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Risk Factors of Intervertebral Disc Pathology—A Point of View Formerly and Today—A Review

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Risk Factors of Intervertebral Disc Pathology—A Point of View Formerly and Today—A Review Journal of Clinical Medicine Review Risk Factors of Intervertebral Disc Pathology—A Point of View Formerly and Today—A Review Nicol Zielinska 1 , Michał Podgórski 2 , Robert Haładaj 3, Michał Polguj 3 and Łukasz Olewnik 1,* 1 Department of Anatomical Dissection and Donation, Medical University of Lodz, 90-752 Lodz, Poland; [email protected] 2 Department of Radiology and Diagnostic Imaging, Polish Mother’s Memorial Hospital Research Institute, 93-338 Lodz, Poland; [email protected] 3 Department of Normal and Clinical Anatomy, Chair of Anatomy and Histology, Medical University of Lodz, 90-752 Lodz, Poland; [email protected] (R.H.); [email protected] (M.P.) * Correspondence: [email protected] Abstract: Intervertebral disc pathology is a common disorder that can be caused by genetic, mechan- ical, and behavioral factors; however, it is possible to slow its progression. Although environmental and behavioral factors were previously considered to be the sole causes of intervertebral disc patholo- gies such as disc herniation, recent studies have shown that genetic factors also play an important role. This review compares the perception of major risk factors from the last and present centuries. It also examines individual genetic and non-genetic factors acting as risk factors, as well as some approaches for preventing intervertebral disc pathologies, and compares available statistics regarding disc herniation. Keywords: review; disc herniation; lumbar; cervical; thoracic; factors; prevention; statistics Citation: Zielinska, N.; Podgórski, 1. Introduction M.; Haładaj, R.; Polguj, M.; Olewnik, Ł. Risk Factors of Intervertebral Disc The spinal column consists of a series of intervertebral discs and vertebrae that origi- Pathology—A Point of View nates at the base of the skull and extends to the coccyx. The complete structure is typically Formerly and Today—A Review. J. divided into five parts: the cervical region (C1-C7), the thoracic region (T1-T12), the lumbar Clin. Med. 2021, 10, 409. https:// region (L1-L5), the sacral region (S1-S5), and the coccygeal region (Co1-Co4/5). It provides doi.org/10.3390/jcm10030409 flexibility and mobility for the body and gives protection to the spinal cord [1]. The intervertebral discs support the spinal column and behave like shock-absorbing Received: 30 December 2020 cushions against the axial loading of the human body [1]. These structures are built of two Accepted: 20 January 2021 components: a nucleus pulposus (which is the inner part) and an outer annulus fibrosus Published: 21 January 2021 (AF) [2] (Figure1). The nucleus pulposus, which consists of collagen (type II), makes up 20 percent Publisher’s Note: MDPI stays neutral of the dry weight of the disc. It also contains numerous proteoglycans that maintain with regard to jurisdictional claims in hydrostatic pressure by retaining water. The other ingredients are water and chondrocyte- published maps and institutional affil- like cells. This composition helps the nucleus pulposus remain elastic, capable of absorbing iations. compression, and flexible under stress forces [2,3]. In turn, the annulus fibrosus is formed from collagen type I, which forms a fibrous tissue around the nucleus pulposus. The annulus fibrosus is attached to the vertebral body by Sharpey fiber [3]. Copyright: © 2021 by the authors. Intervertebral disc pathology is a common name for various pathologies connected Licensee MDPI, Basel, Switzerland. with intervertebral discs. This group includes degeneration of discs, disc-associated pain, This article is an open access article disc herniation, and histology findings. Disc degeneration can be graded on MRI T2 distributed under the terms and spin-echo weighted images using a grading system (grade 1–5) proposed by Pfirmann [4]. conditions of the Creative Commons Grade 1 is represented by an inhomogeneous disc with bright hyperintense white signal Attribution (CC BY) license (https:// intensity and normal disc height. In turn, grade 5 disc degeneration is characterized by an creativecommons.org/licenses/by/ inhomogeneous disc with a hypointense black signal intensity. There is no clear distinction 4.0/). J. Clin. Med. 2021, 10, 409. https://doi.org/10.3390/jcm10030409 https://www.mdpi.com/journal/jcm J. Clin. Med. 2021, 10, 409 2 of 17 between the AF and NP, and the disc space is collapsed [5]. There are also histological findings associated with disc degeneration. An increase in cell density (chondrocyte proliferation), the occurrence of granular changes, structural alterations with tears and clefts, and a severe increase in acid mucopolysaccharides (mucous degeneration) with dark-blue staining areas around clones of chondrocytes are the main characteristic features observed during histomorphological examination [6]. Another pathology that can be included in intervertebral disc pathologies is low back pain. However, it may be caused not J. Clin. Med. 2021, 10, x FOR PEER REVIEW 2 of 18 only by disc herniation, but also by infection, rheumatoid arthritis, fracture, osteoporosis, or tumors [7]. FigureFigure 1. 1. TheThe intervertebral intervertebral disc. disc. TheDisc nucleus herniation pulposus, is an intervertebral which consists disc of pathology collagen (type that occurs II), makes when up either 20 percent part of theof thewhole dry ofweight the nucleus of the disc. pulposus It also protrudes contains throughnumerous the proteoglycans annulus fibrosus. that The maintain mostcommon hydro- staticcause pressure is chronic by herniation, retaining water. i.e., disc The degeneration other ingredients occurring are water due to and reduced chondrocyte-like proteoglycan cells.content, This in composition which the nucleus helps the pulposus nucleus is weakenedpulposus remain due to aelastic, loss of capable hydration. of absorbing In contrast, compression,acute herniation and can flexible occur un asder a result stress of forces trauma, [2,3]. resulting in the nucleus pulposus extruding throughIn turn, a defect the annulus in the annulus fibrosus fibrosus. is formed Many from genetic, collagen mechanical, type I, which and behavioral forms a fibrous factors tissueare believed around tothe be nucleus responsible pulpos [8us.]. MRI The isannulus a first-choice fibrosus examination is attached method.to the vertebral It allows body disc byherniations Sharpey fiber to be [3]. classified according to their shape or extent and distinguishes three types: protrusionIntervertebral (largest disc diameter pathology of the isdisc a commo materialn name projecting for various beyond pa thethologies normal connected margin of withthis intervertebral disc is narrower discs. than This the group general includes width degeneration of the base), of extrusion discs, disc-associated (characterized pain, by a discbase herniation, length less and than histology the height), findings. and sequestration Disc degeneration (a subtype can be of graded extrusion, on MRI which T2 occursspin- echowhen weighted there is noimages connection using between a grading the system herniated (grade material 1–5) and proposed the intervertebral by Pfirmann disc) [4]. [9 ]. GradeThere 1 is is also represented a disc bulge by an (which inhomogeneous involves more disc than with 25% bright of thehyperintense circumference), whiteanother signal intensitykind of discopathyand normal that disc MRI height. also In reveals. turn, grade It is important5 disc degeneration that the prevalence is characterized of disc by bulge an inhomogeneousin asymptomatic disc individuals with a hypointense increases from black 30% signal of thoseintensity. 20 years There of is age no to clear 84% distinc- of those tion80 yearsbetween of age. the InAF turn, and NP, more and advanced the disc disc space herniations is collapsed usually [5]. There compress are also neural histological structure, findingswhich causes associated various with types disc ofdegeneration. pain [10]. An increase in cell density (chondrocyte pro- liferation),Due tothe the occurrence biomechanical of granular forces changes, in the flexible structural parts alterations of the spinal with column, tears theand cervical clefts, andand a lumbarsevere increase regions ofin spinalacid mucopolysaccharides column are more susceptible (mucous to degeneration) occurrence of with disc dark-blue herniation. stainingThoracic areas disc around herniation clones is much of chondrocytes less common are [ 8the]. main characteristic features observed during2. Embryology histomorphological of Vertebrate examination [6]. Another pathology that can be included in intervertebral disc pathologies is low back pain. However, it may be caused not only by Ossification occurs in all vertebrae after around eight weeks of embryo development. disc herniation, but also by infection, rheumatoid arthritis, fracture, osteoporosis, or tu- It occurs in three centers: one in the endochondral centrum and two in neural processes. mors [7]. The process in endochondral centrum is responsible for the development of vertebral Disc herniation is an intervertebral disc pathology that occurs when either part of the bodies, while those in the neural processes are associated with formation of pedicles. whole of the nucleus pulposus protrudes through the annulus fibrosus. The most common cause is chronic herniation, i.e., disc degeneration occurring due to reduced proteoglycan content, in which the nucleus pulposus is weakened due to a loss of hydration. In contrast, acute herniation can occur as a result of trauma, resulting in the nucleus
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