Fenestrated/branched endovascular aneurysm repair is a feasible and effective treatment option for patients with postdissection thoracoabdominal/abdominal aneurysm. However, this technique is cumbersome when the target vessel originates from the false lumen. We herein report our primary experiences in utilizing a reversed off-the-shelf iliac branched device (IBD) stent to reconstruct the renal artery originating from the false lumen. This technique was performed in 3 patients (all men; 49, 46, and 45 years old) in our center. After deployment of the main aortic endograft, the distal re-entry in the common iliac artery was dilated by a balloon. The off-theshelf IBD was then reversely deployed to allow for deployment of the bridging stent graft. Finally, the IBD and the bridging stents were assembled and the IBD was connected to the main graft. No migration of the IBDs occurred, and all target vessels remained patent during follow-up. Utilization of a reversed off-the-shelf IBD for the renal artery originating from the false lumen is a feasible option, especially for patients with specific anatomical characteristics of postdissection aortic aneurysms.

患者,男,29岁,因外伤致右踝疼痛、肿胀、活动受限20d,于2017年5月10日入院.患者于20d前外伤致右踝部疼痛、肿胀、活动受限,急被家人送往当地医院,拍右踝X线片未见明显骨折,诊断为右踝关节扭伤(图1a),经保守治疗、对症处理后,症状未见明显缓解,为求进一步治疗,就诊于我院门诊.CT平扫显示:右距骨后三角骨骨质不连续(图1b,1c).门诊以“右距骨后三角骨骨折”收住院.现右踝疼痛、肿胀、活动不利.查体:右踝部肿胀,后侧压痛明显,踝关节主被动跖屈时疼痛加重,足背动脉及胫后动脉搏动可触及,各足趾活动、感觉、血运良好.入院后予消肿、止痛对症治疗,完善各项化验检查,除外手术禁忌后于椎管内麻醉下行右踝关节镜下清理、距骨后三角骨切除术.

OBJECTIVE AND BACKGROUND: To report symptomatic seizures of a patient with an old type II odontoid fracture with atlantoaxial dislocation. The type II odontoid fracture is a dangerous disease and presents as neurological deficits. Because of the compression of upper cervical cord, without timely diagnosis and treatment, a type II odontoid fracture may result in sudden death. Although it has been shown that epileptic seizures may lead to type II odontoid fracture, there is no report of symptomatic seizures in patients with odontoid fracture.METHODS: A 16-year-old adolescent boy with neurological deficits, especially grand mal seizures for duration of 5 years, was diagnosed as an old type II odontoid fracture with atlantoaxial dislocation and treated in our hospital. A 1-year follow-up was performed.RESULTS: Systematic analyses of the clinical history, manifestations, physical examination, and radiologic results of the patient revealed an old type II odontoid fracture. Magnetic resonance imaging showed spinal cord compression and degeneration. The patient received posterior atlantoaxial fixation and fusion procedure following successful closed reduction. The frequency of seizures was reduced to once a month and there was a thorough recovery in other neurological functions 1 year after the operation.CONCLUSIONS: Old type II odontoid fracture might present as symptomatic seizures in addition to other neurological deficits. Posterior atlantoaxial screwplate fixation and fusion is an effective treatment for old type II odontoid fracture.

目的 探讨骨质疏松性单节段椎体骨折经皮椎体后凸成形术(percutoneous kyphoplasty,PKP)后,责任椎体引起背部疼痛复发的原因,为预防和临床治疗提供参考.方法 笔者所在单位同一组医生自2006年1月至2009年12月共收治因骨质疏松引起单节段椎体压缩骨折而行PKP的患者共52例,其中28例术后随访＞ 12个月,其中男11例,女17例;年龄68 ～ 86岁,平均(74.13±4.18)岁.随访时间12 ～ 34个月,平均(18.50±7.26)个月.按照是否复发背部疼痛分为A、B组:术后未复发背部疼痛为A组(n=20),术后复发背部疼痛为B组(n=8).所有患者均记录年龄、性别、症状出现的时间,采用相同手术方法(PKP),记录骨水泥注入量(filling PMMP volume,FPV).手术前、后及复查时均采用视觉模拟评分(visual analogue scale,VAS)评估疼痛程度;通过骨密度(bone mineral density,BMD)比较手术前后及随访时BMD的T评分;通过X线、MRI检查比较手术前后及随访时骨折椎体的压缩率(compression rate,CR)、压缩的恢复率或丢失率,比较手术前后及随访时骨折椎体的后凸角度(kyphotic angle,KA)和后凸角度恢复率或丢失率;比较术后及随访时骨水泥(甲基丙烯酸甲酯)与椎体上下终板间距离(postoperation PMMP to endplate distance,PPED)的改变.对所有数据进行统计学分析.结果 背部疼痛复发患者原手术椎体均有不同程度的再骨折或塌陷.A、B组FPV有差异,但无统计学意义.A、B组CR术后均明显增加,两组差异无统计学意义;末次随访时B组CR恢复率为(17.4±9.3)％,A组为(24.1±11.1)％,两组间差异有统计学意义(P＜0.05);KA呈现同样的改变.A、B两组手术前VAS评分分别为(8.8±0.6)分、(8.6±0.5)分;术后分别为(2.1±0.6)分、(2.2±0.8)分,与术前比较差异有统计学意义(P＜0.05);B组末次随访时VAS评分为(7.5±1.2)分,与B组术后及A组末次随访(3.1±0.7)分比较,差异有统计学意义(P＜0.05).A组骨水泥上缘至上终板距离术后与末次随访比较,差异无统计学意义(P＞0.05);术后A组骨水泥下缘至下终板距离平均为(2.5±0.6)mm,末次随访时为(2.4±0.7)mm,与术后比较差异无统计学意义(P＞0.05);术后B组骨水泥上缘至上终板距离平均为(3.5±0.4) mm,末次随访时为(2.7±0.9)mm,与术后比较差异有统计学意义(P＜0.05),术后B组骨水泥下缘至下终板距离平均为(4.5±0.6)mm;末次随访时(3.3±0.4)mm,与术后比较差异有统计学意义(P＜0.05).结论 手术椎体再骨折或塌陷是引起单椎体压缩骨折PKP术后背痛复发的重要原因,适量的FPV可能有利于减少手术椎体再骨折或塌陷.适时监测CR、KA、T评分、PPED的变化可以为预防复发背部疼痛提供参考.

OBJECTIVES: We designed a novel surgical strategy named one-stage selective discectomy combined with expansive hemilaminectomy, which might theoretically reduce the postoperative complications of cervical spon-dylotic myelopathy (CSM). The objective of this study is to evaluate its efficacy and safety.METHODS: Sixty-two patients with CSM were enrolled in this study. The procedure includes selective discectomy with fusion at 1 or 2 segments of maximal cord compression and expansive hemilaminectomy on the symptomatic or severe side of the body. Neurologic function was evaluated using the Japanese Orthopedics Association Score before and after surgery. Midsagittal dural sac diameter, dural sac transverse area at segments of discetomy on magnetic resonance imaging, and lordosis of the cervical spine on lateral plain film were measured. All patients were followed up for more than 1 year.RESULTS: A total of 88 discs and 272 hemilaminas were resected from 62 patients. The Japanese Orthopedics Association Score improved from 8.7 +/- 1.76 preoperatively to 13.4 +/- 1.61 at 1 year follow-up (P < 0.001). The mean midsagittal dural sac diameter, dural sac area, and lordotic angle also increased from 0.45 +/- 0.10 cm, 0.83 +/- 0.14 cm(2), and 7.9 +/- 2.60 +/- to 0.81 +/- 0.08 cm, 0.96 +/- 0.14 cm(2), and 11.7 +/- 3.06 degrees, respectively (P < 0.05). No case of postoperative axial pain, C5 palsy, nonunion, or kyphosis was reported.CONCLUSIONS: One-stage selective discectomy combined with expansive hemilaminectomy is an effective surgical approach for the treatment of CSM in patients whose neurologic function, midsagittal dura sac diameter, and dura transverse area can be improved and has few postoperative complications.

Objective To explore the expressions and signiifcance ofμ-Calpain after spinal cord ischemia-reperfusion injury. Methods An adult Sprague-Dawley ( SD ) rat model of spinal cord ischemia-reperfusion injury was established. Quantitative real-time lfuroscent polymerase chin reaction ( PCR ) and Western-blot technique were used to detect the expressions of mRNA and protein ofμ-Calpain at 2 h, 6 h, 12 h, 24 h, 48 h and 72 h after the model was established. The degradation ofα-II specrin of the speciifc substrate of ofμ-Calpain was detected by Western-blot technique, and the results were compared with that of the control group. Results The expressions ofμ-Calpain mRNA of the injured spinal cord began to increase at 2 h after the model was established, but there were no statistically significant differences. The expressions were obviously increased at 12 h, and there were statistically significant differences ( P<0.05 ). The peak was reached at 48 h after the model was established ( P<0.001 ). The expressions ofμ-Calpain mRNA remained at a higher level at 72 h when compared with that of the control group, and there were statistically signiifcant differences ( P<0.05 ). The expressions ofμ-Calpain protein of the injured spinal cord began to increase at 2 h after the model was established, and the peak was reached at 48 h ( P<0.001 ). The expressions ofμ-Calpain protein remained at a higher level at 72 h after the model was established when compared with that of the control group, and there were statistically signiifcant differences ( P<0.05 ). Theα-II spectrin began to degenerate at 2 h after the model was established, but there were no statistically signiifcant differences. There were still someα-II spectrin remains at 72 h. Conclusions The expressions ofμ-Calpain mRNA and protein are increased after the spinal cord ischemia-reperfusion injury model is established, and meanwhile theα-II specrin of its speciifc substrate begins to degenerate. Theμ-Calpain is involved in the pathological course of spinal cord ischemia-reperfusion injury.

[目的]探讨腰椎手术切口内应用氨甲环酸对术后失血的影响及其应用的安全性.[方法]对2012年6月～2013年6月间初次行腰椎单节段或双节段腰椎后路椎间融合术的267例患者进行前瞻性研究,将患者随机分为实验组(A组)和对照组(B组).在手术缝合深筋膜后向A组患者切口内注射氨甲环酸10ml (1g),B组向切口内注射生理盐水10 ml作为对照,并夹闭引流管1h.比较两组患者一般资料、术前血液学指标、术中失血量及输血量、术后引流时间、第一个24h引流量及总引流量、术后血D-二聚体浓度、术后输血例数及输血量.分别比较A、B两组中单、双节段术后引流量.术后1周及术后3个月随访时检查双下肢血管超声,观察有无深静脉血栓形成.[结果]A组患者133例,B组患者134例.术前A、B组性别、年龄、体重指数、平均血红蛋白浓度、凝血酶原时间比较无明显统计学差异;术中失血及输血量两组间无明显统计学差异;术后拔管时蛋白浓度A组为(113.6±13.0)g/L,B组为(105.1±14.4)g/L,两组间有显著统计学差异.术后平均拔管时间A组为(2.1 ±0.4)d,B组为(2.8±0.8)d,两组间有统计学差异;术后平均引流总量A组患者为(272±124) ml,B组患者为(412±189)ml,两组间有统计学差异;A组术后输血5例,B组术后输血15例,两组间具有统计学差异.术后A组患者平均输血(400±100) ml;B组患者平均输血(503±179) ml,两组患者术后输血量无明显统计学差异.术后1周及3个月随访时两组患者均未发现有下肢深静脉血栓形成.[结论]腰椎后路椎间融合术切口内局部应用氨甲环酸可减少术后伤口失血量、缩短拔管时间、不增加局部血肿压迫神经和深静脉血栓形成的风险,减少了术后失血.

腰痛影响着人们的工作和学习,该病患者在骨科门诊中占有相当大的比例。在引发腰痛的各种原因中,由于椎间盘本身病变引起的腰痛约占39%。腰椎间盘内部各种病变刺激椎间盘内的疼痛感受器产生的腰痛被定义为椎间盘源性腰痛。对于椎间盘源性腰痛的治疗,各种文献报道结果并不一致。本文结合国内外文献,综述了椎间盘源性腰痛的非手术治疗及手术治疗的优缺点,为医务工作者选择椎间盘源性腰痛的治疗方法提供参考。

Objective To explore the surgical treatment of ankylosing spondylitis the clinical curative effect of protru-sion deformity after.Methods Choice of protrusion deformity after ankylosing spondylitis patients admitted in our hos-pital orthopaedic 38 cases,according to the wishes are divided into two groups,patients with multiple segmental bone cutting group s line wedge bone cutting,single vertebral body bone cutting line group pedicle v-shaped cut bone,post-operative follow-up of 1 to 3 years,and observe all patients with a recent curative effect.Results Segmental bone cutting groups more increased an average of 7.4+/-1.2 cm,operation time on average 4.2+/-0.5 h,intraoperative bleeding an average of 2108 +/-106 ml,is superior to single vertebral body bone cutting groups,follow-up of all patients to achieve bony fusion,and no infection,paralysis,and death.Conclusion Multiple segmental bone cutting convex deformity after surgical treatment of ankylosing spondylitis curative effect,can effectively improve the protrusion deformity.

[Objective]To analyse the outcome of cervical spondylotic myelopathy treated with one-term posterior cervical lamioplasty and anterior cervical discectomy and interbody fusion with self-anchoring cage.[Methods]Fifty-two patients with cervical spondylotic myelopathy were treated with above-mentioned surgical procedure.Fuctional outcome according to JOA scoring system,lordosis angle of cervical spine and intervertebral space angle and height on neutral lateral radiographs were recorded preoperatively and postoperatively.[Results]All patients were followed up for 24~40 months.No complication occurred.Sufficient decompression and solid interbody fusion were achieved in all patients.Clinical symptoms and signs were significantly relieved.The height of disk space and cervical lordosis curve were improved.Average JOA score increased from 7.3±0.5 preoperatively to 14.1±0.7 at 6 months,14.7±0.6 at 12 months and 14.9±1.2 at 24 months postoperatively.Clinical follow-up outcome at 6,12 and 24 months postoperatively were excellent in 21,good in 25 and fair in 6 patients.[Conclusion]One-term posterior cervical laminoplasty and anterior cervical discectomy and interbody fusion with self-anchoring cage are an effective surgical procedure for cervical spondylotic myelopathy.

OBJECTIVE:To evaluate the efficacy and clinical outcome of the treatment of thoracolumbar single compression fracture by using in situ rod rotation reduction and short segment pedicle screw at the fracture level. METHODS:From December 2008 to May 2010,12 cases of traumatic thoracolumbar single compression fracture (T11-L2) were treated, including 9 males and 3 females, with an average age of 35.8 years old (ranging from 24 to 52). There were 2 case with T11 fracture, 2 cases with T12, 6 cases with L1 and 2 cases with L2, without osteoporosis,pathological fractures or neurologic deficits. Radiographic data were collected preoperatively, 5 days postoperatively and at last follow-up (at least 12 months). Cobb's angle, vetebral compression ratio, internal fixation state were observed. RESULTS:All patients were followed up from 12 to 30 months postoperatively,with an average of 19 months. There was no pseudoarticulation and solid bone fusion was achieved in all cases. There were no complications such as loosening or rupturing of internal fixation and so on. Sagittal kyphotic Cobb angle was corrected from preoperative (25.8 +/- 9.4) degrees to postoperative (6.7 +/- 2.3) degrees and (6.9 +/- 2.6) degrees at last follow-up. The percentage of vertebral compression was corrected from preoperative (42.5 +/- 10.4)% to postoperative (7.5 +/- 3.9)% and (8.4 +/- 4.5)% at last follow-up.There was significant difference between the postoperative data and preoperative data (P < 0.05), while the difference was not significant between the postoperative data and the last follow-up (P > 0.05). CONCLUSION:The thoracolumbar single compression fracture can obtain and maintain a good restoration by using the technic of in situ rod rotation reduction and short segment pedicle screw at the fracture level. The technique should be highly recommended.

Objective To investigate the characteristics and associated risk factors of new-onset vertebral compression fractures after percutaneous vertebroplasty.Methods We retrospectively reviewed patients with osteoporotic compression fractures from December 2005 to August 2009.There were 218 patients,including 44 males and 174 females.The age ranged from 48 years to 82 years,with an average of 72.1 years.The patients received percutaneous vertebroplasty with bone cement augmentation.Long-term radiographical follow-up identified the occurrence of vertebral fracture(minimum follow-up for 18 months) after the initial vertebral fracture.Results In 218 patients(286 vertebrae),60.7% of new compression fractures after vertebroplasty were adjacent vertebral compression fractures.Adjacent fractures occurred much sooner than nonadjacent fractures(P<0.001).In patients who experienced vertebral compression fractures 2 or more times,older age and lower baseline bone mineral density(BMD) were demonstrated in this study(P<0.005).The gender and amount of cemented polymethyl methacrylate were not statistically different between Groups A(1 vertebral compression fracture) and B(vertebral compression fracture≥2 times).Conclusion New-onset vertebral compression fractures occur repeatedly within a few years after vertebroplasty.New-onset adjacent-level fractures occur sooner and are more predominate than nonadjacent level fractures.The results of this study suggest that older patient age and lower baseline BMD are risk factors for multiple vertebral compression fractures.Postvertebroplasty disc space bone cement leakage also plays an important role in the onset of new adjacent fractures.

The aim of current study was to elucidate whether aquaporin-9 (AQP9) expression was involved in the progression of bone loss induced by microgravity. We used the hind-limb suspension (HLS) mice model to simulate microgravity and induce bone loss. It was found that HLS exposure decreased femur bone mineral density (BMD), and enhanced femur AQP9 mRNA and protein levels. Then, the relationship between AQP9 mRNA expression and BMD was studied and it was showed that femur AQP9 mRNA level was negatively related to femur BMD in mice exposed to HLS. We sought to exam the function of AQP9 in the femur using the AQP9-null mice. It was found that AQP9 knockout attenuated bone loss and inhibited osteoclastogenesis under the condition of HLS exposure, but had no similar effect on bone under normal physiological conditions. In addition, it was found that exposure to simulated hypergravity or exercise training, main countermeasures against microgravity, reduced AQP9 mRNA and protein levels in femur of mice. Moreover, it was found that both aging and estrogen deprivation, another two risk factors of bone loss, had no significant effect on femur AQP9 expression. In conclusion, AQP9 plays an important role in the development of microgravity-induced bone loss, and may be a potential target for the prevention or management of microgravity-induced bone loss.

STUDY DESIGN:The expression of netrin-1 and its deleted in colorectal cancer (DCC) receptor was investigated in human lumbar discs using immunohistochemistry.OBJECTIVE:To investigate the expression of netrin-1 and DCC receptor in human diseased and healthy lumbar intervertebral discs (IVDs) and to clarify the correlation between netrin-1 expression and the degree of neurovascular ingrowth.SUMMARY OF BACKGROUND DATA:Previous studies have shown neurovascular ingrowth into the inner regions of degenerated IVD and suggested that the ingrowth may contribute to discogenic low back pain. Netrin-1 is an axon guidance molecule that regulates axons seeking their final targets and has been identified as involved in various pathological conditions, so is its DCC receptor. However, the role of netrin-1 in diseased IVDs remains unknown.METHODS:Thirty-five diseased IVD specimens were collected from 34 patients with different lumbar diseases during posterior lumbar interbody fusion. Eight normal discs were obtained at autopsy as control. Using polyclonal or monoclonal antibody, the disc slides were immmunostained to detect the expression and distribution of netrin-1, the DCC, the neuronal marker (neurofilament), and the vascular endothelial cell marker (CD34).RESULTS:Netrin-1 and DCC immunopositive cells distributed substantially from the annulus fibrosus to the nucleus pulposus (NP), and the immunopositivity was detected in the disc cells, endothelial cells and granulation tissue cells in the diseased discs. The percentage of netrin-1 positive disc cells of the NP was more than that of the annulus fibrosus. The expression of netrin-1 and DCC was weak in the normal discs. A significant positive correlation between the percentage of netrin-1 immunopositive disc cells and neurovascular scores was found.CONCLUSION:The increased expression of netrin-1 and DCC in diseased IVDs compared with controls suggested that they might play an important role in the process of neurovascular ingrowth.

<正>小腿和足踝部皮下软组织薄,血运差,外伤后极易导致创面严重污染和骨质或肌腱外露,易感染,难愈合,临床上较多见,处理不当严重影响踝关节活动及负重功能,治疗较为棘手。2008年8月至2011年5月对19例小腿和足踝部软组织缺损患者采用先行清创及封闭负压引流(VSD)治疗,然后岛状皮瓣修复,取

Objective:The purpose of this study was to analyze the association between lumbar facet fluid on MRI and sagittal dynamic instability on standing lateral flexion-extension(SLFE) in patients with degenerative disease at L4～5.Methods:MRI and SLFE films of 98 patients seen at our institution for the treatment of degenerative lumbar disease at L4～5 between 2006,1 and 2009,12.The facet fluid on axial T2 MRI images,dynamic instability on SLFE films through the L4～5 facets were analyzed.The presence of facet effusions,anterior sagittal plane translation were recorded.The data were analyzed to determine if there was a significant association between the presence of lumbar dynamic instability and facet effusion.Results:Ninty-eight patients were included in the study,there were 65 patients without lumbar dynamic instability(LDI) and 33 with LDI on SLFE films at L4,5.24(73%)patients with LDI have facet fluid on the MRI,the mean facet fluid size and percent anterior slip of L4 on L5 was 1.98mm(range,0～6.28mm) and 11.6%(range,0%～32%),respectively,average facet osteoarthritis grade was 2.23.22(34%)patients without LDI have facet fluid,the mean percent anterior slip of L4 on L5 was 1.02mm(range,0～4.36mm).The amount of facet fluid detected on MRI have a positive correlation to sagittal dynamic instability detected on the lateral flexion radiograph(P<0.05).Conclusions:A clinically measurable facet effusion in MRI suggests the lumbar degenerative dynamic instability.There is a postive association between the facet fluid size and the amount of radiographic lumbar dynamic instability.

Objective:To evaluate the effect of L2 dorsal root ganglion(DRG) blockage on chronic low back pain(LBP).Methods:155 consecutive cases suffering from chronic low back pain accompanying with leg pain or not had received L2 DRG blockage using ropivacaine and compound betamethasone(Diprospan,Schering-Plough Labo N.V.) from June 2009 to June 2010.Comparing the patients' VAS scores at 0h,1d,7d,1m,3m,6m with that of pre-block.Pain relief is considered positive if there was a decrease at 50% in VAS scores,otherwise negative.Result:There were 155,150,102,78,40,27 patients reaching a pain relief at least 50% in VAS at corresponding point listed above.None of patients developed complications associated with blockage.Conclusion:L2 DRG blockage is effective for chronic low back pain in short term,and it would make surgery on them be postponed or avoided for a small number of patients.

<正>80%的人一生中都会遭遇腰痛,而腰痛人群中24% ～87%的人一年内会出现腰痛复发。腰痛的原因多种多样,有外伤导致腰背部肌肉骨骼损伤引起的,如急性腰扭伤或慢性腰肌劳损、各种外力引起的各种骨折、小关节紊

<正>我院2004年9月至2009年8月对52例原发性三叉神经痛患者进行微血管减压手术治疗,疗效明显,现报告如下:资料与方法1.一般资料男35例,女17例;年龄35~70岁,平均48.7岁;病程2~16年;平均6.5年。52例均表现为短暂而重复的单侧严重的疼痛爆发,具有局限性;其中左侧19例,右侧33例。单独第1支疼痛9例,第1支疼痛及第2支疼痛29例,3支均疼痛14例。所有患者均经过药物治疗,部分患者则经过局部封闭或射

Objective:To observe the outcome after lumbar discectomy in patients with disc herniation,concordant sciatica,and low-back pain with or without Modic degenerative changes Methods:Thirty-eight consecutive patients with single level disc herniation and low-back pain with Modic degenerative changes underwent fusion or lumbar dics neuclectomy.Group 1 consisted of 17 patients with Modic degenerative changes,8 men and 9 women,with a mean age of 35.8 years(range,22 to 55 y).Group 2 contained 21 patients without Modic degenerative changes,11 men and 10 women,with a mean age of 35.5 years(range,21 to 60 y).The visual analog scale(VAS) was used to grade low-back pain at 3,6,and 12 months and the Oswestry and JOA score were used to grade overall disability at 12 months postoperatively.Results:There was no significant difference in VAS and JOA scores for group 1 versus group 2 patients preoperatively.Average VAS scores of patients in group 1 were 1.9±0.6,2.1±0.8 and 2.3±0.9 at 3,6,12 months,VAS score in group 2 were 1.9±1.0,2.2±0.6 and 2.4±0.8 respectively.JOA scores in group 1 at 12 months were 13.3±1.1,the scores in group 2 were 12.1±2.1.The patients of both groups show significant improvement in postoperative JOA score(P<0.05).Conclusions:Discectomy was an effective treatment for single level disc herniation and concordant sciatica and low-back pain with or without Modic I and II degenerative changes.