The influence of endplate (Modic) changes on clinical outcomes in lumbar spinal stenosis surgery: a Swiss prospective multicenter cohort study

From Modic to Disc Endplate Bone Marrow Complex - The Natural Course and Clinical Implication of Vertebral Endplate Changes

STUDY DESIGN

Review article.

OBJECTIVES

A review of literature on the epidemiology, natural course, pathobiology and clinical implications of vertebral endplate changes.

METHODS

A literature search was performed using the Cochrane Database of Systematic Reviews, EMBASE, and PubMed. Studies published over the last 10 years were analysed. The searches were performed using Medical Subject Headings terms, and the subheadings used were "Vertebral endplate changes", "Modic changes", "Disc Endplate Bone Marrow complex".

RESULTS

The disc, endplate (EP), and bone marrow region of the spine constitute a unified morphological and functional unit, with isolated degeneration of any one structure being uncommon. Disc degeneration causes endplate defects, which result in direct communication and a constant cross-talk between the disc and the vertebral body. This may result in a persistent inflammatory state of the vertebral bone marrow, serving as a major pain generator. This review article focuses on vertebral endplate changes and how the current understanding has progressed from the Modic classification to the Disc Endplate Bone Marrow complex classification. It provides a clear portrayal of the natural course of these alterations and their clinical implications in low back pain.

CONCLUSIONS

In light of the heightened interest and current prominence of vertebral endplate changes within the spine community, we must progress beyond the Modic changes to achieve a comprehensive understanding. The DEBM complex classification will play a major part in disc degeneration research and clinical care, representing a considerable advancement in our understanding of the vertebral endplate changes over the classical Modic changes.

Modic changes in patients with lumbar disc herniation followed more than 1 year after lumbar discectomy: a systematic review and meta-analysis

Background

Modic changes (MCs) are identified as an independent risk factor for low back pain. Different subtypes of MCs vary in their impact on postoperative pain relief. However, consensus on the transformation of postoperative MC fractions in patients with distinct MC subtypes is lacking.

Methods

This comprehensive systematic review and meta-analysis searched English-language articles in PubMed, Cochrane Library, Web of Science, and Embase databases until January 2024. Studies included focused on patients transitioning between various microcrack subtypes post-discectomy. The primary outcome measure was the transformation between different postoperative microcrack fractions.

Results

Eight studies with 689 participants were analyzed. Overall, there is moderate to high-quality evidence indicating differences in the incidence of MC conversion across MC subtypes. The overall incidence of MC conversion was 27.7%, with rates of 37.0%, 20.5%, and 19.1% for MC0, MC1, and MC2 subtypes, respectively. Thus, postoperative MC type transformation, particularly from preoperative MC0 to MC1 (17.7%) or MC2 (13.1%), was more common, with MC1 transformation being predominant. Patients with preoperative comorbid MC1 types (19.0%) exhibited more postoperative transitions than those with MC2 types (12.4%).

Conclusion

This study underscores the significance of analyzing post-discectomy MCs in patients with lumbar disc herniation, revealing a higher incidence of MCs post-lumbar discectomy, particularly from preoperative absence of MC to MC1 or MC2. Preoperative MC0 types were more likely to undergo postoperative MC transformation than combined MC1 or MC2 types. These findings are crucial for enhancing surgical outcomes and postoperative care.

Study of the Distribution of Lumbar Modic Changes in Patients with Low Back Pain and Correlation with Lumbar Degeneration Diseases

Purpose

To study the distribution of lumbar Modic changes (MC) in low back pain patients, and to explore the relationship between Modic changes and age, gender, segment and lumbar degeneration diseases (disc degeneration, spinal stenosis, lumbar spondylolisthesis).

Patients and Methods

Modic changes were counted and analysed in 500 randomly selected patients who visited the outpatient clinic for lumbar spine MRI for low back pain from 2019 to 2022. The relationship between Modic changes and bulging disc, protrusion, extrusion, sequestration, Schmorl's node, spinal stenosis, and lumbar spondylolisthesis was studied. Data correlations were compared using the chi-square test, P<0.05 was considered a statistically significant difference.

Results

Modic changes were present in 184 segments. 58 were type I, 119 were type II, and 7 were type III. The number of Modic changes segments in L1-2, L2-3, L3-4, L4-5, and L5-S1 was 10, 22, 22, 58, and 72, respectively. Modic changes by gender occurred in 44 males and 82 females, and by age grouping were 0 cases in 10-19 years, 3 cases in 20-29 years, 6 cases in 30-39 years, 41 cases in 40-49 years, 64 cases in 50-59 years, 38 cases in 60-69 years, 15 cases in 70-79 years, and 5 cases in 80-89 years, respectively. Modic changes occurred in 56 with bulging disc, 45 with Protrusion, 57 with Extrusion and Sequestration, 32 with Schmorl's node, 32 with spondylolisthesis, and 56 with stenosis. Modic changes correlated with all of the above factors except bulging disc, and all differences were statistically significant (P<0.05).

Conclusion

The most common type of Modic changes is type II; Modic changes have correlation with age, gender, segment, lumbar disc herniation, lumbar spondylolisthesis, and lumbar spinal stenosis, and are a very important factor in low back pain.

The Effect of Paraspinal Fatty Muscle Infiltration and Cumulative Lumbar Spine Degeneration on the Outcome of Patients With Lumbar Spinal Canal Stenosis: Analysis of the Lumbar Stenosis Outcome Study (LSOS) Data

STUDY DESIGN

Prospective.

OBJECTIVE

To investigate the influence of paraspinal fatty muscle infiltration (FMI) and cumulative lumbar spine degeneration as assessed by magnetic resonance imaging on long-term clinical outcome measures in patients with lumbar spinal canal stenosis (LSCS) of the Lumbar Stenosis Outcome Study (LSOS) cohort.

SUMMARY OF BACKGROUND DATA

Past studies have tried to establish correlations of morphologic imaging findings in LSCS with clinical endpoints. However, the impact of FMI and overall lumbar spinal degeneration load has not been examined yet.

MATERIALS AND METHODS

Patients from the LSOS cohort with moderate to severe LSCS were included. Two radiologists assessed the degree of LSCS as well as cumulative degeneration of the lumbar spine. FMI was graded using the Goutallier scoring system. Spinal Stenosis Measure (SSM) was used to measure the severity level of symptoms and disability. European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L) was used to measure health-related quality of life.

RESULTS

The nonsurgically treated group consisted of 116 patients (age 74.8±8.5 yr), whereas the surgically treated group included 300 patients (age 72.3±8.2 yr). Paraspinal FMI was significantly different between the groups (54.3% vs. 32.0% for Goutallier grade ≥2; P <0.001). Total degeneration score was comparable in both groups (9.5±2.0 vs. 9.3±2.0; P =0.418). FMI was associated with lower SSM function and lower EQ-5D-3L (all P <0.05), but not with SSM symptoms. Total degeneration of the lumbar spine was associated neither with SSM symptoms, nor with SSM function, nor with EQ-5D-3L (all P >0.05).

CONCLUSIONS

FMI is associated with higher disability and worse health-related quality of life of LSCS patients in the LSOS cohort. There was no significant association between total cumulative lumbar spine degeneration and the outcome of either surgically or nonsurgically treated patients.

LEVEL OF EVIDENCE

3.

Identification of preoperative radiological risk factors for reoperation following percutaneous endoscopic lumbar decompression to treat degenerative lumbar spinal stenosis

Background

This study aimed to identify radiological risk factors associated with reoperation after percutaneous transforaminal endoscopic decompression (PTED) for degenerative lumbar spinal stenosis (DLSS).

Methods

The preoperative clinical data of 527 consecutive patients with DLSS who underwent PTED were retrospectively reviewed. Overall, 44 patients who underwent reoperation were matched for age, sex, body mass index, and surgical segment to 132 control patients with excellent or good clinical outcomes. Radiological characteristics were compared between the groups using independent sample t-tests and Pearson's chi-square tests. A predictive model was established based on multivariate logistic regression analysis.

Results

The analyses revealed significant differences in the presence of lumbosacral transitional vertebra (LSTV, 43.2% vs. 17.4%, p = 0.001), the number of levels with senior-grade disc degeneration (2.57 vs. 1.96, p = 0.018) and facet degeneration (1.91 vs. 1.25 p = 0.002), and the skeletal muscle index (SMI, 849.7 mm²/m² vs. 1008.7 mm²/m², p < 0.001) between patients in the reoperation and control groups. The results of the logistic analysis demonstrated that LSTV (odds ratio [OR] = 2.734, 95% confidence interval [CI]:1.222-6.117, p < 0.014), number of levels with senior-grade facet degeneration (OR = 1.622, 95% CI:1.137-2.315, p = 0.008), and SMI (OR = 0.997, 95% CI:0.995-0.999, p = 0.001) were associated with reoperation after PTED. The application of the nomogram based on these three factors showed good discrimination (area under the receiver operating characteristic curve 0.754, 95% CI 0.670-0.837) and good calibration.

Conclusion

LSTV, more levels with senior-grade facet degeneration, and severe paraspinal muscle atrophy are independent risk factors for reoperation after PTED. These factors can thus be used to predict reoperation risk and to help tailor treatment plans for patients with DLSS.

Comparison between Decompression Alone and with Additional Fusion for Degenerative Lumbar Spondylolisthesis: A Systematic Review and Meta-Analysis

Introduction

Degenerative lumbar spondylolisthesis affects approximately 10% of adults over 40. Although decompression has been the treatment of choice, some surgeons note possible instability development after decompression alone (D). Previous studies show that decompression with fusion (DF) has similar complication rates but is better at preventing slip progression and reducing pain. However, others stated the additional instrumentation does not result in superior functional outcomes and has higher costs and complication rates. This study aims to provide an objective, two-arm comparison of the two treatments using systematic review and meta-analysis.

Methods

The study design was a systematic review and meta-analysis of relevant randomized controlled trials and nonrandomized comparative studies. A systematic search was conducted from April 2021 to September 2021 to identify relevant studies using PubMed, Google Scholar, EMBASE, and Cochrane databases based on PRISMA guidelines.

Results

This systematic review included 8 studies (6,669 patients); 7 (6,569 patients) were included in the meta-analysis, with a follow-up period of up to 143 months. The most commonly affected level was L4-5, with females being more affected than males. Visual Analog Scale improvement on back pain was significantly better in DF group (Heterogeneity, I²=32%; WMD -0.72; 95% Confidence Interval (CI), -1.35 to -0.08; P=0.03), as well as postoperative back pain (I²=96%; WMD 0.87; 95% CI, 0.19 to 1.55; P=0.01). The leg pain, Oswestry Disability Index (ODI), satisfaction rate, complication rate, and revision rate were comparable between the two procedures.

Conclusions

Current systematic review and meta-analysis proved that DF is better than D in terms of back pain improvement, and the two procedures are comparable in terms of leg pain, ODI, satisfaction rate, complication rate, and revision rate.

Evaluating the Impact of Modic Changes on Operative Treatment in the Cervical and Lumbar Spine: A Systematic Review and Meta-Analysis

Modic changes (MCs) are believed to be potential pain generators in the lumbar and cervical spine, but it is currently unclear if their presence affects postsurgical outcomes. We performed a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies evaluating cervical or lumbar spine postsurgical outcomes in patients with documented preoperative MCs were included. A total of 29 studies and 6013 patients with 2688 of those patients having preoperative MCs were included. Eight included studies evaluated cervical spine surgery, eleven evaluated lumbar discectomies, nine studied lumbar fusion surgery, and three assessed lumbar disc replacements. The presence of cervical MCs did not impact the clinical outcomes in the cervical spine procedures. Moreover, most studies found that MCs did not significantly impact the clinical outcomes following lumbar fusion, lumbar discectomy, or lumbar disc replacement. A meta-analysis of the relevant data found no significant association between MCs and VAS back pain or ODI following lumbar discectomy. Similarly, there was no association between MCs and JOA or neck pain following ACDF procedures. Patients with MC experienced statistically significant improvements following lumbar or cervical spine surgery. The postoperative improvements were similar to patients without MCs in the cervical and lumbar spine.

Modic changes - An evidence-based, narrative review on its patho-physiology, clinical significance and role in chronic low back pain

OBJECTIVE

Lumbar degenerative spinal ailments are the most important causes for chronic low back pain. Modic changes (MC) are vertebral bone marrow signal intensity changes seen on MRI, commonly in association with degenerative disc disease (DDD). Despite being widely studied, majority of issues concerning MC are still controversial. The current narrative, evidence-based review comprehensively discusses the various aspects related to MC.

LITERATURE SEARCH

An elaborate search was made using keywords "Modic changes", "lumbar Modic changes", "Modic changes in lumbar spine", and "vertebral Endplate Spinal Changes", on pubmed and google (scholar.google.com) databases on the 3rd of March 2020. We identified crucial questions regarding Modic changes and included relevant articles pertaining to these topics for this narrative review.

RESULTS

The initial search using the keywords "Modic changes", "lumbar Modic changes", "Modic changes in lumbar spine", and "vertebral Endplate Spinal Changes" on pubmed yielded a total of 568, 412, 394 and 216 articles on "pubmed" database, respectively. A similar search using the aforementioned keywords yielded a total of 3650, 3548, 3726 and 21570 articles on "google scholar" database. The initial screening involved exclusion of duplicate articles, articles unrelated to MC, animal or other non-clinical studies, and articles in non-English literature based on abstracts or the titles of articles. This initial screening resulted in the identification of 405 articles. Full manuscripts were obtained for all these selected articles and thoroughly scrutinised at the second stage of article selection. All articles not concerning Modic changes, not pertaining to concerned questions, articles concerning other degenerative phenomena, articles discussing cervical or thoracic MC, case reports or animal studies, articles in non-English language and duplicate articles were excluded. Review articles, randomised controlled trials and level 1 studies were given preference. Overall, 69 articles were included in this review.

CONCLUSION

Modic change (MC) is a dynamic phenomenon and its true etiology is still not definitely known. Disc/end plate injury, occult discitis and autoimmune reactions seem to trigger an inflammatory cascade, which leads to their development. Male sex, older age, diabetes mellitus, genetic factors, smoking, obesity, spinal deformities, higher occupational loads and DDD are known risk factors. There is no conclusive evidence on the causative role of MC in chronic low back pain (LBP) or any influence on the long term outcome in patients with LBP or lumbar disc herniations (LDH). Patients with MC have been reported to have less satisfactory outcome following conservative treatment or discectomy, although the evidence is still unclear.