The lumbar spinal endplate lesions grades and association with lumbar disc disorders, and lumbar bone mineral density in a healthy Chinese cohort

doi:10.21203/rs.3.rs-1984893/v1

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The lumbar spinal endplate lesions grades and association with lumbar disc disorders, and lumbar bone mineral density in a healthy Chinese cohort

https://doi.org/10.21203/rs.3.rs-1984893/v1

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Background Lumbar vertebral endplates lesions (LEPLs), as one of the etiology of low back pain (LBP) which is one of the most common causes of health care cost, have an unclear pathogenesis. Although it gradually regarded as the focus in recent years, almost all studies have focused on symptomatic people, not healthy people. Therefore, our study was designed to determine the prevalence and distribution patterns of LEPLs and their associations with lumbar disc herniation (LDH), lumbar disc degeneration (LDD), and lumbar vertebral volumetric bone mineral density (vBMD) in a health cohort.

Methods Seven hundred and fifty healthy participants aged 20–60 years were enrolled in the study from a study on the degeneration of the spine and knee. In this observational study, a lumbar quantitative computed tomography (QCT) and MRI scan were performed among participants within 48 hours. T2-weighted sagittal lumbar MRI images for all included subjects were identified for LEPLs by two independent observers based on morphological and local characteristics. Lumbar vertebral vBMD was measured with QCT. The age, BMI, waistline, hipline, lumbar vBMD, LDD, and LDH were measured to investigate their associations with LEPLs.

Results The prevalence was higher among the male subjects. 80% of endplates were recognition as no lesions with a significant difference between female (75.6%) and male subjects (83.4%) (p < 0.001). The most common lesions were “wavy/irregular” and “notched”, and “fracture” is most involved in L3-4 inferior endplate both in two genders. Lesions were found to be associated with LDH (≥2 levels： OR=6.859, P＜0.001； 1 level： OR=2.328， P=0.002 in men. OR=5.004, P＜0.001； OR=1.805， P= 0.014 in women) reference for non-LDH, and hipline in men(OR=1.123, P＜0.001). Weighted kappas of 0.66 and 0.87 were, respectively, assessed for the inter-and intra-observer reliabilities of the classification system.

Conclusions Endplate lesions are also the common findings on lumbar MRIs in general people, particularly in men, and the presence, and advance from slightly to severely could be mainly attributed to LDH and men’s higher hipline.

Endplate lesions

Lumbar intervertebral disc herniation

Pfirrmann grading

volumetric bone mineral density

Low back pain (LBP), which presents the world’s highest burden of disease related to years lived with disability in both developed and developing countries, is one of the most common causes of lost or restricted working hours [1, 2]. LBP is a multifactorial symptom, while standard diagnostic approaches usually fail to reveal any pathoanatomical cause of the pain within the cognition of modern medicine [1, 3]. Changes in endplates (EPs)’ biomechanical and biochemical properties are associated with the development of LBP. Lumbar vertebral endplates lesions (LEPLs), as one of the etiology of LBP [4], have been gradually regarded as the focus in recent years [5–7]. The most common endplate lesions observed is probably the Schmorl’s node, which is regarded as a herniation of nucleus pulposus through the focal weak spots of cartilaginous and bony endplate into the body of the adjacent vertebrae. Schmorl’s node begins as small defects and usually are viewed as synonymous with LEPLs, especially in radiological studies. Chen et al. revealed that it was endplate defects, that represented the dominant association with lifetime back pain [4].

The perception focused on the pathogenesis of LEPLs is vague. The relationship between LEPLs with lumbar disc disorders, such as lumbar intervertebral disc herniation (LDH), and lumbar disc degeneration (LDD) is scarce. As the connective tissue between the vertebrae and the intervertebral disc, the EPs play an important role in spinal function, maintaining intervertebral disc integrity and disc nutritional supply, and absorbing pressure that results from mechanical loading of activities of the spine [8]. The disc is an avascular structure, and nutrients coming from the bloodstream need to cross the EPs and the disc matrix via diffusion processes to be available to the disc cells. EPs are also responsible for the exchange of molecular information between the vertebrae and the intervertebral disc. In contrast to the discs, the central endplate is well innervated, as is the adjacent vertebral marrow, satisfying a strong physiological basis for being a primary pain generator. Also, although current studies have standardized the LEPLs and their nomenclature system and weakened the existence of inconsistency through the introduction of universal nomenclature [5, 9], most of their studies were focused on patients with low back pain.

Although the presents of the endplates lesions and lumbar disc disorders are often in general people without LBP, the prevalence of EPLs in generally healthy people was hardly studied. Moreover, the vertebral bone mass vertebral trabecular volumetric bone mineral density (Trab.vBMD, hereinafter referred to as the “vBMD”) was observed in healthy volunteers [10], the association of endplates lesions with lumbar BMD is obscure [11, 12]. The objective of the present study is to investigate the prevalence of lumbar endplates lesions (LEPLs) in affected levels (L1/L2–L5/S1), stratified by sex, and detect possible associations of the presence and advance of the EPLs with potential risk factors, including characteristics data, lumbar vBMD, the grade of LDD, and LDH in a healthy Chinese cohort.

Study design and population

The subjects were from a 10-year longitudinal study on the degeneration of the spine and knee performed running in June 2014, and the basic data collection of this population was completed in 2017. Participants who are healthy community-dwelling adults, aged 20–60 years, not engaged in heavy physical activity, and residents in Beijing >5 years were included to facilitate follow-up and reveal the onset and development of the degeneration. Therefore, we use the baseline data to design a cross-sectional study to research LEPLs. The study was approved by the ethics committee of our hospital. The study was conducted under the Helsinki Declaration. Informed consent was obtained from all individual participants included in the study. The exclusion criteria were: autoimmune disease (e.g., rheumatoid arthritis), congenital disorders (e.g., juvenile idiopathic scoliosis), prior lumbar spine surgery, a history of metabolic bone disease, or chronic diseases related to calcium absorption (hyperparathyroidism), a history of malignant tumors, the use of medications known to affect bone metabolism, and pregnancy [13].

750 healthy volunteers were included in our study, who had experienced a lumbar quantitative computed tomography (QCT) and MRI scan within 48 hours. The lumbar spine disorders such as LDH, LDD (decreased signal intensity and losing the height of disc), and LEPLs were assessed by the radiologists by MRI examination performed by a 1.5 T scanner (Espree, SIEMENS, Munich, Germany). All subjects were scanned with the same multi-channel gradient waist coil. T2-weighted TSE imaging (TR/TE 2500/100 ms, slice thickness 4 mm, intersection gap 0.8 mm, voxel 240 × 282, FOV 180 × 280 mm) were performed in the sagittal plane. In the axial plane, T2-weighted TSE imaging was performed with TR/TE 2500/100 ms, slice thickness 4 mm, intersection gap 0.4 mm, voxel 248 × 198, and FOV 160 × 180 mm.

As part of the study protocol, the lumbar spines of all-volunteer scans were performed on a Toshiba CT scanner (Aquilion PRIME, Toshiba, Otawara, Japan). A QCT calibration phantom (Mindways Inc., Austin, TX, USA) was placed beneath the spine and scanned simultaneously according to the standard scanning protocol by Wang et al. [14]. The spine was kept parallel to the long axis of the calibration phantom, and minimal air gaps existed between the phantom and the volunteer. The scanning parameters were as follows: 120 kV 187 mAs, the field of view 50 cm, 1 mm slice thickness, and reconstruction matrix 512 × 512. Other methodological details have been described previously [15].

Demographic (sex, age), and physical (weight, height, waistline, and hipline) characteristics were collected from the enrolled population. Body mass index (BMI) was acquired as weight (kg) / height squared (m²).

Scoring system for the LEPLs and the lumbar disc disorders

Under the supervision of a senior radiologist, T2-weighted sagittal images were evaluated by two independent observers. All 30 out of 750 cases showing inter- and intra-observer differences in the assigned total score of LEPLs were re-evaluated by another expert radiologist. Ten endplates in the lumbar spine (L1-S1) were evaluated for the presence or absence of any type of defect. The score was calculated by labeling L1/L2 to L5/S1 intervertebral spaces as: “normal (1 point) = no lesions in the intervertebral space, physiological curvature of both EPs; wavy/irregular (2 points) = no specific lesions detectable in the intervertebral space, alterations in the physiological curvature of at least one of the EPs; notched (3 points) = a V-shaped or circular small lesion visible in at least one sagittal MRI slice; Schmorl’s node (4 points) = a deep focal defect of the vertebral EP with a smooth margin and a rounded appearance; fracture (5 points)” as previously reported by Brayda-Bruno et al. [5, 7]. For each of the five intervertebral levels, if two or more defects co-existed on an endplate or there were two types of defects in a disc level (including the upper and lower endplates), the higher score was counted. To conduct a comprehensive score for LEPLs of each individual, we define non-LEPLs (Grade I) when the upper and lower endplates of each of the five lumbar intervertebral discs were normal, mild LEPLs (Grade II) when one or more of the EPs was scored as 2(wavy/irregular) or 3(a V-shaped or circular small lesion) points, and severe LEPLs (Grade III) when the presentations of 4/5 points were evaluated (Fig. 1).

MRI degeneration of the L1/2–L5/S1 intervertebral discs in the whole cohort were assessed using a 5-point scoring system proposed by Pfirrmann et al. [16] as follows: Grade I: the homogeneous disc is with a bright hyperintense white signal intensity and a normal disc height. Grade II: The inhomogeneous disc with a hyperintense white signal and a normal disc height, and with or without horizontal gray bands. Grade III: the inhomogeneous disc with an intermediate gray signal intensity, with a normal or slightly decreased height, and indistinction between nucleus and annulus. Grade IV: the inhomogeneous disc with a hypointense dark gray signal intensity, with a normal or moderately decreased disc height, and the distinction between nucleus and annulus is lost. Grade V: the inhomogeneous disc with hypointense black signal intensity, the distinction between the nucleus and annulus is lost, and its space is collapsed. The intervertebral discs (IVD) were then classified into 3 groups. A subject was defined as having slight degeneration if their average grade of Pfirrmann stage was < 3, moderate degeneration if their average grade was ≥3 and < 4, and severe degeneration if their grade was ≥4 [17].

To describe the overall lumbar intervertebral disc herniation of each subject, we defined the non-LHD group as follows: normal, or bulge/protrusion with no evident contact of disk material with the nerve root, and without severe thecal sac compression or diminished dimensions of the neural foramen. The LDH group was defined as follows: the bulge, protrusion with the visible contract of disk material with the nerve root, severe thecal sac compression, and diminished dimensions of the neural foramen, extraction, and sequestration. The number of discs with herniation counts is distributed into the following 3 groups, non-lumbar intervertebral disc herniation, a single-level disc herniation, and ≥2 segments herniation.

Lumbar Vertebral Trabecular Volumetric Bone Mineral Density (Trab.vBMD) Measurement

After scanning, the CT DICOM images were transferred to the QCT workstation for further analysis with the QCT Pro 5.0.3 software (Mindways Inc.). lumbar vBMD was measured within a specific region of interest, which was defined as the oval-shaped areas containing the largest areas of the trabecular bone in the mid-plane of each vertebral body, not including the cortical bone or basivertebral vein [15, 18]. The Trab.vBMD values (mg/cm3) of L2–4 were recorded and analyzed, respectively, and the average was calculated [18].

Statistical Analysis.

Weighted Kappa statistic was used to assess the inter-and intra-observer reliability. The Kappa-values in intra-observer is 0.87, and the inter-observer values are 0.66, showing strong consistency.

The data were stratified into the male and female groups and then the normality was tested in the continuous variables. The descriptive statistics were presented as mean ± standard deviation for the normally distributed variables and as a median for the categorical and non-normally distributed variables. Then, the data were stratified by lumbar endplates condition, the normally distributed variables were analyzed using the one-way analysis of variance (ANOVA), and others were evaluated with the Kruskal–Wallis H test. The linear relationship of LEPLs with the stage of LDH and LDD was analyzed by Mantel-Haenszel chi-square tests. Finally, the ordinal logistic regression（OLR）was performed to estimate the effect of age, BMI, waistline, hipline, lumbar vBMD, lumbar intervertebral disc herniation, and lumbar disc degeneration on lumbar endplates lesions status and adjusting for confounding factors. Odds ratios (ORs) and 95% confidence intervals (CIs) for the occurrence of LEL were calculated as approximations of the relative risk estimates. A P-value <0.05 was considered statistically significant. SPSS 26.0 software was used to perform statistical analysis.

Demographic characteristics

Seven hundred and fifty participants (326 men, median age 39 years old; 424 women, median age 40 years old) were enrolled in the study for analysis. The characteristics, mean lumbar vBMD, and the prevalences of LDH, LDD, and LEPLs of this cohort were shown in Table.1, and are incomparable between both genders, therefore, they are dichotomous in the analyses and exhibitions.

Prevalence and distribution of lumbar endplates lesions

LEPLs were identified in 1072/3750 (28.6%) levels of discs, 1500/7500 (20.0%) endplates, and 487/750 (64.9%) subjects. The detail was shown in Fig. 2. The predilection for males over females in LEPLs (72.7% vs. 59.0%, p < 0.001), and the positive rates of both sexes increased with the descent of the lumbar segment (from 15.6% to 32.8% in women and from 29.7% to 40.5% in men). The type of EPLs most commonly observed in both the sex was the “wavy/irregular”, subsequently followed by the “notched”, “fracture” and “Schmorl’s node”. For total types of lesions, the observed prevalence was higher among the male subjects rather than the female ones. Of the 5 lumbar segments in women, “wavy/irregular”（range: from 7.3% to 24.3%）and “notched” （range: from 4.2% to 7.8%） are most commonly disturbed at the L5-S1 segment, “Schmorl’s node”（from 0.2% to 3.1%）at the L2-3 segment, and “fracture”（from 0 to 8%）is most commonly occur at L3-4 disc; while in men, the distribution is similar to that of females except for “notched”（from 4.6% to 12%）and “Schmorl’s node” (from 0.3% to 3.7%）is most commonly affected at L2-3 segment. Interestingly, “fractures” occur most frequently at the L3-4 intervertebral level, especially at the inferior endplate.

Although LEPLs slightly more affected the cranial than the caudal endplates of the lumbar (761 vs. 739), the L4-5 level was a clear demarcation both in women and men, namely, the superior endplates were fewer endplate lesions than the inferior endplates above the L4-5 level and more lesions than the inferior endplates below the L4-5 level. The incidence with 3-levels affected had the greatest statistically differences between women (8.5%) and men (15.3%) (P=0.0035), although the prevalence of lesions involving more levels progressively declined (Table. 2).

174 (41.0%) women and 89 (27.3%) men were discriminated as normal, namely no defects of the lumbar endplates in all of the 5 levels of the lumbar disc, 178 (42.0%) women and 179 (54.9%) men had at least one wavy/irregular or notched endplate, and 73 (17.2%) women 58 (17.8%) men were found to have Schmorl’s node or fracture. The differences in age and mean lumbar Trab.vBMD between the three grades of endplate lesion were statistically significant both in men and women, as detailed in Table 1. The median age in the individuals with non-LEPLs (Grade I), mild-LEPLs (Grade II), and severe-LEPLs(Grade III) is 38, 40, and 45 years old respectively in women (P＜0.001), and 37, 39, and 43.5 in men (P＜0.001), and the average of Trab.vBMD values of L2–4 in Grade I, Grade II, and Grade III are 168.4 ± 35.1 mg/cm3, 163.1 ± 38.1 mg/cm3, and 156.1 ± 33.5 mg/cm3respectively in women（P = 0.049）, and 153.5 ± 30.3 mg/cm3, 149.7 ± 29.7 mg/cm3, and 135.5 ± 34.4 mg/cm3 in men（P = 0.002）. Moreover, there were statistically significant differences in height, weight, and hipline among the three lesion grades, and they all increased with the increase of lesion grades of the endplate, although BMI did not change significantly between the three groups.

The association between EPLs and LDH and IVDD

The prevalence of LDH and IVDD that were stratified by gender and EPLs status in all volunteers was shown in Table 1. The Chi-square tests of linear-by-linear association indicate that EPLs had a linear relationship with LDH and LDD both in women and men (the 4 P values were all less than 0.001). In post hoc tests between EPLs and LDH, the groups whose absolute value of adjusted standardized residual is greater than 3 are non-LDH and without EPLs people (male: 4.9, female: 4.1), more than 2 levels LDH and without EPLs people (-4.0, -4.4), more than 2 levels LHD and EPLs of Schmorl’s node or Fracture people (5.6, 6.4) and non-LDH and EPL of Schmorl’s node or Fracture women (-3.1). This result implies that the grade of LDH lesions increases with the increase of LEPLs grades in both men and women, and there is a statistically significant linear relationship. Between LEPLs and LDD, the absolute value of adjusted standardized residual in slightly LDD and EPLs of Schmorl’s node or Fracture people was the largest, which was -3.2 both in women and men, and the difference was statistically significant, indicating that people without severely LDD were not inclined to develop a higher level of EPLs.

Risk factors for advancement of EPLs

The OLR analysis for these factors is shown in Table 3 ＆ 4. The results reveal that the OR of serious LEPLs statuses were 2.328 (P=0.002) and 6.859 (P＜0.001) among the volunteers within 1 level LDH and ≥2 levels LDH respectively in men and 1,805 (P= 0.014) and 5.004 (P＜0.001)in women when a reference for the non-LDH. Moreover, the factors significantly influencing LEPLs were hipline (OR= 1.123, P＜0.001). Although both lumbar vertebral vBMD and LDD were related to EPLs, vBMD (OR= 0.997, P= 0.537 for men, and 1003, 0.55 for women) and LDD (≥2 levels： OR=6.859, P＜0.001； 1level： OR=2.328， P=0.002 in men. OR=5.004, P＜0.001； OR=1.805， P= 0.014 in women) reference for non-LDH did not affect the progression of EPL after the calibration of covariates.

Based on a T2-weighted MRI Classification system for the LEPLs and a lumbar spine QCT scanning for vBMD measurements, the associations between LEPLs and LDH, LDD, and lumbar vBMD were investigated in a healthy cohort of Chinese adults. LEPLs were common findings in the male lumbar spine, particularly in the lower lumbar region. The presence of endplate lesions was associated with several factors, but these associations only remained lumbar herniation and male hipline after adjusting for the effects of age, BMI, waistline, lumbar vBMD, and disc degeneration.

Our study showed remarkable gender differences not only in characteristics data and lumbar vBMD but also in the prevalence of lumbar disc lesions. Male gender is associated with a higher positive incidence for LEPLs than females whether from the prevalence of EPLs and the number of the lesioned endplates, in which men often do harder physical labor than women [19], which might explain for a larger hipline accompanies and exacerbates the advance of LEPLs. Hormonal factors may play some as yet consequential role in the development of EPLs [7]. Moreover, our study finds that except for one level, the incidence of EPLs was lower in males than in females, and the incidence of other 2–5 levels was higher in males than in females.

Our results showed that LEPLs involved 263 (64.9%) general people, 1072 (28.6%) discs, and 1500 (20.0%) lumbar endplates, and this is corresponding with the previous study[4, 5, 9]. However, Wang et al. observed 1148 vertebral endplates (L1–S1) from the cadaveric spines of 136 men and found 45.6% of lumbar vertebral endplates with lesions [20]. Although, it is unexceptional that the prevalence of LEPLs is higher in men than women and even the whole cohort, the difference can be accounted for that the medical imaging is not on a par with the pathological examination, and the two methods should not compare immediately without segregation in clinical studies and diagnoses.

Brayda-Bruno[5] et al. researched that “notched” was the most common type of EPLs followed by “Schmorl’s node” observed in patients with low back pain, our studies reveal that the most common EPLs are “Wavy/irregular” and “notched”. This difference could account for our subjective population being the general people without low back pain conditions occur that can be severe enough to affect normal work and activity. Based on the fact that “Wavy/irregular” & “notched” are more common in general people, and “notched” & “Schmorl’s node” are more common in a person with low back pain, we can preliminarily infer that “Wavy/irregular” is physiological, while “notched” & “Schmorl’s node”, especially the latter, are more likely to be symptomatic or even pathological. At least, "Notched" and "Schmorl's Nodes" are risk factors for low back pain. This is also consistent with Chen’s finding that focal defects were statistically significantly associated with the presence of back pain over the past 12 months (OR = 2.10, P = 0.009)[4]. Moreover, we find that the fracture is most involved in L3-4 inferior endplate. This may be because the stress distinctiveness of L3-4 intervertebral discs at the boundary between the upper and lower lumbar spine is predisposed to mechanical failure.

Proteoglycan molecules are critical for the control of solute transport and maintenance of water content in the disc, and consumption of proteoglycans from the endplate cartilage is associated with loss of proteoglycans from the nucleus [8]. Then, a finite element analysis concludes that variations in proteoglycan content of the disc were associated with variations in high tensile strains in the endplates, which is responsible for vertebral compressive strength [21]. As a result, we found that LDH and LDD are associated with LEPLs, and LDH is one of the risk factors for LEPLs progression and is following previous studies[5, 9, 22, 23]. Moreover, Sahoo has identified that endplate lesions are commonly associated with symptomatic LDH, and bony lesions are affiliated with adverse outcomes [24].

This is the first study determining the role of lumbar vertebral vBMD in the severity and advancement of LEPLs among healthy Chinese cohorts. As the conjunct structure, the endplate is vital for maintaining the integrity of the vertebral trabeculae and disc. Damage to the endplate may impair not only the adjacent disc but the vertebra. Fujiwara et al. [6] have shown that EPLs are associated with vertebral fractures and the healing of osteoporotic vertebral fractures. We find that the relationship between lumbar vBMD and LEPLs vanished after adjustment for covariates, suggesting that changes in BMD are not a protective or risk factor for LEPLs both in women and men. This is consistent with the result of Gungor that there was no significant relationship between the total number of Schmorl’s nodes per patient and the mean vBMD (p = 0.156) [11], and different from the result of Okano that higher TEPS (score 10 − 12, b = 14.2, p༜0.001) was shown to be independent contributors to vBMD [12]. The age difference demographic variance maybe accounts for this non-conformity.

In 2018, two common and certified nomenclature systems for endplate lesions had been almost recommended simultaneously by Brayda-Bruno [5] and Feng [9], respectively. Although Wang’s team contributed to the lumbar spine study both in vivo and cadaveric spines for many years [20, 25], Feng et. al considers that the different types of endplate defects differed in morphology, distribution patterns, and strength of association with disc degeneration, suggesting they represent different pathologies[9]. Nevertheless, the classification systems of Brayda-Bruno suppose that same as Pfirrmann’s classification of lumbar intervertebral disc degeneration, lesion grade from lower to higher is a progressive or continuous process. And our results using Brayda-Bruno’s classification also show that people with higher grades of lesions are older both men and women. Although the etiology of LEL is blear, our study is in line with the known theory that the majority of endplate lesions are asymptomatic, and is frequently incidental by radiological, and can partly suggest that the occurrence and development of LEL is a cumulative process. And the monistic study of the disease may reduce unnecessary controversy and confusion.

Although we used the more accurate strategy, QCT to measure vBMD in a large cohort of 750 healthy subjects, there are several limitations to this study. First, we executed a cross-sectional study, whereas endplate and disc disorders, and decreasing BMD being a continuing occurrence needs a longitudinal follow-up study to elaborate further on their relationship, which was not done in this study. Second, our study population was drawn from community-dwelling adults in the city of Beijing and might underestimate the prevalence of LEPLs in the general population, because LEPLs are associated with physical activity and economic well-being. Third, the loss of older people would likely have reduced the chance of showing significant relationships between evaluations of LEL and other variates.

In summary, EPLs are also the common findings on lumbar MRIs in general people, particularly in men. The present results suggest that the presence and advance of LEPL could be mainly attributed to LDH, and hipline in men, suggesting that treatment of LDH and avoidance of inappropriate physical activity may delay the progression of LEPLs. However, further studies are needed to evaluate the clinical implication of endplate lesions and remission of the back pain it causes.

EPs	endplates
LEPLs	lumbar vertebral endplates lesions
LBP	low back pain
LDH	lumbar disc herniation
LDD	lumbar disc degeneration
vBMD	volumetric bone mineral density
QCT	quantitative computed tomography
BMI	Body mass index
ANOVA	analysis of variance
OLR	ordinal logistic regression

Acknowledgements

We sincerely appreciate all the patients who participated in this study.

Funding

This work was supported by the National Natural Science Foundation of China (grant no. 81971617; 81771831), Beijing Hospitals Authority Youth Programme (code: 20200402), Beijing Natural Science Foundation-Haidian Primitive Innovation Joint Fund (grant no. L172019), Beijing Hospitals Authority Clinical Medicine Development of Special Funding Support (code: ZYLX202107), and Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding Support (code: XMLX201843).

Availability of data and materials

The data that support the findings of this study are available from the corresponding author but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Beijing Jishuitan Hospital.

Compliance with ethical standards

The design and protocol of this retrospective study were approved by the Ethics Committee of Beijing Jishuitan Hospital (No. 201210-01), and written informed consent was obtained from all participants. All methods in the study were carried out in accordance with the Helsinki guidelines and declaration.

Competing interests

The author(s) declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.

Consent for publication

Not Applicable.

Authors’ contributions

All authors contributed to the study's conception and design. Material preparation, data collection, and analysis were performed by Xiaoguang Cheng, Jian Geng, Aihong Yu, Jingzhe Pei, Yandong Liu, Ling Wang, Jia Shi, FengYun Zhou, Tianyu Zhang and Pengju Huang. The first draft of the manuscript was written by Xiaoguang Cheng, Jian Geng and Aihong Yu, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Author details

1 Beijing Jishuitan Hospital Department of Radiology, 31 Xinjiekou East Street, Xicheng District, Beijing, China. 2 Shaanxi University of Chinese Medicine School of Medical Technology, Middle Section of Shiji Avenue, Xixian New District, Xianyang City, Shaanxi Province, China. 3 National Institute of Nutrition and Health, Chinese Center for Disease Control and Prevention, 29 Nanwei Road, Xicheng District, Beijing, China

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Table 1. Characteristics of subjects with different stages of the lumbar endplates lesions.
	Female, N=424				Male, N=326
Parameters	Non-LEPLs	LEPLs n= 251		P	Non-LEPLs	LEPLs n= 237		P
Parameters	Non-LEPLs	Mild-LEPLs	Severe-LEPLs	P	Non-LEPLs	Mild-LEPLs	Severe-LEPLs	P
%(n)	41.0(174)	42.0(178)	17.0(72)		27.3(89)	54.9(179)	17.8(58)
Age(years)	38	40	45	＜.001^*	37	39	43.5	＜.001^*
Height (cm)	160.2 ± 5.4	163.1 ± 5.6	161.0 ± 5.9	.469^¶	170.7 ± 6.2	172.6 ± 5.9	173.6 ± 5.2	.008^¶
Weight (Kg)	59	60	61	.21^*	75	77	80.5	.013^*
BMI	24.7	23.2	23.5	.556^*	25.9	25.5	27.0	.275^*
Waistline(cm)	78	79	79	.638^*	90	90	92	.155^*
Hipline(cm)	95	95	97	.314^*	98	101	101.8	＜.001^*
Mean vBMD(mg/cm³)	168.4±35.1	163.1 ± 38.1	156.1 ± 33.5	0.049^¶	153.5 ± 30.3	149.7 ± 29.7	135.5 ± 34.4	0.002^¶
The status of LHD
Non-LHD n (expected n)	62 (44.1) ^a	38 (45.3)	8 (18.6) ^a	＜.001^ծ	41 (23.5)^a	38 (47.2)	7 (15.3)	＜.001^ծ
1-level LHD n (expected n)	84 (82.0)	94 (84.4)	23 (34.6)		40 (43.7)	100 (87.97)	20 (28.5)
≥2 levels LHD n (expected n)	27 (46.9)^a	446 (48.3)	42 (19.8)^a		8 (21.8)^a	41 (43.9)	31 (14.2)^a
The LDD stages
Slight n (expected n)	78 (69.0)	74 (70.9)	17 (29.1)^a	＜.001^ծ	48 (38.2)	78 (76.9)	14 (24.9)^a	＜.001^ծ
Moderate n (expected n)	93 (98.7)	99 (101.6)	50 (41.7)		41 (49.7)	99 (99.9)	42 (32.4)
Severe% n (expected n)	2(5.3)	5(5.5)	6(2.2)		0 (1.1)	2 (2.2)	2 (0.7)

LEPLs: lumbar endplates lesions (EPLs), Non-LEPLs: the score of the LEPLs is 1 point, mild-LEPLs: the score of the LEPLs is 2/3, and severe-LEPLs: the score of the LEPLs is 4/5; 1 to 5 points represent normal, wavy/irregular, notched, Schmorl’s node, and fracture; BMI: body mass index; vBMD: volumetric bone mineral density; LDH: lumbar intervertebral disc herniation; LDD: lumbar intervertebral disc degeneration; ^* by Kruskal–Wallis H test; ^¶ by one-way variance analysis (ANOVA); ^ծby Mantel-Haenszel chi-square tests; ^aabsolute value of adjusted standardized residual is greater than 3.

Table 2. Incidence of endplate lesions in all participants

Parameters	Total		Female		Male		P
Parameters	n	%	n	%	n	%	P
Normal¹	263	35.1	174	41.0	89	27.3	<0.001
1-level	192	25.6	111	36.2	81	34.8	0.6785
2-levels	116	15.5	66	15.6	57	17.5	0.4818
3-levels	86	11.5	36	8.5	50	15.3	0.0035
4-levels	54	7.2	22	5.2	32	9.8	0.0151
5-levels	32	4.3	15	3.5	17	5.2	0.2600
Total	750	100	424	100	326	100
Normal²	6000	80.0	3536	83.4	2464	75.6	<0.001
Superior	761	10.1	356	8.4	405	12.4	<0.001
Inferior	739	9.9	348	8.2	391	12.0	<0.001
Total	7500	100	4240	100	3260	100

¹Percentage (%) to the total number of subjects is encompassed

²Percentage (%) to the total number of endplates is encompassed

Table 3. The results of the ordinal logistic regression for Lumbar Endplate lesions in women.

Parameter		B	Wald Chi-Square	P	OR	95% Wald Confidence Interval for OR
Parameter		B	Wald Chi-Square	P	OR	Lower	Upper
Threshold of EPLs grade	Grade II	2.559	1.855	.173	12.924	.325	513.652
Threshold of EPLs grade	Grade III	4.712	6.220	.013	111.236	2.743	4511.656
age		.028	3.490	.062	1.029	.999	1.060
BMI		-.045	.950	.330	.956	.874	1.046
waistline		-.009	.464	.496	.991	.964	1.018
hipline		.029	1.339	.247	1.029	.980	1.081
mean L BMD		.002	.358	.550	1.002	.996	1.008
The number of levels of LDH
≥2 levels 1 level 0 level		1.610	27.557	.000	5.004	2.743	9.128
		.591	6.069	.014	1.805	1.128	2.888
		0	.	.	1	.	.
The grade of LDD
severely moderately slightly		.431	.502	.479	1.539	.467	5.078
		-.201	.662	.416	.818	.504	1.327
		0^a	.	.	1	.	.

Table 4. The results of the ordinal logistic regression for Lumbar Endplate lesions in men.

Parameter		B	Wald Chi-Square	P	OR	95% Wald Confidence Interval for OR
Parameter		B	Wald Chi-Square	P	OR	Lower	Upper
Threshold of EPLs grade	Grade II	6.103	6.339	.012	447.122	3.865	51730.770
Threshold of EPLs grade	Grade III	9.047	13.552	.000	8494.497	68.746	1049603.691
age		.005	.066	.798	1.005	.969	1.042
BMI		-.081	1.554	.213	.922	.812	1.048
waistline		-.035	1.720	.190	.966	.916	1.017
hipline		.116	13.491	.000	1.123	1.055	1.194
mean L BMD		-.003	.381	.537	.997	.989	1.006
The number of levels of LDH
≥2 levels 1 level 0 level		1.926	24.933	.000	6.859	3.221	14.607
		.845	9.304	.002	2.328	1.353	4.006
		0	.	.	1	.	.
The grade of LDD
severely moderately slightly		.917	.708	.400	2.501	.296	21.137
		.272	.834	.361	1.313	.732	2.356
		0^a	.	.	1	.	.

No competing interests reported.

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The lumbar spinal endplate lesions grades and association with lumbar disc disorders, and lumbar bone mineral density in a healthy Chinese cohort

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