ISSLS prize winner: a study of effects of in vivo mechanical forces on human lumbar discs with scoliotic disc as a biological model: results from serial postcontrast diffusion studies, histopathology and biochemical analysis of twenty-one human lumbar scoliotic discs.

STUDY
DESIGN: A comprehensive study of 21 lumbar scoliotic discs by in vivo serial post contrast diffusion magnetic resonance imaging (MRI), histopathological, and biochemical analysis.
OBJECTIVE: To investigate the in vivo effects of compressive and tensile mechanical stress on the lumbar discs with scoliotic disc as the biologic model. SUMMARY OF BACKGROUND DATA: Most studies implicating mechanical stress in degenerative disc disease (DDD) are on animals, in vitro conditions and cadavers. They are also restricted to histopathological or biochemical evaluation without analyzing the endplate (EP) and nucleus pulposus (NP) separately. The few human studies have not analyzed diffusion changes which is the final pathway for DDD. Adolescent scoliotic disc offer a perfect model to study the effects of mechanical stress.
METHODS: Twenty-one discs from 6 patients with adolescent idiopathic scoliosis undergoing anterior corrective surgery were assessed before surgery by postcontrast MRI to document the EP diffusion patterns. The same discs harvested during surgery were analyzed histologically and biochemically. The results were correlated to clinical and radiologic parameters.
RESULTS: Altered diffusion patterns was seen in all discs with site specific breaks in 2, double peak pattern in 3, high intensity pattern in 14, and frank contrast leak in 2. There was marked decrease in cell density and viability in all discs on both convex and concave sides compared to the control disc (P = 0.001). Neovascularization, calcification, and matrix degeneration were observed to varying extent in different regions of NP and EP. There was a decrease in water content with increasing severity of curves with significant difference between mild and severe curves (NP: P = 0.000, EP: P = 0.002). Lactate was significantly higher in caudal EP (P = 0.035) and discs with coronal migration of more than 15 mm (P = 0.007). Regression analysis showed that truncal decompensation was a main factor for decrease in cell density, matrix degeneration, calcification, and water content.
CONCLUSION: The study documents widespread changes in the EP and NP even in discs with minimal wedging. EP damage and alterations in diffusion were observed earlier than MRI changes and could indicate nutritional factors as the primary mechanism of degeneration induced by mechanical stress. Degeneration was more severe in caudal discs and those with truncal decompensation. Its implications on the timing and choice of surgery in scoliosis are discussed.