The Clinical Study Of Relationship Between Chronic Low Back Pain And End Plate Changes Of Lumbar Intervertebral Disc

Objective:Chronic low back pain is a common orthopedic diseases. This study explored the relationship between Modic endplate change and lumbar MRI imaging of the patients with low back, the inflammatory factor tumor necrosis factor (TNF alpha) and somatostat (CGRP), substance P (substance P) and protein gene product9.5(PGP9.5) marked expression of endogenous nerve endings in lumbar nucleus and end plate tissue, different expression in various modic type of the inflammation media and nerve endings of the endplate. Observe the treatment effect by Chinese prescription for patients with low back pain.Methods:During June of2010to October2011, we recorded the pain score of70low back pain in-patients, MRI, lumbar endplate Modic change type, the area of modic endplate changes in MRI, lumbar curvature of the patients whose endplate have Modic changes. We analyzed the incidence of Modic MRI changes, the correlation with low back pain, and the correlation of endplate area and the curvature. Nucleus pulposus and endplate organization were dyed with HE collected Intra-operatively. Pathological changes were observed. The content of TNF alpha, CGRP, substance P and PGP9.5in nucleus pulposus and endplate tissue were measured through immuno-histochemical method. The Real-time PCR method was adopted to detect the gene content of IL-8, IL-6, PGE-2in pulp nuclear and end plate.Results:1.70patients (male39cases, female31cases, aged29-80years old, the median age is50.0years, mean age is51.0±11.89years old. The Course of disease last6to54months, average time is26±4.3months). Modic changes classification were observed in70patients, of which16cases (22.8%) has no Modic change,15cases (21.4%) is Modic type I,21cases (30.0%) is Modic Ⅱ type,11patients (15.7%)is Modic type Ⅲ,7patients (10.0%) is Modic mixed type. JOA and VAS score were as follows:no Modic change type (15.0±2.7,3.8±0.5);Modic type Ⅰ (13.2±4.5,4.2±0.2), Modic Ⅱ type (18.4±3.1,3.9±0.1), Modic III type (20.0±2.4,3.2±0.2Modic mixed type (19.7±3.9,3.4±0.3). Except no Modic change type, the area change rate of the MRI image and the curvature of other Modic type is as follows:Modic type Ⅰ (area change rate21.36±13.86%, curvature0.96±0.43cm), Modic Ⅱ type (area change rate15.14±12.07%, curvature0.87±0.25cm), Modic Ⅲ type (area change rate16.28±8.68%, curvature0.92±0.36cm), Modic mixed type (area change rate11.14±7.66%, curvature0.95±0.28cm). Modic type Ⅰ, Modic Ⅱ type area change rate positively associated with the pain score and has significant difference statistically in multiple regression analysis.2. Nucleus pulposus and endplate organization were taken from Modic change patient, dyed with HE and gone pathology observing. Modic Ⅰ type (inflammation period or edema period):osseous endplate was torn, end plate and subendplate area is rich in the compact granulation tissue, fiber blood essels replaced thickening of bone between small beams of normal bone marrow. Modic Ⅱ type (fat period or yellow bone marrow period):yellow bone marrow substituted, a lot of fat cells deposition was fund in chronic damaged endplate and subendplate area. Modic Ⅲ type (bone sclerosis period):end plate and subendplate bone hardened. Modic mixed type: yellow bone marrow and vascularization could be seen in the same end plate. No modic change type:no pathological changes were observed.3. Immuno-histochemical stains results show that brownish yellow particles were seen in each nucleus pulposus and end plate cartilage cells, spoted or spreading. The results of TNF alpha immuno-histochemical stains:The score of TNF alpha immuno-histochemical stains of endplate is statistically higher (P<0.05) than that of nucleus pulposus in Modic Ⅰ type. Modic Ⅱ type and Modic Ⅲ type are similar, no statistic difference were observed. Obvious differences (P<0.05) were foud compare Modic Ⅱ type and Modic Ⅲ type to no Modic change type. CGRP, substance P and PGP9.5content in the nucleus pulposus are low,and could not found in endplate organization.4. Gene content of IL-8, IL-6and PGE-2in nucleus pulposus and end plate are different.The values of ΔCT in no Modic type separately are (14.41±1.98,13.99±2.35),(11.48±3.04,11.75±3.83),(11.61±2.38,10.75±3.29). The values of△Ct in Modic Ⅰ type separately are(6.34±1.82,4.07±1.86).(10.62±1.88,5.92±1.31).(9.97±2.21,5.94±1.78)；The values of△Ct in Modic Ⅱ type separately are(13.15±3.67,14.52±0.91).(12.44±4.10,10.37±3.21).(12.26±3.10,10.37±3.21)；The values of△Ct in Modic Ⅲ type separately are(8.16±3.71,13.48±2.01).(6.72±0.38,10.06±O.15).(7.88±2.58,10.41±2.06); The values of△Ct in Modic mixed type separately are(9.21±2.00,10.38±1.50).(7.38±0.65,8.15±0.67).(6.54±1.45,6.44±0.23)5.Modic change rates and end-plate TNF--α concentration of inflammatory cytokines has a positive correlation between Modic Ⅰ and Ⅱ type.But there is no correlation between Modic Ⅲ-and Modic mixed type.6.Before and after Chinese prescription treatment,the JOA scores of Modic Ⅰ type have a significant difference,t=6.4,P<0.01.And the JOA scores of Modic Ⅱ type also have a significant difference,t=8.84,P<0.01Conclusions:1.Modic type Ⅰ,Modic Ⅱ type area change rate positively associated with the pain score and has significant difference statistically in patients with low back pain.2.Modic area change rate of patients with low back pain has no correlation with lumbar curvature change.3.TNF alpha,IL-8,IL-6,PGE-2content of elldplate is statistically higher(P<0.05) than that of nucleus pulposus in Modic Ⅰ type.Type Ⅰ is inflammatory edema period, inflammatory factor levels in the endplate is higher than in the nucleus pulposus presents low back pain and endplate changes were positively correlated.The concentration of nucleus pulposus and endplate in Modic Ⅱ type has no obvious difierence.Because Modic Ⅱ type endplate is stable,low back pain of patients is the results of degeneration of endplate and nucleus pulposus.The concentration of inflammation factors in nucleus pulposus is higher than that in endplate of Modic Ⅲ type.The reason is endplate of this type is in a stable phase.The pathologic change is bone sclerosis.Low back pain symptoms usually caused by the degeneration of nucleus pulposus.The inflmmation factors concentration is no difierence in Modic mixed type because it's the transition phrase. 4. CGRP, substance P and PGP9.5content in the nucleus pulposus is low, and could not fond in endplate organization.5. Modic changes rates and end-plate TNF--α concentration of inflammatory cytokines has a positive correlation between Modic Ⅰ and Ⅱ type. But there is no correlation between Modic Ⅲ-and Modic mixed type.6. Chinese medicine have an effect of relief symptom on Modic Ⅰ and Ⅱ types.