Effect of Modic Changes in Cervical Degenerative Disease

Quantitative assessment of cervical disc degeneration using disc signal intensity index

BACKGROUND/CONTEXT

The assessment of disc degeneration remains a significant challenge in clinical research. Pfirrmann grade is a frequently used classification for lumbar disc degeneration on MRI. However, there has been no gold standard for cervical spine disc degeneration. Recently, we introduced the Disc Signal Intensity Index (DSI2) as a quantitative disc assessment for the lumbar spine, which is easily measurable in the cervical spine.

PURPOSE

The aim of this study was to apply DSI2 in the cervical intervertebral disc and investigate the factors associated with the cervical disc degeneration.

STUDY DESIGN/SETTING

Cross-sectional study using retrospectively collected data.

PATIENT SAMPLE

Cervical MRIs from a database of patients undergoing ACDF between 2015 and 2018 were retrospectively reviewed.

OUTCOME MEASURES

Demographic variables included age, sex, body mass index (BMI), race, smoking status, and comorbidities such as diabetes, chronic kidney disease, and coronary artery disease.

METHODS

DSI2 measurements were performed on midsagittal T2-weighted MRI images by determining the intensity within regions of interest (ROI). One ROI was set in the cerebrospinal fluid (CSF) and three ROIs were set per disc at the anterior, middle, and posterior third. The mean of the three measurements per disc was then divided by that of the CSF to calculate the DSI2 score. Multivariable linear regression analyses with mixed model were conducted to determine the potential contributing factors for disc degeneration.

RESULTS

A total of 149 patients and 770 discs were included in the final analysis. Ninety-three patients (37.6%) were female and the mean (SD) age was 55.6 (11.7) years. The distribution of DSI2 scores among the different Pfirrmann grades was as follows: Grade 1: 0.259±NA; Grade 2: 0.226±0.090; Grade 3: 0.175±0.070; Grade 4: 0.136±0.060; Grade 5: 0.131±0.050. Multivariable linear mixed-effect regression analysis, setting with DSI2 as the objective variable, demonstrated that age (β=-0.130, p<.05), BMI (β=-2.06, p<.05), Modic changes (Type1 β= -2.70, p<.01) were independent contributors to disc degeneration. The segments C4/5 and C7/T1 were less prone to disc degeneration (C4/5: β=1.37, p<.001; C7/T1: β=2.63, p<.001) and the history of diabetes (β=5.31, p<.01) was associated with high DSI2.(p<.01).

CONCLUSIONS

The present study provides valuable insights for identifying risk factors in degenerative cervical conditions utilizing the DSI2. The DSI2 method emerges as a promising alternative for future disc research, excelling in the detection of subtle progressions of degeneration and distinguishing itself from the subjective Pfirrmann grading system.

The Association of Modic Changes and Disc-Endplate-Bone Marrow Complex Classification in Patients With Cervical Degenerative Disc Disease

STUDY DESIGN

Observational cohort study.

OBJECTIVE

To assess the association of Modic changes and DEBC classification in patients with cervical degenerative disc disease.

METHODS

The study includes 2 groups, neck pain patients presenting to the out-patient services (neck pain group) (n = 301) and polytrauma patients without cervical spine injury or a history of neck pain, who underwent whole spine MRI (control group) (n = 200). Degenerative changes in the MRI were classified according to the Modic changes (MC) and DEBC classification. Modifiers including End-Plate (EP) erosion and herniation (H+) presence were documented.

RESULTS

3612 EPs of 301 patients with neck pain and 2400 EPs of 200 controls were assessed. The incidence of MC and DEBC in the neck pain group was 20.93% and in the control group, it was 12%, (P < 0.05). In the neck pain group with DEBC changes, the distribution was Type A-6.51%; Type B-20.71%; Type C-71.6%; and Type D - 1.18%, while in the controls the distribution was Type A-10.29%, Type B-29.41%, Type C-54.41%, and Type D - 5.88%, The co-occurrence of H+ with DEBC in cases and controls was 13.95% vs 5.5% (P < 0.005). The odds ratio for the need for surgery was highest (OR: 6.8) when H+ and DEBC change co-occurred.

CONCLUSION

Our study highlights that patients with DEBC changes and disc herniation were more likely to experience neck pain and require surgical intervention, indicating the reliability and clinical significance of the DEBC classification in degenerative cervical spine patients.

A Strong Association Between Modic Changes Type 2 and Endplate Defects at Nonfused Segments After Anterior Cervical Decompression and Fusion

BACKGROUND

To determine the association between Modic changes (MCs) with other magnetic resonance imaging parameters and clinical symptoms of cervical degenerative disc disease.

METHODS

A retrospective analysis of data on patients with cervical degenerative disc disease who underwent single-level anterior cervical discectomy and fusion. Preoperative demographic data (age, sex, surgical data) were collected, cervical magnetic resonance imaging parameters (disc degeneration grade, MCs, and endplate defects, each determined at each cervical level), and clinical data (numerical pain rating scale [NPRS] neck and arm, the Neck Disability Index) were compared to preoperative data.

RESULTS

The study included 121 patients at Visit 1 and 83 patients at Visit 2. The median follow-up duration was 26.5 [18.9; 33.1] months. Patients with MC had more intense NPRS-based neck pain before surgery compared to patients without MC (P = 0.001). There were significant changes in MC rate at the C5-C6 levels due to a significant number of new MC type 1 and MC type 2 (P = 0.002 and P < 0.001, respectively). MC type 2 was associated with disc degeneration, endplate defects, patients' age, and clinical scales (Neck Disability Index, NPRS) (P < 0.05). The endplate defects score threshold for predicting MC type 2 at the C3-C7 cervical levels was 5.

CONCLUSIONS

The factor predicting MC type 2 at the C3-C7 cervical levels is submaximal damage to the endplate. The MC rate is increased due to MC type 1 and MC type 2. MC types at the cervical levels may not represent consecutive stages of the same process.

Prevalence, risk factors, natural history, and prognostic significance of Modic changes in the cervical spine: a comprehensive systematic review and meta-analysis of 12,754 participants

OBJECTIVE

Modic changes (MCs) in the cervical spine are common, but remain an under-researched phenomenon, particularly regarding their prevalence, natural history, risk factors, and implications for surgical outcomes. This systematic review and meta-analysis endeavors to elucidate the multifactorial dimensions and clinical significance of cervical MCs.

METHODS

Following PRISMA guidelines, a comprehensive systematic search was performed using Medline (via PubMed), EMBASE, Scopus, and Web of Science databases from their dates of inceptions to September 4, 2023. All identified articles were meticulously screened based on their relevance to our investigative criteria. Bias was assessed using quality assessments tools, including Quality in Prognosis Studies (QUIPS) and Newcastle-Ottawa Scale (NOS). Diverse datasets encompassing MCs prevalence, demographic influences, risk factors, cervical sagittal parameters, and surgical outcomes were extracted. Meta-analysis using both random and common effects model was used to synthesis the metadata.

RESULTS

From a total of 867 studies, 38 met inclusion criteria and underwent full-text assessment. The overall prevalence of cervical MCs was 26.0% (95% CI: 19.0%, 34.0%), with a predominance of type 2 MCs (15% ; 95% CI: 0.10%, 0.23%). There was no significant difference between MCs and non-MCs in terms of neck pain (OR:3.09; 95% CI: 0.81, 11.88) and radicular pain (OR: 1.44; 95% CI: 0.64, 3.25). The results indicated a significantly higher mean age in the MC group (MD: 1.69 years; 95% CI: 0.29 years, 3.08 years). Additionally, smokers had 1.21 times the odds (95% CI: 1.01, 1.45) of a higher risk of developing MCs compared to non-smokers. While most cervical sagittal parameters remained unaffected, the presence of MCs indicated no substantial variation in pain intensity. However, a significant finding was the lower Japanese Orthopaedic Association (JOA) scores observed in MC patients at the 3-month (MD: -0.34, 95% CI: -0.62, -0.07) and 6-month (MD: -0.40, 95% CI: -0.80, 0.00) postoperative periods, indicating a prolonged recovery phase.

CONCLUSION

This study found a predominant of type 2 MCs in the cervical spine. However, there was no significant mean difference between MCs and non-MC groups regarding neck pain and radicular pain. The results underscore the necessity for expansive, longitudinal research to elucidate the complexity of cervical MCs, particularly in surgical and postoperative contexts.

Prevalence and Risk Factors for Modic Changes in Symptomatic Cervical Ossification of the Posterior Longitudinal Ligament: A Retrospective Study of 203 Patients

BACKGROUND Modic changes (MC) are abnormal bone signals under the vertebral endplates on magnetic resonance imaging (MRI) of the spine. Three types of MC may be seen on MRI as abnormal bone signals of the vertebral endplate and adjacent bone marrow. This retrospective study of 203 patients with symptomatic cervical ossification of the posterior longitudinal ligament (OPLL) aimed to evaluate factors associated with MC on cervical spine MRI. MATERIAL AND METHODS We included 203 patients with symptomatic cervical ossification of the OPLL. All patients underwent MRI with T1 and T2 sequences to assess the presence and type of MC. Univariate and multivariate logistic regression analyses were used to identify the risk factors for MC. RESULTS The prevalence of MC in patients with symptomatic cervical OPLL was 21.18%. Type 2 MC accounted for 88.64% of the cases. Local type and MC share the same segment (100.00%), followed by segmental type (77.27%), mixed type (75.00%), and continuous type (75.00%). Age (OR=1.05, 95% CI: 1.01-1.09, P=0.013) and neck pain (OR=2.67, 95% CI: 1.04-6.83, P=0.041) were significantly correlated with MC. Further receiver operating characteristic (ROC) analysis displayed an area under the curve (AUC) of 0.657 (P=0.002) for age, and the optimal cutoff was 60.50 years (sensitivity 0.67, specificity 0.68). CONCLUSIONS The results of this study found that older age and neck pain were significantly associated with development of cervical spine MC. Patients ≥60.5 years with symptomatic cervical OPLL had a higher probability of developing MC.

Disc degeneration is easily occurred at the same and adjacent cephalad level in cervical spine when Modic changes are present

OBJECTIVE

This research aimed to evaluate the influence of Modic changes (MCs) on disc degeneration at the same and adjacent cephalad levels in the cervical spine.

METHODS

This research retrospectively reviewed 1036 patients with neck pain, upper limb pain, or numbness who were treated at our out-patient clinic and underwent cervical MRI and cervical anteroposterior/lateral radiography from Jan, 2016 to Jan, 2021. MCs and disc degeneration parameters at same and nearby cephalad levels of MCs were evaluated. Discs were divided into the MCs, adjacent, and control groups, and the association between MCs and disc degeneration at the same and adjacent cephalad levels was investigated.

RESULTS

Of the 1036 patients whose MRI scans were reviewed, 986 met the inclusion criteria (503 women and 483 men; average age, 62.8 years; scope of 35-79 years). The prevalence of MCs in the cervical spine was 13.0% (128/986). Type I, II, III changes were observed in 38 (29.69%), 82 (64.06%), and 8 (6.25%) patients, respectively. MCs were most frequently identified at the C5-6 (59/986; 5.98%) and C6-7 (38/986; 3.85%) levels. Disc with MCs showed worse outcomes with regard to disc degeneration grade, anterior osteophyte formation than the adjacent and control groups (p < 0.05), whereas they were more severe in the adjacent group compared to normal group.

CONCLUSION

Our findings indicate that MCs increased disc degeneration at the same and nearby cephalad levels in cervical spine, and the severity of degeneration at the same segment was more serious than that at the cephalad level.

The Modic-endplate-complex phenotype in cervical spine patients: Association with symptoms and outcomes

This study describes a novel, combined Modic changes (MC) and structural endplate abnormality phenotype of the cervical spine, which we have termed the Modic-Endplate-Complex (MEC), and its association with preoperative symptoms and outcomes in anterior cervical discectomy and fusion (ACDF) patients. This was a retrospective study of prospectively collected data at a single institution. Preoperative cervical magnetic resonance imagings were used to assess the presence of MC and endplate abnormalities. Patients were divided into four groups: MC-only, endplate abnormality-only, the MEC and controls. The MEC was defined as the presence of both a MC and endplate abnormality in the cervical spine. Phenotypes were further stratified by location and compared to controls. Associations with patient-reported outcome measures were assessed using regression controlling for baseline characteristics. A total of 628 patients were included, with 84 MC-only, 166 endplate abnormality-only, and 187 MEC patients. Both MC (p < 0.001) and endplate abnormalities (p < 0.001) were independently associated with one another. MC at the adjacent level (p = 0.018), endplate abnormalities (regardless of location) (p = 0.001), and the MEC within the fusion segment (p = 0.027) were all associated with higher Neck Disability Index scores. Both MC within the fusion segment (p = 0.008) and endplate abnormalities within the fusion segment (p = 0.017) associated with lower Veteran's Rand 12-item scores. MC and structural endplate abnormalities commonly manifest concomitantly in patients indicated for ACDF for degenerative pathology. Patients with the endplate pathology, including the MEC phenotype, reported significantly higher levels of postoperative disability following ACDF. These findings add valuable data to the prognostic assessment of degenerative cervical spine patients.

Modic changes are associated with activation of intense inflammatory and host defense response pathways - molecular insights from proteomic analysis of human intervertebral discs

BACKGROUND CONTEXT

Patients with modic changes (MC) form a distinct clinical subset with reports of higher intensity of pain, poor clinical and surgical outcomes and higher incidence of recurrence. MC also is an independent risk factor for increased post-operative surgical site infection.

PURPOSE

This study aimed to investigate the biological changes at molecular level, in discs with MCs. We also aim to identify biological biomarkers and potential targets for molecular therapy.

STUDY DESIGN

Experimental analysis MATERIALS AND METHODS: Nucleus pulposus (NP) from 24 patients undergoing microdiscectomy for disc herniation [14 discs with MC and 10 without modic changes (NMC)] were procured. The overall expression of proteins, biological processes, protein-protein and metabolite interactions were analysed and compared. Host defense response proteins (HDRPs) and immunological pathways activated in patients with MC were documented and analysed.

RESULTS

Label-free proteomic approach with stringent filters revealed a total of 208 proteins in MC and 193 in NMC groups. 45 proteins were specific to MC; 30 to NMC and 163 common to both. Downregulated proteins in MC belonged to components of extracellular matrix such as collagens (COL- 6A1, 6A2, 6A3, 11A1, 12A1, and 20A1), and proteoglycans (versican (VCAN), and biglycan (BGN)). Inflammatory molecules [plasminogen (PLG), angiogenin (ANG), fibroblast growth factor-binding protein 2 (FGFBP2), tetranectin (CLEC3B), cartilage acidic protein 1(CRTAC1), kininogen (KNG-1), chitinase-3-like protein 2 (CHI3L2), and ferritin (FTL) were expressed only in the MC group. The significantly altered pathways in MC included Fc Fragment of IgG Receptor IIIa (FCGR3A)-mediated phagocytosis, regulation of Toll-like receptors (TLR) by endogenous ligand, neutrophil and platelet degranulation. 50 HDRPs were identified in the study, 14 of which were specific to MC and included acute phase reactants, antimicrobial peptides, complement cascade proteins, inflammatory molecule and stress response proteins. Metabolite-protein interaction analysis revealed a significant interaction between 19 proteins, specifically involving ubiquitin mediating proteasome degradative pathway and an association with the metabolite-glutamic acid in the MC group. Accumulation of glutamic acid in MC discs was confirmed by quantitative amino acid analysis using High-performance liquid chromatography.

CONCLUSION

Our study confirms that MC represents an intense inflammatory status and activation of host defense response and immunological pathways. Downstream effects leading to ubiquitin mediated proteasomal degradation of ECM proteins and the resulting metabolites such as glutamic acid could cause excessive pain and needs further investigation.

CLINICAL SIGNIFICANCE

We have documented the expression of inflammatory molecules, immune mechanisms and host defense response proteins which throw molecular insights into the pathological mechanisms of MC. Further, ubiquitin mediated proteasomal degradation and accumulation of glutamate in discs with MC might serve as targets for molecular therapy.

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.

The Impact of Modic Changes on Preoperative Symptoms and Clinical Outcomes in Anterior Cervical Discectomy and Fusion Patients

Objective

To assess the impact of Modic changes (MC) on preoperative symptoms, and postoperative outcomes in anterior cervical discectomy and fusion (ACDF) patients.

Methods

We performed a retrospective study of prospectively collected data of ACDF patients at a single institution. Preoperative magnetic resonance imagings were used to assess the presence of MC. MC were stratified by type and location, and compared to patients without MC. Associations with symptoms, patient-reported measures, and surgical outcomes were assessed.

Results

A total of 861 patients were included, with 356 patients with MC (41.3%). MC more frequently occurred at C5–6 (15.1%), and type II was the most common type (61.2%). MC were associated with advanced age (p < 0.001), more levels fused (p < 0.001), a longer duration of symptoms, but not with specific symptoms. MC at C7–T1 resulted in higher postoperative disability (p < 0.001), but did not increase risk of adjacent segment degeneration or reoperation.

Conclusion

This study is the first to systematically examine the impact of cervical MC, stratified by type and location, on outcomes in ACDF patients. Patients with MC were generally older, required larger fusions, and had longer duration of preoperative symptoms. While MC may not affect specific outcomes following ACDF, they may indicate a more debilitating preoperative state for patients.

Cervical Cord Compression and Whole-Spine Sagittal Balance: Retrospective Study Using Whole-Spine Magnetic Resonance Imaging and Cervical Cord Compression Index

OBJECTIVE

We sought to investigate the relationship between cervical cord compression and factors related to whole-spine sagittal balance.

METHODS

This retrospective single-center study included patients who visited our clinic for the evaluation of lumbar pathology including trauma and degeneration. Patients aged 60-89 years who underwent whole-spine sagittal T2 scout magnetic resonance imaging and whole-spine radiograph between 2014 and 2018 were included in our study. We consecutively enrolled 100 patients for our study without any prejudice. We collected data on patient characteristics, diagnosis, cervical cord compression index (CCI), sagittal vertical axis (C7-S1, C2-7), and other parameters related to sagittal balance such as pelvic incidence minus lumbar lordosis. Pearson correlation coefficients were calculated to compare CCI with each whole-spine sagittal balance parameter.

RESULTS

Of the 100 patients, 44 were men. The mean age was 74.21 years. On the basis of Pearson correlation coefficients, CCI showed the strongest positive linear correlation with C7-S1 sagittal vertical axis (r = 0.688; P < 0.01), followed by the C2-7 sagittal vertical axis (r = 0.563; P < 0.01).

CONCLUSIONS

Cervical cord compression is more likely to develop in patients with sagittal imbalance. It is important to use whole-spine radiograph and whole-spine T2 scout magnetic resonance imaging to analyze CCI in these patients.

Asymmetrical degenerative marrow (Modic) changes in cervical spine: prevalence, correlative factors, and surgical outcomes

Background

The current study aimed to discuss the prevalence and surgical outcomes of the asymmetrical Modic changes and identify its correlative factors by multivariate logistic regression analysis.

Methods

Two hundred seventy-eight patients with single-level Modic changes and nerve compression symptoms were reviewed retrospectively from January 2008 to January 2015. 1.5-T MRI was performed to determine the Modic changes. Multivariate logistic regression analysis was used to identify the correlative factors of asymmetrical Modic changes. Surgeries were performed according to the surgical indications. The outcomes were recorded by Japanese Orthopaedic Association (JOA) score, Neck Disability Index (NDI) score, and recovery rate.

Results

Asymmetrical Modic changes were observed in 76 patients (27.34%) with 4 type 1, 69 type 2, and 3 type 3. C5/6 was the most frequently affected segment with 39 patients showing signal changes on MRI. Statistically significant difference was showed in conservative rehabilitation rate between two groups (p = 0.043). Multiple logistic regression analysis identified disc herniation and neurological symptoms as correlative factors of asymmetrical Modic changes, and the adjusted odds ratios (95% CI) were 2.079 (1.348–3.208) and 0.231 (0.143–0.373) respectively. No statistically significant difference was found in JOA scores and NDI scores between the two kinds of Modic changes.

Conclusions

C5/6 was the most commonly affected level by Modic changes. Disc herniation and nerve root compression symptom were more closely correlated with asymmetrical Modic changes than conventional Modic changes. Asymmetrical Modic changes indicated poor result in conservative treatment; however, the final operation rate was similar between the two kinds of Modic changes. The outcomes of surgical treatment were satisfactory both in patients with asymmetrical Modic changes and conventional Modic changes.