The association between vertebral endplate structural defects and back pain: a systematic review and meta-analysis

Eur Spine J. 2021 Sep;30(9):2531-2548. doi: 10.1007/s00586-021-06865-6. Epub 2021 May 22.


Purpose: To clarify the current state of knowledge on the association of endplate structural defects and back pain.

Methods: Five databases were searched for studies reporting on the association between endplate structural defects and back pain. Covidence and comprehensive meta-analysis software were used for article screening and selection and pooling of extracted data. Overall quality of evidence was assessed using GRADE.

Results: Twenty-six studies comprised of 11,027 subjects met inclusion criteria. The presence of moderate heterogeneity (I2 = 73%; p = 0.001) prevented the pooling of estimates across all studies. However, it was possible to pool studies of specific endplate defect phenotypes, such as erosion (OR: 2.69; 95% CI: 1.35-5.50) and sclerosis (OR: 1.97; 95% CI: 1.50-2.58), which yielded significant associations with back pain. Schmorl's nodes were also associated with most individual back pain phenotypes (OR: 1.53-1326, I2 = 0-7.5%) and back pain overall (OR: 1.63, 95% CI: 1.37-1.94, I2 = 26%) in general population samples. The pooling of data from all studies of specific back pain phenotypes, such as frequent back pain (OR: 2.83; 95% CI: 1.77-4.52) and back pain incidence (OR: 1.65; 95% CI: 1.30-2.10), each yielded significant association with endplate structural defects and was supported by low heterogeneity (I2 = < 7.5.%).

Conclusion: Overall, there is moderate quality evidence of an association between back pain and endplate structural defects, which is most evident for erosion, sclerosis and Schmorl's nodes. Going forward, research on specific endplate defect phenotypes and back pain case definitions using strong study designs will be important in clarifying the extent of associations and underlying mechanisms. The study was prospectively registered in Prospero (CRD42020170835) on 02/24/2020.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Back Pain / epidemiology
  • Humans
  • Intervertebral Disc Degeneration* / complications
  • Intervertebral Disc Degeneration* / epidemiology
  • Intervertebral Disc Displacement*