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<p>Vol.:(0123456789)1 3</p><p>Indian Journal of Orthopaedics (2022) 56:1083–1089</p><p>https://doi.org/10.1007/s43465-022-00619-2</p><p>ORIGINAL ARTICLE</p><p>Disc Degeneration in Lumbar Spine of Asymptomatic Young Adults:</p><p>A Descriptive Cross‑Sectional Study</p><p>Manish Chadha1 · Amit Srivastava1 · Vipin Kumar1 · Anupama Tandon2</p><p>Received: 13 July 2021 / Accepted: 28 February 2022 / Published online: 20 March 2022</p><p>© Indian Orthopaedics Association 2022</p><p>Abstract</p><p>Objective This descriptive cross-sectional observational study aimed to investigate the prevalence of various types of disc</p><p>degeneration in the lumbar spine of asymptomatic young adults. The disc degeneration of lumbar spine could be due to age-</p><p>related physiological changes than to pathological changes in asymptomatic people. Due to the ethnic and racial differences</p><p>in lifestyle, it is proposed that the prevalence of disc degeneration in the normal population in different region of the world</p><p>would differ. There are scarce data on the Indian population on the same.</p><p>Methods Fifty individuals between 15 and 30 years of age, with no history of low back pain undergoing MR imaging for</p><p>spinal pathology other than the lumbar spine, were included in the study. Various abnormalities (herniation HN, annular</p><p>fissure AF, nuclear degeneration ND) were recorded and their prevalence was calculated by disc counts (DC) and person</p><p>count (PC). DC is the number of discs with degeneration and PC is the number of patients with disc degeneration.</p><p>Results 56% asymptomatic individuals were found to have either HN or AF or ND at one or more levels. The DC of disc</p><p>degeneration was 20.8% and it was most commonly observed in L4–L5 intervertebral disc (38%) followed by L5–S1 disc</p><p>(30%). Thirteen individuals had disc degeneration at single level, 12 at two levels and 3 individuals at all the five lumbar</p><p>intervertebral disc levels.</p><p>Conclusion The current study showed a high prevalence of disc degeneration (either HN, AF or ND) in young asymptomatic</p><p>individuals. Even if the MRI shows disc degeneration, patients can be asymptomatic and one needs to correlate the symptoms</p><p>with the MRI. The limitations of the current study are small numbers of patients from a localized geographical area; hence,</p><p>we recommend a larger multi-centric study as a follow-up.</p><p>Keywords Intervertebral disc degeneration · Magnetic resonance imaging · Asymptomatic · Young adults · Spine</p><p>Introduction</p><p>Low back pain (LBP) [1] is one of the most common com-</p><p>plaints and has the highest prevalence amongst all symp-</p><p>toms both at individual as well at outpatient department level</p><p>[2–5]. LBP affects major portions of the population ranging</p><p>from 64 to 80%, at some point of time in their whole life</p><p>because of a wide range of causative factors and is one of</p><p>the most frequent reasons both for consulting primary care</p><p>physician and for taking leaves [2, 3, 6, 7].</p><p>Disc degeneration (DD) is common in patients with low</p><p>back pain, but the impact of DD on LBP disorder is contro-</p><p>versial, since DD is a common finding in asymptomatic sub-</p><p>jects [8, 9]. According to the Western literature, prevalence</p><p>of DD in lumbar region is 30–40% in asymptomatic indi-</p><p>viduals in age group 15–30 years of age [8, 9]. MR imag-</p><p>ing is an effective modality for this study because it depicts</p><p>* Amit Srivastava</p><p>amitsrvstv00@gmail.com</p><p>Manish Chadha</p><p>mchadha@hotmail.com</p><p>Vipin Kumar</p><p>vipinkumar@gmail.com</p><p>Anupama Tandon</p><p>anupamatandon@hotmail.com</p><p>1 Department of Orthopaedics, University College of Medical</p><p>Sciences and Guru Teg Bahadur Hospital, Dilshad Garden,</p><p>Delhi 110095, India</p><p>2 Department of Radio-Diagnosis, University College</p><p>of Medical Sciences and Guru Teg Bahadur Hospital,</p><p>Delhi 110095, India</p><p>http://crossmark.crossref.org/dialog/?doi=10.1007/s43465-022-00619-2&domain=pdf</p><p>1084 Indian Journal of Orthopaedics (2022) 56:1083–1089</p><p>1 3</p><p>anatomic, physical, and chemical nature of the intervertebral</p><p>disc, but MRI shows not only pathological lesions, but also</p><p>physiological changes at the same time [10, 11].</p><p>There are large numbers of adults who undergo advanced</p><p>imaging to determine the aetiology of their back pain; thus,</p><p>it is essential to know the prevalence of imaging findings of</p><p>degenerative disease in asymptomatic populations [12]. The</p><p>degenerative changes could be considered to be more closely</p><p>related to age-related physiological changes than to patho-</p><p>logical changes in asymptomatic people. Such information</p><p>will help both clinical providers and patients interpret the</p><p>importance of degenerative findings noted in radiology</p><p>reports.</p><p>Asymptomatic patients show high degeneration preva-</p><p>lence at lumber disc in previous literature reported for Cau-</p><p>casian and Korean population [12]. Due to the ethnic and</p><p>racial differences in lifestyle, there has been an opinion that</p><p>the prevalence of disc degeneration in the normal population</p><p>in different region of the world differ [8, 9, 12]. There are</p><p>scarce data on the Indian population on the same. The aim</p><p>of the current study was to fill this lacunae and to document</p><p>the prevalence of disc degeneration in lumbar spine of young</p><p>adults using MRI.</p><p>Materials and Methods</p><p>The descriptive cross-sectional observational study was con-</p><p>ducted at a tertiary care centre after obtaining Institutional</p><p>Ethical Clearance. Fifty individuals/volunteers between 15</p><p>and 30 years of age with history of trauma/tumour/tubercu-</p><p>losis of cervical/dorsal region requiring screening MRI were</p><p>shortlisted. Only those patients who never had prior his-</p><p>tory of low back pain (> 3 weeks) were included if the MRI</p><p>included lumbar spine. Subjects with the criteria depicted</p><p>in Table 1 were enrolled in the study after obtaining the</p><p>informed consent.</p><p>MRI scans were obtained with a 1.5-T unit (Sigma,</p><p>General Electric, Milwaukee, WI) using the imaging pro-</p><p>tocol for sagittal T1-weighted spin echo and T2-weighted</p><p>fast spin echo of the entire lumbar spine and the grad-</p><p>ing was done as per the defined criteria (Table 2) [12].</p><p>The grading was done by two independent observers (one</p><p>orthopedist and one radiologist) and their observations</p><p>were recorded in a predesigned proforma.</p><p>Three measurement categories, i.e. herniation (HN),</p><p>annular fissure (AF) and nucleus degeneration (ND) were</p><p>used to establish disc abnormalities in all patients. There</p><p>are many classifications for disc herniation and degenera-</p><p>tion, we have used the most prevalent terms for HN and</p><p>modified Pfirrmann’s classification for ND [13, 14].</p><p>Disc herniation is classified as local protrusion in the</p><p>intervertebral space. The following terms were used to</p><p>describe disc abnormalities: normal, bulging, protrusion,</p><p>extrusion, and sequestration (Table 2) [13, 15, 16].</p><p>Annular fissure (AF) was defined as a high signal at</p><p>the fibrous ring of an intervertebral disc on T2-weighted</p><p>images (T2WI) of MRI. The high signal-intensity zone</p><p>(HIZ) is a signal (bright white) located in the substance of</p><p>the annulus fibrosus, clearly dissociated from the signal of</p><p>the nucleus pulposus [13–16]. AF was graded according</p><p>to the site of fissure on the mid-sagittal section of the disc</p><p>on T2WI (Table 2).</p><p>The extent of intervertebral disc nucleus degenera-</p><p>tion (ND) was graded on mid-sagittal T2WI according</p><p>to the criteria of modified Pfirrmann classification [14]</p><p>(Table 3). For the purpose of this investigation, grades 0–2</p><p>were grouped together and grades 3–6; the more advanced</p><p>grades of ND were grouped together.</p><p>The prevalence of the various abnormalities was calcu-</p><p>lated by disc counts (DC) and person count (PC). DC is the</p><p>number of discs with degeneration regardless of patients</p><p>Table 1 Subjects inclusion &</p><p>exclusion criteria</p><p>Inclusion criteria Exclusion criteria</p><p>15–30 years age 30 years</p><p>Lumbar spine MRI for indications other than back pain (tumour,</p><p>trauma, tuberculosis)</p><p>Pain radiating to lower extremity</p><p>No previous history of back pain needing rest or consultation Surgical intervention of spine</p><p>Not fit for MRI (claustrophobic,</p><p>morbid</p><p>obese, steel implants), not giving</p><p>consent</p><p>Table 2 Degree of disc degeneration (Kim et al. [12])</p><p>P peripheral, A anterior, B both anterior and posterior</p><p>Grade Herniation Annular fissure Nucleus degeneration</p><p>0 Normal Normal Bright</p><p>1 Diffuse bulging Annular fissure-p Bright—band</p><p>2 Protrusion Annular fissure-A Bright—narrow</p><p>3 Extrusion Annular fissure-B Dim</p><p>4 Sequestration Dim—slight</p><p>5 Dim—moderate</p><p>6 Dim—collapsed</p><p>1085Indian Journal of Orthopaedics (2022) 56:1083–1089</p><p>1 3</p><p>and PC is the number of patients with disc degeneration</p><p>at least one or more lumbar level.</p><p>Results</p><p>Analysis of 250 lumbar disc was done in fifty asymptomatic</p><p>subjects (45 male, 5 female) for different levels of disc</p><p>degeneration and assessment was done for—(a) herniation</p><p>(HN), (b) annular fissure (AF) and (c) nucleus degenera-</p><p>tion (ND) as depicted in Table 3. The disc count (DC) and</p><p>patient count (PC) for each abnormality were calculated and</p><p>recorded (Table 4).</p><p>The collective data for disc herniation (HN), annular fis-</p><p>sure (AF) and nucleus degeneration (ND) were analysed</p><p>and it was found that 56% (28/50) asymptomatic individu-</p><p>als were found to have either herniation or annular fissure</p><p>or nucleus degeneration at one or more levels (Figs. 1, 2,</p><p>3). Thus, the person count (PC) for disc degeneration was</p><p>found to be 56%. The disc count (DC) for disc degeneration</p><p>was 20.8% (52/250) and it was most commonly observed</p><p>in L4–L5 intervertebral disc (38%) followed by L5–S1 disc</p><p>(30%).</p><p>Out of fifty asymptomatic individuals analysed for disc</p><p>degeneration (either HN, AF or ND) in lumbar spine, 13</p><p>individuals had disc degeneration at single level, 12 at two</p><p>levels and 3 individuals at all the five lumbar intervertebral</p><p>disc levels (Fig. 4).</p><p>Table 3 Degree of nucleus degeneration [12]</p><p>Nucleus degeneration Nucleus/annulus</p><p>distinction</p><p>Nucleus signal Disc height</p><p>Bright Clear Hyper-intense, homogeneous Normal</p><p>Bright—band Clear Hyper-intense w/horizontal dark band Normal</p><p>Bright—narrow Clear Hyper-intense w/ or w/o horizontal dark band Decreased</p><p>Dim Unclear Decreased, slightly or heterogeneous irregularity Normal</p><p>Dim—slight Unclear Decreased, slightly or heterogeneous irregularity Slightly decreased ( 2/3)</p><p>Table 4 Radiological findings</p><p>of different grades of disc</p><p>degeneration in our patients</p><p>Disc hernia-</p><p>tion (HN)</p><p>Annular fis-</p><p>sure (AF)</p><p>Nuclear degen-</p><p>eration (ND)</p><p>Any evidence of disc</p><p>degeneration (HN/AF/</p><p>ND)</p><p>Total discs evaluated (lumbar)</p><p>n-250</p><p>36/250 15/250 20/250 52/250</p><p>Disc count (DC) (percent) 14.4 6 8 20.8</p><p>Total subjects evaluated</p><p>n-50</p><p>21/50 15/50 14/50 28/50</p><p>Patient Count (PC) (percent) 42 30 28 56</p><p>Fig. 1 Disc protrusion at L4–L5 level, i.e. grade 2 disc herniation in</p><p>25-year-old female</p><p>1086 Indian Journal of Orthopaedics (2022) 56:1083–1089</p><p>1 3</p><p>Discussion</p><p>The degenerative changes of the disc can be closely related</p><p>to age-related physiological changes than to pathological</p><p>changes in asymptomatic people. Such information will help</p><p>both clinical providers and patients to interpret the impor-</p><p>tance of degenerative findings noted in radiology reports.</p><p>Due to the ethnic and racial differences in lifestyle, there</p><p>has been an opinion that the prevalence of disc degeneration</p><p>in the normal population in different region of the world dif-</p><p>fer [17–21]. There are scarce data on the Indian population</p><p>on the same [17–21]. The current study was done to evalu-</p><p>ate the likelihood of radiological presence of degenerative</p><p>changes on MRI of lumbosacral spine in young individuals</p><p>with no clinical symptoms.</p><p>In the current study, the prevalence of HN, AF, and ND</p><p>was 42%, 30%, and 28%, respectively, in asymptomatic indi-</p><p>viduals of age group 15–30 years. The disc degeneration</p><p>(either HN, AF or ND) in lumbar spine of asymptomatic</p><p>individuals in our study was 56% (28/50).</p><p>High prevalence of disc degeneration in asymptomatic</p><p>subjects 15–30 years of age is very interesting. Multiple</p><p>studies have shown similar findings that asymptomatic</p><p>patients have a high prevalence of disc abnormalities, espe-</p><p>cially in advanced age (Table 5).</p><p>Greenberg et al. [28] reported the MRI findings of lumbar</p><p>spine in 28 asymptomatic subjects (20–39 years of age).</p><p>They analysed the MRI findings as loss of signal intensity,</p><p>bulge, protrusion and herniation and concluded that 50% of</p><p>them had degenerative disc disease, primarily involving the</p><p>L3–L4, L4–L5 and L5–S1 levels. These findings are similar</p><p>to our study.</p><p>Kim et al. [12] performed MRI sagittal scans from T12 to</p><p>S1 on 102 asymptomatic subjects (50 men and 52 women)</p><p>between the ages of 14 and 82 years (mean age 46.3 years)</p><p>Fig. 2 Grade 1 annular fissure at L5–S1 level in 21 years old</p><p>Fig. 3 Disc degeneration at multiple levels with L1–L2 disc having</p><p>grade 4 ND. Grade 1 AF present at L5–S1 level, whereas L2–L3,</p><p>L3–L4 and L4–L5 levels show grade 1 disc herniation in 45-year-old</p><p>male</p><p>22</p><p>13</p><p>12</p><p>0 0</p><p>3</p><p>0</p><p>5</p><p>10</p><p>15</p><p>20</p><p>25</p><p>zero one two three four five</p><p>nu</p><p>m</p><p>be</p><p>r o</p><p>f i</p><p>nd</p><p>iv</p><p>id</p><p>ua</p><p>ls</p><p>number of intervertebral disc level having degenera�on</p><p>Fig. 4 Depicting number and level of disc degeneration in all subjects</p><p>1087Indian Journal of Orthopaedics (2022) 56:1083–1089</p><p>1 3</p><p>and showed that the prevalence of HN, AF, and ND was</p><p>81.4%, 76.1%, and 75.8%, respectively, in asymptomatic</p><p>individuals. However, they included older subjects also and</p><p>mean age was 46.3 years; hence, their data show a higher</p><p>prevalence than our study, which is understandable.</p><p>Jesen et al. [23] studied 98 asymptomatic people, from 20</p><p>to 80 years old and stated that 64% of these people without</p><p>back pain had an intervertebral disc abnormality (i.e. bulge,</p><p>protrusion and extrusion), and 38% had an abnormality at</p><p>more than one level. However in age group 20–29 years,</p><p>approximately 60% of these people had intervertebral disc</p><p>abnormality. In comparison to their results, we found preva-</p><p>lence of disc herniation (i.e. bulge, protrusion and extrusion)</p><p>to be 42%.</p><p>Several studies were conducted in young asymptomatic</p><p>individuals who were athletically more active (i.e. tennis</p><p>players, cricketers, gymnasts and weight lifters, etc.), to look</p><p>for the abnormalities in lumbar intervertebral discs [29–31].</p><p>Rajeswaran [30] performed MRI on 98 asymptomatic</p><p>junior elite tennis players with a mean age of 18 years to</p><p>evaluate abnormal MRI findings in the lumbar spines of</p><p>these players and found that prevalence of disc degeneration</p><p>in lumbar spine of these players was 62.2%. He also stated</p><p>that disc degeneration occurred in only 20.7% of the discs</p><p>evaluated (122 out of 588) and the degree of degeneration</p><p>was mild in 76.2% (93 out of 122) and moderate in 22.1%</p><p>(27 out of 122). They also observed other abnormalities in</p><p>these players like facet joint arthropathy (89.7%), synovial</p><p>cysts (22.4%) and pars interarticularis abnormalities in</p><p>29.6%.</p><p>Thus, it was observed that athletically active young indi-</p><p>viduals, who were otherwise asymptomatic, had higher prev-</p><p>alence of disc degeneration and many other abnormalities</p><p>in lumbar spine compared to normal individuals [29, 32].</p><p>The findings of the current study show that the preva-</p><p>lence of having disc degeneration (either HN, AF or ND) in</p><p>the age group 15–30 in asymptomatic individuals of Indian</p><p>ethnicity was 56%. Out of 50 asymptomatic individual, 13</p><p>individuals had involvement of one level, 12 individuals had</p><p>two levels involved and 3 even had all five levels involved.</p><p>20.8% of the 250 lumbar disc evaluated by MRI in asymp-</p><p>tomatic young individuals had disc degeneration. The preva-</p><p>lence of disc degeneration was highest at L4–L5 (19/50;</p><p>38%), followed by L5–S1 (15/50; 30%).</p><p>The clinical implication of our study is that even if the</p><p>MRI shows disc degeneration, it may not be leading to any</p><p>symptoms. One needs to correlate the symptoms with the</p><p>MRI findings as these may just be part</p><p>of the normal ageing</p><p>process. One should not blindly treat the imaging findings</p><p>as nearly 56% of individuals (i.e. one out of two) who were</p><p>asymptomatic had disc degeneration present at one or more</p><p>levels.</p><p>The limitations of our study were—small numbers of</p><p>subjects (more males than females) were enrolled, all sub-</p><p>jects were from same geographical area and thus they may</p><p>not represent the variety of population in different zones</p><p>of Indian subcontinent. Thus, we propose a multi-centric</p><p>trial involving large number of subjects from different geo-</p><p>graphical zone of the Indian subcontinent to extrapolate the</p><p>outcome for the adult asymptomatic population.</p><p>Conclusion</p><p>The current study showed a high prevalence of disc degen-</p><p>eration (either HN, AF or ND) in age group 15–30 years</p><p>in asymptomatic individuals of Indian ethnicity (person</p><p>count = 56% and disc count = 20.8%). 13 individuals had</p><p>single level, 12 had two levels and 3 had all the five lev-</p><p>els involved. Most common level involved was L4–L5</p><p>(n = 19/50; 38%) followed by L5–S1 (n = 15/30; 30%).</p><p>The demonstration of a significant number of young indi-</p><p>viduals having radiological changes without any clinical</p><p>Table 5 International literatures comparison of herniation, annular fissure, and nucleus degeneration in asymptomatic subjects (%)</p><p>Study Year Case Nucleus</p><p>degeneration</p><p>Annual fissure Herniation</p><p>Annual fissure</p><p>(presence)</p><p>High-signal</p><p>intensity zone</p><p>Bulging Protrusion Extrusion</p><p>DC PC DC PC DC PC DC PC DC PC DC PC</p><p>Modic et al. [22] (US) 1994 85.0 63.0</p><p>Jesen et al. [23] (US) 1994 98 14.0 52.0 27.0 1.0</p><p>Boos et al. [24] (SWZ) 1995 46 84.8 51.0 63.1 3.0</p><p>Weishaupt et al. [25] (SWZ) 1998 60 20.0 72.0 8.0 32.5 14.0 62.0 16.0 67.0 3.7 18.0</p><p>Boos et al. [26] (SWZ) 2000 46 48.8 65.9 7.3</p><p>Borenstein et al. [27] (US) 2001 31 74.2 65.0</p><p>Kim et al. [12] (Korea) 2013 102 38.3 75.8 36.0 76.1 8.1 36.3 16.8 60.1 11.9 45.4 7.0 31.0</p><p>Current study (India) 50 8 28 6 30 13.6 38 0.4 2 0.4 2</p><p>1088 Indian Journal of Orthopaedics (2022) 56:1083–1089</p><p>1 3</p><p>symptoms suggests that clinical correlation of radiological</p><p>findings is a must when treating these patients.</p><p>The clinical implication of our study is that even if the</p><p>MRI shows disc degeneration, patients can be asymptomatic.</p><p>One needs to correlate the symptoms with the MRI findings.</p><p>Author Contributions Dr MC—Substantial contribution in the con-</p><p>ception, analysis and interpretation of the study, final approval of the</p><p>version to be published. Dr AS—rafting of the work and revising it</p><p>critically for important intellectual content. Dr VK—Contribution in</p><p>data collection and in the conception of the study. 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MRI findings in the</p><p>lumbar spines of asymptomatic, adolescent, elite tennis players.</p><p>British Journal of Sports Medicine, 41(11), 836–841.</p><p>Publisher's Note Springer Nature remains neutral with regard to</p><p>jurisdictional claims in published maps and institutional affiliations.</p><p>Disc Degeneration in Lumbar Spine of Asymptomatic Young Adults: A Descriptive Cross-Sectional Study</p><p>Abstract</p><p>Objective</p><p>Methods</p><p>Results</p><p>Conclusion</p><p>Introduction</p><p>Materials and Methods</p><p>Results</p><p>Discussion</p><p>Conclusion</p><p>References</p>