The Vertebral End Plate in Low Back Pain

Outcomes

As a result of participating in this activity, learners will be better able to:

• Diagnose and treat lower back pain
• Interpret MRI results for the etiology of pain
• Discuss pathophysiology therapeutic options with patients
• Differentiate discogenic and vertebrogenic pain

Desirable Physician Attributes

• Medical Knowledge [ACGME/ABMS] about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
• Employ Evidenced-based Practice [IOM] Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible

Accreditation & Designation

Release date: This activity was released 8/19/2022.

Termination date: The content of this activity remains eligible for CME Credit until 8/18/2025, unless reviewed or amended prior to this date.

Claiming Credit: Watch the entire presentation and complete the Improvement Plan/Evaluation.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

California Required CME on Pain Management and the Appropriate Treatment of the Terminally Ill
AB487 requires physicians licensed in California to complete a one-time CME activity for 12 hours of credits that addresses both pain management and the appropriate care and treatment of the terminally ill. This activity contributes to achievement of requirements with AB487.

Disclosure of Financial Relationships & Measures to Resolve of Conflicts of Interest

[Presenter] Jeff Lotz discloses the following financial relationships within the past 24 months: Consulting: Relievant MedSystems; Aclarion, LLC

No other person with control of, or responsibility for, the planning, delivery, or evaluation of accredited continuing education has, or has had within the past 24 months, financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships have been mitigated. Materials were reviewed in advance of the activity by person(s) that do not have conflicts of interest related to the content. In some cases, content may have been modified as part of the review and mitigation process. All clinical recommendations are evidence-based and free of commercial bias (e.g., peer-reviewed literature, adhering to evidence-based practice guidelines).

Additional Reading

• Roberts, S., Menage, J., & Urban, J. P. (1989). Biochemical and structural properties of the cartilage end-plate and its relation to the intervertebral disc. Spine, 14(2), 166-174.
• Biyani, A., & Andersson, G. B. (2004). Low back pain: pathophysiology and management. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 12(2), 106-115.
• Berg-Johansen, B., Han, M., Fields, A. J., Liebenberg, E. C., Lim, B. J., Larson, P. E., ... & Lotz, J. C. (2018). Cartilage endplate thickness variation measured by ultrashort echo-time MRI is associated with adjacent disc degeneration. Spine, 43(10), E592.
• Snow, C. R., Harvey-Burgess, M., Laird, B., Brown, S. H., & Gregory, D. E. (2018). Pressure-induced end-plate fracture in the porcine spine: Is the annulus fibrosus susceptible to damage?. European Spine Journal, 27(8), 1767-1774.
• Fu, M. C., Webb, M. L., Buerba, R. A., Neway, W. E., Brown, J. E., Trivedi, M., ... & Grauer, J. N. (2016). Comparison of agreement of cervical spine degenerative pathology findings in magnetic resonance imaging studies. The Spine Journal, 16(1), 42-48.
• Dunphy, L., Iyer, S., & Brown, C. (2016). Rare cause of back pain: Staphylococcus aureus vertebral osteomyelitis complicated by recurrent epidural abscess and severe sepsis. Case Reports, 2016, bcr2016217111.
• Urban, J. P., & Winlove, C. P. (2007). Pathophysiology of the intervertebral disc and the challenges for MRI. Journal of Magnetic Resonance Imaging: An Official Journal of the International Society for Magnetic Resonance in Medicine, 25(2), 419-432.
• Yu, J., Tirlapur, U., Fairbank, J., Handford, P., Roberts, S., Winlove, C. P., ... & Urban, J. (2007). Microfibrils, elastin fibres and collagen fibres in the human intervertebral disc and bovine tail disc. Journal of anatomy, 210(4), 460-471.
• Horner, H. A., & Urban, J. P. (2001). 2001 Volvo award winner in basic science studies: effect of nutrient supply on the viability of cells from the nucleus pulposus of the intervertebral disc. Spine, 26(23), 2543-2549.
• Adams, M. A., Freeman, B. J., Morrison, H. P., Nelson, I. W., & Dolan, P. (2000). Mechanical initiation of intervertebral disc degeneration. Spine, 25(13), 1625-1636.
• Urban, J. P., Holm, S., Maroudas, A., & Nachemson, A. (1977). Nutrition of the intervertebral disk. An in vivo study of solute transport. Clinical orthopaedics and related research, (129), 101-114.
• Fields, A. J., Rodriguez, D., Gary, K. N., Liebenberg, E. C., & Lotz, J. C. (2014). Influence of biochemical composition on endplate cartilage tensile properties in the human lumbar spine. Journal of Orthopaedic Research, 32(2), 245-252.
• Shirazi-Adl, S. A., Shrivastava, S. C., & Ahmed, A. M. (1984). Stress analysis of the lumbar disc-body unit in compression. A three-dimensional nonlinear finite element study. Spine, 9(2), 120-134.
• Fields, A. J., Lee, G. L., & Keaveny, T. M. (2010). Mechanisms of initial endplate failure in the human vertebral body. Journal of biomechanics, 43(16), 3126-3131.
• Berg-Johansen, B., Han, M., Fields, A. J., Liebenberg, E. C., Lim, B. J., Larson, P. E., ... & Lotz, J. C. (2018). Cartilage endplate thickness variation measured by ultrashort echo-time MRI is associated with adjacent disc degeneration. Spine, 43(10), E592.
• Berg-Johansen, B., Jain, D., Liebenberg, E. C., Fields, A. J., Link, T. M., O’Neill, C. W., & Lotz, J. C. (2018). Tidemark avulsions are a predominant form of endplate irregularity. Spine, 43(16), 1095.
• Berg‐Johansen, B., Fields, A. J., Liebenberg, E. C., Li, A., & Lotz, J. C. (2018). Structure‐function relationships at the human spinal disc‐vertebra interface. Journal of Orthopaedic Research®, 36(1), 192-201.
• Dudli, S., Haschtmann, D., & Ferguson, S. J. (2015). Persistent degenerative changes in the intervertebral disc after burst fracture in an in vitro model mimicking physiological post-traumatic conditions. European Spine Journal, 24(9), 1901-1908.
• Annen, M., Peterson, C., Leemann, S., Schmid, C., Anklin, B., & Humphreys, B. K. (2016). Comparison of outcomes in MRI confirmed lumbar disc herniation patients with and without modic changes treated with high velocity, low amplitude spinal manipulation. Journal of Manipulative and Physiological Therapeutics, 39(3), 200-209.
• Schistad, E. I., Espeland, A., Pedersen, L. M., Sandvik, L., Gjerstad, J., & Røe, C. (2014). Association between baseline IL‐6 and 1‐year recovery in lumbar radicular pain. European Journal of Pain, 18(10), 1394-1401.
• Dudli, S., Fields, A. J., Samartzis, D., Karppinen, J., & Lotz, J. C. (2016). Pathobiology of Modic changes. European Spine Journal, 25(11), 3723-3734.
• Fields, A. J., Rodriguez, D., Gary, K. N., Liebenberg, E. C., & Lotz, J. C. (2014). Influence of biochemical composition on endplate cartilage tensile properties in the human lumbar spine. Journal of Orthopaedic Research, 32(2), 245-252.
• Bogduk, N. (1983). The innervation of the lumbar spine. Spine, 8(3), 286-293.
• Bailey, C. S., Sjovold, S. G., Dvorak, M. F., Fisher, C. G., & Oxland, T. R. (2011). The strength profile of the thoracolumbar endplate reflects the sagittal contours of the spine. Spine, 36(2), 124-128.