Search Results (49)

Low-back pain (LBP) is a leading cause of disability worldwide. When symptoms persist beyond 4–6 weeks, when red flags are suspected, or when precise patient selection for procedures is needed, imaging—primarily MRI (Magnetic Resonance Imaging)—becomes pivotal. The purpose is to provide a pragmatic, radiology-first roadmap that aligns an imaging phenotype with anatomical targets and appropriate image-guided interventions, integrating MRI-based phenotyping with image-guided interventions for subacute and chronic LBP. In this narrative review, we define operational MRI criteria to distinguish radicular from non-radicular phenotypes and to contextualize endplate/Modic and facet/sacroiliac degenerative changes. We then summarize selection and technique for major procedures: epidural and periradicular injections (including selective nerve root blocks), facet interventions with medial branch radiofrequency ablation (RFA), sacroiliac joint injections and lateral branch RFA, basivertebral nerve ablation (BVNA) for vertebrogenic pain, percutaneous disc decompression, minimally invasive lumbar decompression (MILD), and vertebral augmentation for painful fractures. For each target, we outline preferred and alternative guidance modalities (fluoroscopy, CT, or ultrasound), key safety checks, and realistic effect sizes and durability, emphasizing when to avoid low-value or poorly indicated procedures. This review proposes a phenotype-driven reporting template and a care-pathway table linking MRI patterns to diagnostic blocks and definitive image-guided treatments, with the aim of reducing cascade testing and therapeutic ambiguity. A standardized phenotype → target → tool approach can make MRI reports more actionable and help clinicians choose the right image-guided intervention for the right patient, improving outcomes while prioritizing safety and value. Full article

Scheuermann’s kyphosis (SK) is a rigid dorsal kyphosis of unclear pathophysiological origin. The aim of this review is to summarise current theories and both clinical and experimental findings regarding the underlying mechanisms of SK. Emerging evidence highlights the significant role of excessive mechanical loading as a major contributor to defective growth of the cartilaginous vertebral endplate. This is associated with the formation of Schmorl’s nodes, disruption of the ring apophysis, and compromised intervertebral disc integrity—ultimately resulting in vertebral body wedging and thickening of the anterior longitudinal ligament. In addition, numerous studies have investigated the genetic contribution and underlying molecular mechanisms involved in the pathogenesis of SK. Recent in vivo findings suggest an association between asymmetric mechanosensory activation of cerebrospinal fluid (CSF), contacting neurons, and defective Reissner fibre signalling, which may contribute to abnormal spinal morphogenesis in the sagittal thoracic plane. These findings indicate a potential link between altered CSF dynamics and the development of SK. Taken together, the evidence supports a multifactorial aetiology, with both genetic and biomechanical factors playing central roles in the development of Scheuermann’s kyphosis. The interpretation of the underlying pathophysiological mechanism could result in the early detection of the subjects that may have genetical predisposition for SK appearance and the development of target molecular treatments in order to counter the progression of the deformity. Full article

Posterior instrumentation is used to treat severe adolescent idiopathic scoliosis (AIS) with a Cobb angle greater than 40 degrees. Clinical studies indicate that AIS patients may develop adjacent segment degeneration (ASD) post-surgery. However, there is limited research on the biomechanical effects on adjacent segments after surgery, and straightforward methods for creating finite element (FE) models that reflect vertebral deformation are lacking. Therefore, this study aims to use biplanar X-ray images to establish a case-specific, parameterized FE model reflecting coronal plane vertebral deformation and employ FE analysis to compare pre- and postoperative changes in the range of motion (ROM), endplate stress, and intervertebral disk stress of adjacent segments. We developed an FE model from biplanar X-ray images of a patient with AIS, using ANSYS software to establish pre- and postoperative models. The shape of the preoperative model was validated using computed tomography (CT) reconstruction. A flexion moment was applied to C7 of the spine model to achieve the same forward bending angle in the pre- and postoperative models. This study successfully developed a case-specific parameterized FE model based on X-ray images. The differences between Cobb angle and thoracolumbar kyphosis angle measurements in X-ray images and CT reconstructions were 6.5 and 5.4 mm. This FE model was used to analyze biomechanical effects on motion segments adjacent to the fixation site, revealing a decrease in maximum endplate and disk stress in the cranial segment and an increase in stress in the caudal segment. Full article

Introduction: Currently, static interbody cages are the gold standard for achieving solid arthrodesis in the spine, enhancing segmental stability, obtaining neuroforaminal decompression, and improving as well as maintaining segmental lordosis. It is well known that restoring sagittal balance and segmental lordosis is crucial for long-term outcomes in lumbar spine fusion. For some cases, expandable interbody cages are emerging as an alternative to static cages. This study aims to evaluate the radiographic outcomes and complications of standard open transforaminal lumbar interbody fusion (TLIF). Methods: A standard open TLIF procedure using expandable cages was performed at 1 to 3 levels in 71 patients (129 levels in total), with a follow-up of two years. All patients underwent radiological assessments preoperatively, immediately postoperatively, and at one and two years postoperatively. Radiological evaluation was conducted using standing lateral X-rays. Results: Segmental lordosis (SL) increased significantly from the preoperative value (9.0° ± 3.6°) to 24 months postoperatively (15.4° ± 3.0°), with improvements maintained throughout the 24-month follow-up period (p < 0.001). Similarly, anterior disc height (ADH), posterior disc height (PDH), and foraminal height (FH) each increased significantly from preoperative to immediate postoperative measurements, and these gains were maintained over the two-year follow-up (p < 0.001 each). Lumbar lordosis increased significantly from the preoperative value (41.9° ± 10.5°) to the immediate postoperative period (45.7° ± 10.8°); however, this improvement decreased slightly at the one- and two-year follow-ups. No revisions were required for cage-related complications. One patient experienced a surgical site infection, and two patients had mechanical complications (screw loosening and proximal junctional kyphosis). Conclusions: Expandable interbody cages enable excellent restoration and maintenance of disc height and segmental lordosis in a standard open TLIF procedures at two-year. Achieving these outcomes depends on several factors, including proper preparation of the vertebral endplates, accurate cage placement and expansion, posterior facet osteotomy, and the application of posterior compression prior to final fixation. These steps are essential to fully maximize the potential of expandable cage technology. Full article

Background and Objectives: Diffuse idiopathic skeletal hyperostosis (DISH)-related spinal fractures with marked anterior distraction are highly unstable and pose substantial surgical challenges. The transdiscal screw for diffuse idiopathic skeletal hyperostosis (TSD) technique has been proposed to enhance fixation strength by penetrating adjacent vertebral endplates; however, its clinical utility in large-displacement cases remained unclear. Materials and Methods: In this retrospective study, we reviewed 21 patients with thoracolumbar DISH-related fractures and an anterior fracture gap ≥ 15 mm, who underwent posterior fixation between 2010 and 2024. 11 patients underwent TSD fixation (TSD group), and 10 underwent conventional fixation without bilateral TSD (control group). Results: The mean number of fused segments did not differ significantly between the groups (5.0 ± 1.4 vs. 5.0 ± 1.3, p = 0.43). Operative time was comparable (164 ± 57 vs. 168 ± 60 min, p = 0.90). Blood loss tended to be lower in the TSD group (306 ± 334 vs. 528 ± 658 mL, p = 0.33). For fracture-gap reduction, the TSD group improved from 17.4 ± 2.3 mm preoperatively to 13.8 ± 4.4 mm postoperatively and 2.0 ± 3.6 mm at final follow-up, while the control group showed less reduction (16.8 ± 2.2, 15.4 ± 1.4, and 7.0 ± 9.1 mm, respectively). Screw loosening occurred in three TSD patients and six controls (p = 0.13). All patients in the TSD group achieved bone union without reoperation, whereas four controls experienced implant backout, three required reoperation, and two failed to achieve bone union (p = 0.035). Conclusions: Posterior fixation using TSD provided reliable stability, maintained reduction, and reduced the risk of implant failure compared with conventional fixation in highly unstable DISH-related fractures with anterior distraction. Although larger prospective studies are needed, TSD may represent a valuable surgical option for this challenging patient population. Full article

Bone health is a key determinant of success in spine surgery, making preoperative assessment of bone quality essential to optimal surgical risk stratification. Magnetic resonance imaging (MRI)-based vertebral bone quality (VBQ) score offers a novel approach to assess bone health in spine surgery candidates. The ability of MRI to assess bone quality without exposure to ionizing radiation makes it a potentially advantageous alternative to other traditional measures of bone density. VBQ has additionally shown potential to predict adverse outcomes, such as fragility fractures, instrumentation failure, subsidence and proximal junctional kyphosis. Variations of VBQ, such as endplate bone quality, S1 VBQ, and cervical VBQ, provide targeted insights at specific anatomical regions and potentially enhance the predictive accuracy of VBQ. However, clinical application of VBQ is limited by variability in MRI systems, patient-specific factors, and lack of standardized threshold values. This review aims to critically evaluate VBQ scores as an opportunistic, MRI-based assessment of bone health and its potential role in predicting surgical outcomes. While VBQ may provide some valuable insights into bone health, its role in preoperative risk assessment likely remains supplementary and requires further research to establish clinical validity and optimal cutoffs. Full article

Background/Objectives: Vertebral degenerative features are promising but often subjectively scored indicators for adult age estimation. We evaluated an objective surface roughness metric, the “average distance to the fitted ellipse” score (DS), calculated automatically for every vertebra from C7 to S1 on routine CT images. Methods: CT scans of 176 adults (94 males, 82 females; 21–94 years) were retrospectively analyzed. For each vertebra, the mean orthogonal deviation of the anterior superior endplate from an ideal ellipse was extracted. Sex-specific multiple linear regression served as a baseline; support vector regression (SVR), random forest (RF), k-nearest neighbors (k-NN), and Gaussian naïve-Bayes pseudo-regressor (GNB-R) were tuned with 10-fold cross-validation and evaluated on a 20% hold-out set. Performance was quantified with the standard error of the estimate (SEE). Results: DS values correlated moderately to strongly with age (peak r = 0.60 at L3–L5). Linear regression explained 40% (males) and 47% (females) of age variance (SEE ≈ 11–12 years). Non-parametric learners improved precision: RF achieved an SEE of 8.49 years in males (R² = 0.47), whereas k-NN attained 10.8 years (R² = 0.45) in women. Conclusions: Automated analysis of vertebral cortical roughness provides a transparent, observer-independent means of estimating adult age with accuracy approaching that of more complex deep learning pipelines. Streamlining image preparation and validating the approach across diverse populations are the next steps toward forensic adoption. Full article

Background: Chronic low back pain (CLBP) is the leading cause of disability both within the United States and globally. However, reliable diagnosis and treatment remains limited due to a lack of objective and image-based biomarkers. Modic changes (MCs) are visible vertebral endplate and bone marrow changes in signal intensity seen on MRI. MCs have emerged as promising correlates with degenerative disc disease and CLBP. Methods: This is a non-systematic literature review. Results: This review synthesizes current evidence on the classification, pathophysiology, and imaging of MCs, with a particular focus on their associations with patient-reported outcomes, including pain (Visual Analog Scale), functional status (Oswestry disability index and Roland-Morris Disability Questionnaire), and health-related quality of life (Short Form-36 and EuroQol 5-Dimension 5 Level). MC type 1 and 2 show significant correlations with symptom severity and predict positive response to basi-vertebral nerve (BVN) ablation, a minimally invasive intervention inhibiting the nerves’ ability to transmit pain signals. Conclusions: Across multiple trials, BVN ablation has shown significant sustained improvements in patient-reported outcomes among patients with MC, reinforcing their role as both a diagnostic and therapeutic biomarker. Full article

Background/Objectives: Diagnosis of Persistent Spinal Pain Syndrome Type 2 (PSPS-T2) currently lacks objective biomarkers. Therefore, this retrospective study aimed to investigate differences in glucose metabolism in the axial musculoskeletal system in PSPS-T2 patients by means of [¹⁸F]FDG PET-CT imaging. Methods: Nine PSPS-T2 patients (five females, four males; mean age of 53 ± 4.82 years) and nine age- and gender-matched healthy controls (five females, four males; mean age of 53 ± 3.91 years) were included. For each participant, 24 regions of interest (ROIs) were manually drawn, including areas of the vertebral endplates, the intervertebral discs, and the psoas muscles. For each ROI, the mean standardized uptake values (SUVs) were assessed. Group differences were evaluated using repeated measures ANOVA with Bonferroni-adjusted post-hoc pairwise comparisons. Additionally, Pearson correlation analyses examined associations between SUV_mean values and the Numerical Rating Scale (NRS) pain scores. Results: Results demonstrated significantly higher SUV_mean values in healthy controls compared to PSPS-T2 patients, particularly at the superior endplates of L4 and S1, the intervertebral discs at L4-L5 and L5-S1, and the posterior endplates of L4 and L5. Although PSPS-T2 patients exhibited higher SUV_mean values than controls in the psoas muscle, these differences were not statistically significant. Additionally, no significant correlations were found between SUV_mean values and NRS pain scores, suggesting that metabolic activity alone does not directly reflect pain severity. Conclusions: Despite the limited sample size of this pilot study, the metabolic fingerprint of the axial musculoskeletal system was shown to be distinctly different in PSPS-T2 patients compared to healthy controls. This could lead to an improved understanding of PSPS-T2 pathophysiology and might open new doors for better diagnosis and treatment strategies. Full article

Background/Objectives: Endplate lesions of the lumbar spine are often asymptomatic and frequently observed incidentally by radiological assessment. Variants in the vitamin D receptor gene (VDR) and an increase in some biochemical markers related to the osteo-cartilaginous metabolism were found in patients with endplate lesions. The aim of this study was to identify biochemical and genetic markers putatively associated with the presence of endplate lesions of the lumbar spine. Methods: Quantification of circulating bone remodeling proteins was obtained from 10 patients with endplate lesions and compared with age- and sex-matched controls. Whole exome sequencing (WES) was performed on patient genomic DNA using the Novaseq 6000 platform (Illumina, San Diego, CA, USA), obtaining a median read depth of 117×–200×, with ≥98% of regions covering at least 20×. The sequencing product was aligned to the reference genome (GRCh38.p13-hg38) and analyzed with Geneyx software. Results: We observed modifications in the levels of circulating proteins involved in bone remodeling and angiogenesis. We identified variants of interest in aggrecan (ACAN), bone morphogenetic protein 4 (BMP4), cytochrome P450 family 3 subfamily A member 4 (CYP3A4), GLI family zinc finger 2 (GLI2), heparan sulfate proteoglycan 2 (HSPG2), and mesoderm posterior bHLH transcription factor 2 (MESP2). VDR polymorphism (rs2228570) was present in nine patients, with the homozygotic ones having more severe endplate lesions and higher levels of the analyzed circulating markers in comparison with heterozygotic patients. Conclusions: These data represent interesting evidence of genetic variants, particularly in VDR, and altered levels of circulating markers of bone remodeling associated with endplate lesions, which should be confirmed in a larger population. The hypothesis suggested by our results is that the endplate lesions could be the consequence of an altered ossification mechanism at the vertebral level. Full article

Background/Objectives: Symptomatic intravertebral vacuum cleft (SIVC) is a complication of vertebral compression fractures (VCFs) that leads to persistent pain and deformity. Its prediction remains challenging due to multifactorial causes. Paraspinal muscle fat infiltration has been associated with spinal fracture outcomes but has not been extensively explored in SIVC prediction. Our aim was to develop machine learning (ML) models for predicting SIVC and to evaluate the role of muscle-related variables in improving predictive performance. Methods: Demographic, radiological, and muscle-related variables were collected. ML models—including Logistic Regression, Random Forest, XGBoost, and Multi-Layer Perceptron—were trained and tested under two input conditions: baseline variables (SETTING_1) and baseline plus muscle-related variables (SETTING_2). Model performance was evaluated using accuracy, the area under the receiver operating characteristic curve (AUC), and feature importance analysis. Results: The Random Forest model in SETTING_2, which incorporated muscle-related variables, achieved the highest accuracy (96.6%) and AUC (0.956). Multifidus fatty infiltration (MFfi), erector spinae fatty infiltration (ESfi), and endplate CSA were identified as the most significant predictors. The inclusion of muscle-related variables significantly improved the predictive performance of all ML models. Conclusions: ML models, particularly Random Forest, demonstrated high accuracy in predicting SIVC when muscle-related variables were included. Paraspinal muscle fat infiltration is a critical predictor of SIVC and should be integrated into risk assessment strategies to improve early diagnosis and management. Full article

Background: The present study aims to investigate the influence of systematic radiological screening for silent vertebral fractures (VFs) on osteoporosis diagnosis, treatment decisions, and long-term clinical outcomes compared to standard care without routine screening in elderly patients hospitalised primarily for fractures requiring surgical treatment at sites other than the spine. Material/Methods: In a level 1 trauma centre, patients with fractures requiring surgical treatment after low-energy trauma were prospectively examined over a period of 12 months. Using radiographs of the thoracic and lumbar spine in two planes, previously unknown VFs were identified and categorised according to the classification for osteoporotic fractures (OFs) of the thoracolumbar spine. Results: A total of 106 patients with a mean age of 79.4 years participated in this study, and 112 previously unknown vertebral compression fractures were diagnosed in 57% (60/106) of the patients. In this group, lumbar vertebra 2 was the most frequently affected, and the majority of these VFs were classified as OF 2, which corresponds to an isolated endplate fracture with minimal involvement of the posterior wall. Furthermore, 26% (28/106) of the patients in the evaluation showed VFs at multiple levels. This study revealed no statistically significant difference in the prevalence of silent VFs between male and female patients (p = 0.055). Additionally, the analysis revealed that nearly 75% of patients exhibited vitamin D insufficiency. Conclusions: The high prevalence of silent VFs in elderly patients emphasises the necessity for systematic radiological investigations, irrespective of gender. Full article

Purpose: We assessed the feasibility of qualitative, semiquantitative, and multiparametric quantitative magnetic resonance imaging (MRI) using a three-dimensional (3D) ultrashort echo time (3D-UTE) sequence together with 2D-T2 and 3D-T1 mapping sequences to evaluate normal and pathological discovertebral complexes (DVCs). We assessed the disc (nucleus pulposus [NP] and annulus fibrosus [AF]), vertebral endplate (cartilage endplate [CEP] and growth plate [GP]), and subchondral bone (SB) using a rat model of degenerative disc disease (DDD). We also assessed whether this complete MRI cartography can improve the monitoring of DDD. Methods: DDD was induced by percutaneous disc trituration and collagenase injection of the tail. Then, the animals were imaged at 4.7T. The adjacent disc served as the control. The MRI protocol was performed at baseline and each week (W) postoperatively for 2 weeks. Visual analysis and signal intensity measurements from the 3D-UTE images, as well as T2 and T1 measurements, were carried out in all DVC portions. Histological analysis with hematoxylin–eosin and Masson trichrome staining was performed following euthanization of the rats at 2 weeks and the results were compared to the MRI findings. Results: Complete qualitative identification of the normal zonal anatomy of the DVC, including the AF, CEP, and GP, was achieved using the 3D-UTE sequence. Quantitative measurements of the signal-to-noise ratio in the AF and NP enabled healthy DVCs to be distinguished from surgery-induced DDD, based on an increase in these values post-surgery. The 2D-T2 mapping results showed a significant increase in the T2 values of the AF and a decrease in the values of the NP between the baseline and W1 and W2 postoperatively (p < 0.001). In the 3D-T1 mapping, there was a significant decrease in the T1 values of the AF and NP between baseline and W1 and W2 postoperatively in immature rats (p < 0.01). This variation in T1 and T2 over time was consistent with the results of the 3D-UTE sequence. Conclusions: Use of the 3D-UTE sequence enabled a complete, robust, and reproducible visualization of DVC anatomy in both immature and mature rats under both normal and pathological conditions. The findings were supported quantitatively by the T2 and T1 mapping sequences and histologically. This sequence is therefore of prime interest in spinal imaging and should be regularly be performed. Full article

Lower back pain (LBP) is a widely prevalent global health issue, affecting over half a billion people and remaining the leading cause of years lived with disability (YLDs). LBP significantly impacts healthcare systems, with substantial costs related to surgical procedures and lost workdays. Vertebrogenic back pain (VBP), characterized by specific clinical symptoms and associated with Modic changes (MC) in vertebral endplates, best seen on MRI, is a significant subset of LBP. This paper explores the pathophysiology, diagnosis, and current reports and studies focusing on VBP and the role of basivertebral nerve (BVN) ablation as a therapeutic intervention. Multiple studies, including randomized controlled trials (RCTs) and meta-analyses, demonstrate the efficacy of BVN ablation in reducing pain and improving function in patients with chronic LBP associated with MC. Full article

Introduction: The disco-vertebral junction (DVJ) of the lumbar spine contains thin structures with short T2 values, including the cartilaginous endplate (CEP) sandwiched between the bony vertebral endplate (VEP) and the nucleus pulposus (NP). We previously demonstrated that ultrashort-echo-time (UTE) MRI, compared to conventional MRI, is able to depict the tissues at the DVJ with improved contrast. In this study, we sought to further optimize UTE MRI by characterizing the contrast-to-noise ratio (CNR) of these tissues when either single echo or echo subtraction images are used and with varying echo times (TEs). Methods: In four cadaveric lumbar spines, we acquired 3D Cones (a UTE sequence) images at varying TEs from 0.032 ms to 16 ms. Additionally, spin echo T1- and T2-weighted images were acquired. The CNRs of CEP-NP and CEP-VEP were measured in all source images and 3D Cones echo subtraction images. Results: In the spin echo images, it was challenging to distinguish the CEP from the VEP, as both had low signal intensity. However, the 3D Cones source images at the shortest TE of 0.032 ms provided an excellent contrast between the CEP and the VEP. As the TE increased, the contrast decreased in the source images. In contrast, the 3D Cones echo subtraction images showed increasing CNR values as the second TE increased, reaching statistical significance when the second TE was above 10 ms (p < 0.05). Conclusions: Our study highlights the feasibility of incorporating UTE MRI for the evaluation of the DVJ and its advantages over conventional spin echo sequences for improving the contrast between the CEP and adjacent tissues. Additionally, modulation of the contrast for the target tissues can be achieved using either source images or subtraction images, as well as by varying the echo times. Full article