Magnetic Resonance Imaging of The Lumbar Spine-Rec

Pain Medicine Page 2 of 42
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6 Magnetic resonance imaging of the lumbar spine – recommendations
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9 for acquisition and image evaluation from the BACPAC Spine Imaging
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Working Group
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16 Nico Sollmann, MD, PhD1,2,3,4; Aaron J. Fields, PhD5; Conor O’Neill, MD5;
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19 Lorenzo Nardo, MD, PhD6; Sharmila Majumdar, PhD1,7; Cynthia T. Chin, MD1;
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21 Duygu Tosun, PhD1; Misung Han, PhD1; An T. Vu, PhD1,8; Eugene Ozhinsky, PhD1,8;
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23 Lubdha M. Shah, MD9; Richard E. Harris, PhD10; Remy Lobo, MD11;
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William Anderst, PhD12; Richard Herzog, MD13; Matthew A. Psioda, PhD14;
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28 Christopher J. Standaert, MD15; River T. Price14; Jeffrey C. Lotz, PhD5;
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30 Thomas M. Link, MD1; Roland Krug, PhD1
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34 1 Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA;
35 2 Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany;
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3 Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar,
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38 Technical University of Munich, Munich, Germany;
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4 TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany;
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41 5 Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA;
42 6 Department
43 of Radiology, University of California, Davis, Sacramento, CA, USA;
44 7 Center for Digital Health Innovation, University of California, San Francisco, San Francisco, CA, USA;
45 8 VA Advanced Imaging Research Center, San Francisco VA Health Care System, San Francisco, CA, USA;
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47 9 Department of Radiology, University of Utah, Salt Lake City, UT, USA;
48 10 Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA;
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11 Department of Radiology, University of Michigan, Ann Arbor, MI, USA;
51 12 Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA;
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13 Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA;
54 14 Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel
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Hill, Chapel Hill, NC, USA;
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57 15 Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine,
58 Pittsburgh, PA, USA.
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60 © The Author(s) 2022. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium,
provided the original work is properly cited.
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Page 3 of 42 Pain Medicine
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3 ABSTRACT
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Management of patients suffering from low back pain (LBP) is challenging and requires
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8 development of diagnostic techniques to identify specific patient subgroups and phenotypes
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10 in order to customize treatment and predict clinical outcome. The Back Pain Consortium
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(BACPAC) Spine Imaging Working Group has developed standard operating procedures
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15 (SOPs) for spinal imaging protocols to be used in all BACPAC studies. These SOPs include
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17 procedures to conduct spinal imaging assessments with guidelines for standardizing the
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19 collection, reading/grading (using structured reporting with semi-quantitative evaluation
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22 using ordinal rating scales), and storage of images. This article presents the approach to
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24 image acquisition and evaluation recommended by the BACPAC Spine Imaging Working
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26 Group. While the approach is specific to BACPAC studies, it is general enough to be applied
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at other centers performing MRI acquisitions in patients with LBP. The herein presented
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31 SOPs are meant to improve understanding of pain mechanisms and facilitate patient
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33 phenotyping by codifying MRI-based methods that provide standardized, non-invasive
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assessments of spinal pathologies. Finally, these recommended procedures may facilitate
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38 the integration of better harmonized MRI data of the lumbar spine across studies and sites
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40 within and outside of BACPAC studies.
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45 Key Words: magnetic resonance imaging; intervertebral disc degeneration; low
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47 back pain; paraspinal musculature; vertebral endplate
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Running Title: The BACPAC Imaging Protocol
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Official Journal of the American Academy of Pain Medicine
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3 ABBREVIATIONS
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8 3D Three-dimensional
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10 BACPAC Back Pain Consortium
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BM Bone marrow
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15 CSE-MRI Chemical shift encoding-based water-fat MRI
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17 CSF Cerebrospinal fluid
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19 FJ Facet joint
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22 FOV Field of view
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24 FS Fat suppression
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26 FSE Fast spin-echo
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LBP Low back pain
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31 LSTV Lumbosacral transitional vertebrae
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33 MRI Magnetic resonance imaging
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MRN Magnetic resonance neurography
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38 MRS Magnetic resonance spectroscopy
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40 NEX Number of excitations
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42 rBW Receiver bandwidth
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45 SIJ Sacroiliac joint
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47 SOP Standard operating procedure
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49 TE Echo time
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TR Repetition time
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54 TSL Spin-lock times
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56 UTE Ultra-short echo-time
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3 INTRODUCTION
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Magnetic resonance imaging (MRI) is the imaging modality often used to depict spinal
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8 structural abnormalities that may cause low back pain (LBP). With its high soft tissue
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10 contrast, MRI allows assessment of multiple structures including intervertebral discs, nerve
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roots, contents of the central spinal canal, ligaments and facet joints (1-5). While MRI is
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15 superb at identifying tissue-specific pathology along the spine, the clinical relevance of these
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17 findings is often uncertain. Thus, diagnostic MRI for LBP is only recommended in certain
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19 patients. The American College of Physicians’ guidelines for diagnostic imaging suggest
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22 immediate imaging when there are major risks (such as suspicion of cancer, spinal infection,
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24 cauda equina syndrome, or presence of severe neurological deficits), but advise deferral of
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26 imaging pending a trial of treatment in cases where there are weaker risk factors (6, 7).
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Notably, only in about 10% of patients can LBP be attributed to a specific pathology (e.g.,
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31 vertebral fracture or disc herniation with nerve compression), while the great majority of
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33 patients are assigned a diagnosis of non-specific LBP (i.e., pain for which the distinct patho-
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anatomical basis cannot be determined) (7, 8).
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38 Some lumbar MRI findings that are common in patients with LBP are also common
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40 in asymptomatic subjects, which makes it difficult to define a causal relationship in individual
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42 patients and has led to questions about the diagnostic value of such findings (9-11).
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45 However, some lumbar MRI findings are more prevalent in patients with LBP than in
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47 asymptomatic subjects (10-12). Those include bone marrow (BM) lesions located at the
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49 vertebral endplates, disc bulges and herniation, and spondylolysis (10-12). Such lumbar
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MRI findings could potentially function as biomarkers that can distinguish patients whose
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54 pain is due to a primary nociceptive process in the spine from patients with central
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56 modulating mechanisms that can be influenced by a number of psychosocial factors as well
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as central sensitization (i.e., increased responsiveness of nociceptors to either normal or
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sub-threshold afferent input, resulting in amplified pain) (13-16).
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3 A major focus of the Back Pain Consortium (BACPAC) is to advance knowledge of
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the etiology and treatment of chronic LBP by developing a better understanding of the
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8 mechanisms contributing to chronic LBP and by identifying specific therapies that are most
9
10 effective in identifiable subgroups of patients. The BACPAC Spine Imaging Working Group
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has developed standard operating procedures (SOPs) for lumbar spine imaging exams to
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15 be used in all BACPAC studies. These SOPs include procedures to conduct imaging
16
17 assessments with guidelines for standardizing the collection, reading/grading, and storage
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19 of images across studies and sites within and outside of BACPAC. Our aim was to
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22 harmonize imaging protocols and implement a comprehensive evaluation scheme for
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24 identifying potential imaging biomarkers of LBP.
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IMAGING PROTOCOL
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31 Setup and sequence planning
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33 Patients eligible for BACPAC studies will undergo an MRI examination (acquisition
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duration <60 min, depending on the distinct pulse sequence protocol) that is performed in a
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38 supine position using a spine coil or a table-embedded coil array. Following an initial phase
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40 of sequence optimization at each BACPAC site (including testing and determination of flip
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42 angles, fat suppression [FS] parameters, field of view [FOV] sizes, and subject/coil
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45 configurations for an optimized signal-to-noise ratio), MRI acquisition with a standardized
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47 pulse sequence protocol is performed. The recommendations of the BACPAC Spine
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49 Imaging Working Group regarding the distinct pulse sequence protocols refer to non-
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contrast MRI using a 3-Tesla or 1.5-Tesla MRI scanner. Further, recommended is the use
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54 of the available clinical protocol for lumbar spine imaging as a starting point and make
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56 adjustments, if necessary, as described below.
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Sequences will be manually planned (i.e., positioning and angulation of the FOV)
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using an initially acquired survey scan. At least the entire lumbosacral spine in cranio-caudal
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3 direction as well as the complete diameter of the vertebrae, facet joints (FJs),
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neuroforamina, and paraspinal musculature in transverse direction (and for predefined
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8 sequences also the sacroiliac joints [SIJs]) will be covered. When magnetic resonance
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10 neurography (MRN) of the lumbosacral plexus is additionally acquired, the anterior body coil
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(or torso coil) array should be used in addition to the spine coil or table-embedded coil array,
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15 and the FOV should cover the area from L1/L2 through the ischial tuberosities.
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19 Imaging sequences
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22 Regarding imaging with T1- and T2-weighted sequences, the BACPAC Spine
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24 Imaging Working Group recommends a minimal pulse sequence protocol that will be
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26 acquired in each patient, supplemented by additional sequences based on technical
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infrastructure at the acquisition site:
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31 a) Minimal recommended sequence protocol:
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33  Sagittal T2-weighted fast spin-echo (FSE) sequence with FS: sagittal T2 FS
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36  Sagittal T1-weighted FSE sequence without FS: sagittal T1
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38  Axial T2-weighted FSE sequence without FS: axial T2
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40 b) Additional recommended sequences (if feasible):
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43  Sagittal T2-weighted FSE sequence without FS: sagittal T2
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45  Sagittal T1-weighted FSE sequence without FS (covering the SIJ): sagittal T1
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47  Coronal T1-weighted FSE sequence without FS (covering the SIJ): coronal T1
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50  Axial T1-weighted FSE sequence without FS: axial T1
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52  MRN lumbosacral plexus: Three-dimensional (3D) T2-weighted FSE sequence
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54 with FS: axial MRN
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57 The specific parameters for these T1- and T2-weighted FSE sequences used for the
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59 MRI machine (GE 3T Discovery MR750; GE Healthcare, Waukesha, WI) and coil (8-channel
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3 phased-array spine coil; GE Healthcare, Waukesha, WI) at one site of image acquisitions
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are shown in Table 1. Due to variations of pulse sequence implementations and hardware
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8 specifics between different MRI machines or vendors, ranges for pulse sequence protocols
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10 are proposed and shown in Table 2.
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Of note, the preference for specific echo times (TEs) of T2-weighted FSE sequences
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15 can also vary depending on whether structures within vertebral bodies and intervertebral
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17 discs are more important (typical TE around 60 ms), or depictions of spinal cord and nerves
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19 are more important (longer TEs, 80 ms or higher). As an additional recommended sequence,
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22 dedicated 3D MRN can be acquired in selected cases to delineate the peripheral nerves of
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24 the lumbosacral plexus for diagnosis and characterization of neuropathy (e.g., due to
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26 compressive effects in relation to a herniated disc) (17-22).
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31 EVALUATION OF IMAGING DATA
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33 Based on the MRI data acquired, we propose qualitative/semi-quantitative image
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evaluation (e.g., using ordinal rating scales) using structured reporting with a predefined
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38 scoring system that incorporates the different structures and related grading of pathology as
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40 captured by the FOV of the T1- and T2-weighted sequences (Modic-type endplate changes,
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42 endplate defects, intervertebral disc changes, FJ and SIJ changes, and stenosis).
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47 Modic changes
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49 Modic-type endplate changes summarize three categories based on specific signal
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characteristics of vertebral BM adjacent to the endplates in MRI (23). Most commonly, type
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54 1 changes are considered an inflammatory, fibrovascular stage and may indicate an ongoing
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56 active degenerative process (e.g., disruption and fissuring of endplates and formation of
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granulation tissue) (23, 24). Type 2 changes are related to a fatty degenerative remodeling
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processes, with replacement of red by yellow BM within the vertebrae (23, 24). Furthermore,
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3 type 3 changes reflect the sclerotic stage (23, 24). Related to their suggested
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pathophysiological entity, the three different types of Modic-type endplate changes differ in
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8 their appearances using the combination of sagittal T1- and T2-weighted sequences, with
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10 Modic changes type 1 typically showing hypointense signal on T1- and hyperintense signal
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on T2-weighted images, Modic changes type 2 showing hyperintense signal on T1- and
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15 hyper- or iso-intense signal on T2-weighted images without FS (typically relatively
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17 hypointense on T2-weighted images with FS), and Modic changes type 3 showing
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19 hypointense signal on T1- and T2-weighted images (23, 25, 26). However, mixed types can
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22 be observed frequently for one lumbar segment (e.g., presence of signal characteristics
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24 indicative of Modic changes type 1 and type 2), and categorization may be done by reporting
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26 the dominant type.
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Regarding reliability of assessments of Modic-type endplate changes on lumbar MRI,
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31 literature reports on varying but substantial to excellent intra-rater agreement (κ > 0.70) and
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33 inter-rater agreement (κ > 0.78) (27, 28). Furthermore, the diagnostic performance of the
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Modic classification for discography-concordant pain yielded a specificity of at least 95%
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38 (29-33). Yet, corresponding sensitivity was reported to be rather low and variable, with
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40 values ranging between 14% and 48% (29-33). In addition to classifications into the three
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42 types of Modic-type endplate changes, the extent of changes in relation to vertebral body
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45 height and diameter is determined (Table 3). Example cases for Modic-type endplate
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47 changes are shown in Figure 1.
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Endplate defects
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54 Structural changes at the vertebral endplates are scored according to their
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56 appearance into degenerative changes (e.g., erosive intervertebral osteochondrosis),
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Scheuermann variant, and osteoporotic fractures. Erosive intervertebral osteochondrosis
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entails widespread erosions of the vertebral body endplates with disc degeneration,
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3 commonly leading to findings of vacuum phenomenon within the intervertebral disc,
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hypointensity within the intervertebral disc on T2-weighted images, band-like subchondral
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8 edema, and fat accumulation or sclerosis for affected vertebral bodies (34). Scheuermann
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10 variant is a developmental disorder with a hereditary predisposition component, with
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characteristic features of thoracic spine kyphosis >40° or thoraco-lumbar spine kyphosis
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15 >30° and vertebral wedge configuration of at least 5° at each level, involving at least three
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17 adjacent vertebral bodies according to the Sorensen criteria (35, 36). A differential diagnosis
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19 is represented by changes of vertebral body configuration due to osteoporotic fractures,
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22 which can also appear as wedging of one or more vertebral bodies (37, 38). Yet, the entity
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24 is different, with osteoporosis being characterized by low bone mineral density in
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26 combination with micro-architectural deterioration of bone tissue, thus increasing the risk for
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fragility fractures (39-44). To provide further insights into the distinct appearance of endplate
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31 defects, they are further categorized according to shape as well as size and depth for a
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33 representative section (Table 4). Example cases for endplate defects are illustrated by
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Figure 2.
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40 Intervertebral disc changes
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42 Lumbar disc degeneration is graded according to the widely used Pfirrmann
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45 classification, which defines five grades in total according to the intervertebral disc height as
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47 well as signal characteristics shown on T2-weighted sequences (45). Specifically, it spans
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49 from grade I for a homogeneous disc with normal height and bright hyperintense white signal
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intensity to grade V for an inhomogeneous disc with collapsed disc space and a hypointense
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54 black signal intensity (45). The Pfirrmann classification for degenerative disc disease has
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56 been reported to show substantial to excellent inter-rater (κ > 0.65) and intra-rater (κ > 0.73)
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reliability (45-48). This grading is supplemented by information on potential contact between
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3 disc material and nerve roots, or deviation or compression of nerve roots due to disc
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degeneration (Table 5) (49).
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8 Further, location and morphology of disc herniation is classified according to shape
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10 characteristics, including bulge, protrusion, and extrusion (50, 51). Specifically, bulge is
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defined as annular tissue that projects beyond the margins of the adjacent vertebral bodies,
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15 affecting more than 90° of circumference (50, 51). A disc protrusion is a focal herniation of
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17 disc material beyond the margins of the adjacent vertebral bodies (over less than 90° of
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19 circumference and with a base that is wider than the dome) (50, 51). Further, a disc extrusion
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22 is a focal herniation of disc nuclear material through an annular defect (remaining in
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24 continuity with the disc and with a base narrower than the dome) (50, 51). Additionally, the
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26 absence or presence of an annular fissure and its location is taken into consideration, which
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is commonly characterized by a zone of high signal on T2-weighted images at the lateral
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31 edges of the annulus (Table 5) (50, 51). Example cases for degenerative disc disease are
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33 provided by Figures 3 and 4.
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38 Facet and sacroiliac joint changes
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40 Arthropathies of the FJ or SIJ are typically characterized by joint space reductions,
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42 hypertrophy of articular processes, and formation of osteophytes. For the FJs, grading into
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45 four groups according to these characteristics is made with respect to the grading
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47 approaches by Fujiwara and Pathria and their coworkers (Table 6) (52, 53). For grading of
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49 FJ arthropathy using MRI, a rather weak inter-rater reliability (κ > 0.40) has been reported,
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although this grading has been widely used (46, 54). Example cases for FJ arthropathy
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54 grading are shown in Figure 5.
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56 For the SIJ, edematous or fatty changes are evaluated, together with presence or
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absence of insufficiency fractures or alterations suggestive for osteitis condensans ilii (55-
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57). Furthermore, the presence and degrees of lumbosacral transitional vertebrae (LSTV)
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1
2
3 are evaluated based on a rating scheme modified from that of Castellvi et al. (Table 6) (58,
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59). The inter-rater reliability was demonstrated to be excellent for the detection (κ = 0.93)
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8 and classification (κ = 0.83) of LSTV based on MRI (60).
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Stenosis
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15 Evaluation of central canal stenosis is made according to the contour of the thecal
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17 sac and amount of cerebrospinal fluid (CSF) space around the spinal cord. In detail,
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19 discrimination is made between no thecal sac constriction, mild constriction (minimal loss of
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22 CSF around rootlets), moderate grade (CSF diminished but present), and severe grade of
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24 central canal stenosis with complete loss of CSF signal (Table 7). In addition, features
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26 indicative of congenital narrowing of the spinal canal (i.e., shorter pedicular length and
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related smaller cross-sectional spinal canal area) are documented (Table 7) (61). Example
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31 cases for spinal canal narrowing are given by Figure 6.
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33 With regard to the course of the exiting spinal nerve roots, contact to surrounding
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compressive structures (e.g., herniated intervertebral discs or FJ arthropathy) with or without
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38 deviation and side are evaluated for the subarticular zone. For the neuroforamina, stenosis
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40 is classified as mild (i.e., slight deformity of epidural fat, still completely surrounding nerve
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42 root), moderate (i.e., marked deformity of epidural fat, only partially surrounding nerve root),
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45 and severe (i.e., obliteration of epidural fat), according to changes in epidural fat
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47 configuration as a surrogate of compression at the level of the neuroforamina (Table 7) (62).
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49 Inter-rater agreement for the grading of neuroforaminal stenosis has been reported to be
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excellent (κ > 0.90), with slightly lower agreement for intra-rater comparisons (κ > 0.79) (62).
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54
55
56 DISCUSSION
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Within the BACPAC Research Program, MRI studies are being used to facilitate
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better understanding of pain mechanisms in chronic LBP by developing, establishing, and
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3 translating standardized MRI-based methods. A main goal is to identify specific phenotypes
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of LBP that would enable reliable guidance for patient selection for certain treatment
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8 regimens and to predict responses to treatments, with the ultimate goal to improve clinical
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10 management and therapy.
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The SOPs we have described address two sources of variability in MRI for patients
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15 with LBP – image acquisition and image interpretation. While lumbar MRI is a powerful
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17 modality for LBP in cases where imaging is warranted, imaging protocols and MRI systems
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19 vary greatly between sites. Imaging within the BACPAC Research Program implements a
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22 standardized procedure for scanning, whilst technical variations and particularities between
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24 scanners at different sites are acknowledged by recommending ranges for pulse sequence
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26 protocols. The herein presented SOPs may help to better integrate data across studies and
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sites to facilitate robust analyses and inferences using much larger datasets than would
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31 otherwise be available. Furthermore, evaluation of better harmonized MRI data of the lumbar
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33 spine across studies and sites within and outside of BACPAC studies is supported by these
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SOPs, given that variability in used equipment and pulse sequence protocols could be
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38 reduced. For evaluation of conventional MRI using T1- and T2-weighted sequences in LBP,
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40 structured reporting is established to reduce inconsistent reporting or subjective
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42 misinterpretations of findings during image reading. Structured reporting uses predefined
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45 terms and formats to generate a radiological report, thus ensuring a high degree of
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47 standardized and organized information that is presented in template context (63, 64).
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49 Structured reporting is not broadly utilized in LBP, but it may help reduce variations during
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51
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image reading, and it could thus provide condensed information relevant for structural
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54 alterations potentially linked to pain perception and for identification of imaging-based
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56 biomarkers.
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58
Potential biomarkers of LBP that are commonly detected on routine clinical scans
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include BM lesions at the vertebral endplates, disc bulges and herniation, and spondylolysis
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1
2
3 (10-12). The proposed comprehensive scoring system is based on visual reading of T1- and
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T2-weighted sequences with structured reporting. A strength is that this scoring system
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8 integrates previously established grading schemes within a standardized approach. The
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10 majority of such schemes has demonstrated at least substantial inter- and/or intra-rater
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reliability (e.g., classification of Modic-type endplate changes or Pfirrmann grading for
13
14
15 degenerative disc disease) (27, 28, 45-48). On the other hand, potential weaknesses include
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17 the qualitative/semi-quantitative nature of analyses by visual image reading and bias
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19 towards only structural findings rather than compositional findings. Related, the relationships
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22 between pathologies evaluated by these established grading schemes and pain might be
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24 variable, and thus, the clinical implications are unclear. For instance, it has been reported
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26 that Modic-type endplate changes have inconsistent associations with pain (12, 65-70).
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Inconsistencies may stem from several sources, including imprecise description of Modic-
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31 type endplate changes for clinical reports, utilization of MRI equipment that introduces
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33 grading bias, or acquisition of imaging sequences that inadvertently misrepresent these
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35
changes (71). Specifically, omission of basic methodological details and, most notably,
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38 restriction to mainly qualitative/semi-quantitative, non-standardized evaluation of MRI data
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40 for Modic-type endplate changes make it difficult to draw more final conclusions about the
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42 correlation of LBP and vertebral endplate pathology (71).
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45 Several novel MRI-based methods are undergoing research and development that
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47 may allow detection of biomarkers not seen on conventional lumbar MRI on the way to
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49 improved understanding of LBP mechanisms. For example, magnetic resonance
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51
52
spectroscopy (MRS) was used to quantify spectral features related to intervertebral disc
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54 structure and acidity, and results from MRS correlated well with provocative discography,
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56 thus could potentially support improved surgical outcomes among patients with chronic LBP
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(72). Furthermore, ultra-short echo-time (UTE) imaging and chemical shift encoding-based
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water-fat MRI (CSE-MRI) have been proposed to be more sensitive to endplate damage or
13
1
2
3 BM pathology and allow both to be quantified, yet without the need for specialized MRI
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5
6
hardware or application of contrast agents (73-79). Structural damage of the endplate is
7
8 believed to trigger endplate neo-innervation and painful endplate BM lesions, and cartilage
9
10 endplate fibrosis blocks nutrient transport to the disc cells, thereby hindering cell survival,
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disc matrix homeostasis, and regenerative potential (80, 81).
13
14
15 Another novel MRI-based approach that may provide important information related to
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17 LBP is CSE-MRI for assessment of paraspinal muscle quality, which may not be well
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19 characterized on routine MRI. This approach permits spatial measurement of fat fraction
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21
22 within the paraspinal muscles (e.g., erector spinae or multifidus muscles) (82-87).
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24 Paraspinal muscle fat fractions showed significant correlations to isometric muscle strength
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26 as well as vertebral BM fat fractions, hence potentially reflecting the actual
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28
29
(patho)physiological muscle status (82, 87). Furthermore, in a study investigating the
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31 interplay between vertebral endplate pathology and paraspinal muscle quality in patients
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33 with chronic LBP, cartilage endplate defects at the lower lumbar spine were predictive of
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35
pain when adjacent to paraspinal musculature with increased fat fractions (73). Yet, the
36
37
38 distinct role of paraspinal musculature and particularly the fat fraction as a quantitative
39
40 parameter remains largely unclear to date in patients with LBP.
41
42 While the efforts of the BACPAC Spine Imaging Working Group focus on the spine
43
44
45 with distinct SOPs for spinal MRI protocols, it has to be acknowledged that particularly in
46
47 patients suffering from chronic LBP, perceived pain may not only relate to the level of the
48
49 spine. Thus, novel conceptualizations and mechanistic descriptors that involve interactions
50
51
52
and structures beyond the lumbar spine might play an important role as well. Specifically,
53
54 besides nociceptive pain (arising from ongoing input from tissue injury) and neuropathic pain
55
56 (arising from injury to the peripheral or central nervous system), the concept of nociplastic
57
58
pain has been described for chronic pain states that are not related to obvious nociceptor
59
60
activation or neuropathy, whereas clinical and psychophysical findings suggest alterations
14
1
2
3 in nociceptive function (88, 89). As such, nociplastic pain can stem from altered pain-related
4
5
6
sensory pathways that relate to enhanced sensitivity, and thus nociplastic pain may exist
7
8 either as a comorbid or isolated state in patients with chronic pain that has been
9
10 predominantly characterized as nociceptive or neuropathic (16, 88). Particularly patients
11

12
suffering from non-specific chronic LBP may show a continuum of nociceptive, neuropathic,
13
14
15 and nociplastic components, with related increased activation of brain regions that contribute
16
17 to the processing of pain and other sensory functions (88, 90-92). Concerning patients with
18
19 such mixed pain, lumbar MRI may contribute to detection of the site that initiated pain, but
20
21
22 imaging of central mechanisms (e.g., by functional MRI) might be needed to provide a more
23
24 complete picture of the complex individual pain states.
25
26 Another relevant aspect beyond the lumbar spine might be the analysis of whole-
27
28
29
body composition in relation to sarcopenia, which is defined as a progressive and
30
31 generalized skeletal muscle disorder that involves the accelerated loss of muscle mass and
32
33 function (93, 94). While paraspinal muscle structure is routinely captured by standard lumbar
34
35
MRI exams at least for some spinal levels, it is often neglected during reporting among
36
37
38 patients with LBP, and investigations of dedicated muscle composition beyond the
39
40 musculature adjacent to the spinal column are uncommon from LBP. However, it has been
41
42 suggested that sarcopenia is correlated with back muscle strength and in turn also with the
43
44
45 presence of degenerative spinal disorders (95-97). With improved MRI hardware and
46
47 software technology, it becomes possible to acquire high-quality images of large parts of the
48
49 whole body in reasonable amounts of time, thus potentially making assessments of body
50
51
52
and muscle composition beyond the direct paraspinal compartments also attractive for
53
54 research in the field of chronic LBP.
55
56
57
58
CONCLUSION
59
60
15
1
2
3 Management of patients suffering from LBP is challenging and requires development
4
5
6
of diagnostic techniques to identify specific patient subgroups and phenotypes in order to
7
8 customize treatment and predict clinical outcome. While lumbar MRI is frequently performed
9
10 in patients with LBP, it has not yet developed into a reliable and standardized tool for these
11

12
purposes. The BACPAC Spine Imaging Working Group has developed SOPs that will
13
14
15 facilitate identification of biomarkers in lumbar MRI, which will help to support patient
16
17 selection for certain treatment regimens and to predict responses to treatment. Moreover,
18
19 the approach and methods outlined in this article may also serve as a recommendation for
20
21
22 other centers performing MRI acquisitions in patients with LBP, thus potentially supporting
23
24 standardization of clinical routine MRI acquisitions and reporting. Ultimately, the SOPs
25
26 presented may facilitate the integration of better harmonized MRI data of the lumbar spine
27
28
29
across studies and sites within and outside of BACPAC studies.
30
31
32
33 FUNDING
34
35
This research was supported by the National Institutes of Health through the NIH HEAL
36
37
38 Initiative as well as by the German Academic Exchange Service (Deutscher Akademischer
39
40 Austauschdienst, DAAD: N.S.), the Joachim Herz Foundation (N.S.), and the Rolf W.
41
42 Günther Foundation (N.S.). L.N. is principal investigator of service agreement with United
43
44
45 Healthcare.
46
47
48
49 DISCLAIMER
50
51
52
The content is solely the responsibility of the authors and does not necessarily represent
53
54 the official views of the National Institutes of Health or its NIH HEAL Initiative.
55
56
57
58
59
60
16
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47 Deformity Society, and the European Section of the Cervical Spine Research Society 2022.
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54 81. Wong J, Sampson SL, Bell-Briones H, Ouyang A, Lazar AA, Lotz JC, Fields AJ. Nutrient supply and
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60 82. Sollmann N, Dieckmeyer M, Schlaeger S, Rohrmeier A, Syvaeri J, Diefenbach MN, Weidlich D,
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3 Associations Between Lumbar Vertebral Bone Marrow and Paraspinal Muscle Fat Compositions-An
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9 83. Dieckmeyer M, Inhuber S, Schlaeger S, Weidlich D, Mookiah MRK, Subburaj K, Burian E, Sollmann
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16 84. Burian E, Syvari J, Dieckmeyer M, Holzapfel C, Drabsch T, Sollmann N, Kirschke JS, Rummeny EJ,
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18 Zimmer C, Hauner H, Karampinos DC, Baum T, Junker D. Age- and BMI-related variations of fat
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85. Burian E, Becherucci EA, Junker D, Sollmann N, Greve T, Hauner H, Zimmer C, Kirschke JS,
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25 Karampinos DC, Subburaj K, Baum T, Dieckmeyer M. Association of Cervical and Lumbar
26 Paraspinal Muscle Composition Using Texture Analysis of MR-Based Proton Density Fat Fraction
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28 Maps. Diagnostics (Basel) 2021;11(10).
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31 86. Sollmann N, Bonnheim NB, Joseph GB, Chachad R, Zhou J, Akkaya Z, Pirmoazen AM, Bailey JF,
32 Guo X, Lazar AA, Link TM, Fields AJ, Krug R. Paraspinal Muscle in Chronic Low Back Pain:
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Comparison Between Standard Parameters and Chemical Shift Encoding-Based Water-Fat MRI.
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35 Journal of magnetic resonance imaging : JMRI 2022.
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38 87. Schlaeger S, Inhuber S, Rohrmeier A, Dieckmeyer M, Freitag F, Klupp E, Weidlich D, Feuerriegel G,
39 Kreuzpointner F, Schwirtz A, Rummeny EJ, Zimmer C, Kirschke JS, Karampinos DC, Baum T.
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41 Association of paraspinal muscle water-fat MRI-based measurements with isometric strength
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10 Sayer AA, Schneider SM, Sieber CC, Topinkova E, Vandewoude M, Visser M, Zamboni M, Writing
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18 94. Cruz-Jentoft AJ, Sayer AA. Sarcopenia. Lancet 2019;393(10191): 2636-46.
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22 Hori Y, Nakamura H. The association of back muscle strength and sarcopenia-related parameters in
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the patients with spinal disorders. European spine journal : official publication of the European Spine
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25 Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine
26 Research Society 2019;28(2): 241-49.
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29 96. Eguchi Y, Suzuki M, Yamanaka H, Tamai H, Kobayashi T, Orita S, Yamauchi K, Suzuki M, Inage K,
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31 Fujimoto K, Kanamoto H, Abe K, Aoki Y, Toyone T, Ozawa T, Takahashi K, Ohtori S. Associations
32 between sarcopenia and degenerative lumbar scoliosis in older women. Scoliosis Spinal Disord
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2017;12: 9.
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97. Park S, Kim HJ, Ko BG, Chung JW, Kim SH, Park SH, Lee MH, Yeom JS. The prevalence and
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38 impact of sarcopenia on degenerative lumbar spinal stenosis. Bone Joint J 2016;98-B(8): 1093-8.
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1
2
3 FIGURE LEGENDS
4
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8 Figure 1: Modic-type endplate changes
9
10 Examples of Modic-type endplate changes, which can be identified according to
11

12
characteristic signal alterations in T1- and T2-weighted images. Modic changes type 1 are
13
14
15 typically hypointense on T1- and hyperintense on T2-weighted fat-suppressed images (a;
16
17 arrowheads), and Modic changes type 2 are hyperintense on T1- and hyper- or iso-intense
18
19 on T2-weighted images without fat suppression (b; arrowheads). Modic type 3 changes are
20
21
22 primarily characterized by sclerotic changes (not shown).
23
24
25
26 Figure 2: Endplate defects
27
28
29
Examples of endplate defects with degenerative appearance (erosive osteochondrosis) on
30
31 T1- and T2-weighted fat-suppressed sequences (a; arrowheads) and focal Schmorl’s nodes
32
33 on T1- and T2-weighted fat-suppressed sequences (b; arrowheads).
34
35
36
37
38 Figure 3: Degenerative disc disease
39
40 Examples for grading of intervertebral discs: homogeneous, hyperintense, normal height of
41
42 disc (a; Pfirrmann grade I); inhomogeneous, hyperintense, normal height, clear distinction
43
44
45 annulus vs. nucleus (b; Pfirrmann grade II); inhomogeneous, grey, normal height, no clear
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47 distinction between annulus vs. nucleus (c; Pfirrmann grade III); inhomogeneous, grey to
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49 black, normal height to moderate loss, no distinction between annulus vs. nucleus (d;
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Pfirrmann grade IV); and inhomogeneous, black, > 50% height loss (e; Pfirrmann grade V).
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27
1
2
3 Figure 4: Disc herniation
4
5
6
Example cases for disc protrusion (a; arrowheads) and disc extrusion (b; arrowheads) on
7
8 sagittal T1- and T2-weighted fat-suppressed sequences and axial T2-weighted sequences.
9
10 A disc protrusion is considered in case of a focal herniation of disc material beyond the
11

12
margins of the adjacent vertebral bodies, while a disc extrusion is a focal herniation of disc
13
14
15 nuclear material through an annular defect. In both presented cases, absent to minor
16
17 resulting constriction of the thecal sac is shown on axial sequences.
18
19
20
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22 Figure 5: Facet joint (FJ) degenerative changes
23
24 Examples for grading of FJ changes: normal appearance (a); narrowing, small osteophytes
25
26 or hypertrophy (b); narrowing, moderate osteophytes or hypertrophy (c); and narrowing,
27
28
29
large osteophytes or severe hypertrophy (d).
30
31
32
33 Figure 6: Spinal canal stenosis
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35
Normal configuration and diameter of the spinal canal (a) and severely narrowed spinal
36
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38 canal with complete loss of cerebrospinal fluid (CSF) signal due to degenerative changes
39
40 with a synovial cyst (b; arrowhead).
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45 Figure 1: Modic-type endplate changes
46 Examples of Modic-type endplate changes, which can be identified according to characteristic signal
47 alterations in T1- and T2-weighted images. Modic changes type 1 are typically hypointense on T1- and
hyperintense on T2-weighted fat-suppressed images (a; arrowheads), and Modic changes type 2 are
48 hyperintense on T1- and hyper- or iso-intense on T2-weighted images without fat suppression (b;
49 arrowheads). Modic type 3 changes are primarily characterized by sclerotic changes (not shown).
50
51 141x190mm (96 x 96 DPI)
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60 Official Journal of the American Academy of Pain Medicine
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45 Figure 2: Endplate defects
46 Examples of endplate defects with degenerative appearance (erosive osteochondrosis) on T1- and T2-
47 weighted fat-suppressed sequences (a; arrowheads) and focal Schmorl’s nodes on T1- and T2-weighted fat-
suppressed sequences (b; arrowheads).
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49 120x190mm (96 x 96 DPI)
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22
Figure 3: Degenerative disc disease
23 Examples for grading of intervertebral discs: homogeneous, hyperintense, normal height of disc (a;
24 Pfirrmann grade I); inhomogeneous, hyperintense, normal height, clear distinction annulus vs. nucleus (b;
25 Pfirrmann grade II); inhomogeneous, grey, normal height, no clear distinction between annulus vs. nucleus
26 (c; Pfirrmann grade III); inhomogeneous, grey to black, normal height to moderate loss, no distinction
27 between annulus vs. nucleus (d; Pfirrmann grade IV); and inhomogeneous, black, > 50% height loss (e;
Pfirrmann grade V).
28
29 170x81mm (150 x 150 DPI)
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29 Figure 4: Disc herniation
30 Example cases for disc protrusion (a; arrowheads) and disc extrusion (b; arrowheads) on sagittal T1- and
31 T2-weighted fat-suppressed sequences and axial T2-weighted sequences. A disc protrusion is considered in
case of a focal herniation of disc material beyond the margins of the adjacent vertebral bodies, while a disc
32
extrusion is a focal herniation of disc nuclear material through an annular defect. In both presented cases,
33 absent to minor resulting constriction of the thecal sac is shown on axial sequences.
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35 253x175mm (100 x 100 DPI)
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38 Figure 5: Facet joint (FJ) degenerative changes
39 Examples for grading of FJ changes: normal appearance (a); narrowing, small osteophytes or hypertrophy
40 (b); narrowing, moderate osteophytes or hypertrophy (c); and narrowing, large osteophytes or severe
41 hypertrophy (d).
42
180x177mm (96 x 96 DPI)
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23 Figure 6: Spinal canal stenosis
24 Normal configuration and diameter of the spinal canal (a) and severely narrowed spinal canal with complete
25 loss of cerebrospinal fluid (CSF) signal due to degenerative changes with a synovial cyst (b; arrowhead).
26
181x90mm (96 x 96 DPI)
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59

2
3 SAG T2 FS SAG T2 SAG T1 AX T2 AX T1 SAG T1 COR T1 AX MRN
4 Sequence (Lumbosacral)
(Lumbar) (Lumbar) (Lumbar) (Lumbar) (Lumbar) (with SIJ) (with SIJ)
5 Head first, Head first, Head first, Head first, Head first, Head first, Head first, Feet first,
6 Patient Position
supine supine supine supine supine supine supine supine
7 AX
Plane SAG SAG SAG AX AX SAG COR
8
Variable
9
Flip Angle [°] 120 120 110 120 110 115 115 Refocusing Flip
10
Angle
11
TE [ms] 60 60 14.1 60 14.1 14.1 14.1 100
12
13 TR [ms] 4,551 5,035 869 8,414 594 720 595 2,500
14 Echo Train Length 16 18 6 16 6 6 6 100
15 Receiver Bandwidth [kHz/0.5FOV] 50 50 50 50 50 50 50 62.5
16 36x29
FOV [cm] 26 26 26 18 18 30 30
17
18 Slice Thickness [mm] 3.0 3.0 3.0 4.0 4.0 8.0 4.0 1.2
19 Slice Spacing [mm] 3.0 3.0 3.0 5.0 5.0 10 5.0 N/A
20 Frequency Matrix 384 384 384 288 288 320 384 300
21 Phase Matrix 224 224 224 192 192 160 224 240
22
Frequency Direction A/P A/P A/P R/L R/L A/P R/L R/L
23
24 NEX averages 3.0 3.0 2.0 2.0 2.0 2.0 2.0 1.0
25 Fat suppression On Off Off Off Off Off Off On
26 Acceleration Off Off Off Off Off Off Off On
27
Number of Slices 24 24 24 42 42 36 20 120
28
29 Scan Time [min:sec] 3:16 3:16 3:34 3:31 3:47 2:06 1:42 8:30
30 Table 1: Pulse sequence parameters for conventional T1- and T2-weighted sequences (standardized protocol)
31
32 This table shows the sequence parameters for the conventional T1-/T2-weighted sequences for the main site’s magnetic resonance
33
34
35 imaging (MRI) system (GE 3T Discovery MR750; GE Healthcare, Waukesha, WI). For MRN, acceleration is achieved with 2 x 1.5 x 1.4
36
37 (ky phase-encode direction x kz phase-encode direction x compressed sensing factor).
38
39
40
41
42
44
45
46

2
3 Abbreviations: AX, axial; SAG, sagittal; COR, coronal; FS, fat suppression; TE, echo time; TR, repetition time; FOV, field of view; R/L,
4
5
6
right/left; A/P, anterior/posterior; NEX, number of excitations (averages); SIJ, sacroiliac joint
7
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46

2
3 SAG T2 FS SAG T2 SAG T1 AX T2 AX T1 SAG T1 COR T1 AX MRN
4 Sequence
(Lumbar) (Lumbar) (Lumbar) (Lumbar) (Lumbar) (with SIJ) (with SIJ) (Lumbosacral)
5 Head first, Head first, Head first, Head first, Head first, Head first, Head first, Feet first,
6 Patient Position
supine supine supine supine supine supine supine supine
7 Plane SAG SAG SAG SAG SAG SAG COR AX
8 Variable Flip
9 Flip Angle [°] 105-180 105-180 105-180 105-180 105-180 105-180 105-180
Angle
10 TE [ms] 40-80 40-80 8-20 40-80 8-20 8-20 8-20 80-120
11
TR [ms]  2,000  2,000 500-900  2,000 500-900 500-900 500-900 1,500-2,500
12
13 Echo Train Length 15-24 15-24 3-8 15-24 3-8 3-8 3-8 60-120
14 Receiver Bandwidth
31-62 31-62 31-62 31-62 31-62 31-62 31-62 31-62.5
15 [kHz/0.5FOV]
16 FOV [cm] 25-28 25-28 25-28 14-22 14-22 30-32 26-32 36-38
17 Slice Thickness [mm]  4.0  4.0  4.0  4.0  4.0  8.0  4.0  1.5
18 N/A
Slice Spacing [mm] 4 4 4 5 5  10 5
19
Frequency Matrix 320-512 320-512 320-512 256-512 256-512 320-512 256-512 256-380
20
21 Phase Matrix 192-320 192-320 192-320 192-320 192-320 160-320 192-320 200-304
22 Frequency Direction A/P A/P A/P R/L R/L A/P R/L R/L
23 NEX averages 1-4 1-4 1-4 1-4 1-4 1-4 1-4 1
24
Fat suppression On Off Off Off Off Off Off On
25
26 Number of Slices  12  12  12  30  30  30  12 256-300
27 Scan Time [min]  5 min  5 min  5 min  5 min  5 min  4 min  3 min  10 min
28 Table 2: Pulse sequence parameters for conventional T1- and T2-weighted sequences (recommended ranges)
29
30
31 Due to variations in magnetic resonance imaging (MRI) machines and vendors between imaging sites, ranges for pulse sequence
32
33 protocols are proposed for other than the main site regarding conventional T1-/T2-weighted sequences.
34
35 Abbreviations: AX, axial; SAG, sagittal; COR, coronal; FS, fat suppression; TE, echo time; TR, repetition time; FOV, field of view; R/L,
36
37
38
right/left; A/P, anterior/posterior; NEX, number of excitations (averages); SIJ, sacroiliac joint
39
40
41
42
44
45
46

2
3
4 0 1 2 3 4 Sequences
5 Modic Changes absent present
6 T1: hyperintense
7 T1: hypointense T1: hypointense SAG T2
T2: hyperintense
8 Modic Type T2: hyperintense T2: hypointense SAG T1
T2 FS: iso-/hypo-
9 T2 FS: hyperintense T2 FS: hypointense SAG T2 FS
intense
10 less than 25% of 25 to 50% of more than 50% of SAG T2
11 Vertebral Body localized at
vertebral body vertebral body vertebral body SAG T1
12 Height endplate only
height height height SAG T2 FS
13 Affected Endplate
14 SAG T2
Area less than 25% of 25 to 50% of more than 50% of
SAG T1
15 (largest diameter in endplate area endplate area endplate area
SAG T2 FS
16 a single section)
17
18
19
Table 3: Modic-type endplate changes
20
21
22 This table provides the scoring scheme for Modic changes and the sequences used for evaluation of different categories. In case that
23
24 Modic changes were detected, the type (Modic type I – III) as well as the spatial characteristics of changes with respect to vertebral body
25
26 height and vertebral endplate area were graded.
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
44
45
46

2
3
4 0 1 2 3 4 Sequences
5 Endplate Defect absent present
6 Scheuermann
7 degenerative (e.g., variant (Schmorl’s
8 osteoporotic
erosive nodes); wedge- SAG T1
9 Type (normal sagittal other
intervertebral shaped deformity SAG T2
10 diameter)
osteochondrosis) and increased
11 sagittal diameter
12 Schmorl’s node, sharp, angular, SAG T1
13 Shape irregular, diffuse other
subchondral cyst focal SAG T2
14 Size between 1/3 and
less than 1/3 of more than 2/3 of SAG T1
15 (largest diameter in 2/3 of endplate
endplate area endplate area SAG T2
16 a single section) area
17 Depth less than 25% of 25 to 50% of more than 50% of
SAG T1
18 (largest diameter in vertebral body vertebral body vertebral body
SAG T2
19 a single section) height height height
20
21
22 Table 4: Endplate defects
23
24
25 This table outlines the scoring scheme for vertebral endplate defects and the sequences used for evaluation of single categories. In
26
27 case that vertebral endplate defects were detected, the type as well as the spatial characteristics of changes with respect to vertebral
28
29 body height and vertebral endplate area were graded, as well as their shapes.
30
31
32
33
34
35
36
37
38
39
40
41
42
44
45
46

2
3
4 0 1 2 3 4 5 Sequences
5 inhomogeneous,
6 inhomogeneous, inhomogeneous,
grey to black,
7 hyperintense, grey, normal
homogeneous, normal height to Inhomogeneous,
8 Degenerative Disc normal height, height, no clear
hyperintense, moderate loss, black, > 50% SAG T2
9 Disease clear distinction distinction
normal height no distinction height loss
10 annulus vs. between annulus
between annulus
11 nucleus vs. nucleus
vs. nucleus
12 less than 10% 10%-50% loss >50% loss
Disc Height SAG T2
13 loss (mild) (moderate) (severe)
14 SAG T2 FS
Disc Herniation normal bulge protrusion extrusion
15 AX T2
16 Protrusion/Extrusion
central subarticular zone foraminal extraforaminal SAG T2
17 Location
18 Protrusion/Extrusion
left right SAG T2
19 Side
20 Annular Fissure absent present SAG T2
21 Annular Fissure central/ left/ right/
SAG T2
22 location posterior subarticular subarticular
23 nerve root – left nerve root – left nerve root – right nerve root –right SAG T1
Nerve Root no nerve root
24 contact without deviation and contact without deviation and bilateral SAG T2
Involvement contact
25 deviation compression deviation compression AX T2
26
27
28 Table 5: Intervertebral disc changes
29
30
31
This table shows the scoring scheme for intervertebral disc changes and the sequences used for evaluation of respective categories. In
32
33 case that degenerative disc disease was detected, its characteristics including signal, height, herniation specifics, and nerve root
34
35 involvement were graded, together with screening for an annular fissure.
36
37
38
39
40
41
42
44
45
46

2
3
4 0 1 2 3 Sequences
5 Facet joint (FJ)
6 narrowing, narrowing, narrowing, SAG T2 FS
7 Joint Space none small osteophytes or moderate osteophytes or large osteophytes or AX T2
8 hypertrophy hypertrophy severe hypertrophy Ax T1
9 Joint Fluid absent present Ax T2 FS
10 Sacroiliac joint (SIJ)
11 SAG T2 FS
12 Appearance normal abnormal
COR T1
13 Joint Space normal degenerative erosions COR T1
14 SAG T1
15 Bone Marrow normal edema fatty transformation
COR T1
16 SAG T1
17 Bone normal insufficiency fractures Osteitis condensans ilii other
COR T1
18 Lumbosacral large transverse process SAG T1
19 large transverse large transverse process
Transitional Vertebrae none articulating with the SAG T2 FS
processes (>2.1cm) fused with sacrum
20 Type sacrum COR T1
21 Lumbosacral SAG T1
22 Transitional Vertebrae bilateral left right asymmetric SAG T2 FS
23 Location COR T1
24
25
26 Table 6: Facet and sacroiliac joint changes
27
28
29 This table illustrates the scoring scheme for changes of the facet joints (FJs) and sacroiliac joints (SIJs) and the sequences used for
30
31 evaluation of different categories. In addition, presence and degree of lumbosacral transitional vertebrae (LSTV) were assessed.
32
33
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2
3
4 0 1 2 3 Sequences
5
mild constriction,
6 no thecal sac CSF diminished but SAG T2 FS
Central Canal minimal loss of CSF complete loss of CSF
7 constriction present AX T2
around rootlets
8 Congenital Narrowing SAG T2 FS
9 no yes
of Central Canal AX T2
10 Subarticular Zone
11 nerve root contact SAG T2 FS
Stenosis no nerve root contact nerve root compression
12 without deviation AX T2
Characteristics
13 Subarticular Zone SAG T2 FS
14 left right bilateral
Stenosis Side AX T2
15 mild – slight deformity of moderate – marked
16 Neuroforaminal
epidural fat, still deformity of epidural fat, severe – obliteration of SAG T1
17 Stenosis normal epidural fat
completely surrounding only partially epidural fat SAG T2 FS
18 Characteristics
the nerve root surrounding nerve root
19 Neuroforaminal SAG T1
left right bilateral
20 Stenosis Side SAG T2 FS
21
22
23
24
Table 7: Stenosis
25
26 This table outlines the scoring scheme for central canal stenosis and neuroforaminal stenosis or stenosis at the subarticular zone and
27
28 the sequences used for evaluation of such stenotic changes. In case that vertebral endplate defects were detected, the type as well as
29
30 the spatial characteristics of changes with respect to vertebral body height and vertebral endplate area were graded, as well as their
31
32
33 shapes.
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Magnetic Resonance Imaging of The Lumbar Spine-Rec

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