVDD was more common in obese patients than in non-obese patients (73.5% vs. 50.4%, p = 0.017). When we compared the groups level by level, the significant difference for severe IVDD was present only at L4-L5 disc level (50% vs. 27.4%, p = 0.013). There was a higher trend of harboring Modic change at any lumbar level in obese patients, significantly in women (35.9% vs. 16.4%, p = 0.026). More severe fatty infiltration in the paraspinal muscles was seen at upper lumbar levels of the obese patients, particularly in women. Patients with higher BMI and suffering from LBP, had more fatty infiltration in the paraspinal muscles at the upper lumbar levels, more severe IVDD, and Modic changes at the lower lumbar levels; particularly women.

Is the Distribution Pattern of Modic Changes in Vertebral End-plates Associated With the Severity of Intervertebral Disc Degeneration?: A Cross-sectional Analysis of 527 Caucasians.

BACKGROUND: Low back pain (LBP) is one of the most common disorders, with many possible causes including intervertebral disc degeneration (IVDD) and Modic changes. In this study we aimed to analyze whether the distribution pattern of Modic changes in the vertebral end-plates was associated with the severity of IVDD. METHODS: We conducted a cross-sectional analysis of a retrospective database. Patients with constant LBP were evaluated in terms of IVDD and Modic changes on lumbar spine magnetic resonance imaging. Statistical analyses were specifically performed for the lower lumbar levels. RESULTS: We evaluated 527 patients. Modic changes were detected in 25% of the patients. Severe IVDD was detected in 90% and 88% of patients with Modic changes through the whole end-plates at L4-L5 and L5-S1 levels, respectively. Patients with Modic changes at L5-S1 level had significantly lower lumbar lordosis. Presence of severe IVDD at L4-L5 and L5-S1 levels was associated with 2.7- and 2.9-times higher risk of more widely distributed Modic changes in those vertebral end-plates, respectively. CONCLUSIONS: Severe IVDD was significantly more common in patients with Modic changes through the whole end-plate and in those with Modic type I changes.

Reciprocal relationship between multifidus and psoas at L4-L5 level in women with low back pain.

Background Low back pain (LBP) may originate from different sources such as intervertebral disc degeneration (IVDD), end-plate and paraspinal muscle changes. Our aim is to explore the relevance of paraspinal muscles' fat-infiltration in women with LBP and its association with IVDD and Modic changes.Methods Consecutive female patients presenting with chronic LBP to the outpatient clinics were included. Patients were evaluated in terms of IVDD, vertebral end-plate changes, and fatty infiltration in the paraspinal muscles at all lumbar levels on lumbar spine magnetic resonance imaging (MRI). Visual Analogue Scale (VAS) scores were recorded using our prospectively collected database.Results Patients with higher VAS scores were significantly more likely to have more fatty infiltration in the multifidus and less fatty infiltration in the psoas at L4-L5 level when compared to those with lower VAS scores (69.1 vs. 31.8%, p = 0.003). To predict LBP, fatty infiltration in the multifidus and psoas had odds ratio (OR) of 4 (p = 0.010), and 0.3 (p = 0.013), respectively; whereas disc degeneration had an OR of 0.5 (p = 0.028).Conclusion This is the first clinical cross-sectional study suggested that women with chronic low back pain could have less fat-infiltrated psoas to compensate more fat-infiltrated multifidus at L4-L5 disc level.

Association between facet joint orientation/tropism and lumbar intervertebral disc degeneration.

Background: The aim of this study was to understand how facet joint orientation (FJO) and facet joint tropism (FJT) affected severe intervertebral disc degeneration (IVDD) process at lower lumbar levels in patients with LBP.Methods: This study is a cross-sectional analysis of a retrospective database. Patients were evaluated in terms of IVDD, FJO, and FJT at all lumbar levels on magnetic resonance imaging.Results: In this study (n: 123) facet joints were aligned more coronal in men than in women at upper lumbar levels. Men had less FJT compared to women, significantly at L2-L3 and L3-L4 levels. Severe IVDD at L4-L5 was associated with more coronal aligned L1-L2 (29.0 ± 2.5° vs. 23.3 ± 2.3°, p = 0.006) and misaligned L5-S1 (8.3 ± 1.9° vs. 4.5 ± 1.7°, p = 0.008). Besides, severe IVDD at L3-L4 was associated with more coronal aligned L4-L5 (49.1 ± 3.2° vs. 41.4 ± 2.8°, p = 0.014).Conclusion: There is a close association between FJO/FJT with lumbar IVDD. Facet joint orientation and FJT do not affect the disc at only the corresponding level; the lumbar spine should be evaluated as a whole.

Proposal for a new scoring system for spinal degeneration: Mo-Fi-Disc.

OBJECTIVE: We aimed to develop a new scoring system for spinal degeneration including Modic changes, fatty infiltration (fi) in the paraspinal muscles, and intervertebral disc degeneration (IVDD), briefly Mo-fi-disc, using current radiological classification systems. We also aimed to understand whether Mo-fi-disc could predict patients with more intense low back pain (LBP). PATIENTS AND METHODS: We conducted a cross-sectional analysis of a retrospective database between March 2018 and July 2020. We evaluated patients in terms of Modic changes, fatty infiltration in the paraspinal muscles, and IVDD at all lumbar levels on lumbar spine MRI. We grouped patients based on their LBP intensity. Visual analog scale (VAS) scores were used for LBP intensity. RESULTS: We evaluated 134 patients (female: 66, male: 68; mean age: 35.44 ± 6.5 years). Patients with higher VAS scores had significantly higher 'Mo-disc' scores and higher 'fi' scores compared to those with lower VAS scores (3.54 ± 2.7 vs. 2.55 ± 2.8, p = 0.0075; 6.85 ± 3.2 vs. 5.25 ± 2.9, p = 0.0092). Patients with higher VAS scores had significantly higher 'Mo-fi-disc' scores compared to those with lower VAS scores (10.4 ± 4.2 vs. 7.94 ± 3.8, p = 0.0003). The most significant predictor for patients with higher VAS scores was 'Mo-fi-disc' scoring system with an OR of 1.193 (95 % CI: 1.055-1.349, p = 0.005). CONCLUSION: Patients with more intense LBP had higher 'Mo-fi-disc' scores. This scoring system suggests an easy and objective classification to evaluate the spinal degeneration.

Cervical intradural extramedullary epidermoid cyst at the background of congenital scoliosis with a semi-segmented C6 hemivertebra.

In the present case study, we present a female adolescent patient harboring a rare clinical presentation of spinal intradural extramedullary epidermoid cyst concomitant with congenital scoliosis. A 17-year-old female patient was admitted to the clinic with long-lasting neck pain. She was neurologically intact yet had cervicothoracic scoliosis. Cervical MRI and CT depicted a right C6 hemivertebra, fused to the lower endplate of the C5 vertebra. At the same vertebra level, she had an intradural extramedullary mass lesion anterior to the spinal cord. We planned to excise the mass lesion first. We used neuromonitoring during the surgery and made the surgery via posterior approach. We observed a pearl-like mass lesion anterolateral to the spinal cord. We excised the mass lesion with its capsule microsurgically via peace-meal route. She was neurologically stable following the surgery. Histopathological diagnosis was epidermoid cyst. Most of spinal inclusion cysts occur secondary to spinal dysraphism or iatrogenic inoculation. Isolated spinal inclusion cyst located anterior to the spinal cord concomitant with vertebral anomalies should be kept in mind before making proper surgical planning. Surgery is the modality of choice for spinal inclusion cyst and should be performed under the guidance of neuromonitoring, especially in cases with lesions located at higher spinal levels.

Serotonin Syndrome Following Tramadol and Gabapentin Use After Spine Surgery.

BACKGROUND: Serotonin syndrome (SS) is a common disease entity and could result in death if missed. The incidence of SS is underestimated due to misdiagnosis of many cases, especially the ones with less severe presentation. Many medications have been depicted as the source of SS. We present a case of SS in a patient who received intravenous tramadol and oral gabapentin as pain management after spine surgery. CASE DESCRIPTION: A 66-year-old man was admitted to our outpatient clinic with walking difficulties for 2 months. He was neurologically intact. However, he had neurologic claudication. He was on insulin, telmisartan-hydrochlorothiazide, amlodipine, and albuterol before the surgery, and these drugs were continued after the surgery. After he was diagnosed with lumbar spinal stenosis, he underwent total laminectomies of L3 and L4 and bilateral transpedicular screw placement from L1 to L5. He received tramadol 100 mg once daily intravenously and gabapentin 300 mg thrice daily orally after the spine surgery. He became confused, aggressive, and agitated during his stay in the hospital postoperatively. He became frustrated with even his children and wife. He started receiving haloperidol and quetiapine after psychiatry consultation. Because he worsened immediately after quetiapine and haloperidol, his medications were ceased in a step-by-step manner (first, tramadol and second, gabapentin). He became stable in a few hours, and his symptoms have improved since then. CONCLUSIONS: Physicians treating spine patients should be alert about SS in patients using both tramadol and gabapentin.