Top

European Radiology

Published in:

01-03-2017 | Musculoskeletal

Does the high-intensity zone (HIZ) of lumbar Intervertebral discs always represent an annular fissure?

Authors: Zhi Shan, Huanhuan Chen, Junhui Liu, Hong Ren, Xuyang Zhang, Fengdong Zhao

Published in: European Radiology | Issue 3/2017

Abstract

Objectives

The aim of this study was to examine high-intensity zone (HIZ) characteristics on both T1- and T2-weighted sagittal magnetic resonance (MR) images, and to reveal their exact nature.

Materials

Seventy-three patients with low back pain and HIZs (identified on T2-weighted images) were included. Patients, aged 25-80 years (mean 51), were divided into two groups: the ‘single-HIZ’ group exhibited HIZs only on T2-weighted images, while the ‘dual-HIZ’ group exhibited HIZs on both T2-weighted and T1-weighted images. Tissue corresponding to the HIZ was harvested from surgery for analysis.

Results

Eighty-two discs were studied, from 39 patients with single HIZs, 30 with dual HIZs, and four with both in the posterior annulus. HIZ volume, volume ratio, and signal intensity on T2-weighted images from the dual-HIZ group were significantly greater. Surgery was able to successfully restore patients’ ability in both groups, while conservative treatments were less effective for patients with dual HIZs. Histology revealed outer annular fissures invaded by granulation tissue in the single-HIZ group. In dual-HIZ discs, Von Kossa staining and CT scans showed more calcified or ossified lesions (94.1 vs. 0 %, P<0.001), and chemical analysis showed significantly higher calcium content.

Conclusions

HIZs on both T2- and T1-weighted images represent calcified tissue, possibly from a vertebral endplate. A new concept of dual HIZ should be defined.

Key Points

• Conventional definition of an HIZ refers to T2-weighted images only.

• Dual HIZs have greater HIZ volume, volume ratio, and signal intensity.

• HIZs on both T2- and T1-weighted images represent calcified tissue.

• Conservative treatments are less likely to be effective for patients with dual HIZs.

Zhang YG, Guo TM, Guo X, Wu SX (2009) Clinical diagnosis for discogenic low back pain. Int J Biol Sci 5(7):647–658CrossRefPubMedPubMedCentral

Kallewaard JW, Terheggen MAMB, Groen GJ et al (2010) 15. Discogenic Low Back Pain. Pain Practice 10(6):560–579CrossRefPubMed

Derby R, Kim BJ, Chen Y, Seo KS, Lee SH (2005) The relation between annular disruption on computed tomography scan and pressure-controlled diskography. Arch Phys Med Rehabil 86(8):1534–1538CrossRefPubMed

Modic MT, Ross JS (2007) Lumbar degenerative disk disease. Radiology 245(1):43–61CrossRefPubMed

Bartynski WS, Dejohn LM, Rothfus WE, Gerszten PC (2013) 'Progressive-onset' versus injury-associated discogenic low back pain: features of disc internal derangement in patients studied with provocation lumbar discography. Interv Neuroradiol 19(1):110–120CrossRefPubMedPubMedCentral

Buenaventura RM, Shah RV, Patel V, Benyamin R, Singh V (2007) Systematic review of discography as a diagnostic test for spinal pain: an update. Pain Physician 10(1):147–164PubMed

Carragee EJ, Don AS, Hurwitz EL, Cuellar JM, Carrino JA, Herzog R (2009) 2009 ISSLS Prize Winner: Does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study. Spine (Phila Pa 1976) 34(21):2338–2345CrossRef

Aprill C, Bogduk N (1992) High-intensity zone: a diagnostic sign of painful lumbar disc on magnetic resonance imaging. Br J Radiol 65(773):361–369CrossRefPubMed

Khan I, Hargunani R, Saifuddin A (2014) The lumbar high-intensity zone: 20 years on. Clin Radiol 69(6):551–558CrossRefPubMed

10.

Dongfeng R, Hou S, Wu W et al (2011) The expression of tumor necrosis factor-alpha and CD68 in high-intensity zone of lumbar intervertebral disc on magnetic resonance image in the patients with low back pain. Spine (Phila Pa 1976) 36(6):E429–E433CrossRef

11.

Carragee EJ, Tanner CM, Yang B, Brito JL, Truong T (1999) False-positive findings on lumbar discography. Reliability of subjective concordance assessment during provocative disc injection. Spine (Phila Pa 1976) 24(23):2542–2547CrossRef

12.

Carragee EJ, Tanner CM, Khurana S et al (2000) The rates of false-positive lumbar discography in select patients without low back symptoms. Spine (Phila Pa 1976) 25(11):1373–1380, discussion 81CrossRef

13.

Carragee EJ, Chen Y, Tanner CM, Truong T, Lau E, Brito JL (2000) Provocative discography in patients after limited lumbar discectomy: A controlled, randomized study of pain response in symptomatic and asymptomatic subjects. Spine (Phila Pa 1976) 25(23):3065–3071CrossRef

14.

Carragee EJ, Paragioudakis SJ, Khurana S (2000) 2000 Volvo Award winner in clinical studies: Lumbar high-intensity zone and discography in subjects without low back problems. Spine (Phila Pa 1976) 25(23):2987–2992CrossRef

15.

Rodrigues SA, Wade KR, Thambyah A, Broom ND (2012) Micromechanics of annulus-end plate integration in the intervertebral disc. Spine J 12(2):143–150CrossRefPubMed

16.

Rajasekaran S, Bajaj N, Tubaki V, Kanna RM, Shetty AP (2013) ISSLS Prize winner: The anatomy of failure in lumbar disc herniation: an in vivo, multimodal, prospective study of 181 subjects. Spine (Phila Pa 1976) 38(17):1491–1500CrossRef

17.

Lama P, Zehra U, Balkovec C et al (2014) Significance of cartilage endplate within herniated disc tissue. Eur Spine J 23(9):1869–1877CrossRefPubMed

18.

Dora C, Schmid MR, Elfering A, Zanetti M, Hodler J, Boos N (2005) Lumbar disk herniation: do MR imaging findings predict recurrence after surgical diskectomy? Radiology 235(2):562–567CrossRefPubMed

19.

Ito M, Incorvaia KM, Yu SF, Fredrickson BE, Yuan HA, Rosenbaum AE (1998) Predictive signs of discogenic lumbar pain on magnetic resonance imaging with discography correlation. Spine (Phila Pa 1976) 23(11):1252–1258, discussion 9-60CrossRef

20.

Schellhas KP, Pollei SR, Gundry CR, Heithoff KB (1996) Lumbar disc high-intensity zone. Correlation of magnetic resonance imaging and discography. Spine 21(1):79–86, Phila Pa 1976CrossRefPubMed

21.

Carragee EJ, Hannibal M (2004) Diagnostic evaluation of low back pain. Orthop Clin N Am 35(1):7–16CrossRef

22.

Lim CH, Jee WH, Son BC, Kim DH, Ha KY, Park CK (2005) Discogenic lumbar pain: association with MR imaging and CT discography. Eur J Radiol 54(3):431–437CrossRefPubMed

23.

Kim SY, Lee IS, Kim BR et al (2012) Magnetic resonance findings of acute severe lower back pain. Ann Rehabil Med 36(1):47–54CrossRefPubMedPubMedCentral

24.

Lam KS, Carlin D, Mulholland RC (2000) Lumbar disc high-intensity zone: the value and significance of provocative discography in the determination of the discogenic pain source. Eur Spine J 9(1):36–41CrossRefPubMedPubMedCentral

25.

Rankine JJ, Gill KP, Hutchinson CE, Ross ER, Williamson JB (1999) The clinical significance of the high-intensity zone on lumbar spine magnetic resonance imaging. Spine (Phila Pa 1976) 24(18):1913–1919, discussion 20CrossRef

26.

Yu SW, Sether LA, Ho PS, Wagner M, Haughton VM (1988) Tears of the anulus fibrosus: correlation between MR and pathologic findings in cadavers. AJNR Am J Neuroradiol 9(2):367–370PubMed

27.

Adams MA, Hutton WC (1985) The effect of posture on the lumbar spine. J Bone Joint Surg (Br) 67(4):625–629

28.

Peng B, Hou S, Wu W, Zhang C, Yang Y (2006) The pathogenesis and clinical significance of a high-intensity zone (HIZ) of lumbar intervertebral disc on MR imaging in the patient with discogenic low back pain. Eur Spine J 15(5):583–587CrossRefPubMed

29.

Stefanakis M, Al-Abbasi M, Harding I et al (2012) Annulus fissures are mechanically and chemically conducive to the ingrowth of nerves and blood vessels. Spine (Phila Pa 1976) 37(22):1883–1891CrossRef

30.

Rothoerl RD, Woertgen C, Holzschuh M, Rueschoff J, Brawanski A (1998) Is there a clinical correlate to the histologic evidence of inflammation in herniated lumbar disc tissue? Spine (Phila Pa 1976) 23(11):1197–1200, discussion 200-1CrossRef

31.

Burke JG, Watson RW, McCormack D, Dowling FE, Walsh MG, Fitzpatrick JM (2002) Intervertebral discs which cause low back pain secrete high levels of proinflammatory mediators. J Bone Joint Surg (Br) 84(2):196–201CrossRef

32.

Henkelman RM, Watts JF, Kucharczyk W (1991) High signal intensity in MR images of calcified brain tissue. Radiology 179(1):199–206CrossRefPubMed

33.

Major NM, Helms CA, Genant HK (1993) Calcification demonstrated as high signal intensity on T1-weighted MR images of the disks of the lumbar spine. Radiology 189(2):494–496CrossRefPubMed

34.

Bangert BA, Modic MT, Ross JS et al (1995) Hyperintense disks on T1-weighted MR images: correlation with calcification. Radiology 195(2):437–443CrossRefPubMed

35.

Malghem J, Lecouvet FE, Francois R et al (2005) High signal intensity of intervertebral calcified disks on T1-weighted MR images resulting from fat content. Skeletal Radiol 34(2):80–86CrossRefPubMed

36.

Nosikova Y, Santerre JP, Grynpas MD, Kandel RA (2013) Annulus fibrosus cells can induce mineralization: an in vitro study. Spine J 13(4):443–453CrossRefPubMed

37.

Iwasawa T, Iwasaki K, Sawada T et al (2006) Pathophysiological role of endothelin in ectopic ossification of human spinal ligaments induced by mechanical stress. Calcif Tissue Int 79(6):422–430CrossRefPubMed

38.

Tsukamoto N, Maeda T, Miura H et al (2006) Repetitive tensile stress to rat caudal vertebrae inducing cartilage formation in the spinal ligaments: a possible role of mechanical stress in the development of ossification of the spinal ligaments. J Neurosurg Spine 5(3):234–242CrossRefPubMed

39.

Wang Y, Videman T, Battie MC (2012) Lumbar vertebral endplate lesions: prevalence, classification, and association with age. Spine (Phila Pa 1976) 37(17):1432–1439CrossRef

40.

Shan Z, Fan S, Xie Q et al (2014) Spontaneous resorption of lumbar disc herniation is less likely when modic changes are present. Spine (Phila Pa 1976) 39(9):736–744CrossRef

Title: Does the high-intensity zone (HIZ) of lumbar Intervertebral discs always represent an annular fissure?
Authors: Zhi Shan
Huanhuan Chen
Junhui Liu
Hong Ren
Xuyang Zhang
Fengdong Zhao
Publication date: 01-03-2017
Publisher: Springer Berlin Heidelberg
Published in: European Radiology / Issue 3/2017
Print ISSN: 0938-7994
Electronic ISSN: 1432-1084
DOI: https://doi.org/10.1007/s00330-016-4408-1

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Does the high-intensity zone (HIZ) of lumbar Intervertebral discs always represent an annular fissure?

Abstract

Objectives

Materials

Results

Conclusions

Key Points

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Objectives

Materials

Results

Conclusions

Key Points

Please log in to get access to this content

Other articles of this Issue 3/2017

CT spectral imaging for monitoring the therapeutic efficacy of VEGF receptor kinase inhibitor AG-013736 in rabbit VX2 liver tumours

Prognosis prediction of non-enhancing T2 high signal intensity lesions in glioblastoma patients after standard treatment: application of dynamic contrast-enhanced MR imaging

Prediction of infarction development after endovascular stroke therapy with dual-energy computed tomography

Hepatic radiofrequency ablation: markedly reduced systemic effects by modulating periablational inflammation via cyclooxygenase-2 inhibition

Larger corpus callosum and reduced orbitofrontal cortex homotopic connectivity in codeine cough syrup-dependent male adolescents and young adults

Ultrasound assessment of the posterior circumflex humeral artery in elite volleyball players: Aneurysm prevalence, anatomy, branching pattern and vessel characteristics