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INTRODUCTION
High-intensity zone (HIZ) has been described as an important
sign visualized on magnetic resonance (MR) images for the diag-
nosis of internal disc disruption causing discogenic low back pain
(DLBP). However, its identification in asymptomatic individuals
has made it a controversial issue. This report discusses recent and
changing trends in the diagnostic significance and management of
HIZs.
BACKGROUND
In approximately 85% cases with low back pain, the specific cause
remains unidentified (1, 2). More than 40% of cases with chronic
LBP are attributed to intervertebral disc damage, of which over
70% of cases have no nerve root compression (3- 6). DLBP due to
internal disc disruption is considered to be the most common cause
for chronic LBP (4, 5). Since clinical examination alone is not ca-
pable of identifying the exact source of chronic LBP, various in-
vestigations and related signs have been identified in the last few
decades (7, 8). Provocative discography, first described by Lin-
dolm and Hirsch in 1948, provides information on the morpho-
logical characteristics of the disc as well as the provoked pain re-
sponse (9, 10). Hence, it is still considered the gold standard by
many clinicians for the diagnosis and management of DLBP. How-
ever, provocative discography remains controversial due to its
invasive nature and associated complications, such as infection,
neurological injury, and possible contrast medium reaction. More-
over, the interpretation of the results is strongly influenced by the
psychological condition of the patient (11, 12). For this reason,
many clinicians have reservations regarding the significance and
utility of provocative discography in the diagnosis of DLBP.
A significant breakthrough was made in 1992, when, for the first
time, Aprill and Bogduk described HIZs on MR images for diag-
nosing DLBP (13). Their study demonstrated a prevalence of 28.6%
for HIZs, with sensitivity, specificity, and positive predictive value
(PPV) of 71%, 89%, and 86%, respectively, for diagnosing sympto-
matic LBP patients (13). After that, various studies have investi-
gated the significance of HIZs : some reports have described a
limited role of HIZs in the diagnosis of LBP due to low sensitivity
and high prevalence in asymptomatic subjects, while many other
reports have considered HIZs to be a reliable non - invasive means
of confirming painful internal disc disruption.
Figure 1 shows typical MR images in a patient with DLBP. This
patient is a 36- year-old male baseball player who experienced
LBP on flexion while playing. On sagittal and axial MR images
(Figure 1a, 1b), the HIZ is obvious at the L4 -5 level, with concor-
dant pain on provocative discography (Figure 1c). When he ex-
perienced severe pain, he was treated by intradiscal injection. He
was able to play through the season by repeating the intradiscal
injection therapy. At the end of the season, he retired from pro-
fessional baseball.
DEFINITION AND EPIDEMIOLOGY
Originally, HIZ was defined as a high- intensity signal on T2-
weighted MR images, located posteriorly in the annulus fibrosus,
which is clearly dissociated from the signal of the nucleus pulposus
(13). However, most authors now believe that a similar lesion
occurring at the posterolateral annulus fibrosus should also be
REVIEW
Clinical Significance of High-intensity Zone for Discogenic
Low Back Pain : A Review
Subash C. Jha, Kosaku Higashino, Toshinori Sakai, Yoichiro Takata, Mitsunobu Abe, Kazuta Yamashita,
Masatoshi Morimoto, Shoji Fukuta, Akihiro Nagamachi, and Koichi Sairyo
Department of Orthopedics, Tokushima University, Tokushima, Japan
Abstract : High- intensity zone (HIZ) was originally described as a high - intensity signal on T2 - weighted magnetic
resonance (MR) images, located in the posterior annulus fibrosus, clearly separated from the nucleus pulposus.
Among symptomatic patients with low back pain, HIZ is present in 28 - 59
%
% of cases. In morphologically abnormal
discs, high sensitivity and specificity of 81
%
%and79
%
%, respectively, were reported for HIZs and concordant pain
during discography. In contrast, another report indicated low rates. Although most papers reported high sensi-
tivity and specificity for this relationship, it remains controversial. Regarding the pathology of HIZs, inflamma-
tory granulation tissues are found at sites showing HIZs. Such inflammatory tissues produce pro- inflammatory
cytokines and mediators, which sensitize the nociceptors within the disc and cause pain. An effective treatment
for this condition is yet to be established. Recently, minimally invasive surgery using percutaneous endoscopic
discectomy (PED) under local anesthesia was introduced. After removal of the degenerated disc material, the HIZ
is identified with the endoscope and then coagulated and modulated with a bipolar radio pulse. This technique
is called thermal annuloplasty. In conclusion, HIZs is an important sign of painful intervertebral disc disruption,
if identified precisely based on factors such as location and intensity. J. Med. Invest. 63 : 1 - 7, February, 2016
Keywords :High-intensity zone, Magnetic resonance images, Discography, Percutaneous endoscopic discectomy, Thermal annuloplasty
Received for publication July 20, 2015 ; accepted August 17, 2015.
Address correspondence and reprint requests to Koichi Sairyo, MD,
PhD
,
Department of Orthopedics
,
Tokushima University
3-
18
-
15 Kuramoto
,
Tokushima 770-8503, Japan and Fax : +81 - 88 - 633 - 0178.
The Journal of Medical Investigation Vol. 63 2016
1
considered as HIZ, and such lesions are usually included in related
studies (14- 18). Bogduk (19) and Liu et al. (18) emphasized that
HIZ must be an intense signal, rather than any spot, in the posterior
annulus.
The prevalence of HIZs ranges from 28% to 59% in patients with
LBP, but its prevalence has also been reported to be as high as 56%
in patients without LBP (Table 1). In a prospective study of 144
patients, Lam et al. (20) concluded that HIZs are a reliable indicator
of symptomatic annular tears causing pain, with prevalence up to
51%. Their findings were comparable to the results of Aprill and
Bogduk (13). Wang et al. (16) reported that among 623 patients,
32.1% exhibited an HIZ in at least one disc, and the LBP rate among
the patients with HIZs was significantly higher than that among
the patients without HIZs (57.5% vs. 47.8%, P!
0.05). In a prospec-
tive comparative study conducted by Liu et al. (18), the prevalence
of HIZs was 45.8% in symptomatic LBP patients but 20.2% in the
asymptomatic control group.
Rankine et al. (21) assessed 156 patients with LBP and concluded
that HIZs occurred at a prevalence of 45.5%, but its occurrence
did not define a group of patients with specific clinical features.
Mitra et al. (22) found a 28.6% prevalence of HIZs, but concluded
that the correlation between HIZs and symptomatic changes was
not statistically significant. Carragee et al. (23) noted that the preva-
lence of HIZs was 59% in a symptomatic group of patients and 24%
in the asymptomatic group. Therefore, they questioned the mean-
ingful clinical use of this sign in the diagnosis of DLBP. Weishaupt
et al. (24) and Stadnik et al. (25) found the prevalence of HIZs to
be 32% and 56% in asymptomatic subjects, respectively. Factors
such as study population, size of the study cohort, technical factors
related to MR imaging, and the subjective nature of the assess-
ment of HIZs may have caused the difference in the prevalence of
HIZs reported in these studies (24).
CORRELATION WITH DISCOGRAPHY
Studies have demonstrated that in morphologically abnormal
discs, a significant correlation exists between HIZ- positive discs
and exact or similar pain reproduction on provocative discography
(Table 2). In a retrospective study, Saifuddin et al. (14) reviewed
58 patients based on MR images and discography findings. Of 152
discs injected on discography, they identified 86 annular tears, of
which 70 were associated with concordant pain provocation. On
MR images, HIZs were identified in 27 discs, of which 24 were
associated with pain reproduction on provocative discography.
The specificity, PPV, and negative predictive value (NPV) of MR
images in diagnosing a concordantly painful annular tear were
95.2%, 88.9%, and 47%, respectively. The sensitivity was only 26.7%,
which was lower than the findings of Aprill and Bogduk. However,
Lam et al. (20) conducted a study of 144 patients, and reported find-
ings similar to those of Aprill and Bogduk, with sensitivity, speci-
ficity, and PPV of 81%, 79%, and 87%, respectively, for HIZs and
concordant pain in morphologically abnormal discs. Schellehas
et al. (15) assessed 63 patients and found that 87 of 100 discs with
HIZs were concordantly painful on discography, with PPV and
NPV of 87% and 97%, respectively. In a retrospective study by Smith
et al. (27) the sensitivity and specificity of HIZs and concordant
painful discs were 31% and 90% respectively, but PPV was relatively
low at 40%, suggesting that HIZs may not be indicative of internal
disc disruption. Although some reports have observed a low rate
of correlation between HIZ and concordant pain in discography,
the majority of reports have shown good agreement with the re-
port of Aprill and Bogduk (13) indicating that these two parame-
ters are positively correlated. This issue remains controversial.
PATHOGENESIS
In the literature, discogenic pain is described as LBP with or with-
out leg pain, caused by disc degeneration and/or annular rupture
Figure 1. (a) Sagittal and (b) axial T2- weighted magnetic resonance
(MR) images showing high- intensity zones (HIZs) within the posterior
annulus fibrosus at the L4- 5 level (arrows). (c) Positive on discography.
Table 1 : Prevalence of HIZs in symptomatic and asymptomatic popu-
lations.
Study Symptomatic
(%)
Asymptomatic
(%) No. of patients
Aprill and Bogduk (13) 28 N/A 500
Liu et al. (18) 45.8 20.2 72/79
Lam et al. (20) 51 N/A 144
Rankine et al. (21) 45.5 N/A 156
Mitra et al. (22) 28.6 N/A 650
Carragee et al. (23) 59 24 42
Weishaupt et al. (24) N/A 32 60
Stadnik et al. (25) N/A 56 36
Table 2 : Correlation between HIZs and exact or similar pain repro-
duction on discography.
Study Sensitivity
(%)
Specificity
(%)
PPV
(%)
NPV
(%)
Itoet al. (5) 52.2 95.6 60 N/A
Aprill and Bogduk (13) 71 89 86 N/A
Saifuddin et al. (14) 26.7 95.2 88.9 47
Schellhas et al. (15) N/A N/A 87 97
Lam et al. (20) 81 79 87 N/A
Hebelka et al. (26) 49 69 70 76
Smith et al. (27) 31 90 40 N/A
2S. C. Jha, et al. High intensity zone
(28-30). Potential causes of non - discogenic LBP include spondy-
lolisthesis, spinal stenosis, degenerative scoliosis, disc herniation,
spinal fracture, infection, and neoplasm. Routine MR imaging of
the lumbosacral spine for investigating the cause of DLBP can
reveal various abnormalities of the disc, but the presence of an
abnormality does not necessarily indicate that it is responsible for
the pain (24, 31).
In normal adults, the annulus fibrosus is innervated by the re-
current meningeal nerve and by branches from the ventral ramus
of the somatic spinal nerve (32). Most of the nerve supply of the
intervertebral disc is limited to the periphery of the annulus fi-
brosus (32-34). With this knowledge, Sach et al. (35) found that
annular tears extending to the inner third of the annulus fibrosus
were asymptomatic, whereas tears that extended to the peripheral
third produced pain in 70% of their patients. Since the posterior
annulus is considered structurally weak and experiences high stress
concentrations, this site is more vulnerable to disruption and HIZs
compared with the anterior annulus (36).
Various authors have proposed that HIZs comprise fluid-filled
zones, possibly due to a detached nucleus pulposus that is trapped
between the lamellae of a torn annulus fibrosus, following secon-
dary inflammation that results in edema, causing the characteris-
tic signal abnormality on MR images (13, 15, 37, 38). This area
appears to enhance on gadolinium DTPA - MR images, indicating
the presence of granulation tissue or neovascularization induced
by inflammation (39). This was supported by the results of a ca-
daveric study by Yu et al. (40), which demonstrated that radial and
transverse tears could be identified on MR images, as well as a
histological study by Peng et al. (41) on lumbar intervertebral discs
containing HIZs in the posterior annulus. Such inflammatory granu-
lation tissue produces pro - inflammatory cytokines and mediators,
which sensitize the nociceptors within the disc, causing pain (8,
41). These findings suggest that biomechanical mediators are
more important than mechanical compression alone in the patho-
genesis of back pain (8, 17).
INFLUENCE OF THE MEASUREMENT CONDITIONS
AND STRENGTH OF MAGNETIC FIELD
Originally, HIZ was identified and defined on T2 - weighted MR
pulse sequence (13), and most of the studies about HIZ have used
1.5 Tesla (T) superconducting magnet in common (14 - 16, 18, 20,
22, 27). It is not clear whether strength or any other sequence of
MR imaging influences the detection of HIZ. It is considered that
more powerful MR imaging system has more resolution, making
the detection of HIZ easier and effective (20). Pande et al. (42)
used 0.5 T system for evaluating significance of HIZ in 200 patients.
They demonstrated prevalence of HIZ was 13% and 17% according
to observer A and B respectively, without any clinical significance
for diagnosis of disrupted and painful disc. Similarly, only 27 HIZs
were identified in MR images, out of 152 discs (17.7%) examined
by Saifuddin et al. (14) using 0.5 - 1.5 T system. The exact numbers
of patient examined by 0.5 T or 1 T or 1.5 T, was not included.
Rankine et al. (21) demonstrated prevalence of HIZ as high as
45.5% using 1 T system in their study. Hence, it is difficult to com-
ment the significance of strength of MR imaging for detection of
HIZ. We believe 1.5 T system frequently used worldwide is opti-
mum strength for detection of HIZ.
Sagittal and axial T2 - weighted sequences with slice thickness
from 3-5 mm and interspace gap ranging from 0.4 - 1.5 mm have
been used in majority of studies of HIZs (14 - 16, 18, 20, 22, 27, 51).
Use of short tau inversion recovery (STIR) MR sequence can be
helpful in HIZ identification but it will be too early to comment
so, without any relevant clinical study. Liu et al. (18) in their study
conducted MR study at about 3 : 00 PM to minimize the effect of
water influx and hydration of the discs, causing increase in disc
signal as much as 25% on T2-weighted images.
LOCATION
More than two - third of HIZs are identified at lower lumbar seg-
ments, with the highest number being identified at L4 - 5, followed
by L5- S1 (Table 3). Wang et al. revealed that the prevalence of
multisegmental HIZs (Figure 2) was 16.5%, and 25 of 33 cases with
multisegmental HIZs exhibited HIZs in an adjacent disc (16). In
the same study, HIZs were more frequently observed in the infe-
rior part of the annulus fibrosus (superior- middle - inferior ratio,
39 : 59 : 140), with statistically significant differences (16). Thus,
along with the original definition for the location of HIZs, which
included lesions in only the posterior annulus fibrosus, many
authors now think that HIZs exist circumferentially and that the
original definition should be expanded to include non- midline le-
sions, while keeping in mind that posterior lesions are the com-
monest (15-17).
INTENSITY
With growing controversies surrounding the definition of HIZ
and its significance, an important factor is the identification of true
HIZs. Failure to distinguish true HIZs from low/medium intensity
zones may lead to a lower diagnostic value of HIZs (44). Reliable
and sophisticated measures are needed for the precise detection
and assessment of HIZs to improve the clinical utility of this finding
(26). O’Neil et al. (45) divided HIZs into grades of mild, moderate,
and marked hyperintense. They found that moderate and marked
lesions had higher specificities. Carragee et al. (23) found that if
the signal was within 10% of the cerebral spinal fluid (CSF) inten-
sity, it could be considered as a true HIZ, but they did not discuss
reliability. In a quantitative study conducted by Liu et al. (18), the
mean signal of HIZs was significantly brighter in symptomatic
subjects than in asymptomatic subjects. Therefore, they defined
a true HIZ as a lesion with signal intensity at least as bright as 50%
of the CSF signal intensity. In their study, the corresponding disc
with HIZs was outlined first on T1 - weighted MR images. The con-
tour of the disc obtained on T1-weighted MR images was copied
Table 3 : Distribution of HIZs in different lumbar intervertebral discs.
Study L1-2 L2-3 L3 - 4 L4 - 5 L5 - S1 Total no. of HIZs
Saifuddin et al. (14) 0 2 3 14 8 27
Schellhas et al. (15) 2 1 14 46 37 100
Wang et al. (16) 7 10 40 106 75 238
Lam et al. (20)0 2 13443291
Ricketson et al. (37)000729
Wilkens et al. (43)0059923
The Journal of Medical Investigation Vol. 63 February 2016 3
and moved to T2- weighted MR images, with some fine adjust-
ments. A clear sample of CSF located adjacent to the disc was used
as the reference to adjust signal intensity. The CSF -adjusted HIZ
was a ratio of the mean signal intensity of the HIZ to that of the
adjacent CSF. If the adjacent spinal canal was too narrow to obtain
an adequate sample of CSF, the nearest level possible was taken
as the reference point for adjusting the signal intensity. Liu et al.
also recommended this method as a more practical protocol to
increase measurement precision and reduce error in both clinical
and radiological studies, with both excellent intra- and inter - ob-
server reliability (18). All these findings support the Bogduk hy-
pothesis : A “low/medium intensity zone”representing an annular
fissure can be found in MR images in asymptomatic populations,
whereas the symptomatic population will have true HIZs, which
are significantly brighter and are a reliable marker of discogenic
pain (18, 19).
TREATMENT
Various treatment modalities have been described based on the
consideration of HIZs as a potential source of DLBP. In a longitu-
dinal study, Mitra et al. (22) concluded that HIZs do not change,
spontaneously resolve, or improve in most patients over time and
that there is no statistically significant relationship between the
evolution of HIZs and changes in symptoms. However, various
medical and minimally invasive surgical techniques for treating
HIZs and DLBP are presently under trial, with varying clinical
results.
In a randomized controlled trial by Wilkens et al. (43), oral glu-
cosamine intake for 6 months did not alter the presence of HIZs
as compared with placebo. In their study, HIZs resolved in 3 of 23
discs in 3 of 21 patients : 1 of 8 patients on oral glucosamine ther-
apy and 2 of 13 patients on placebo. The idea behind using glu-
cosamine therapy is to target interleukin (IL) - 1β(46), considering
that HIZ is a potential marker of an osteoarthritic degenerative
process and is related to the secretion of pro- inflammatory me-
diators (8), and that HIZs may contain IL - 1β. Previous research has
also demonstrated the inability of glucosamine to reduce LBP or
LBP-related disability (47).
Various minimally invasive procedures, such as intradiscal elec-
trothermal therapy (IDET), intradiscal injections, and percutane-
ous endoscopic discectomy and thermal annuloplasty (PEDTA)
have been assessed. Promising effects have been observed but
no clear conclusions have been reached (48 - 50). While these thera-
pies offer satisfactory symptomatic relief from LBP, as noted by
treating clinicians, their mechanisms of action have yet to be com-
prehensively explained. Narvani et al. (51) reported symptomatic
improvement in 8 of 10 patients treated with IDET at 6 months post
-
procedure, though the HIZs were noted to persist even after the
procedure. They postulated three possible explanations for their
findings : (1) the presence of HIZ does not accurately predict an-
nular tear ; (2) IDET does not seal the annular tear but rather stiff-
ens the annulus and offloads the pain- sensitive areas ; and (3)
IDET seals the tears but does not reverse the chronic inflamma-
tory changes of HIZs.
In a prospective study, Miller et al. (48) suggested that intradis-
cal injection of a solution consisting of 50% dextrose and 0.25%
bupivacaine may have a place in the management of pain arising
from advanced lumbar degenerative disc disease. Since oral glu-
cosamine was ineffective, Derby et al. (49) compared IDET with
intradiscal restorative injections consisting of injectable glucosamine
and chondroitin sulfate combined with hypertonic dextrose and
dimethylsulfoxide to reduce pain and disability in patients with
chronic DLBP. The results were similar for intradiscal injections
and IDET, but the injections provided a better cost - benefit ratio.
IDET was performed in 74 patients, while 35 patients received in-
tradiscal injection ; while satisfactory results were noted in both
procedures, outcomes were slightly better for the injections than
those for IDET. Moreover, only 47.8% of the patients who under-
went IDET reported improvement, whereas 65.6% of the patients
who received intradiscal injection were satisfied with the outcome.
Percutaneous endoscopic discectomy (PED) was initially estab-
lished as a novel surgical technique for the management of lumbar
disc herniation (52). It is a minimally invasive procedure, where
an endoscope is inserted intradiscally via the posterolateral, trans-
foraminal approach through an 8 mm skin incision under local an-
esthesia, causing minimum injury to the back muscles (52, 53).
Additionally, radiofrequency thermal annuloplasty (TA) with PED
(PEDTA) has been reported as the most recent advancement in
the treatment of DLBP (54-56).
In a retrospective study of 113 patients of DLBP treated by
PEDTA, Tsou et al. (54) reported 73.5% satisfactory outcomes (ex-
cellent 15%, good 28.3%, and fair 30.1%) at 2- year follow - up, while
26.5% patients were found to have poor results. Sairyo et al. (55)
reported the cases of 4 professional athletes with DLBP, including
2 showing HIZs on MR images, who were successfully treated by
PEDTA. The endoscopic visualization of vascularized granulation
tissue in the outer region of the annulus fibrosus, which correlated
with the location of HIZs on MR images, further supports the sig-
nificance of HIZs and helps in radiofrequency TA under direct vi-
sion (54, 55, 57). Hence, PEDTA appears to provide better results
than other procedures, as it can significantly reduce intradiscal
pressure, remove the inflammed nucleus pulposus under direct
vision, provide the TA effect, and reduce the presence of inflam-
matory factors involved in pain through irrigation (52-57).
Figure 3 demonstrates a case of DLBP due to HIZs, a 48- year-
old man who had chronic DLBP for approximately 20 years. MR
images revealed HIZs at L4-5, and discography showed concor-
dant pain at the same level ; thus, PEDTA was performed under
local anesthesia. Before surgery, the patient had LBP graded 2/
10 on the visual analog scale (VAS). He also had a history of 3 - 4
episodes of severe LBP requiring sick leave every year. After the
surgery, his LBP almost completely resolved. After undergoing
strenuous rehabilitation, including hamstring stretching, trunk
Figure 2. (a) Sagittal and (b and c) axial T2- weighted MR images
showing multisegmental HIZs within the posterior annulus fibrosus of L4 -
5 and L5-S1 levels (arrows).
4S. C. Jha, et al. High intensity zone
muscle core exercises, and thoracic spine stretching, he was able
to resume activities of daily living without LBP. Sugiura et al. (57)
endoscopically observed the site showing HIZs and found red col-
oration at the site, suggesting neovascularization into the disc
space. Thus, with direct vision of the inflammatory site, TA could
be performed as pinpoint surgery that accurately targeted the ori-
gin of the pain. Figure 4 shows the MR images of a 36-year -old
professional baseball player. He presented with a 1 - year history
of chronic LBP. The initial MR images (Figure 4a, 4b) revealed
herniated nucleus pulposus at the L3- 4 and L4 - 5 levels, with ad-
ditional HIZs at the L4- 5 level. However, provocative discography
revealed concordant pain at only the L4 - 5 level. Hence, discogenic
pain due to HIZs at the L4- 5 level was diagnosed. Treatment with
intradiscal injections was attempted, but little symptomatic relief
was achieved. Repeat MR examination (Figure 4c, 4d) after 10
months revealed that the HIZs had become more prominent, with
increased intensity at the L4- 5 level. PEDTA was therefore per-
formed. Postoperatively, his LBP disappeared, and he returned to
playing at the professional level from the next season. At 5 years
postoperatively, he has remained very active as a professional
baseball player.
PEDTA is a comparatively new technique, and there is not yet
much evidence regarding its effects on DLBP. As presented in
Figures3and4,PEDTAappearstobehighlyeffectiveincertain
cases. Due to its minimal invasiveness, PEDTA could become the
gold standard surgical procedure for DLBP associated with HIZs,
following meticulous clinical and basic studies.
CONCLUSION
HIZ is not merely a feature of disc degeneration in MR images ;
we consider it to be an important sign of painful intervertebral disc
disruption, if identified precisely based on factors such as loca-
tion and intensity. With advances in MR imaging techniques and
minimally invasive surgical techniques, further studies are essen-
tial for clarifying the controversies regarding the diagnostic sig-
nificance and management of HIZs.
CONFLICT OF INTERESTS
The authors declare that there are no conflicts of interests in
relation to the article.
ACKNOWLEDGEMENT
The manuscript submitted does not contain information about
medical device(s)/drug(s).
No funds were received in support of this work.
Figure 3. (a) Sagittal and (b) Axial T2 - weighted MR images showing
HIZs at the L4- 5 level (arrows).
Figure 4. (a and c) Sagittal and (b and d) axial T2- weighted MR images of the lumbar spine of a professional baseball player. (a and b) MR im-
ages at presentation, showing a herniated nucleus pulposus at the L3 -4 and L4 -5, with additional HIZs at the L4- 5 level (arrows). (c and d) Subse-
quent MR examination performed after 10 months showed increased intensity of HIZs at the L4- 5 level (arrows).
The Journal of Medical Investigation Vol. 63 February 2016 5
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