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

Degenerative endplate changes of the lumbosacral spine: dynamic contrast-enhanced MRI profiles related to age, sex, and spinal level

PURPOSE

To investigate differences in perfusion profiles between degenerative endplate marrow changes and normal vertebral marrow in relation to spinal level, age, and sex with dynamic contrast-enhanced magnetic resonance imaging (DCE MRI).

MATERIALS AND METHODS

Ninety-two consecutive patients referred for evaluation of low back pain or sciatica, without history of malignant or chronic disease, underwent conventional and DCE MRI of the lumbosacral spine. Fifty-two of them demonstrated degenerative endplate marrow changes. Regions of interest were placed on sites of normal marrow (group A) and degenerative changes (group B) on subtracted images. Fitted time-intensity curves (fTICs) were generated and evaluated for curve pattern. Both groups were stratified into upper (L1-L2) and lower (L3-I1) levels, males and females younger or older than 50 years. Perfusion parameters were calculated and statistically compared for both groups and subgroups. Receiver operator curve (ROC) analysis was also performed.

RESULTS

Two fTIC patterns were identified. Perfusion parameters of degenerative changes and normal marrow differed significantly, even when groups were stratified for spinal level, age, and sex (P < 0.05). A time to peak value >108 seconds was characteristic for degenerative changes with sensitivity 69.5% and specificity 84.6%.

CONCLUSION

DCE MRI profiles of degenerative endplate marrow changes of the lumbosacral spine differ significantly from normal marrow regardless of spinal level, age, or sex.

Diffusion magnetic resonance imaging to differentiate degenerative from infectious endplate abnormalities in the lumbar spine

STUDY DESIGN

A retrospective observational study of healthy volunteers and patients with degenerative and infectious endplate abnormalities in the lumbar spine.

OBJECTIVES

Our purpose was to evaluate the usefulness of diffusion-weighted imaging (DWI) for the differentiation of degenerative and infectious endplate abnormalities using 1.5-T magnetic resonance imaging (MRI).

SUMMARY OF BACKGROUND DATA

DWI can provide valuable structural information about tissues that may be useful for clinical applications in differentiation between degenerative and infectious endplate abnormalities.

METHODS

Sixteen consecutive patients with endplate abnormalities that was detected by MRI of the lumbar spine, and 15 healthy volunteers were studied. DWI was performed using whole-body imaging with background body signal suppression with a b value of 1000 s/mm2. Apparent diffusion coefficient values of normal and abnormal vertebral bone marrow were calculated.

RESULTS

Twenty-nine vertebral abnormalities were found in 16 patients. Nine vertebral abnormalities in 5 patients were because of infections and 20 vertebral abnormalities in 11 patients were because of degenerative changes; 7 levels were classified as Modic type 1, 7 levels as type 2, and 6 levels as type 3. DWI showed hyperintensity in all patients with infection, similar to that used in positron emission tomography, but not in the intervertebral spaces of any patients with degenerative disease. Apparent diffusion coefficient values of infectious bone marrow were significantly higher than normal and degenerative bone marrow.

CONCLUSION

DWI is useful for differentiation of degenerative and infectious endplate abnormalities. Moreover, MRI is widely used clinically because of the lack of ionizing radiation, low cost, and fast imaging time as compared with positron emission tomography. Therefore, DWI has the potential to be used as a screening tool.

Correlação entre instabilidade radiográfica e presença do sinal de modic

OBJETIVOS: Este artigo tem por objetivo avaliar a presença de alterações do platô vertebral (Modic) e a sua associação com a instabilidade demonstrada nas radiografias em flexo-extensão e neutra no plano sagital. MÉTODOS: Análise seccional dos estudos de imagens realizados no serviço de radiologia do Hospital Mãe de Deus em Porto Alegre (RS), entre o período de julho de 2008 e fevereiro de 2010, em 115 pacientes. Foram analisados os segmentos de L1 a S1, num total de 575 segmentos nos exames radiográficos e de ressonância nuclear magnética. RESULTADOS: Analisou-se 115 pacientes sendo 59 (51,30%) do sexo feminino e 56 (48,70%) do sexo masculino. A idade variou de 13 anos e seis meses a 81 anos e dois meses com uma média de 43 anos e oito meses. Com os critérios utilizados, observou-se 224 segmentos instáveis e 351 segmentos estáveis. O Modic I apresentou-se em sete segmentos instáveis e em 22 segmentos estáveis. Quanto à prevalência, o segmento L4-L5 foi o mais instável, correspondendo por 32,58% de todos os segmentos instáveis. CONCLUSÃO: Este artigo refuta a idéia de que as alterações de Modic tipo I estejam associadas a segmentos instáveis.

[Diagnostic imaging in neck and low back pain]

BACKGROUND

Diagnostic imaging in neck and low back pain can confirm serious pathology, but the clinical significance of findings is often unknown. Indications for diagnostic imaging in these patients are presented and the significance of common findings is discussed.

MATERIAL AND METHODS

The review is based mainly on Norwegian guidelines (evidence-based) on low back pain, other selected publications, and a non-systematic PubMed-search for systematic reviews and randomised controlled trials of imaging in neck or low back pain.

RESULTS

Routine imaging in neck or back pain is not documented to improve patient outcomes and we therefore advise against it. Imaging is indicated when serious conditions are suspected and should be considered for symptoms that have not improved after 4-6 weeks. Of the imaging modalities available, MRI has the highest sensitivity for most important disorders in the neck and back. Degenerative changes in vertebrae and intervertebral discs (including disc herniations) are common also in asymptomatic individuals and usually have uncertain relation to pain. Some MRI findings in bone marrow (so called Modic-changes) are more frequent among patients with low back pain, but their relevance to treatment is not clarified.

INTERPRETATION

Imaging (usually MRI) in neck or back pain is only recommended for suspected serious conditions or clear symptoms that have not improved after 4-6 weeks. Degenerative changes seldom explain symptoms or influence treatment.

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.

Reliability of diffusion weighted MR imaging in differentiating degenerative and infectious end plate changes

Background

The aim of the study was to investigate the value of diffusion weighted MR imaging in the diagnosis of Modic type 1 change, which may be confused with the acute infectious spondylodiscitis on conventional MR imaging.

Patients and methods

Twenty-seven patients with erosive intervertebral osteochondrosis, Modic type 1 and 18 patients with spondylodiscitis were included in this retrospective study. All images were acquired using on 1.5 Tesla MR units. Lumbar spinal MR imaging of 45 patients were retrieved from a digital database of a radiology record system and evaluated by one experienced radiologist. Patients with Modic type 1 change had CT slices obtained from the diseased disc space and the affected vertebrae.

Results

Bone marrow adjacent to the vertebral end plate in both Modic type 1 change and acute spondylodiscitis were hypointense on T1-weighted images. On T2-weighted images corresponding levels of vertebral end-plates showed hyperintense signal intensity in both group. All the patients with spondylodiscitis and Modic type 1 change were hyperintense and hypointense on diffusion-weighted MR images, respectively.

Conclusions

Our findings suggest that diffusion weighted MR imaging is an useful method in differentiating Modic type 1 changes from acute spondylodiscitis, both of which may mimic each other, either on clinical or conventional MRI findings.

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.

Magnetic resonance imaging for low back pain: indications and limitations

Magnetic resonance imaging (MRI) is the preferred investigation for most spinal diseases and is increasingly requested for people with low back pain (LBP). However, determining the cause of back pain is complicated as it is often multifactorial and anatomical abnormalities are common in the spine and may not necessarily translate into clinical symptoms. Thus, national guidelines discourage the use of MRI in non-specific LBP and recommend reserving it for the investigation of severe or progressive neurological deficits or for those cases in which serious underlying pathology is suspected. It also has an acknowledged role in planning surgical management in cases of radiculopathy and spinal stenosis. This review summarises the indications for MRI in LBP and calls for improved education of patients and health professionals in the limitations of this investigation.

Imaging of seronegative spondyloarthritis

Magnetic resonance imaging (MRI) and ultrasonography (US) are useful adjuncts in the diagnosis of seronegative spondyloarthritides (SpA); a group of diseases that present early at a stage when radiographic assessment is invariably normal. This chapter will review how MRI and US can be used in the evaluation of early SpA. The diffuse osteitis/enthesitis on MRI may serve as a diagnostic hallmark for SpA spinal disease, but needs confirmatory studies for comparison with other spinal pathologies. MRI is the modality of choice for monitoring axial disease in anti-tumour necrosis factor (TNF) therapy responses in the research environment, but it is not yet certain whether this will be relevant in clinical practice. Anti-TNF therapy may be associated with regression of MRI-determined osteitis, but retardation of associated bony fusion is debatable. MRI and US are still undergoing evaluation for the diagnosis of enthesitis of the appendicular skeleton; US, in particular, shows promise at these sites.

Reliability of a modified Modic classification of bone marrow changes in lumbar spine MRI

OBJECTIVE

The purpose of this study was to determine the intra- and interobserver reliability of a modified Modic classification for bone marrow changes seen on lumbar spine magnetic resonance imaging (MRI), taking into consideration mixed signals.

METHODS

Lumbar MRI scans from 94 patients with low back pain were assessed independently by 2 spine specialists (senior [senior1], junior) and a radiologist (senior2). One reviewer (senior1) assessed the MR images twice at a three-week interval for evaluation of intraobserver reliability. Senior2 and junior reviewers assessed the MR images once. Pure edema endplate signal changes were classified as Modic type I, and pure fatty endplate changes as Modic type II. A mixture of types I and II but predominantly edema signal changes was classified as Modic I-2 and a mixture of types I and II but predominantly fatty changes was classified as Modic II-1.

RESULTS

The intraobserver agreement was excellent (weighted kappa 0.85). The interobserver agreement was moderate to substantial (weighted kappa range 0.56-0.74). Interobserver reliability depended on the experience of the observer, thus highlighting the importance of a learning curve.

CONCLUSION

This study shows that the modified Modic classification is reliable and easy to apply for observers with different clinical experience. The inclusion of mixed marrow changes in the modified classification may have clinical and therapeutic implications.