Disc degeneration is a common finding on MRI that often does not correlate with low back pain. While MRI can identify structural changes in the discs, many asymptomatic individuals also demonstrate disc degeneration on imaging. Modic type 1 changes, disc extrusions, and sequestrations are more strongly associated with low back pain. However, not all patients require MRI, as many imaging findings do not necessarily require treatment and can increase patient stress. The relationship between disc degeneration and low back pain is complex with multiple contributing factors.

1. Journal Club Presentation
Dr. Vijay Kumar Loya
FNB Spine Surgery

2. • Review article.
• Study conducted at Cipto Mangukusumo
Hospital, Univertas Indonesia, Jakarta, Indonesia.
• Published in April 2020, Asian Spine Journal
• Available online from November 2019.
• Cite: Asian Spine J 2020;14(2):245-257.
• Citation count: 1

3. Introduction
• Most common symptom in musculoskeletal
condition: Low back pain(LBP)
• 84% of all adults - incidence, 18% in all age
groups at any given time & lifetime
probability of experiencing LBP is 80%.
• 100 billion $ expense per year with LBP.

5. • Most common cause : Disc disruption.
• Disruption & Degeneration —>spinal motion
instability changes—>pain.
• Imaging techniques include - X-ray, CT scan, MRI
which should follow a thorough clinical history &
exam.
• X-ray may show deformity, disc space
narrowing, osteophyte formation.
• Most reliable tool to assess disc is MRI with its
signal characteristics reflecting the findings of
aging & degeneration.

6. • But how much of it correlates clinically - RESEARCH QUESTION
• Review of 33 articles with >3110 individuals with no complain of
back ache showed a high prevalence of disc degeneration.
• Vice-versa also has been shown in other studies.
• In spite of all this it is also proven that disc degeneration on MRI
correlates with a high odds ratio (OR) of 2.8 in individuals with
LBP.
• Surgical intervention based on MRI images can prove risky &
futile.
• Obtaining an MRI & positive results can also evoke patients’s
stress levels thereby increasing sensitivity & worsening back pain

7. • NP consists of chondrocytes, COL II, and a
matrix of proteoglycan.
• Peripheral AF is composed of densely fibrous
COL I
• Due to age, microtrauma, nutritional factors
and genetic predisposition results in change in
disc characteristics & surrounding structures.

8. son SE, Alini M, Ito K. Correlation of radiographic and MRI parameters to morphological and biochemical assessment of intervertebral disc degenerat

9. Imaging changes in ASYMPTOMATIC populations
• Disc degeneration can be a normal aging phenomenon which can confound the findings on MRI.
• Teraguchi et.al - >90% prevalence of disc degeneration in >50 years & 70% in those <50 years.
Jensen et.al - 64%, Boden et.al 28%, Kanayama 60-80%.
• Prevalence of disc bulge, protrusion, extrusion, and schmorl’s node in asymptomatic population
in Jensen study was 52%, 27%, 1% and 19% respectively.
• Another systematic review by Steffans et.al in 2014 has failed to prove anything conclusively.

11. ANTERIOR SEGMENT SIGNS

12. • Posterior facet joint arthritis - Grogan’s classification
• Interspinous bursitis - Basstrup disease
• Degenerative Spondylolisthesis - Meyerding classification
• Spondylolysis - Hollenberg classification.
POSTERIOR SEGMENT SIGN

13. • Of all radiological signs in <50 years old - most predictive for pain is MODIC TYPE 1
change. (PPV - 81%, Specificity-98%) followed by Schmorl’s nodule with associated
intraosseous edema.
• Hancock et al. Reports that if changes height >25% of height of vertebral body then it is 32
times more likely that these sign will be present when an individual has LBP than when he
or she does not.
• Decreased disc height, dehydration and a bulging disc NPV high but PPV & specificity low
even in presence of Grade 3/4 Pfirrmann classification.
• Extrusions & Sequestration are correlated with radicular pain but not axial pain.
• HIZ alone has poor correlation but with disc extrusion may have value, but no study has
conclusively proven this.
• NO SIGN is valuable when evaluating posterior segment signs except for intense severe
zygapophyseal edema & T2-weighted high intensity of pedicle in fractures of isthmus in
adolescents.
CONCLUSION OF PART I

14. Imaging changes in SYMPTOMATIC
patients.

19. CONCLUSION OF PART II
• Disruption of the normal architecture and function of the intervertebral disc due to
degenerative processes needs to be considered as the reason for the generation of
back pain- which can be multitude of changes (like decreased disc height, HIZ, annular
tear, fissured or ruptured disc irritating nerves or causing root compression)
• “Moreover, an increased number of affected levels and more contiguous patterns of
disc degeneration are associated with a more profound effect on the spinal
biomechanic and kinematics that may result in more severe pain symptoms in
individuals”
• “Nevertheless, with several studies reporting degenerative changes in the MRI
examination in LBP patients, the high prevalence in asymptomatic individuals also
needs to be considered. It is unclear whether these degenerative changes are the
actual source of back pain....

20. • Multiple studies overtime has proven that disc degeneration is a part of
normal aging process albeit genetics& environment involved.
• Modic type I change, disc extrusion & sequestration were associated with
LBP in most patients.
• % MRI index(showing severity of structural & content changes in disc) -
greatest positive correlation with least degenerated disc & highest
negative correlation with second-most degenerated disc.
• There is no link between increased pain severity & increased disc
degeneration.
• CMDD had higher prevalence of LBP & pain severity than SLDD
• Not all patients with LBP need MRI & not all MRI findings need treatment
& sometimes positive MRI findings may evoke increased psychosocial
stress and behavioural changes in patients.
To Summarise...