Comparison of lumbar muscle morphology in patients with chronic nonspecific low back pain with and without clinical lumbar segmental instability.

OBJECTIVES: Evaluation of spinal muscle morphology may be critical because of its impact on segmental stability and control of the lumbar spine in the subset of patients with clinical lumbar segmental instability (LSI). The purpose of this study was to compare lumbar muscle morphology in CNLBP patients with clinical LSI, CNLBP patients without clinical LSI. METHODS: This case-control study included 30 patients with CNLBP (15 with clinical LSI and 15 without clinical LSI) and 15 subjects without LBP. Axial magnetic resonance images from the L2 to S1 lumbar levels were used to evaluate the morphology of the lumbar muscles. RESULTS: A significant increase in the muscle-to-fat infiltration index and a significant decrease in the relative muscle cross-sectional area (rmCSA) of the multifidus muscle at the L3-L4 to L5-S1 levels were observed in both CNLBP groups compared to the control group (p<0.05). The mean erector spinae mean rmCSA was significantly greater in the clinical LSI group compared to the control group (SMD = 0.853, 95% CI = 0.105 to -1.6, P = 0.044) and also compared to the CNLBP without clinical LSI (SMD = 0.894, 95% CI = -1.645 to -0.144, P = 0.030) at the L4-L5 level. CONCLUSIONS: The atrophic changes of the multifidus muscle, in CNLBP patients with or without clinical LSI was observed. However, hypertrophic changes of the erector spinae muscle at the L4-L5 lumbar level were observed only in the clinical LSI group. Psaos major did not show significant atrophic or hypertrophic changes.

Paraspinal Muscle Changes in Individuals with and without Chronic Low Back Pain over a 4-Month Period: A Longitudinal MRI Study.

Background and Objectives: Previous research has shown associations between atrophy and fatty infiltration of the lumbar paraspinal musculature and low back pain (LBP). However, few studies have examined longitudinal changes in healthy controls and individuals with LBP without intervention. We aimed to investigate the natural variations in lumbar paraspinal musculature morphology and composition in this population over a 4-month period. Materials and Methods: Healthy controls and individuals with LBP were age- and sex-matched and completed several self-administered questionnaires. MRIs of L1-L5 were taken at baseline, 2 months, and 4 months to investigate cross-sectional area (CSA), along with DIXON fat and water images. A total of 29 participants had clear images for at least one level for all three time points. Means and standard deviations were calculated for the participant demographics. A two-way repeated measures ANOVA was performed to investigate CSA, fat signal fraction, and CSA asymmetry. Results: A total of 27 images at L3/L4, 28 images at L4/L5, and 15 images at L5/S1 were included in the final analysis. There were significant main effects of group for psoas CSA at the L3/L4 level (p = 0.02) and erector spinae (ES) CSA % asymmetry at the L3/L4 level (p < 0.001). There was a significant main effect of time for lumbar multifidus (LM) CSA % asymmetry at L4/L5 level (p = 0.03). Conclusions: This study provides insights into LM, ES, and psoas morphology in both healthy controls and affected individuals over a 4-month period without any intervention. Our findings suggest that psoas CSA at higher lumbar levels and CSA % asymmetry in general may be a better indicator of pathology and the development of pathology over time. Evaluating natural variations in paraspinal musculature over longer time frames may provide information on subtle changes in healthy controls and affected individuals and their potential role in chronic LBP.

The enhanced connectivity between the frontoparietal, somatomotor network and thalamus as the most significant network changes of chronic low back pain.

The prolonged duration of chronic low back pain (cLBP) inevitably leads to changes in the cognitive, attentional, sensory and emotional processing brain regions. Currently, it remains unclear how these alterations are manifested in the interplay between brain functional and structural networks. This study aimed to predict the Oswestry Disability Index (ODI) in cLBP patients using multimodal brain magnetic resonance imaging (MRI) data and identified the most significant features within the multimodal networks to aid in distinguishing patients from healthy controls (HCs). We constructed dynamic functional connectivity (dFC) and structural connectivity (SC) networks for all participants (n = 112) and employed the Connectome-based Predictive Modeling (CPM) approach to predict ODI scores, utilizing various feature selection thresholds to identify the most significant network change features in dFC and SC outcomes. Subsequently, we utilized these significant features for optimal classifier selection and the integration of multimodal features. The results revealed enhanced connectivity among the frontoparietal network (FPN), somatomotor network (SMN) and thalamus in cLBP patients compared to HCs. The thalamus transmits pain-related sensations and emotions to the cortical areas through the dorsolateral prefrontal cortex (dlPFC) and primary somatosensory cortex (SI), leading to alterations in whole-brain network functionality and structure. Regarding the model selection for the classifier, we found that Support Vector Machine (SVM) best fit these significant network features. The combined model based on dFC and SC features significantly improved classification performance between cLBP patients and HCs (AUC=0.9772). Finally, the results from an external validation set support our hypotheses and provide insights into the potential applicability of the model in real-world scenarios. Our discovery of enhanced connectivity between the thalamus and both the dlPFC (FPN) and SI (SMN) provides a valuable supplement to prior research on cLBP.

Biochemical changes in lumbar facet joint and disc degeneration by T2* mapping.

BACKGROUND: To investigate the biochemical changes in lumbar facet joint (LFJ) and intervertebral disc (IVD) with different degenerative grade by T2* mapping. METHODS: Sixty-eight patients with low back pain (study group) and 20 volunteers (control group) underwent standard MRI protocols and axial T2* mapping. Morphological evaluation of LFJ and IVD were performed on T2-weighted imaging according to Weishaupt and Pfirrmann grading system, respectively. T2* values of LFJ and of AF (anterior annulus fibrosus), NP (nucleus pulposus), and PF (posterior annulus fibrosus) in IVD were measured. Kruskal-Wallis test and Wilcoxon rank-sum test were used to compare T2* values of subjects with different degenerative grade. RESULTS: The mean T2* value of grade 0 LFJ (21.68[17.77,26.13]) was higher than those of grade I (18.42[15.68,21.8], p < 0.001), grade II (18.98[15.56,22.76], p = 0.011) and grade III (18.38[16.05,25.07], p = 0.575) LFJ in study group, and a moderate correlation was observed between T2* value and LFJ grade (rho=-0.304, p < 0.001) in control group. In the analysis of IVD, a moderate correlation was observed between AF T2* value and IVD grade (rho=-0.323, p < 0.001), and between NP T2* value and IVD grade (rho=-0.328, p < 0.001), while no significant difference was observed between the T2* values of PF in IVD of different grade in study group. CONCLUSIONS: Downward trend of T2* values can be found in LFJ, AF and NP as the degenerative grade rised. But in elderly patients with low back pain, no change trend was found in LFJ due to increased fluid accumulation in the joint space.

Obstetric-related lower back pain: the effect of number of pregnancy on development of chronic lower back pain, worsening of lumbar disc degeneration and alteration of lumbar sagittal balance.

OBJECTIVE: This study aims to determine whether the number of pregnancies contributes to the development of chronic lower back pain, worsening the lumbar disc degeneration and altering the normal lumbar sagittal balance. MATERIAL METHOD: There are 134 ladies participated in this study. They are divided into two groups based on their number of pregnancies (parity). All patients with chronic back pain were assessed using a visual analog scale for pain and the Oswestry Disability Index for their functional status assessment. Degenerative signs in lumbar MRI, which are Modic changes and the presence of Schmorl's node, were evaluated. Besides that, the sagittal balance of the lumbar spine was also measured via an erect lumbar plain radiograph. RESULTS: Patients with parities < 5 were included in Group 1, and those with parities ≥ 5 in Group 2. The mean visual analog scale score of Group 2 was significantly higher than that of Group 1 (8.42 ± 1.34 vs.6.50 ± 1.61). The mean Oswestry Disability Index score in Group 2 was significantly higher than that of Group 1 (29.87 ± 6.75 vs.18.41 ± 7.97). This relationship between the groups in terms of Modic change was statistically significant. The relationship between the groups regarding the presence of Schmorl's nodes was also statistically significant. The difference between the groups in terms of sagittal balance parameters was not statistically significant. CONCLUSION: Chronic lower back pain is significantly worse and associated with more disability in patients with more than five previous pregnancies. MRI degenerative changes are also significantly higher in these grand multipara groups.

Gray Matter Abnormalities in Patients with Chronic Low Back Pain: A Systematic Review and Meta-Analysis of Voxel-Based Morphometry Studies.

BACKGROUND: Numerous studies utilizing voxel-based morphometry (VBM) have documented gray matter (GM) alterations in patients with chronic low back pain (CLBP) compared to healthy controls. However, the inconsistency in GM abnormalities observed across different studies has hindered their potential application as objective neuroimaging biomarkers or therapeutic targets. To address this issue, we conducted a comprehensive meta-analysis of VBM studies to identify robust GM differences between CLBP patients and healthy controls. METHODS: The databases including PubMed, Embase, and Web of Science were systematically searched from January 2000 to September 2022 to identify eligible neuroimaging studies. In this coordinate-based meta-analysis of VBM studies, the Seed-based d Mapping with Permutation of Subject Images method was used to quantitatively assess regional differences in GM between CLBP patients and healthy controls. RESULTS: Thirteen VBM studies, involving a total of 574 CLBP patients and 1239 healthy controls, were included in the meta-analysis. The findings revealed that CLBP patients exhibited increased GM in the left striatum and left postcentral gyrus and decreased GM in the left superior frontal gyrus, left cerebellum, right striatum, left insula, and right middle occipital gyrus compared to healthy controls. The jackknife sensitivity analysis confirmed the robustness of these neuroimaging findings. CONCLUSIONS: This study provides new insights into potential treatment strategies for CLBP and identifies neuroimaging biomarkers for pain chronification. These findings highlight the importance of considering regional GM abnormalities in the development of clinical interventions for CLBP.

Association between the Thickness of Lumbar Subcutaneous Fat Tissue and the Presence of Hernias in Adults with Persistent, Non-Traumatic Low Back Pain.

We aimed to analyze the association between the average lumbar subcutaneous fat tissue thickness (LSFTT) at each intervertebral level and the presence of hernias in patients with low back pain from an insurance network hospital in Mexico. This observational prospective study included 174 patients with non-traumatic lumbago who underwent magnetic resonance imaging with a 1.5T resonator. Two independent radiologists made the diagnosis, and a third specialist provided a quality vote when needed. The sample size was calculated with a 95% confidence interval using random order selection. Anonymized secondary information was used. Percentages and means with confidence intervals were tabulated. The area under the curve, specificity, and sensitivity of LSFTT were calculated. A regression analysis was performed to analyze the presence of hernias with LSFTT using each intervertebral level as a predictor. The odds of herniation at any intervertebral level increased directly with LSFTT. The average LSFTT predicted the overall presence of hernias; however, the LSFTT at each intervertebral level better predicted hernias for each intervertebral space. The area under the curve for LSFTT in predicting hernias was 68%. In conclusion, the average LSFTT was associated with the overall presence of hernias; patients with more hernias had higher LSFTT values.

Alterations in functional connectivity in patients with non-specific chronic low back pain after motor control exercise: a randomized trial.

BACKGROUND: Motor control exercise (MCE) is effective in alleviating non-specific chronic low back pain (NCLBP). Neuro-imaging research is warranted to explore the underlying neural mechanisms of MCE. AIM: We used resting-state functional magnetic resonance imaging (rs-fMRI) to explore the central mechanism underpinning the effects of MCE in patients with NCLBP. DESIGN: A randomized, single-blinded, controlled trial. SETTING: The setting was out-patient and community. POPULATION: Fifty-eight patients with NCLBP. METHODS: Patients were randomized into the MCE or manual therapy (MT) group. All the participants completed pain-related clinical assessments and rs-fMRI scans before and after intervention. We performed exploratory whole-brain analyses in regional homogeneity (ReHo) and resting-state functional connectivity (rsFC) with significant post-pre differences in ReHo before and after intervention, and investigated associations between imaging and pain-related clinical assessments. RESULTS: Compared with the MT group, a greater alleviation in pain intensity and disability was observed in the MCE group after intervention, and was sustained at the 6-month follow-up (P<0.001). Only the MCE group showed increased ReHo values in the right pre-central gyrus and decreased ReHo values in the bilateral posterior cerebellum (voxel level P<0.001, cluster-level FWE corrected P<0.05). Decreased rsFC of the right posterior cerebellum-left superior parietal gyrus and left insula were significantly positively associated with pain-related disability (voxel level P<0.001, cluster-level FWE corrected P<0.05). CONCLUSIONS: These findings demonstrated that MCE had superior effects in relieving pain and pain-related disability, which might be associated with its modulation of rsFC between the cerebellum and areas involved in sensory-discriminative processing of noxious and somato-sensory stimuli, affection, and cognition. CLINICAL REHABILITATION IMPACT: This study provided preliminary evidence that MCE might alleviate NCLBP through its modulation of the function of brain areas related to chronic pain and postural control. Those results support MCE's clinical application and help physiotherapists to provide better multidisciplinary interventions with the combination of MCE and other first-line treatments.

Reconsidering high intensity zones: its role in intervertebral disk degeneration and low back pain.

PURPOSE: High intensity zones (HIZ) in the lumbar intervertebral disk (IVD) can be associated with degenerative changes which may ultimately manifest as low back pain (LBP). However, the relationship between the prevalence of HIZ and lumbar degenerative parameters is still unclear. The purpose of this study was to determine the prevalence of HIZ in the lumbar spine, analyze the independent relationship between HIZ and lumbar degenerative parameters measured on MRI and X-ray and determine the association between HIZ and the presence of LBP. METHODS: A retrospective review of MRI data, X-ray data, and radiology reports for 136 consecutively recruited patients, above 18-years-age and with both lumbar MRI and X-ray scans was conducted. 57 patients with HIZ were identified. Patients without HIZ (n = 79) made up the control group. RESULTS: HIZ was prevalent in 41.9% of patients and in 11.0% of all lumbar IVDs. The odds of developing HIZ were 6.4 (Exp(B) 6.4, 95%CI [3.157-12.988]) and 3.0 (Exp(B) 3.0, 95%CI [1.603, 5.674]) times higher in IVDs with disk bulge/protrusion and nucleus degeneration, respectively. Odds of HIZ was also increased in disks with larger IVD angle (Exp(B) 1.1, 95%CI [1.034, 1.169]). The odds of patients presenting to imaging with LBP was 3.0 (OR 3.0, 95%CI [1.478-6.338]) times higher in the HIZ compared to the control group. CONCLUSIONS: HIZ was prevalent in 41.9% of participants that were recruited in this study. Nucleus degeneration, disk bulge/protrusion and increased IVD angle were found to be independently associated with HIZ and since there is an increased likelihood of LBP, we posit that HIZ is likely a symptomatic and clinically meaningful diagnostic tool in the assessment of LBP.

Deep learning-accelerated image reconstruction in back pain-MRI imaging: reduction of acquisition time and improvement of image quality.

INTRODUCTION: Low back pain is a global health issue causing disability and missed work days. Commonly used MRI scans including T1-weighted and T2-weighted images provide detailed information of the spine and surrounding tissues. Artificial intelligence showed promise in improving image quality and simultaneously reducing scan time. This study evaluates the performance of deep learning (DL)-based T2 turbo spin-echo (TSE, T2DLR) and T1 TSE (T1DLR) in lumbar spine imaging regarding acquisition time, image quality, artifact resistance, and diagnostic confidence. MATERIAL AND METHODS: This retrospective monocentric study included 60 patients with lower back pain who underwent lumbar spinal MRI between February and April 2023. MRI parameters and DL reconstruction (DLR) techniques were utilized to acquire images. Two neuroradiologists independently evaluated image datasets based on various parameters using a 4-point Likert scale. RESULTS: Accelerated imaging showed significantly less image noise and artifacts, as well as better image sharpness, compared to standard imaging. Overall image quality and diagnostic confidence were higher in accelerated imaging. Relevant disk herniations and spinal fractures were detected in both DLR and conventional images. Both readers favored accelerated imaging in the majority of examinations. The lumbar spine examination time was cut by 61% in accelerated imaging compared to standard imaging. CONCLUSION: In conclusion, the utilization of deep learning-based image reconstruction techniques in lumbar spinal imaging resulted in significant time savings of up to 61% compared to standard imaging, while also improving image quality and diagnostic confidence. These findings highlight the potential of these techniques to enhance efficiency and accuracy in clinical practice for patients with lower back pain.

[Research on Automatic Evaluation Method of Limb Dysfunction of Low Back Pain Based on MRI].

Based on preprocessed MRI images of low back pain patients, this study extracted MRI image features that can reflect the dysfunction of low back pain patients, and proposed a stacking ensemble learning algorithm model based on algorithm diversity, which provided a reliable method and an implementation method for the accurate assessment of limb dysfunction in low back pain patients.

Is the use of diagnostic imaging and the self-reported clinical management of low back pain patients influenced by the attitudes and beliefs of chiropractors? A survey of chiropractors in the Netherlands and Belgium.

BACKGROUND: No previous studies have examined the association between attitudes and beliefs of chiropractors and their adherence to low back pain (LBP) guidelines. The aim of this study is: (1) to assess the attitudes and beliefs towards the management of LBP of Dutch and Belgian chiropractors; and (2) to investigate the association of these attitudes and beliefs on the use of diagnostic imaging and on the adherence to diagnostic guidelines and guidelines in the management of patients with LBP. METHODS: STUDY DESIGN: Cross-sectional study using a web-based questionnaire in chiropractic private practices in the Netherlands and Belgium. The survey included sociodemographic characteristics, use of diagnostic imaging, the Pain Attitude and Beliefs Scale-Physiotherapists (PABS.PT) and 6 vignettes (3 acute and 3 chronic LBP patients). We used Latent Profile Analysis (LPA) to categorise the chiropractors into clusters depending on their PABS.PT outcome, whereby the classes differed primarily on the biomedical score. We used linear, logistic, and mixed models to examine the associations between these clusters, and adherence to the recommendations of guidelines on: (1) diagnostic imaging use, and (2) management of LBP (i.e. advice on activity, treatment, return-to-work, and bedrest). RESULTS: The response rate of the Dutch and Belgian chiropractors was 61% (n = 149/245) and 57% (n = 54/95), respectively. The majority of chiropractors scored midrange of the biomedical scale of the PABS.PT. Three clusters were identified using LPA: (1) high biomedical class (n = 18), (2) mid biomedical class (n = 117) and (3) low biomedical class (n = 23). Results from the vignettes suggest that chiropractors in the high biomedical class better adhere to diagnostic imaging guidelines and to LBP guidelines when it concerns advice on return-to-work and activity compared to the other two classes. However, no differences were identified between the classes for treatment of LBP. All chiropractors adhered to the guidelines' recommendation on bedrest. CONCLUSION: The high biomedical class demonstrated better overall adherence to the practice guidelines for the management of LBP and diagnostic imaging than the other classes. Due to the small numbers for the high and low biomedical classes, these results should be interpreted with caution.

A new classification of lumbar Basstrup's disease based on radiographic and clinical symptoms.

OBJECTIVE: To propose a new classification method for lumbar Basstrup's disease based on radiographic and clinical symptoms, and to test its credibility and reproducibility. METHODS: A retrospective analysis of 116 patients with complete data of lumbar Basstrup's disease in our hospital from January 2019 to January 2022, radiological imaging including X-ray, CT and MRI, were divided into two main types according to the number of segments: type I (single segment) and type II (multiple segments), each type was divided into a total of eight subtypes according to the degree of degeneration: Ia, Ib, Ic, Id, IIa, IIb, IIc, IId; it was further divided into 16 subtypes according to the presence or absence of clinical symptoms (i.e. low back pain or/and lower limb neurological symptoms: no 0, yes 1): Ia0, Ia1, Ib0, Ib1, Ic0, Ic1, Id0, Id1; IIa0, IIa1, IIb0, IIb1, IIc0, IIc1, IId0, IId1.The 116 patients with Basstrup's disease were successively typed twice (1 month interval) by five physicians according to the new classification method, and the reliability and reproducibility of the new classification were assessed using the Kappa consistency test. RESULTS: Among 116 patients with lumbar Basstrup's disease: there were 60 cases of type I (single segment), accounting for 51.72%, including Ia 19 cases, Ib 16 cases, Ic 10 cases, and Id 15 cases; there were 56 cases of type II (multiple segments), accounting for 48.28%, including IIa 10 cases, IIb 20 cases, IIc 14 cases, and IId 12 cases. Of the 116 patients, 47 cases had no clinical symptoms (Ia0 16 cases, Ib0 3 cases, Ic0 6 cases, Id0 1 case, IIa0 8 cases, IIb0 2 cases, IIc0 10 cases, IId0 1 case), accounting for 40.52%; 69 cases were accompanied by low back pain or/and lower extremity nerve symptoms (Ia1 3 cases, Ib1 13 cases, Ic1 4 cases, Id1 14 cases, IIa1 2 cases, IIb1 18 cases, IIc1 4 cases, IId1 11 cases), accounting for 59.48%.Five physicians completed two rounds of a total of 1160 typings, with inter-assessor typing agreement of 82.47% (80.17-85.34%) and a mean Kappa value of 0.723 (0.771-0.831); intra-assessor typing agreement of 82.76% (77.59-86.21%) and a mean Kappa value of 0.801 (0.742-0.841). CONCLUSION: The new classification method for lumbar Basstrup's disease based on radiographic and clinical symptoms is simple, practical, with good credibility and reproducibility, and provides some guidance for clinical treatment.

Reporting of Facet Joint Inflammation in Lumbar Spine MRI Studies in Patients With Low Back Pain.

STUDY DESIGN: Retrospective. OBJECTIVE: We aimed to assess the frequency of facet joint inflammatory features noted in routine radiology reports of lumbar spine magnetic resonance imaging (MRI) studies among patients with chronic low back pain. SUMMARY OF BACKGROUND DATA: Facet joint arthropathy is one of the most common causes of chronic low back pain. It may encompass various inflammatory imaging characteristics, such as facet joint effusion, bone marrow edema, and soft tissue edema. The extent to which radiology reports mention inflammatory features of the lumbar facet joints and the accuracy of these reports have not been investigated. MATERIALS AND METHODS: The authors performed a chart review on 49 subjects with previous facet-related interventions ( i.e . medial branch blocks or intra-articular facet joint injection) and MRI available in the medical record. One senior musculoskeletal radiologist and a musculoskeletal radiology fellow graded the inflammatory features using a published facet joint inflammation grading system [Gold Standard (GS)]. The authors identified the inflammatory markers mentioned in the radiology reports and calculated the sensitivity and positive predictive value of the radiology reports compared with GS readings. RESULTS: Compared with the GS, the sensitivity of radiology reports for facet joint effusion, bone marrow, and soft tissue edema ranged from 6% to 22%, and the positive predictive value ranged from 25% to 100%. L4/5 had the highest number of cases with inflammatory features noted on the reports. CONCLUSION: Inflammatory findings, such as facet joint effusion, bone marrow edema, and soft tissue edema, are not commonly identified in radiology reports. Further investigations are needed to determine the clinical importance of MRI-detected lumbar facet joint inflammatory features as a potential mechanism of nociception and as a predictor of outcomes following injections or other therapies.

Association between cup orientation and low back pain after total hip arthroplasty in patients with osteonecrosis of the femoral head.

BACKGROUND: Postoperative low back pain (LBP) following total hip arthroplasty (THA) is classified as secondary hip-spine syndrome. The purpose of this study was to explore the correlations between cup orientation of THA and postoperative LBP in patients with osteonecrosis of the femoral head (ONFH). METHODS: A retrospective cohort study included 364 ONFH patients who underwent bilateral THA between January 2011 and December 2020. Among them, 53 patients (14.6%) experienced postoperative LBP at the end of follow-up and were designated as pain group (PG). A control group (CG) consisting of 106 patients with similar age, sex, and body mass index (BMI) to those in the PG was selected. Postoperative LBP in the PG was assessed using the visual analogue scale (VAS). Demographic data, clinical information, and radiographic criteria were evaluated as potential predictors of LBP. RESULTS: Patients in PG (mean age, 47.3 years [range, 27 to 75 years]; 42 [79%] male) had a mean VAS score of 4.6 (range, 1 to 9) compared with 0 for the patients in CG (mean age, 47.6 years [range, 19 to 77 years]; 84 [79%] male). There were no significant differences in clinical data between the two groups (p > 0.05). Preoperative radiographic variables also showed no significant differences between the PG and CG (p > 0.05). However, the postoperative inclination, anteversion, and standing ante-inclination (AI) were significantly lower in the PG compared to the CG, whereas the sitting and standing sacral slope (SS) were significantly higher (p < 0.05). Moreover, the variations in standing AI, standing and sitting pelvic tilt (PT) were significantly lower in the PG compared to the CG, while the variations in standing and sitting SS and lumbar lordosis (LL) were significantly higher (p < 0.05). The variation in standing AI in the PG showed a significantly correlation with the variation of standing SS, standing PT, and LL (p < 0.05). CONCLUSION: Postoperative LBP in ONFH patients after bilateral THA is significantly associated with the intraoperative cup orientation. The variation in standing AI is correlated with the variations in standing SS, standing PT, and LL, potentially contributing to the development of postoperative LBP.

Imaging of Discogenic and Vertebrogenic Pain.

Chronic low back pain is a major source of pain and disability globally involving multifactorial causes. Historically, intervertebral disc degeneration and disruption have been associated as primary back pain triggers of the anterior column, termed "discogenic pain." Recently, the vertebral endplates have been identified as another possible pain trigger of the anterior column. This "endplate-driven" model, defined "vertebrogenic pain," is often interconnected with disc degeneration. Diagnosis of vertebrogenic and discogenic pain relies on imaging techniques that isolate pain generators and exclude comorbid conditions. Traditional methods, like radiographs and discography, are augmented by more sensitive methods, including SPECT, CT, and MRI. Morphologic MRI is pivotal in revealing indicators of vertebrogenic (eg, Modic endplate changes) and discogenic pain (eg, disc degeneration and annular fissures). More advanced methods, like ultra-short-echo time imaging, and quantitative MRI further amplify MRI's accuracy in the detection of painful endplate and disc pathology. This review explores the pathophysiology of vertebrogenic and discogenic pain as well as the impact of different imaging modalities in the diagnosis of low back pain. We hope this information can help identify patients who may benefit from personalized clinical treatment and image-guided therapies.

Is unilateral-approach full-endoscopic lumbar fusion effective for single-level lumbar spondylolisthesis with bilateral symptoms? A preliminary report of 43 CT analysis.

PURPOSE: To investigate the clinical results and radiological parameters changes after unilateral-approach endoscopic lumbar interbody fusion (Endo-LIF) for lumbar spondylolisthesis with bilateral symptoms. METHODS: 43 single-level lumbar spondylolisthesis patients with bilateral lower limb symptoms were included from June 2020 to May 2022. All patients underwent unilateral-approach Endo-LIF and postoperative computed tomography. Radiological parameters including disk height (DH), degree of upper vertebral slip (DUVS), and foramen intervertebral parameters including bilateral foraminal height (FH), contralateral foraminal areas (FA) were evaluated. The clinical outcomes including low back pain and bilateral leg pain were evaluated using Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) before and after surgery. RESULTS: All cases were successfully completed surgery and followed for average 15.16 ± 5.2 months. DH (44% ± 11%) and DUVS were significantly improvement postoperatively compared with preoperatively (p < 0.05). Statistically significant increases in bilateral FH (25% ± 11% on the surgical side, 17% ± 8% on the contralateral side) and contralateral FA (26% ± 6%) were observed (p < 0.05). The VAS and the ODI scores were significantly decreased in comparison with the preoperative scores (p < 0.05). CONCLUSION: Unilateral-approach with contralateral indirect decompression in Endo-LIF can acquire satisfactory clinical outcomes. Therefore, unilateral-approach Endo-LIF may be a promising option for lumbar spondylolisthesis with bilateral symptoms.

Relationship between lumbar spinal stenosis and axial muscle wasting.

BACKGROUND CONTEXT: Although the effect of lumbar spinal stenosis (LSS) on the lower extremities is well documented, limited research exists on the effect of spinal stenosis on the posterior paraspinal musculature (PPM). Similar to neurogenic claudication, moderate to severe spinal canal compression can also interfere with the innervation of the PPM, which may result in atrophy and increased fatty infiltration (FI). PURPOSE: This study aims to assess the association between LSS and atrophy of the PPM. STUDY DESIGN: Retrospective cross-sectional study. PATIENT SAMPLE: Patients undergoing MRI scans at a tertiary orthopedic center for low back pain or as part of a preoperative evaluation. OUTCOME MEASURES: The functional cross-sectional area (fCSA) and percent fatty infiltration (FI) of the PPM at L4. METHODS: Lumbar MRIs of patients at a tertiary orthopedic center indicated due to lower back pain (LBP) or as a presurgical workup were analyzed. Patients with previous spinal fusion surgery or scoliosis were excluded. LSS was assessed according to the Schizas classification at all lumbar levels. The cross-sectional area of the PPM was measured on a T2-weighted MRI sequence at the upper endplate of L4. The fCSA and fatty infiltration (FI) were calculated using custom software. Crude differences in FI and fCSA between patients with no stenosis and at least mild stenosis were tested with the Wilcoxon signed-rank test. To account for possible confounders, a multivariable linear regression model was used to adjust for age, sex, body mass index (BMI), and disc degeneration. A subgroup analysis according to MRI indication was performed. RESULTS: A total of 522 (55.7% female) patients were included. The median age was 61 years (IQR: 51-71). The greatest degree of moderate and severe stenosis was found at L4/5, 15.7%, and 9.2%, respectively. Stenosis was the least severe at L5/S1 and was found to be 2% for moderate and 0.2% for severe stenosis. The Wilcoxon test showed significantly increased FI of the PPM with stenosis at any lumbar level (p<.001), although no significant decrease in fCSA was observed. The multivariable regression model showed a significant increase in FI with increased LSS at L1/2, L2/3, and L3/4 (p=.013, p<.01 and p=.003). The severity of LSS at L4/5 showed a positive association with the fCSA (p=.019). The subgroup analysis showed, the effect of LSS was more pronounced in nonsurgical patients than in patients undergoing surgery. CONCLUSIONS: In this study, we demonstrated a significant and independent association between LSS and the composition of the PPM, which was dependent on the level of LSS relative to the PPM. In addition to neurogenic claudication, patients with LSS might be especially susceptible to axial muscle wasting, which could worsen LSS due to increased spinal instability, leading to a positive feedback loop.

Inter-software and inter-threshold reliability of quantitative paraspinal muscle segmentation.

PURPOSE: Changes in the cross-sectional area (CSA) and functional cross-sectional area (FCSA) of the lumbar multifidus (MF) and erector spinae muscles (ES) are factors that can contribute to low back pain. For the assessment of muscle CSA and composition there are various software and threshold methods used for tissue segmentation in quantitative analysis. However, there is currently no gold standard for software as well as muscle segmentation. This study aims to analyze the measurement error between different image processing software and different threshold methods for muscle segmentation. METHODS: Magnetic resonance images (MRI) of 60 patients were evaluated. Muscle CSA and FCSA measurements were acquired from axial T2-weighted MRI of the MF and ES at L4/L5 and L5/S1. CSA, FCSA, and FCSA/CSA ratio were measured independently by two observers. The MRI images were measured using two different software programs (ImageJ and Amira) and with two threshold methods (Circle/Overlap method) for each software to evaluate FCSA and FCSA/CSA ratio. RESULTS: Inter-software comparisons revealed high inter-rater reliability. However, poor inter-rater reliability were obtained with different threshold methods. CSA, FCSA, and FCSA/CSA showed excellent inter-software agreement of 0.75-0.99 regardless of the threshold segmentation method. The inter-rater reliability between the two observers ranged between 0.75 and 0.99. Comparison of the two segmentation methods revealed agreement between 0.19 and 0.84. FCSA and FCSA/CSA measured via the Overlap method were significantly higher than those measured via the Circle method (P < 0.01). CONCLUSION: The present study showed a high degree of reliability with very good agreement between the two software programs. However, study results based on different threshold methods should not be directly compared.

The relationship between low back pain, pelvic tilt, and lumbar lordosis with urinary incontinence using the DIERS formetric 4D motion imaging system.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is a common public health problem and postural changes may be crucial in women presenting with UI. This study was aimed at evaluating the relationship between low back pain (LBP), pelvic tilt (PT), and lumbar lordosis (LL) in women with and without UI using the DIERS formetric 4D motion imaging system. To date no study has to our knowledge compared postural changes and LBP in women with UI using the DIERS 4D formetric system. METHODS: This was a case-control study. We included 33 women with UI and 33 without incontinence. The severity of urogenital symptoms was assessed by the IIQ-7 (Incontinence Impact Score) and UDI-6 (Urogenital Distress Inventory), and disability owing to LBP was evaluated using the Oswestry Disability Index (ODI). Posture and movement assessment, LL angle, thoracic kyphosis, and PT assessment were performed with the DIERS Formetric 4D motion imaging system. RESULTS: The LL angle and pelvic torsion degree were higher in the incontinence group than in the control group (53.9 ± 9.5° vs 48.18 ± 8.3°; p = 0.012, 3.9 ± 4.1 vs 2.03 ± 1.8 mm; p = 0.018 respectively). The LBP visual analog scale value was also significantly higher in the incontinence group (5.09 ± 2.3 vs 1.7 ± 1.8 respectively, p < 0.0001). The LL angle showed a positive correlation with pelvic obliquity, (r = 0.321, p < 0.01) and fleche lombaire (r = 0.472, p < 0.01) and a negative correlation with lumbar range of motion measurements. Pelvic obliquity correlated positively with pelvic torsion (r = 0.649, p < 0.01), LBP (r = 0.369, p < 0.01), and fleche lombaire (r = 0.269, p < 0.01). CONCLUSIONS: Women with UI were more likely to have lumbopelvic sagittal alignment changes and a higher visual analog scale for LBP. These findings show the need for assessment of lumbopelvic posture in women with UI.