Reactive endplate marrow changes: a systematic morphologic and epidemiologic evaluation

Pathobiology of Modic changes

PURPOSE

Low back pain (LBP) is the most disabling condition worldwide. Although LBP relates to different spinal pathologies, vertebral bone marrow lesions visualized as Modic changes on MRI have a high specificity for discogenic LBP. This review summarizes the pathobiology of Modic changes and suggests a disease model.

METHODS

Non-systematic literature review.

RESULTS

Chemical and mechanical stimulation of nociceptors adjacent to damaged endplates are likely a source of pain. Modic changes are adjacent to a degenerated intervertebral disc and have three generally interconvertible types suggesting that the different Modic change types represent different stages of the same pathological process, which is characterized by inflammation, high bone turnover, and fibrosis. A disease model is suggested where disc/endplate damage and the persistence of an inflammatory stimulus (i.e., occult discitis or autoimmune response against disc material) create predisposing conditions. The risk to develop Modic changes likely depends on the inflammatory potential of the disc and the capacity of the bone marrow to respond to it. Bone marrow lesions in osteoarthritic knee joints share many characteristics with Modic changes adjacent to degenerated discs and suggest that damage-associated molecular patterns and marrow fat metabolism are important pathogenetic factors. There is no consensus on the ideal therapy. Non-surgical treatment approaches including intradiscal steroid injections, anti-TNF-α antibody, antibiotics, and bisphosphonates have some demonstrated efficacy in mostly non-replicated clinical studies in reducing Modic changes in the short term, but with unknown long-term benefits. New diagnostic tools and animal models are required to improve painful Modic change identification and classification, and to clarify the pathogenesis.

CONCLUSION

Modic changes are likely to be more than just a coincidental imaging finding in LBP patients and rather represent an underlying pathology that should be a target for therapy.

The relationship between Modic changes and intervertebral disc degeneration

Background

Recent reported results have added to the weight of evidence supporting association between disc degeneration and Modic changes. Endplate or Modic changes are also associated with increased body mass index. The most recent study from Teichtahl et al. titled ‘Modic changes in the lumbar spine and their association with body composition, fat distribution and intervertebral disc height – a 3.0 T-MRI study’ showed associations of Modic changes with quantitatively measured reduced disc height and fat mass index. However, there were some facts, which we would like to address in this Correspondence to their article.

Discussion

The different components of intervertebral disc degeneration such as loss of disc height and disc signal intensity have already been shown associated with endplate changes – but not disc height if it is assessed using newer more precise methods of quantitation of disc height. A possible protective effect of different adiposity distribution in the body to Modic change development would be of interest if observed in a longitudinal study in the future.

Summary

Modic changes have been associated with different components of intervertebral disc degeneration such as loss of disc height and disc signal intensity previously. The influence of body fat distribution on endplate changes would be interesting to study longitudinally.

Refined Phenotyping of Modic Changes: Imaging Biomarkers of Prolonged Severe Low Back Pain and Disability

Low back pain (LBP) is the world's most disabling condition. Modic changes (MC) are vertebral bone marrow changes adjacent to the endplates as noted on magnetic resonance imaging. The associations of specific MC types and patterns with prolonged, severe LBP and disability remain speculative. This study assessed the relationship of prolonged, severe LBP and back-related disability, with the presence and morphology of lumbar MC in a large cross-sectional population-based study of Southern Chinese.We addressed the topographical and morphological dimensions of MC along with other magnetic resonance imaging phenotypes (eg, disc degeneration and displacement) on the basis of axial T1 and sagittal T2-weighted imaging of L1-S1. Prolonged severe LBP was defined as LBP lasting ≥30 days during the past year, and a visual analog scale severest pain intensity of at least 6/10. An Oswestry Disability Index score of 15% was regarded as significant disability. We also assessed subject demographics, occupation, and lifestyle factors.In total, 1142 subjects (63% females, mean age 53 years) were assessed. Of these, 282 (24.7%) had MC (7.1% type I, 17.6% type II). MC subjects were older (P = 0.003), had more frequent disc displacements (P < 0.001) and greater degree of disc degeneration (P < 0.001) than non-MC subjects. In adjusted models, any MC (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.01-2.18), MC affecting whole anterior-posterior length (OR 1.62, 95% CI 1.04-2.51), and MC affecting 2/3 posterior length (OR 2.79, 95% CI 1.17-6.65) were associated with prolonged severe LBP. Type I MC tended to associate with pain more strongly than type II MC (OR 1.80, 95% CI 0.94-3.44 vs OR 1.36, 95% CI 0.88-2.09, respectively). Any MC (OR 1.47, 95% CI 1.04-2.10), type II MC (OR 1.56, 95% CI 1.06-2.31), MC affecting 2/3 posterior length (OR 2.96, 95% CI 1.27-6.89), and extensive MC (OR 1.95, 95% CI 1.21-3.15) were associated with disability. The strength of the associations increased with the number of MC.This large-scale study is the first to definitively note MC types and specific morphologies to be independently associated with prolonged severe LBP and back-related disability. This proposed refined MC phenotype may have direct implications in clinical decision-making as to the development and management of LBP. Understanding of these imaging biomarkers can lead to new preventative and personalized therapeutics related to LBP.

Qualitative grading of disc degeneration by magnetic resonance in the lumbar and cervical spine: lack of correlation with histology in surgical cases

BACKGROUND

Clinically, magnetic resonance (MR) imaging is the most effective non-invasive tool for assessing IVD degeneration. Histological examination of the IVD provides a more detailed assessment of the pathological changes at a tissue level. However, very few reports have studied the relationship between these techniques. Identifying a relationship may allow more detailed staging of IVD degeneration, of importance in targeting future regenerative therapies.

OBJECTIVES

To investigate the relationship between MR and histological grading of IVD degeneration in the cervical and lumbar spine in patients undergoing discectomy.

METHODS

Lumbar (N = 99) and cervical (N = 106) IVD samples were obtained from adult patients undergoing discectomy surgery for symptomatic IVD herniation and graded to ascertain a histological grade of degeneration. The pre-operative MR images from these patients were graded for the degree of IVD (MR grade) and vertebral end-plate degeneration (Modic Changes, MC). The relationship between histological and MR grades of degeneration were studied.

RESULTS

In lumbar and cervical IVD the majority of samples (93%) exhibited moderate levels of degeneration (ie MR grades 3-4) on pre-operative MR scans. Histologically, most specimens displayed moderate to severe grades of degeneration in lumbar (99%) and cervical spine (93%). MR grade was weakly correlated with patient age in lumbar and cervical study groups. MR and histological grades of IVD degeneration did not correlate in lumbar or cervical study groups. MC were more common in the lumbar than cervical spine (e.g. 39 versus 20% grade 2 changes; p < 0.05), but failed to correlate with MR or histological grades for degeneration.

CONCLUSIONS

In this surgical series, the resected IVD tissue displayed moderate to severe degeneration, but there is no correlation between MR and histological grades using a qualitative classification system. There remains a need for a quantitative, non-invasive, pre-clinical measure of IVD degeneration that correlates with histological changes seen in the IVD.

Modic changes in the lumbar spine and their association with body composition, fat distribution and intervertebral disc height - a 3.0 T-MRI study

BACKGROUND

Vertebral endplate (Modic) abnormalities are important structural lesions in the spine, but their association with body composition and fat distribution have not been examined. Moreover, no study has examined whether Modic change are related to other structural features of low back pain, such as reduced intervertebral disc height.

METHODS

Seventy-two community-based individuals not selected for low back pain had lumbar vertebral Modic change and intervertebral disc height assessed from MRI. Dual energy x-ray absorptiometry measured body composition and fat distribution.

RESULTS

The predominance of Modic change was type 2. Modic change was associated with an increased fat mass index (OR 1.20, 95 % CI 1.01 to 1.43), and tended to be associated with a reduced fat-free mass index (OR 0.62, 95 % CI 0.37 to 1.03, p = 0.07). While an increased percentage of gynoid fat was associated with a reduced risk (OR 0.62, 95 % CI 0.43 to 0.89), an increased percentage of android fat was associated with an increased risk of Modic change (OR 2.11, 95 % CI 1.18 to 3.76). Modic change was also associated with reduced intervertebral disc height at L2/3, L4/5 and L5/S1 (OR range 1.4 to 1.8; all p ≤ 0.03).

CONCLUSION

Modic type 2 change is associated with reduced intervertebral disc height and an increased fat mass index. Whereas gynoid fat distribution protected against Modic type 2 change, an android pattern increased the risk of this lesion. Modic type 2 change, which histologically represent fat replacement, might have a metabolic component to its aetiology.

Unusual presentation of vertebral endplate Modic changes in congenital scoliosis associated with pain: a report of two cases

Congenital scoliosis is not normally associated with pain in young children. We are presenting two cases of young patients with congenital scoliosis and moderate to severe pain. There were no spinal cord abnormalities found in these patients. The magnetic resonance imaging and CT scan revealed disc degeneration with Modic changes at the apex of the congenital scoliosis. We hypothesized that the mechanical instability resulting from poor spinal element formations associated with congenital scoliosis was responsible for causing the disc degeneration and endplate changes. Modic changes have been reported to be associated with pain in degenerative conditions of the spine. Both patients underwent a posterior spinal fusion and instrumentation, which relieved their pain immediately.

Phenotype profiling of Modic changes of the lumbar spine and its association with other MRI phenotypes: a large-scale population-based study

BACKGROUND CONTEXT

Modic changes (MC) are associated with low back pain. They represent vertebral endplate and adjacent vertebral marrow changes on magnetic resonance imaging (MRI), classified into three types. Because of small sample sizes, patient cohorts, and limited phenotype assessment, the morphology and involvement of MC and their association with other spinal phenotypes remain speculative.

PURPOSE

We addressed and proposed a phenotypic profiling of MC and their relationship with lumbar MRI phenotypes in a large-scale population-based study.

STUDY DESIGN/SETTING

A cross-sectional study of the Hong Kong Disc Degeneration Cohort.

PATIENT SAMPLE

The study population consisted of 1,546 Southern Chinese volunteers.

OUTCOME MEASURES

Topographical and morphological dimensions of MC, presence of disc degeneration (DD) and displacement, and Schmorl nodes were evaluated.

METHODS

Axial T1-weighted and sagittal T2-weighted MRIs (3T) were assessed.

RESULTS

Females were 62.4% (mean age, 49 years). The overall prevalence of MC was 21.9% (6.3% Type I and 15.5% Type II). Of all MC, 76% were located at the two lowest lumbar levels. Modic changes at the two lowest lumbar levels were more commonly located laterally (p<.001), less commonly anteriorly (p<.001), and were more extensive horizontally (p=.006) but not in vertical height compared with the upper levels. Type I MC were less common in the anterior part (p=.022), larger in size (height p=.004), and affected more likely the whole horizontal plane (p=.016) than Type II MC. Modic changes were associated with disc displacement, Schmorl nodes, and DD at the affected level (all p<.001), and the strength of association increased with the size of the lesion. Type I MC were associated more strongly with disc displacement (p=.008) and DD (p=.022) than Type II MC.

CONCLUSIONS

Our large-scale MRI study is the first to definitely note that MC were size- and type-dependently significantly associated with disc pathology and endplate abnormalities. Our phenotype profiling of MC may have clinical utility.

From Modic 1 vertebral-endplate subchondral bone signal changes detected by MRI to the concept of 'active discopathy'

Late-1980s MRI-detected vertebral-endplate subchondral bone signal changes associated with degenerative disc disease as well as recent studies suggest that in some patients, non-specific chronic low back pain (NS cLBP) can be defined by specific clinical, radiological and biological features, for a concept of active discopathy. This concept allows for associating a particular NS cLBP phenotype to a specific anatomical lesion, namely those with Modic 1 signal changes seen on MRI. Local inflammation is thought to play a pivotal role in these changes. Other etiopathogenic processes may include local infection and mechanical or biochemical stress combined with predisposing genetic factors; treatment strategies remain debated. Modic 1 changes detected by MRI can be considered a first biomarker in NS cLBP. Such changes are of high clinical relevance because they are associated with a specific clinical phenotype and can be targeted by specific treatments.

Oxidative/Nitrosative Stress in Patients With Modic Changes: Preliminary Controlled Study

STUDY DESIGN

Oxidative/nitrosative stress in vertebral endplates of patients with low back pain and Modic changes (MCs) (types I, II, and III) endplate changes on magnetic resonance imaging.

OBJECTIVE

The aim of this study was to assess the levels of oxidative/nitrosative stress biomarkers in patients with MCs.

SUMMARY OF BACKGROUND DATA

Degenerated discs and endplate abnormalities is postulated as a possible source of low back pain. Oxidative/nitrosative stress plays an important the role in various human diseases. However, the presence of oxidative/nitrosative stress has not been studied in patients with low back pain and endplate changes on magnetic resonance imaging.

METHODS

Patients with MCI, II, and III (n = 32) and age- and sex-matched controls subjects (n = 15) were enrolled in this study. Also, 3-nitrotyrosine (3-NT) and nitric oxide levels as nitrosative stress biomarkers were measured with enzyme-linked immunosorbent assay. Also, the activities of catalase (CAT) and superoxide dismutase (SOD), and the levels of malondialdehyde (MDA) as oxidative stress biomarkers were determined on spectrophotometer.

RESULTS

Oxidative/nitrosative stress was confirmed by the significant elevation in nitric oxide, 3-NT, MDA and decreased of CAT and SOD activities in MCI compared with other MCs and the control group (P < 0.05). The highest CAT and SOD activities were found in patients with MCII compared with the other MCs and the control group. However, the levels of nitric oxide, 3-NT, and MDA showed moderate increase in this group (P < 0.05). In addition, the levels of nitrosative stress biomarkers in patients with MCIII were approximated to the control values (P > 0.05). However, the levels of oxidative stress biomarkers in patients with MCIII were slightly higher than that of the control group (P < 0.05).

CONCLUSION

Our findings indicated that oxidative/nitrosative stress in patients with MCI may be aggravated as a result of oxidant/antioxidant imbalance and it may cause formation of the lesion in these patients. However, the increased antioxidant activities and MDA, 3-NT levels in patients with MCII and MCIII may be an adaptative response to against oxidative/nitrosative stress.

LEVEL OF EVIDENCE

4.

Fat infiltration of paraspinal muscles is associated with low back pain, disability, and structural abnormalities in community-based adults

BACKGROUND CONTEXT

Low back pain and disability are major public health problems and may be related to paraspinal muscle abnormalities, such as a reduction in muscle size and muscle fat content.

PURPOSE

The aim of this study was to examine the associations between paraspinal muscle size and fat content with lumbar spine symptoms and structure.

STUDY DESIGN/SETTING

This was a community-based magnetic resonance imaging (MRI) cohort study.

PATIENT SAMPLE

A total of 72 adults not selected on the basis of low back pain were included in the study.

OUTCOME MEASURES

The outcomes measured were lumbar modic change and intervertebral disc height. Pain intensity and disability were measured from the Chronic Pain Grade Questionnaire at the time of MRI.

METHODS

The cross-sectional area (CSA) and amount of fat in multifidus and erector spinae (high percentage defined by >50% of muscle) were measured, and their association with outcome was assessed.

RESULTS

Muscle CSA was not associated with low back pain/disability or structure. High percentage of fat in multifidus was associated with an increased risk of high-intensity pain/disability (odds ratio [OR], 12.6; 95% confidence interval [CI], 2.0-78.3; p=.007) and modic change (OR, 4.3; 95% CI, 1.1-17.3; p=.04). High fat replacement of erector spinae was associated with reduced intervertebral disc height (β=-0.9 mm; 95% CI, -1.4 to -0.3; p=.002) and modic change (OR, 4.9; 95% CI, 1.1-21.9; p=.04).

CONCLUSIONS

Paraspinal fat infiltration, but not muscle CSA, was associated with high-intensity pain/disability and structural abnormalities in the lumbar spine. Although cause and effect cannot be determined from this cross-sectional study, longitudinal data will help to determine whether disabling low back pain and structural abnormalities of the spine are a cause or result of fat replacement of paraspinal muscles.

Comparison of modic changes in the lumbar and cervical spine, in 3167 patients with and without spinal pain

BACKGROUND CONTEXT

There are few comparisons of Modic changes (MCs) in the lumbar and cervical spine.

PURPOSE

Compare the prevalence of MCs in the lumbar and cervical spine, and determine how MC prevalence depends on spinal pain, age, disc degeneration, spinal level, and the presence or absence of kyphosis.

STUDY DESIGN

Retrospective clinical survey.

MATERIALS AND METHODS

Magnetic resonance images (MRIs) were compared from five patient groups: 1. 1223 patients with low-back pain/radiculopathy only; 2. 1023 patients with neck pain/radiculopathy only; 3. 497 patients with concurrent low-back and neck symptoms; 4. 304 asymptomatic subjects with lumbar MRIs; and 5. 120 asymptomatic subjects with cervical MRIs.

RESULTS

The prevalence of MCs was higher in those with spinal pain than in those without, both in the lumbar spine (21.0% vs 10.5%) and cervical spine (8.8% vs 3.3%). Type II MCs were most common and Type III were least common in all groups. The prevalence of lumbar MCs in people with back pain was little affected by the presence of concurrent neck pain, and the same was true for the prevalence of cervical MCs in people with neck pain with or without concurrent back pain. When symptomatic patients were reclassified into two groups (back pain, neck pain), the prevalence of lumbar MCs in people with back pain was greater than that of cervical MCs in people with neck pain. The prevalence of lumbar and cervical MCs increased with age, disc degeneration, (descending) spinal level, and increased kyphosis.

CONCLUSIONS

There is a significantly higher prevalence of MCs in patients with back and neck pain. The reported association with increased kyphosis (flat back) is novel.

Modic (endplate) changes in the lumbar spine: bone micro-architecture and remodelling

PURPOSE

In the literature, inter-vertebral MRI signal intensity changes (Modic changes) were associated with corresponding histological observations on endplate biopsies. However, tissue-level studies were limited. No quantitative histomorphometric study on bone biopsies has yet been conducted for Modic changes. The aim of this study was to characterise the bone micro-architectural parameters and bone remodelling indices associated with Modic changes.

METHODS

Forty patients suffering from disabling low back pain, undergoing elective spinal surgery, and exhibiting Modic changes on MRI (Modic 1, n = 9; Modic 2, n = 25; Modic 3, n = 6), had a transpedicular vertebral body biopsy taken of subchondral bone. Biopsies were first examined by micro-CT, for 3D morphometric analysis of bone volume fraction (BV/TV), trabecular thickness (Tb.Th), trabecular separation, trabecular number, and structure model index. Then, samples underwent histological analysis, for determination of bone remodelling indices: osteoid surface to bone surface ratio (OS/BS), eroded surface to bone surface (ES/BS) and osteoid surface to eroded surface ratio (OS/ES).

RESULTS

Micro-CT analysis revealed significantly higher BV/TV (up to 70% increase, p < 0.01) and Tb.Th (up to +57%, p < 0.01) in Modic 3 biopsies, compared to Modic 1 and 2. Histological analysis showed significantly lower OS/BS in Modic 2 biopsies (more than 28% decrease, p < 0.05) compared to 1 and 3. ES/BS progressively decreased from Modic 1 to 2 to 3, whereas OS/ES progressively increased with significantly higher values in Modic 3 (up to 159% increase, p < 0.05) than in Modic 1 and 2.

CONCLUSIONS

Significant differences were found in bone micro-architectural parameters and remodelling indices among Modic types. Modic 1 biopsies had evidence of highest bone turnover, possibly due to an inflammatory process; Modic 2 biopsies were consistent with a reduced bone formation/remodelling stage; Modic 3 biopsies suggested a more stable sclerotic phase, with significantly increased BV/TV and Tb.Th compared to Modic 1 and 2, linked to increased bone formation and reduced resorption.

Spondyloarthritis-related and degenerative MRI changes in the axial skeleton--an inter- and intra-observer agreement study

Background

The Back Pain Cohort of Southern Denmark (BaPa Cohort) was initiated with the aim of evaluating the clinical relevance of magnetic resonance imaging (MRI) in the diagnosis of early spondyloarthritis (SpA). In order to facilitate the collection of MRI data for this study, an electronic evaluation form was developed including both SpA-related and degenerative axial changes. The objective of the current study was to assess the intra- and inter-observer agreement of the MRI changes assessed.

Methods

Three radiologists evaluated 48 MRI scans of the whole spine and the sacroiliac joints from a subsample of the BaPa Cohort, consisting of patients with non-specific low back pain and patients with different stages of SpA features. The spine was evaluated for SpA-related and degenerative MRI changes and the SIJ for SpA-related changes. Inter- and intra-observer agreements were calculated with kappa statistics. In the interpretation of the kappa coefficient, the standards for strength of agreement reported by Landis and Koch were followed.

Results

A total of 48 patients, 40% men and mean age of 31 years (range 18 – 40 years), were evaluated once by all three readers and re-evaluated by two of the readers after 4-12 weeks. For MRI changes in the spine, substantial to almost perfect observer agreement was found for the location and the size of vertebral signal changes and for disc degeneration and disc contour. For the sacroiliac joints, substantial or almost perfect observer agreement was found for the grading of bone marrow oedema and fatty marrow deposition, the depth of bone marrow oedema and for subchondral sclerosis. Global assessment of the SpA diagnosis had substantial to almost perfect observer agreements.

Conclusion

The acceptable agreement for key MRI changes in the spine and sacroiliac joints makes it possible to use these MRI changes in the BaPa Cohort study and other studies investigating MRI changes in patients with non-specific low back pain and suspected SpA.

Dynamic stabilisation in the treatment of degenerative disc disease with modic changes

Objective. Posterior dynamic stabilization is an effective alternative to fusion in the treatment of chronic instability and degenerative disc disease (DDD) of the lumbar spine. This study was undertaken to investigate the efficacy of dynamic stabilization in chronic degenerative disc disease with Modic types 1 and 2. Modic types 1 and 2 degeneration can be painful. Classic approach in such cases is spine fusion. We operated 88 DDD patients with Modic types 1 and 2 via posterior dynamic stabilization. Good results were obtained after 2 years of followup. Methods. A total of 88 DDD patients with Modic types 1 and 2 were selected for this study. The patients were included in the study between 2004 and 2010. All of them were examined with lumbar anteroposterior (AP) and lateral X-rays. Lordosis of the lumbar spine, segmental lordosis, and ratio of the height of the intervertebral disc spaces (IVSs) were measured preoperatively and at 3, 12, and 24 months after surgery. Magnetic resonance imaging (MRI) analysis was carried out, and according to the data obtained, the grade of disc degeneration was classified. The quality of life and pain scores were evaluated by visual analog scale (VAS) score and Oswestry Disability Index (ODI) preoperatively and at 3, 12, and 24 months after surgery. Appropriate statistical method was chosen. Results. The mean 3- and 12-month postoperative IVS ratio was significantly greater than that of the preoperative group (P < 0.001). However, the mean 1 and 2 postoperative IVS ratio was not significantly different (P > 0.05). Furthermore, the mean preoperative and 1 and 2 postoperative angles of lumbar lordosis and segmental lordosis were not significantly different (P > 0.05). The mean VAS score and ODI, 3, 12, and 24 months after surgery, decreased significantly, when compared with the preoperative scores in the groups (P = 0.000). Conclusion. Dynamic stabilization in chronic degenerative disc disease with Modic types 1 and 2 was effective.

Prevalence of modic changes in active duty military men with lumbar disk herniation who were scheduled for surgery

OBJECTIVE

The purpose of this study was to report on the prevalence of Modic changes (MCs) in a group of Netherlands military men who were scheduled for surgery (lumbar discectomy).

METHODS

This was a retrospective observational study of health records. From 133 patients in active military service seen from January 2004 to March, 77 case files were selected. For all subjects who met inclusion criteria, the health records and T1- and T2-weighted magnetic resonance imaging files of lumbar levels L4/L5 and L5-S1 were assessed. Data including age, sex, rank in military, level of lumbar herniation, and level of MC including their types were evaluated.

RESULTS

Nineteen subjects (24.7%) showed presence of MC at the level of disk herniation, 5 subjects (6.5%) showed MC at a different level, and 10 subjects (13%) showed MC at both levels. In total, 154 segments were analyzed on magnetic resonance imaging for present MC of which 44 levels (28.6%) showed MC type I (31.8%), type II (65.9%), or type III (2.3%). Higher age showed to be significant (P ≤ .001) on developing MC, but no significance was found for physical workload in relation to these changes.

CONCLUSIONS

For the subjects in this study, MCs were most common at the lower lumbar spine segments, with a predominance of type II. In this study, the presence of a disk herniation and MC at the same level was 37.7%; however, a significant association was not demonstrable.

Lumbar modic changes-a comparison between findings at low- and high-field magnetic resonance imaging

STUDY DESIGN

A cross-sectional observational study.

OBJECTIVE

To investigate whether there is a difference in findings of lumbar Modic changes in low-field (0.3 T) magnetic resonance imaging (MRI) compared with high-field (1.5 T).

SUMMARY OF BACKGROUND DATA

It is a challenge to give patients with low back pain a specific diagnosis. Modic changes as seen on MRI have been reported to be a possible source of pain. However, it is unclear whether the diagnosis is independent on the field strength.

METHODS

Twenty patients with Modic changes, 11 women and 9 men (mean age, 53.6 yr; range, 29-81 yr), with or without sciatica, seen in a Danish outpatient low back pain clinic were included. All patients obtained MRI scans on both a high-field and a low-field MRI scanner. Two radiologists evaluated all lumbar endplates independently, using a standardized evaluation protocol. Kappa statistics were used to analyze the interobserver reproducibility. We used paired t test to analyze the difference between low- and high-field MRI.

RESULTS

The total number of Modic changes diagnosed with high-field MRI was significantly higher than that with low-field MRI. However, 3 to 4 times as many Modic type 1 changes were found with low-field MRI compared with high-field MRI. Contrarily, with high-field MRI type 2 changes were diagnosed twice as often.

CONCLUSION

There was a significant difference between low- and high-field MRI regarding the overall prevalence of any Modic change, but this had opposite directions for types 1 and 2: type 2 dominated in high field and conversely in high field [corrected]. The type of MRI unit should be taken into consideration when diagnosing patients with Modic changes

MRI assessment of lumbar intervertebral disc degeneration with lumbar degenerative disease using the Pfirrmann grading systems

Background

To evaluate by MRI intervertebral disc degeneration in patients with lumbar degenerative disease using the Pfirrmann grading system and to determine whether Modic changes correlated with the Pfirrmann grades and modified Pfirrmann grades of disc degeneration.

Methods

The clinical data of 108 surgical patients with lumbar degenerative disease were reviewed and their preoperative MR images were analyzed. Disc degeneration was evaluated using the Pfirrmann grading system. Patients were followed up and low back pain was evaluated using the visual analog scale (VAS) and the effect of back pain on the daily quality of life was assessed using Oswestry disability index (ODI).

Results

Forty-four cases had normal anatomical appearance (Modic type 0) and their Pfirrmann grades were 3.77±0.480 and their modified Pfirrmann grades were of 5.81±1.006. Twenty-seven cases had Modic type I changes and their Pfirrmann grades were 4.79±0.557 and their modified Pfirrmann grades were 7.00±0.832. Thirty-six cases exhibited Modic type II changes and their Pfirrmann grades and modified Pfirrmann grades were 4.11±0.398 and 6.64±0.867, respectively. One case had Modic type III changes. Kruskal-Wallis test revealed significant difference in modified Pfirrmann grade among Modic type 0, I and II changes (P<0.01) but no significant difference between Modic type I and II changes (P>0.05). Binary regression analysis showed that Modic changes correlated most strongly with disc degeneration. Follow up studies indicated that the VAS and ODI scores were markedly improved postoperatively. However, no difference was noted in VAS and ODI scores among patients with different Modic types.

Conclusion

Modic changes correlate with the Pfirrmann and modified Pfirrmann grades of disc degeneration in lumbar degenerative disease. There is no significant correlation between Modic types and surgical outcomes.

Prevalence of vertebral endplate modic changes in degenerative lumbar scoliosis and its associated factors analysis

STUDY DESIGN

A retrospective study of modic changes (MCs) in degenerative lumbar scoliosis (DLS).

OBJECTIVE

To investigate the prevalence of vertebral endplate MCs in DLS and explore their associated factors.

SUMMARY OF BACKGROUND DATA

MCs are common in spinal degenerative diseases. Presently, most of the researches have been focused on investigating the relationship between MCs and chronic low back pain. Little has been known on the distribution of MCs in DLS and the relationship between MCs and scoliosis.

METHODS

The image data of 120 patients who had been diagnosed with DLS in our hospital from March 2005 to March, 2011 were retrospectively reviewed as the study group. The image data of 89 patients who had been diagnosed with degenerative lumbar diseases without scoliosis were selected as the control group. The prevalence, type, and distribution of MCs in 2 groups were observed and compared. Disc degeneration, Cobb angle, body weight, and smoking were recorded in the study group, and the relationship of MCs with these influential factors was analyzed.

RESULTS

Of 1440 endplates from 120 patients in the study group, 247 (17.2%) from 71 (59.2%) patients were found to have MCs. Compared with the control group, of 1068 endplates from 89 patients, 49 (4.5%) endplates from 21 (23.6%) patients were found to have MCs. The prevalence of MCs was significantly higher in the study group than that in the control group (P < 0.01). The MCs in DLS usually had asymmetric distribution with more frequent occurrence on the concave side than on the convex side of major or compensatory curve and mainly occurred at L2-L3, L4-L5, and L5-S1, which were in accordance with the common levels of apex vertebrae. Intervertebral disc degeneration, lumbar scoliosis, overweight and heavy smoking are considered as risk factors to MCs. By multinomial logistic regression analysis on these factors, the regression function was obtained: logit Y = -0.82 + 1.27D + 0.55S + 1.77 D × S (Y for MCs, D for intervertebral disc degeneration, S for scoliosis Cobb's angle and D × S for interaction of D and S).

CONCLUSION

The prevalence of MCs in patients with DLS was significantly higher than that of patients without DLS. Most of them were type 2 and usually located on the concave side of apex vertebrae. MCs were significantly associated with intervertebral disc degeneration and lumbar scoliosis.

Imaging the intervertebral disk: age-related changes, herniations, and radicular pain

The articulations of the spinal motion segment, the intervertebral disk, and the zygapophyseal joints, inevitably undergo age-related changes. This article focuses on the intervertebral disk, specifically when fissures sufficiently weaken the posterior annulus so as to allow herniation of nuclear material into the outer annular structure as a contained protrusion or breach the annulus and pass into the epidural space as an extrusion. This article examines the imaging of the age-related changes of the disk and disk herniation: nomenclature, the reliability and relative merits of imaging modalities, the imaging natural history of disk herniations, and, most importantly, the clinical significance.

Modic type I changes and recovery of back pain after lumbar microdiscectomy

PURPOSE

To investigate whether the presence of Modic changes type I (MC I) found on preoperative MRI scans represent a risk factor for persistent back pain 12 months after surgery amongst patients operated for lumbar disc herniation.

METHODS

Cohort study of 178 consecutive patients operated with lumbar microdiscectomy. Preoperative MRI scans were evaluated by two independent neuroradiologists. Primary outcome measure was the visual analogue scale (VAS) for back pain. Secondary outcome measures were; VAS for leg pain, physical function (Oswestry disability index), and health-related quality of life (EQ-5D), self-reported benefit of the operation and employment status. The presence of MC I was used as exposition variable and adjusted for other risk factors in multivariate analyses.

RESULTS

The Modic classification showed a high inter-observer reproducibility. Patients with MC I had less improvement of back pain 12 months after surgery, compared to those who had no or other types of MC, but this negative association no longer showed statistical significance when adjusted for smoking, which remained the only independent risk factor for persistent back pain.

CONCLUSIONS

Patients with preoperative MC I can expect less but still significant improvement of back pain 1 year after microdiscectomy, but not if they smoke cigarettes.

Magnetic resonance imaging characterization of vertebral endplate changes in the dog

Spinal MR images acquired from canine patients over a 7-year period were reviewed for the presence of vertebral endplate changes. Seventy-five dogs with 76 distinct lesions were identified. Presumptive diagnoses fell into five categories: reactive endplate changes (10 dogs/13.2%), discospondylitis (29 dogs/38.2%), vertebral osteochondrosis (7 dogs/9.2%), intravertebral disc herniation (Schmorl's nodes) (4 dogs/5.3%), and fatty infiltration (26 dogs/34.2%). Fatty infiltration occurred significantly more often in small breed dogs (P < 0.001) and tended to be multifocal. The following features were observed in discospondylitis as well as in other nonfatty endplate pathologies: irregular endplates, endplate hyperintensity in T2w or STIR images, reduced endplate signal intensity in T1w SE, variable T1w GRE signal intensity, and endplate contrast enhancement. Overlap between MR characteristics of nonfatty endplate changes should prompt cautious evaluation of adjacent structures.

Magnetic resonance imaging of subchondral bone marrow lesions in association with osteoarthritis

OBJECTIVES

This nonsystematic literature review provides an overview of magnetic resonance imaging (MRI) of subchondral bone marrow lesions (BMLs) in association with osteoarthritis (OA), with particular attention to the selection of MRI sequences and semiquantitative scoring systems, characteristic morphology, and differential diagnosis. Histologic basis, natural history, and clinical significance are also briefly discussed.

METHODS

PubMed was searched for articles published up to 2011, using the keywords bone marrow lesion, osteoarthritis, magnetic resonance imaging, bone marrow edema, histology, pain, and subchondral.

RESULTS

BMLs in association with OA correspond to fibrosis, necrosis, edema, and bleeding of fatty marrow as well as abnormal trabeculae on histopathology. Lesions may fluctuate in size within a short time and are associated with the progression of articular cartilage loss and fluctuation of pain in knee OA. The characteristic subchondral edema-like signal intensity of BMLs should be assessed using T2-weighted, proton density-weighted, intermediate-weighted fat-suppressed fast spin echo or short tau inversion recovery. Several semiquantitative scoring systems are available to characterize and grade the severity of BMLs. Quantitative approaches have also been introduced. Differential diagnoses of degenerative BMLs include a variety of traumatic or nontraumatic pathologies that may appear similar to OA-related BMLs on MRI.

CONCLUSIONS

Subchondral BMLs are a common imaging feature of OA with clinical significance and typical signal alteration patterns, which can be assessed and graded by semiquantitative scoring systems using sensitive MRI sequences.

Is the development of Modic changes associated with clinical symptoms? A 14-month cohort study with MRI

PURPOSE

Modic changes (MCs) have been suggested to be a diagnostic subgroup of low back pain (LBP). However, the clinical implications of MCs remain unclear. For this reason, the aims of this study were to investigate how MCs developed over a 14-month period and if changes in the size and/or the pathological type of MCs were associated with changes in clinical symptoms in a cohort of patients with persistent LBP and MCs.

METHODS

Information on LBP intensity and detailed information from MRI on the presence, type and size of MCs was collected at baseline and follow-up. Changes in type (type I, II, III and mixed types) and size of MCs were quantified at both time points according to a standardised evaluation protocol. The associations between change in type, change in size and change in LBP intensity were calculated using odds ratios (ORs).

RESULTS

Approximately 40% of the MCs followed the expected developmental path from type I (here type I or I/II) to type II (here type II or II/III) or type I to type I/II. In general, the bigger the size of the MC at baseline, the more likely it was that it remained unchanged in size after 14 months. Patients who had MC type I at both baseline and 14-month follow-up were less likely to experience an improvement in their LBP intensity as compared to patients who did not have type I changes at both time points (OR 7.2, CI 1.3-37). There was no association between change in size of MCs type I and change in LBP intensity.

CONCLUSIONS

The presence of MCs type I at both baseline and follow-up is associated with a poor outcome in patients with persistent LBP and MCs.

Modic vertebral body changes: the natural history as assessed by consecutive magnetic resonance imaging

STUDY DESIGN

Changes in the vertebral body adjacent to the end plate may be associated with degenerative disc disease. These changes can be separated on magnetic resonance imaging (MRI) and have been described by Modic. It is assumed that these end plate changes represent a process that is progressive.

OBJECTIVE

We have retrospectively reviewed patients who had sequential MRI of the lumbar spine to investigate the natural history of Modic vertebral body MRI changes.

SUMMARY OF BACKGROUND DATA

Of 36 end plates with Modic type 1 changes in a first MRI, 18 remained the same, 13 progressed to Modic type 2 change, 3 progressed to Modic type 3 changes, and 2 end plates were found to be normal (type 0) on a subsequent MRI. Of the 22 end plates initially reported as Modic type 2 in a first MRI, 18 remained unchanged, none converted to Modic type 3, and 4 converted from Modic type 2 to Modic type 1 on a subsequent MRI.

METHODS

Magnetic resonance (MR) images of the lumbar spine of 49 subjects were assessed by a senior spinal surgeon. The lumbar vertebral body adjacent to the end plate was classified by using the Modic system from L1 to S1 inclusive.

RESULTS

Of the 36 end plates with Modic 1 changes in the first data set, 18 remained the same; 13 progressed to Modic 2; 3 progressed to Modic 3 changes, and, interestingly, 2 end plates were found to be normal on the repeat scan. Of the 22 end plates initially reported as Modic 2, 18 remained unchanged; none converted to Modic 3 and 4 converted back from Modic 2 to Modic 1.

CONCLUSION

Our findings reflect the dynamic nature of pathological changes in the spine and have demonstrated that Modic changes are reversible. They also raise further doubt that these MRI changes should be used as an indicator of clinical symptoms or of surgical outcome.

Modic changes and associated features in Southern European chronic low back pain patients

BACKGROUND CONTEXT

Conflicting reports exist regarding the prevalence of Modic changes among low back pain (LBP) patients and factors associated with their existence.

PURPOSE

To assess the prevalence of Modic changes and other findings on lumbar magnetic resonance imaging (MRI) among Spanish adult chronic LBP patients and the patient characteristics and radiological findings associated with Modic changes.

STUDY DESIGN

A cross-sectional imaging study among chronic LBP patients.

PATIENT SAMPLE

Four hundred eighty-seven patients (263 women and 224 men) undergoing lumbar spine MRI examination for chronic LBP.

OUTCOME MEASURES

Gender, age, body mass index (BMI), lifetime smoking exposure, degree of physical activity, and image features (disc degeneration, type and extension of Modic changes, disc contour, annular tears, spinal stenosis, and spondylolisthesis).

METHODS

Ten radiologists from six hospitals across six cities in Spain consecutively recruited adult patients in whom lumbar MRI had been prescribed for LBP lasting ≥3 months. Patients' characteristics and imaging findings were assessed through previously validated instruments. A multivariate logistic regression model was developed to assess the features associated with Modic changes.

RESULTS

Modic changes were found in 81% of the patients. The most common was Type II (51.3%), affecting only the end plate. Variables associated with Type I changes were disc contour abnormalities, spondylolisthesis, and disc degeneration. The same variables were associated with a higher risk of Type II or any type of Modic changes, as well as being male, and having a higher BMI.

CONCLUSIONS

Modic changes are found in 81% (95% confidence interval, 77-85) of adult Spanish patients in whom an MRI is prescribed for chronic LBP. Modic changes are more likely to be found in males with a high BMI, who also show disc contour abnormalities, spondylolisthesis, or disc degeneration.

Possible role of autoimmune reaction in Modic Type I changes

Modic changes (MCs) are common abnormalities in the vertebral endplates and adjacent bone marrow, which are visible on magnetic resonance imaging. They are regarded as having a strong association with the clinical symptom of low back pain (LBP). Nevertheless, the general pathogenesis of MCs is still under discussion. MCs can be divided into three types. Type I MCs represent extensive subchondral bone edema and vascular granulation tissue within the bone marrow of the adjacent endplate. The reasons for the edema and vascularization in Type I MCs, which may be the major mechanism underlying LBP, remain unclear. Chronic repetitive shear forces on the endplates lead to local disruption and microfractures. Following a breach of the outer annulus fibrous, the nucleus pulposus (NP) may enter the vertebral body. We hypothesize that the consequent autoimmune response due to a foreign body may cause and promote the development of edema, vascularization and inflammation, which are characteristic of Type I MCs. The production of cytokines evoked by autoimmunity could therefore be responsible for the significant clinical symptoms of LBP. If this underlying etiological pathway is proven, MCs and the consequent LBP could be treated by novel clinical methods.

What happens to Modic changes following lumbar discectomy? Analysis of a cohort of 41 patients with a 3- to 5-year follow-up period

Object

The natural history of Modic changes (MCs) in the lumbar spine is often marked by conversion from one type to another, but their course following lumbar discectomy remains unknown. The authors sought to study the impact of surgery on the natural history of these lesions.

Methods

Forty-one patients treated with lumbar microdiscectomy between 2004 and 2005 were enrolled in this study and underwent clinical evaluation and repeat MR imaging after a median follow-up of 41 months (range 32–59 months). Preoperative and follow-up MR images were reviewed and the type, location, and extent of MCs at the operated level were recorded and compared.

Results

The study population consisted of 27 men and 14 women with a mean age of 54 years (range 24–78 years). During the follow-up period, the prevalence of MCs increased from 46.3% to 78%, and 26 patients (63.4%) had Type 2 lesions at the operated level. Of the 22 patients without MCs, 4 (18.2%) converted to Type 1 and 9 (40.9%) to Type 2. Of the 5 Type 1 lesions, 3 (60%) converted to Type 2, and 2 (40%) remained Type 1 but increased in size. In contrast, none of the 14 Type 2 changes converted to another type, although 10 (71.4%) increased in extent. There were no reverse conversions to Type 0.

Conclusions

Following lumbar discectomy, most patients develop Type 2 changes at the operated level, possibly as a result of accelerated degeneration in the operated disc. Neither the preoperative presence of MCs nor their postoperative course appears to affect the clinical outcome.

Role of imaging in spine, hand, and wrist osteoarthritis

Osteoarthritis (OA) of the wrist is mainly secondary to traumatic ligamentous or bone injuries. Involvement of the radiocarpal joint occurs early on in the disease, whereas the mediocarpal joint is involved at a later stage. Metabolic diseases may also involve the wrist and affect specific joints such as the scapho-trapezio-trapezoid joint. Although OA of the wrist is routinely diagnosed on plain films, a thorough assessment of cartilage injuries on computed tomographic arthrography, magnetic resonance imaging (MRI), or MR arthrography remains necessary before any surgical procedure. OA of the fingers is frequently encountered in postmenopausal women. Distal interphalangeal joints and trapezio-metacarpal joint are the most frequently involved joints. Whereas the clinical diagnosis of OA of the wrist and hand is straightforward, the therapeutic management of symptomatic forms remains unclear, with no clear guidelines. OA of the spine is related to degenerative changes of the spine involving the disc space, vertebral endplates, the facet joints, or the supportive and surrounding soft tissues. The sequelae of disc degeneration are among the leading causes of functional incapacity in both sexes, and are a common source of chronic disability in the working years. Disc degeneration involves structural disruption and cell-mediated changes in composition. Radiography remains usually the first-line imaging method. MRI is ideally suited for delineating the presence, extent, and complications of degenerative spinal disease. Other imaging modalities such as computed tomography, dynamic radiography, myelography, and discography may provide complementary information in selected cases, especially before an imaging-guided percutaneous treatment or spinal surgery. The presence of degenerative changes on imaging examinations is by no means an indicator of symptoms, and there is a high prevalence of lesions in asymptomatic individuals. This article focuses on imaging of OA of the wrist and hand, as well as lumbar spine OA, with an emphasis on current MRI grading systems available for the assessment of discovertebral lesions.

Clinical diagnosis for discogenic low back pain

Discogenic lower back pain (DLBP) is the most common type of chronic lower back pain (LBP), accounting for 39% of cases, compared to 30% of cases due to disc herniation, and even lower prevalence rates for other causes, such as zygapophysial joint pain. Only a small proportion (approximately 20%) of LBP cases can be attributed with reasonable certainty to a pathologic or anatomical entity. Thus, diagnosing the cause of LBP represents the biggest challenge for doctors in this field. In this review, we summarize the process of obtaining a clinical diagnosis of DLBP and discuss the potential for serum-based diagnosis in the near future. The use of serum biomarkers to diagnose DLBP is likely to increase the ease of diagnosis as well as produce more accurate and reproducible results.

Prevalence of degenerative imaging findings in lumbar magnetic resonance imaging among young adults

STUDY DESIGN

A cross-sectional imaging study of young adults.

OBJECTIVE

To investigate the prevalence of disc degeneration (DD) and displacement, anular tears, and Modic changes in lumbar magnetic resonance imaging (MRI) among young adults.

SUMMARY OF BACKGROUND DATA

Although low back pain in young adulthood is common, the prevalence of spinal MRI findings at this age remains virtually unknown.

METHODS

The study population was a subcohort of the Northern Finland Birth Cohort 1986. Subjects living within 100 km of Oulu (n = 874) were invited to participate in lumbar MRI at 20 to 22 years of age (mean: 21.2 years). Degree of DD, type of Modic changes, and presence of disc bulges, herniations, high intensity zone (HIZ) lesions, and radial tears at all lumbar levels were assessed.

RESULTS

Three hundred twenty-five women and 233 men (n = 558) attended the MR imaging. DD was significantly more frequent in men (54% vs. 42%, P = 0.005), as was multiple DD (21% vs. 14%, P = 0.036). The prevalences of disc bulges and radial tears were 25% and 9.1%, respectively, without gender differences. HIZ lesions were more common among women than men (8.6% vs. 4.3%, P = 0.046), whereas herniations were significantly more common among men (5.6% vs. 2.5%, P = 0.047). Only 2 disc extrusions were observed, one in each gender. All degenerative disc findings were more common at the L5-S1 level except HIZ lesions, which were most likely at L4-L5. The prevalence of the Modic changes was 1.4%, without gender difference, type I being more common than type II. Typically, Modic changes were located adjacent to a DD Grade 4 disc and at the 2 lowest levels.

CONCLUSION

Almost half of young Finnish adult aged 21 years had at least one degenerated disc, and a quarter had a bulging disc. Modic changes and disc herniations were, however, relatively rare.

Characteristics and natural course of vertebral endplate signal (Modic) changes in the Danish general population

BACKGROUND

Vertebral endplate signal changes (VESC) are more common among patients with low back pain (LBP) and/or sciatica than in people who are not seeking care for back pain. The distribution and characteristics of VESC have been described in people from clinical and non-clinical populations. However, while the clinical course of VESC has been studied in patients, the natural course in the general population has not been reported. The objectives of this prospective observational study were to describe: 1) the distribution and characteristics of VESC in the lumbar spine, 2) its association with disc degeneration, and 3) its natural course from 40 to 44 years of age.

METHODS

Three-hundred-and-forty-four individuals (161 men and 183 women) sampled from the Danish general population had MRI at the age of 40 and again at the age of 44. The following MRI findings were evaluated using standardised evaluation protocols: type, location, and size of VESC, disc signal, and disc height. Characteristics and distribution of VESC were analysed by frequency tables. The association between VESC and disc degeneration was analysed by logistic regression analysis. The change in type and size of VESC was analysed by cross-tabulations of variables obtained at age 40 and 44 and tested using McNemar's test of symmetry.

RESULTS

Two-thirds (67%) of VESC found in this study were located in the lower part of the spine (L4-S1). VESC located at disc levels L1-L3 were generally small and located only in the anterior part of the vertebra, whereas those located at disc levels L4-S1 were more likely to extend further into the vertebra and along the endplate. Moreover, the more the VESC extended into the vertebra, the more likely it was that the adjacent disc was degenerated. The prevalence of endplate levels with VESC increased significantly from 6% to 9% from age 40 to 44. Again, VESC that was only observed in the endplate was more likely to come and go over the four-year period compared with those which extended further into the vertebra, where it generally persisted.

CONCLUSION

The prevalence of VESC increased significantly over the four-year period. Furthermore, the results from this study indicate that the distribution of VESC, its association with disc degeneration and its natural course, is dependent on the size of the signal changes.

Evaluation of the diagnostic utility of spinal magnetic resonance imaging in axial spondylarthritis

OBJECTIVE

Magnetic resonance imaging (MRI) is increasingly used for the diagnosis of axial spondylarthritis (SpA), but it is unknown whether characteristic lesions are actually specific for SpA. This study was undertaken to compare MRI patterns of disease in active SpA, degenerative arthritis (DA), and malignancy.

METHODS

Fat-suppressed MRI of the axial skeleton was performed on 174 patients with back pain and 11 control subjects. Lesions detected by MRI, including Romanus lesions (RLs) and end-plate, diffuse vertebral body, posterior element, and spinous process bone marrow edema (BME) lesions, were scored in a blinded manner. An imaging diagnosis was given based on MRI findings alone, and this was compared with the gold-standard treating physician's diagnosis.

RESULTS

The physician diagnosis was SpA in 64 subjects, DA in 45 subjects, malignancy in 45 subjects, other diagnoses in 20 subjects, and normal in 11 subjects. There was 72% agreement between the imaging diagnosis and physician diagnosis. End-plate edema, degenerative discs, and RLs were frequently observed in patients with any of the 3 major diagnoses. Single RLs were of low diagnostic utility for SpA, but >or=3 RLs (likelihood ratio [LR] 12.4) and severe RLs (LR infinite) in younger subjects were highly diagnostic of SpA. Posterior element BME lesions of mild or moderate grade were also highly diagnostic of SpA (LR 14.5). The most common diagnostic confusion was between SpA and DA, since both had RLs present and the presence/absence of degenerative discs did not change the diagnostic assessment.

CONCLUSION

This study confirms the high diagnostic utility of MRI in axial SpA, with severe or multiple RLs evident on MRI being characteristic in younger patients and mild/moderate posterior element lesions being specific for SpA. However, MRI lesions previously considered to be characteristic of SpA could also be found frequently in patients with DA and patients with malignancy, and therefore such lesions should be interpreted with caution, particularly in older patients.

Modic changes in vertebral endplates: a comparison of MR imaging and multislice CT

OBJECTIVE

This paper aims to evaluate the presence of endplate sclerosis in different types of Modic changes and to assess the capability of MRI in detecting endplate sclerosis within these changes.

MATERIALS AND METHODS

The lumbar spines (L3-S1) of 70 patients were retrospectively reviewed to determine Modic changes and disc degeneration from MRI and endplate sclerosis from CT. T1- and T2-weighted signal intensity and Hounsfield unit (HU) measurements of type I and II Modic changes were recorded and the association of both Modic types I and II with endplate sclerosis was analyzed with a Mann-Whitney test.

RESULTS

Altogether 82 Modic changes in 36 subjects were recorded: 13% were type I, 12% mixed type I/II, 65% type II, 9% mixed type II/III, and 1% type III. Thirty-eight percent of the endplates with Modic changes had sclerosis in CT. Of specific Modic types, mixed I/II and II/III associated significantly with endplate sclerosis. Endplate sclerosis was not detected in MRI in a quantitative analysis.

CONCLUSION

Endplate sclerosis exists in all types of Modic changes, especially in mixed Modic types, and not only in type III changes, as previously assumed. Endplate sclerosis was not detected in MRI, which may depend on the amount of mineralization of the bone marrow.

Vertebral endplate signal changes (Modic change): a systematic literature review of prevalence and association with non-specific low back pain

The prevalence of "vertebral endplate signal changes" (VESC) and its association with low back pain (LBP) varies greatly between studies. This wide range in reported prevalence rates and associations with LBP could be explained by differences in the definitions of VESC, LBP, or study sample. The objectives of this systematic critical review were to investigate the current literature in relation to the prevalence of VESC (including Modic changes) and the association with non-specific low back pain (LBP). The MEDLINE, EMBASE, and SveMED databases were searched for the period 1984 to November 2007. Included were the articles that reported the prevalence of VESC in non-LBP, general, working, and clinical populations. Included were also articles that investigated the association between VESC and LBP. Articles on specific LBP conditions were excluded. A checklist including items related to the research questions and overall quality of the articles was used for data collection and quality assessment. The reported prevalence rates were studied in relation to mean age, gender, study sample, year of publication, country of study, and quality score. To estimate the association between VESC and LBP, 2 x 2 tables were created to calculate the exact odds ratio (OR) with 95% confidence intervals. Eighty-two study samples from 77 original articles were identified and included in the analysis. The median of the reported prevalence rates for any type of VESC was 43% in patients with non-specific LBP and/or sciatica and 6% in non-clinical populations. The prevalence was positively associated with age and was negatively associated with the overall quality of the studies. A positive association between VESC and non-specific LBP was found in seven of ten studies from the general, working, and clinical populations with ORs from 2.0 to 19.9. This systematic review shows that VESC is a common MRI-finding in patients with non-specific LBP and is associated with pain. However, it should be noted that VESC may be present in individuals without LBP.

Modic changes: a systematic review of the literature

Modic changes (MC) are a common phenomenon on magnetic resonance imaging (MRI) in spinal degenerative diseases and strongly linked with low back pain (LBP). Histology, radiology, potential mechanisms, natural history and clinical studies of MC has formed the foundation on which our understanding of spinal degenerative diseases is built. The objective of this study was to provide a review of recent important advances in the study of MC and their clinical significance. This review article summarizes these studies, by delineating the possible mechanisms, and raising doubts and new questions. The related aspects such as discography and differential diagnosis with spinal infection and tumor on MRI are also discussed. Although most of researchers believe that MC are common findings in patients with spinal degenerative diseases and have an association with discogenic LBP, different results between studies may be produced from the differences in study design, inclusion criteria, and sample size. How the present knowledge of MC affects the management of spinal degenerative diseases remains unclear. Further studies of MC will explore therapeutic possibilities for future treatments of spinal degenerative diseases.

Are the determinants of vertebral endplate changes and severe disc degeneration in the lumbar spine the same? A magnetic resonance imaging study in middle-aged male workers

BACKGROUND

Modic changes are bone marrow lesions visible in magnetic resonance imaging (MRI), and they are assumed to be associated with symptomatic intervertebral disc disease, especially changes located at L5-S1. Only limited information exists about the determinants of Modic changes. The objective of this study was to evaluate the determinants of vertebral endplate (Modic) changes, and whether they are similar for Modic changes and severe disc degeneration focusing on L5-S1 level.

METHODS

228 middle-aged male workers (159 train engineers and 69 sedentary factory workers) from northern Finland underwent sagittal T1- and T2-weighted MRI. Modic changes and disc degeneration were analyzed from the scans. The participants responded to a questionnaire including items of occupational history and lifestyle factors. Logistic regression analysis was used to evaluate the associations between selected determinants (age, lifetime exercise, weight-related factors, fat percentage, smoking, alcohol use, lifetime whole-body vibration) and Modic type I and II changes, and severe disc degeneration (= grade V on Pfirrmann's classification).

RESULTS

The prevalences of the Modic changes and severe disc degeneration were similar in the occupational groups. Age was significantly associated with all degenerative changes. In the age-adjusted analyses, only weight-related determinants (BMI, waist circumference) were associated with type II changes. Exposure to whole-body vibration, besides age, was the only significant determinant for severe disc degeneration. In the multivariate model, BMI was associated with type II changes at L5-S1 (OR 2.75 per one SD = 3 unit increment in BMI), and vibration exposure with severe disc degeneration at L5-S1 (OR 1.08 per one SD = 11-year increment in vibration exposure).

CONCLUSION

Besides age, weight-related factors seem important in the pathogenesis of Modic changes, whereas whole-body vibration was the only significant determinant of severe disc degeneration.

The modic vertebral endplate and marrow changes: pathologic significance and relation to low back pain and segmental instability of the lumbar spine

Two decades following their description, the significance of Modic vertebral endplate and marrow changes remains a matter of debate. These changes are closely related to the normal degenerative process affecting the lumbar spine, and their prevalence increases with age. However, the exact pathogenesis underlying these changes and their relation to segmental instability of the lumbar spine and to low back pain remain unclear. In this paper, we review the literature relevant to this topic and discuss the currently available evidence regarding the pathologic and clinical significance of Modic changes.

Modic changes, possible causes and relation to low back pain

In patients with low back pain (LBP) it is only possible to diagnose a small proportion, (approximately 20%), on a patho-anatomical basis. Therefore, the identification of relevant LBP subgroups, preferably on a patho-anatomical basis, is strongly needed. Signal changes on MRI in the vertebral body marrow adjacent to the end plates also known as Modic changes (MC) are common in patients with LBP (18-58%) and is strongly associated with LBP. In asymptomatic persons the prevalence is 12-13%. MC are divided into three different types. Type 1 consists of fibro vascular tissue, type 2 is yellow fat, and type 3 is sclerotic bone. The temporal evolution of MC is uncertain, but the time span is years. Subchondral bone marrow signal changes associated with pain can be observed in different specific infectious, degenerative and immunological diseases such as osseous infections, osteoarthritis, ankylosing spondylitis and spondylarthritis. In the vertebrae, MC is seen in relation to vertebral fractures, spondylodiscitis, disc herniation, severe disc degeneration, injections with chymopapain, and acute Schmorl's impressions. The aim of this paper is to propose two possible pathogenetic mechanisms causing Modic changes. These are: A mechanical cause: Degeneration of the disc causes loss of soft nuclear material, reduced disc height and hydrostatic pressure, which increases the shear forces on the endplates and micro fractures may occur. The observed MC could represent oedema secondary to the fracture and subsequent inflammation, or a result of an inflammatory process from a toxic stimulus from the nucleus pulposus that seeps through the fractures. A bacterial cause: Following a tear in the outer fibres of the annulus e.g. disc herniation, new capilarisation and inflammation develop around the extruded nuclear material. Through this tissue it is possible for anaerobic bacteria to enter the anaerobic disc and in this environment cause a slowly developing low virulent infection. The MC could be the visible signs of the inflammation and oedema surrounding this infection, because the anaerobic bacteria cannot thrive in the highly aerobic environment of the MC type 1.

PERSPECTIVES

One or both of the described mechanisms can - if proven - be of significant importance for this specific subgroup of patients with LBP. Hence, it would be possible to give a more precise and relevant diagnosis to 20-50% of patients with LBP and enable in the development of efficient treatments which might be antibiotics, special rehabilitation programmes, rest, stabilizing exercise, or surgical fixation, depending on the underlying cause for the MC.

Modic changes in endplates of lumbar vertebral bodies: prevalence and association with low back and sciatic pain among middle-aged male workers

STUDY DESIGN

Cross-sectional comparison of self-reported low back pain (LBP) symptoms and Modic findings on magnetic resonance imaging (MRI).

OBJECTIVES

To investigate associations of frequency and intensity of LBP and sciatic pain with Modic changes in a sample of middle-aged male workers with or without whole-body vibration exposure.

SUMMARY OF BACKGROUND DATA

Vertebral endplate changes are bone marrow lesions visible on MRI and are assumed to be associated with degenerative intervertebral disc disease. Associations of these so-called Modic changes with clinical symptoms are controversial. Furthermore, most of these studies have been performed in selected series of patients.

METHODS

A total of 228 middle-aged male workers (159 train engineers and 69 sedentary controls) from northern Finland underwent sagittal T1 and T2-weighted MRI. Both endplates of 1140 lumbar interspaces were graded for type and extent of Modic changes. Logistic regression was used to analyze associations of pain variables with Modic changes.

RESULTS

Train engineers had on the average higher sciatic pain scores than the sedentary controls, but the prevalence of Modic changes was similar in both occupational groups. Altogether, 178 Modic changes in 128 subjects were recorded: 30% were type I, 66% type II, and 4% both types I and II. Eighty percent of changes occurred at L4-L5 or L5-S1. Modic changes at L5-S1 showed significant association with pain symptoms with increased frequency of LBP (odds ratio [OR] 2.28; 95% confidence interval [CI] 1.44-3.15) and sciatica episodes (OR 1.44; 95% CI 1.01-1.89), and with higher LBP visual analog scores during the past week (OR 1.36; 95% CI 1.06-1.70). Type I lesions and extensive lesions in particular were closely associated with pain.

CONCLUSIONS

Modic changes at L5-S1 and Modic type I lesions are more likely to be associated with pain symptoms than other types of Modic changes or changes located at other lumbar levels.

Prevalence of Modic Degenerative Marrow Changes in the Cervical Spine

OBJECTIVE

The prevalence and distribution of Modic degenerative marrow changes as seen on magnetic resonance imaging scans have been reported for the lumbar spine, and research suggests that type 1 Modic changes are linked to low back pain. The purpose of this study was to report on the prevalence, types, and distribution of the changes found for the cervical spine.

METHODS

One hundred thirty-three cervical spine T1-weighted and T2-weighted sagittal magnetic resonance imaging scans were viewed retrospectively by two radiologists. Data were recorded for patient age, patient sex, and the presence or absence of Modic changes. If Modic changes were present, then the precise vertebral levels of these changes and the specific Modic type were recorded. Descriptive statistics were calculated for the prevalence of Modic changes overall, the prevalence of types 1, 2, and 3 changes, and the prevalence in male vs female patients. The frequency of these changes by spinal level was also determined.

RESULTS

One hundred eighteen patients met the inclusion criteria. Modic changes were seen in 19 patients (16%), with 4 showing changes in more than one segmental level. The most common Modic change observed was type 1. Type 3 marrow changes were the second most common category to be noted. Only 3 patients had Modic type 2 marrow changes. The most common cervical spinal level to show Modic changes was C5-6.

CONCLUSIONS

Modic degenerative bone marrow changes are observed in the cervical spine, with the C5-6 level being the most commonly involved. Unlike in the lumbar spine in which Modic type 2 changes predominate, type 1 marrow changes were far more common in the cervical spine. Further studies should focus on the clinical relevance of these findings.