Modic changes in the cervical spine: Prospective 20-year follow-up study in asymptomatic subjects

Stopping at C2 Versus C3/4 in Elective Posterior Cervical Decompression and Fusion: A 5-Year Follow-up Study

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

In patients undergoing elective posterior cervical laminectomy and fusion (PCLF) with a minimum of 5-year follow-up, we sought to compare reoperation rates between patients with an upper instrumented vertebra (UIV) of C2 versus C3/4.

SUMMARY OF BACKGROUND DATA

The long-term outcomes of choosing between C2 versus C3/4 as the UIV in PCLF remain unclear.

METHODS

A single-institution, retrospective cohort study from a prospective registry was conducted of patients undergoing elective, degenerative PCLF from December 2010 to June 2018. The primary exposure was UIV of C2 versus C3/4. The primary outcome was reoperation. Multivariable logistic regression controlled for age, smoking, diabetes, and fusion to the thoracic spine.

RESULTS

Of the 68 patients who underwent PCLF with 5-year follow-up, 27(39.7%) had a UIV of C2, and 41(60.3%) had a UIV of either C3/4. Groups had similar duration of symptoms (P=0.743), comorbidities (P>0.999), and rates of instrumentation to the thoracic spine (70.4% vs. 53.7%, P=0.210). The C2 group had significantly longer operative time (231.8±65.9 vs. 181.6±44.1 mins, P<0.001) and more fused segments (5.9±1.8 vs. 4.2±0.9, P<0.001). Reoperation rate was lower in the C2 group compared with C3/4 (7.4% vs. 19.5%), though this did not reach statistical significance (P=0.294). Multivariable logistic regression showed increased odds of reoperation for the C3/4 group compared with the C2 group (OR=3.29, 95%CI=0.59-18.11, P=0.170), though statistical significance was not reached. Similarly, the C2 group had a lower rate of instrumentation failure (7.4% vs. 12.2%, P=0.694) and adjacent segment disease/disk herniation (0% vs. 7.3%, P=0.271), though neither trend attained statistical significance.

CONCLUSIONS

Patients with a UIV of C2 had less than half the number of reoperations and less adjacent segment disease, though neither trend was statistically significant. Despite a lack of statistical significance, whether a clinically meaningful difference exists between UIV of C2 versus C3/4 should be validated in larger samples with long-term follow-up.

LEVEL OF EVIDENCE

Level-3.

Modic Changes Increase the Cage Subsidence Rate in Spinal Interbody Fusion Surgery: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To compare the effect of different Modic changes (MC) grades on the cage subsidence rate after spinal interbody fusion surgery.

METHODS

We comprehensively searched the PubMed, Embase, and Web of Science databases from inception to August 13, 2023, for relevant randomized controlled trials and prospective and retrospective cohort studies. Review Manager 5.3 and STATA13.0 were used to conduct this meta-analysis. The subsidence rate was assessed using relative risk and 95% confidence intervals.

RESULTS

Six studies with a total of 716 segments were allocated to four groups according to the type of MC. The subsidence rate in the non-Modic changes (NMC) was significantly lower than that in the MC. The subsidence rate in the NMC was significantly lower than that in the MC in the subgroup of cages with extra instrumentation. No significant difference was identified between the 2 groups in the oblique lumbar interbody fusion subgroup. The subsidence rate in the NMC was significantly lower than that in the MC in the transforaminal lumbar interbody fusion subgroup. The subsidence rate in the NMC was significantly lower than that in the MC1 and MC2. We found no significant difference between NMC and MC3, MC1 and MC2, MC1 and MC3, or MC2 and MC3.

CONCLUSIONS

MC may be associated with a higher cage subsidence rate. With the increase in MC grades, the incidence of subsidence decreased gradually, but it was always higher than that in the NMC. Oblique lumbar interbody fusion may be a better choice for the treatment of lumbar degenerative disease with MC.

Integrating jigsaw puzzle thinking into practice: the assessment of cervical spine radiculopathy

PURPOSE OF REVIEW

Cervical spine radiculopathy (CSR) presents a complex socioeconomic problem for patients, clinicians, families, employers and healthcare systems. Due to the heterogeneity of clinical presentation and underlying mechanisms, clinical assessment can be challenging. This review will examine the literature on the underlying pathophysiology and studies investigating the holistic assessment strategies for this disabling condition. The authors will focus particular attention on the psychological factors associated with CSR and the physical and imaging strategies to establish a diagnosis.

RECENT FINDINGS

Contemporary CSR assessment should identify the underlying pathomechanisms and how this may impact the somatosensory nervous system integrity and function. No physical assessment test in isolation will establish CSR diagnosis; therefore, clinicians should utilise a cluster of tests and recognise the potential limitations as part of a clinical reasoning framework. The assessment of the somatosensory nervous system can provide insights into particular subgroups of CSR presentation, which may provide interesting opportunities to continue to enhance individualised assessment and management strategies for CSR. The interplay between psychological factors can influence the diagnosis and recovery times for a person with CSR, and clinicians should continue to explore how these factors may influence a person's prognosis. The authors will discuss the opportunities for future research and limitations of contemporary approaches to assessment, underpinned by evidence, and how this supports a clinical assessment to establish CSR diagnosis.

SUMMARY

Research should continue to investigate how clinicians assess the interplay between physical and psychological factors to inform the establishment of CSR. Specifically, there is a need to investigate the validity and reliability of combining somatosensory, motor and imaging assessment findings to reach a diagnosis and inform onward management plans.

K-line tilt as a novel potential risk factor for cervical Modic change: a retrospective study

BACKGROUND

Cervical sagittal parameters are important parameters that reflect the mechanical stress in the sagittal plane of the cervical spine and are an important basis for predicting the clinical status and prognosis of patients. Although it has been confirmed that there is a significant correlation between cervical Modic changes and some sagittal parameters. However, as a newly discovered sagittal parameter, there is no report on the relationship between the K-line tilt and the Modic changes of cervical spine.

METHODS

A retrospective analysis was performed for 240 patients who underwent cervical magnetic resonance imaging scan for neck and shoulder pain. Among them, 120 patients with Modic changes, namely the MC(+) group, were evenly divided into three subgroups of 40 patients in each group according to different subtypes, namely MCI subgroup, MCII subgroup and MCIII subgroup. One hundred twenty patients without Modic changes were included in MC(-) group. We measured and compared the sagittal parameters of cervical spine among different groups, including K-line tilt, C2-C7 sagittal axial vertical distance (C2-C7 SVA), T1 slope and C2-7 lordosis. Logistic regression was used to analyse the risk factors of cervical Modic changes.

RESULTS

The K-line tilt and C2-7 lordosis were significantly different between MC(+) group and MC(-) group (P < 0.05). The K-line tilt greater than 6.72° is a risk factor for Modic changes in cervical spine (P < 0.05). At the same time, the receiver operating characteristic curve showed that this change had moderate diagnostic value when the area under the curve was 0.77.

CONCLUSION

This study shows that the K-line tilt greater than 6.72° is a potential risk factor for Modic changes in cervical spine. When the K-line tilt is greater than 6.72°, we should be alert to the occurrence of Modic changes.

TRIAL REGISTRATION NUMBER

2022ER023-1.

Assessment of the correlation between clinical and radiological outcomes in patients suffering from mild to moderate cervical spine dysfunction symptoms: a prospective study

BACKGROUND

Neck pain and cervical disc degeneration (CDD) are common findings. Valid data on correlation between clinical scores and radiological grade of CDD in patients with mild to moderate clinical disability are not available. The study has been designed to investigate the correlation between clinical and radiological outcomes in these patients.

METHODS

A cohort of 150 patients who suffered from mild to moderate cervical spine dysfunction symptoms from September 2020 to May 2021 was enrolled. We evaluated functional status using Japanese Orthopaedic Association scores (JOA), the visual analog scale, and the Neck Disability Index. We assessed the CDD with magnetic resonance imaging-based grading systems. We analyzed relationships between radiological grades of CDD and clinical symptoms along with demographic data.

RESULTS

One hundred thirteen patients [mean age 44.78, 78 (69%) females] were finally included. CDD occurred most at the C5-C6 level, with 56.93% of higher grade III from Miyazaki. The grades of Miyazaki (P < 0.05) and the scores of Nakashima (P < 0.05) were positively correlated with the duration of symptoms, and the severity of the CDD increased with aging (P < 0.01). Moreover, we correlated patients' JOA scores with the current scoring and grading systems, especially the grades of Miyazaki (P < 0.01) and the scores of Nakashima (P < 0.01).

CONCLUSION

Increasing grades of CDD paralleled decreasing JOA scores in the population studied.

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.

Is it Better to Stop at C2 or C3/4 in Elective Posterior Cervical Decompression and Fusion?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

(a) Compare operative variables, complications, and patient-reported outcomes (PROs) in patients with an upper instrumented vertebrae (UIV) of C2 versus C3/4, and (b) assess outcomes based on C2 screw type.

SUMMARY OF BACKGROUND DATA

When performing elective posterior cervical laminectomy and fusion (PCLF), spine surgeons must choose the upper instrumented vertebrae (UIV) at the subaxial cervical spine (C3/4) versus C2. Differences in long-term complications and PROs remain unknown.

METHODS

A single-institution, retrospective cohort study from a prospective registry was conducted. All patients undergoing elective, degenerative PCLF from December 2010 to June 2018 were included. Patients were divided into a UIV of C2 versus C3/4. Groups were 2:1 propensity matched for fusion extending to the thoracic spine. Demographics, operative, perioperative, complications, and 1-year PRO data were collected.

RESULTS

One hundred seventeen patients underwent elective PCLF and were successfully propensity matched (39 C2 vs. 78 C3/4). Groups were similar in fusion extending to the thoracic spine (P = 0.588). Expectedly, the C2 group had more levels fused (5.63 ± 1.89) compared with the C3/4 group (4.50 ± 0.91) (P = 0.001). The C2 group had significantly longer operative time (P < 0.001), yet no differences were seen in estimated blood loss (EBL) (P = 0.494) or length of stay (LOS) (P = 0.424). Both groups significantly improved all PROs at 1-year (EQ-5D; NRS-NP/AP; NDI). Both groups had the same percentage of surgical adverse events at 6.8% (P = 1.00). Between C2 screw type, no differences were seen in operative time, EBL, LOS, complications, or PROs.

CONCLUSION

In patients undergoing elective PCLF, those instrumented to C2 had only longer operative times compared with those stopping at C3/4. No differences were seen in EBL, LOS, 1-year PROs, and complications. Type of C2 screw had no impact on outcomes. Besides increased operative time, instrumenting to C2 had no detectable difference on surgical outcomes or adverse event rates.Level of Evidence: 3.

Associations between clinical neck symptoms and various evaluations ofcervical intervertebral disc degeneration by magnetic resonance imaging

PURPOSE

Magnetic resonance imaging (MRI) is widely used to evaluate intervertebral disc degeneration. Recently, various evaluations of cervical disc degeneration using MRI have been conducted, but there is no gold standard. The purpose of this study was to compare the reproducibilities of previously reported classifications for evaluating cervical disc degeneration by MRI and their associations with clinical symptoms.

PARTICIPANTS AND METHODS

A total of 582 subjects underwent conventional MRI of the cervical spine. Disc degeneration was assessed in each intervertebral disc from C2/3 to C7/T1 using five different classifications: Matsumoto's grading system, Miyazaki's grading system, Nakashima's grading system, Jacobs' grading system, and Suzuki's grading system. MR images of 30 participants were used, and Cohen's kappa coefficient of agreement of each classification was calculated for intra-observer and inter-observer reliabilities. These five classifications of disc degeneration and changes of vertebral endplates were measured, and associations with clinical symptoms were assessed.

RESULTS

Kappa (κ) values of intra-observer agreement were higher for Jacobs' classification, whereas those of inter-observer agreement were higher for Nakashima's and Jacobs' classifications than for other classifications. The prevalences of neck pain and shoulder stiffness were 27.4% and 41.9%, respectively. There were no associations for any classifications of disc degeneration and Modic types with neck pain or shoulder stiffness. Only the presence of Schmorl's nodes was associated with neck pain.

CONCLUSION

At present, there is no specific classification for cervical disc degeneration associated with clinical symptoms. Vertebral endplate changes might be associated with clinical symptoms. It may be necessary to create a new classification for better reproducibility of the evaluation of cervical disc degeneration.

Influence of Modic Changes on Cage Subsidence and Intervertebral Fusion after Single-Level Anterior Cervical Corpectomy and Fusion

OBJECTIVES

This retrospective study aimed to determine the impact of Modic changes (MCs) on cage subsidence (CS) and intervertebral fusion after anterior cervical corpectomy and fusion (ACCF).

METHODS

This study enrolled 61 patients with MCs who underwent single-level ACCF between January 2010 and December 2015 at our institution. The control group included 63 age-matched patients without MCs treated during the same period. The results from clinical and radiological assessments were reviewed, and radiographic CS was defined by an intervertebral height at the final follow-up that was less than the postoperative intervertebral height.

RESULTS

No significant differences in gender, age, operative time, blood loss, or follow-up results were observed between the MCs and control groups. Significantly more patients experienced CS in the MCs group than in the control group (41.0% vs. 15.9%; p = 0.003). The frequencies of CS among patients with type I MCs (40.0%, 8/20) and type II MCs (41.5%, 17/41) were significantly higher than that in the control group (15.9%, 10/63; p < 0.05). Both groups showed significant improvements in clinical assessment scores after surgery and at final follow-up compared with preoperative values (p < 0.05).

CONCLUSION

In summary, all 61 patients with MCs who underwent ACCF achieved good fusion results. MCs in the surgical segment had no significant effect on intervertebral fusion, but both type 1 and type 2 MCs may increase the risk of CS.

Association between Modic changes, disc degeneration, and neck pain in the cervical spine: a systematic review of literature

BACKGROUND

The contribution of Modic changes (MCs) in relation to spinal pain and degenerative changes has been evaluated frequently. However, most studies focus on lumbar spine. The association between MCs, neck pain, and cervical disc degeneration is not clear.

PURPOSE

The objective of this study was to review current literature on the association between MCs, cervical disc degeneration, and neck pain.

STUDY DESIGN

A systematic review METHODS: A literature search was performed in PubMed, Embase, and Web of Science using a sensitive search string combination. Studies were selected by predefined selection criteria and risk of bias was assessed using a validated Cochrane Checklist adjusted for this purpose.

RESULTS

Fourteen articles that associated MCs with neck pain and/or cervical disc degeneration were included in the present study. Ten articles showed low risk of bias and four showed intermediate risk of bias. The prevalence of MCs in cervical spine varied from 5% to 40% and type II was predominant. Patients with MCs were reported to experience more neck pain and disability. Cervical disc degeneration was detected more frequently in patients with MCs.

CONCLUSIONS

Modic changes were found to be associated with neck pain and with disc degeneration. Therefore, the large variation in prevalence that is reported is highly dependent on the nature of the studied population.