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. This study was supported by National Natural Science Foundation of China (No. 3880785 and No. 30700851).     

经后路微创治疗伴终板Modic改变腰椎间盘突出症的疗效分析

目的:探讨经后路内窥镜下微创治疗伴腰椎终板信号改变(Modic改变)腰椎间盘突出症患者的手术疗效。方法:回顾性分析自2005年5月~2009年12月我院采用经后路内窥镜下髓核摘除术(MED)治疗单节段腰椎间盘突出症患者78例,男43例、女35例,平均年龄44.3岁(23~67岁),平均随访36.7个月(7~62个月),根据有无终板改变分为A、B两组。A组:MRI影像显示终板无信号改变,共33例;B组:MRI影像示终板有信号改变,共45例,其中ModlcⅠ、Ⅱ、Ⅲ型分别为13、25、7例。分别记录术前、术后及最终随访时的VAS、ODI值,并进行统计学分析。结果:术前A、B组的VAS、ODI值差异均无统计学意义(P>0.05)。术后ODI值改善率分别为A组86.2%、B组81.3%,VAS改善率分别为A组89.2%、B组77.2%,A组ODI值及VAS改善率与B组比较差异有显著性(P<0.05),B组终板不同Modic改变类型间疗效:术前、术后及末次随访间差异无显著性(P>0.05)。结论:后路内窥镜下髓核摘除术(MED)是治疗腰椎间盘突出症的一种有效术式,终板Modic改变可能是引起术后腰痛的一个原因,并影响术后腰痛的缓解,且MED术对治疗不同类型Modic改变腰椎间盘突出症的临床疗效无差异。     

退变性腰椎侧凸椎体终板Modic改变的分布情况及其影响因素

目的:观察退变性腰椎侧凸患者终板Modic改变的分布情况,分析其相关影响因素及与腰痛的关系。方法:回顾分析2000年3月～2009年3月我院收治的126例退变性腰椎侧凸患者的影像学资料,采用VAS对患者腰痛程度进行评估。观察患者终板Modic改变的发生率、类型及分布特点;比较存在Modic改变与不存在Modic改变患者的VAS评分;分析Modic改变与椎间盘退变、终板倾斜度、腰椎侧凸角及体重指数间的相关性。结果:126例患者756个腰椎间盘中,69例(54.8%)124(18.2%)个椎间盘邻近终板存在Modic改变。存在Modic改变患者VAS评分5.5±2.0,不存在Modic改变患者VAS评分3.0±1.5,两者比较差异有显著性(P<0.01)。Modic分型:Ⅰ型有15例患者(11.9%)19个椎间盘退变(2.5%),Ⅱ型48例(38.1%)97个椎间盘退变(12.8%),Ⅲ型6例(4.8%)8个椎间盘退变(1.1%)。退变终板节段:L5/S1椎间盘32个(25.8%),L4/5椎间盘26个(21.0%),L3/4椎间盘9个(7.3%),L2/3椎间盘47个(37.9%),L1/2椎间盘6个(4.8%),T12/L1椎间盘4个(3.2%)。Modic改变发生于终板凹侧99(13.1%)个,发生于终板凸侧25(3.3%)个;凹侧与凸侧发生率比较差异有显著性(P<0.01)。Modic改变与椎间盘退变、终板倾斜度、腰椎侧凸角及体重指数存在显著相关性(P<0.05)。结论:Modic改变与椎间盘退变、终板倾斜度、腰椎侧凸角及体重指数之间存在相关关系;Modic改变以Ⅱ型多见,多发生于终板的凹侧,以L2/3、L5/S1和L4/5节段多发。     

Modic changes and their associations with clinical findings

It is believed that disc degeneration (DD) is, in general, only mildly associated with low back pain (LBP). MRI-identified Modic changes (MC), probably a late stage of DD, are relatively strongly associated with LBP but it is not known if people with MC also have a specific clinical profile. The purpose of this study was to investigate if the clinical findings differ in people with Modic changes (MC) as compared to those with only degenerative disc findings or none at all. In a population-based sample of 412 40-year-old Danes, information was collected independently with MRI, questionnaires and clinical examination. Three subgroups of people were created: those with both DD and MC, those with only DD, and those with neither DD nor MC. The clinical pattern was investigated for each subgroup in order to test the assumption that the clinical picture differs in the three groups. It was expected that people with both DD and MC would have a more pronounced clinical profile than those with only DD who, in turn, would differ from those with neither of these two MRI findings. Our findings were generally in concordance with our expectations. MC constitutes the crucial element in the degenerative process around the disc in relation to LBP, history, and clinical findings. People with DD and no MC only vaguely differ from those without. People with LBP and MC may deserve to be diagnosed as having specific LBP.     

Type 1 Modic changes was a significant risk factor for 1-year outcome in sick-listed low back pain patients: a nested cohort study using magnetic resonance imaging of the lumbar spine

Background contextIt is not clear whether Modic changes (MC) is associated with low back pain (LBP) outcome.PurposeTo study associations between baseline degenerative manifestations and outcome in sick-listed LBP patients.Study designProspective nested cohort study based on a randomized controlled trial.Patient sampleOut of 325 sick-listed LBP patients, 141 were consecutively examined by magnetic resonance imaging (MRI) and included and 140 completed the study.Outcome measuresDegenerative manifestations of the lumbar spine were quantified; associations were studied in relation to the three primary outcomes: change of back+leg pain, change of function as measured by Roland-Morris questionnaire, and 1-year unsuccessful return to work (U-RTW).MethodsBy using a previously validated MRI protocol, a specialist in radiology, who had no access to clinical data, described the images. Associations were studied by linear and logistic regression with adjustment for previously identified prognostic factors for 1-year pain and function and for U-RTW.ResultsClinically, 43% of the patients had radiculopathy. Degenerative changes were prevalent with altered disc contours in 84%, high-intensity zones in 70%, and nerve root touch or impingement in 63% of the patients. MC was identified in 60% of the patients, 18% with Type 1 changes and 42% with Type 2 changes, Type 1 including both Type 1 and Type 1 in combination with Type 2. Patients with Type 1 changes reported more back pain and did not improve in pain or disability. They increased to include 30% of the patients with U-RTW at 1 year. Patients with Type 2 changes did not differ significantly from patients without MC but differed significantly from patients with Type 1 changes in all three outcomes. Other degenerative manifestations were not significantly associated with any of the three outcomes.ConclusionsThe only degenerative manifestation negatively associated with outcome was Type 1 MC that affected 18% of the cohort at baseline and implied an increased risk for no improvement in pain and function and for U-RTW, even after adjustment for other prognostic factors.     

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.     

腰椎终板Modic改变与腰椎间盘突出的相关性研究

[目的]探讨腰椎终板Modic改变与腰椎间盘突出的相关性及其意义.[方法]对628例患者(年龄14～85岁,平均50岁;男326例,女302例)腰椎MRI上L3、4～L5S1节段的Modic改变和腰椎间盘突出程度进行评估,统计两者的相关性.将单节段中、重度腰椎间盘突出者分为A组(仅该节段有Modic改变)和B组(任一节段均无Modic改变).统计两组下腰痛的发生率并采用疼痛视觉模拟评分(visual analogue scale,VAS)和Oswestry功能障碍指数评分(oswestry disability index,ODI)来评估腰痛程度.[结果]在1844个腰椎间盘中,椎间盘无突出组、轻度突出组、中度突出组和重度突出组Modic改变的发生率分别为6.83％、23.66％、42.72％和50.79％,差异有统计学意义(P＜0.01),Spearman相关检验表明Modic改变和腰椎间盘突出程度呈正相关(r=0.344,P＜0.01).A、B组下腰痛的发生率分别为59.32％和37.97％,差异有统计学意义(P＜0.01),但腰痛VAS评分和ODI评分差异无统计学意义(P＞0.05).[结论]腰椎终板Modic改变的发生与腰椎间盘突出程度呈正相关,当腰椎间盘突出合并Modic 改变特别是Ⅰ型改变时,下腰痛的发生率增加.     

Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography

The vertebral end-plate has been identified as a possible source of discogenic low back pain. MRI demonstrates end-plate (Modic) changes in 20–50% of patients with low back pain. The aim of this study was to investigate the association between Modic changes on MRI and discogenic back pain on lumbar discography. The MRI studies and discograms of 58 patients with a clinical diagnosis of discogenic back pain were reviewed and the presence of a Modic change was correlated with pain reproduction at 152 disc levels. Twenty-three discs with adjacent Modic changes were injected, 21 of which were associated with pain reproduction. However, pain was also reproduced at 69 levels where no Modic change was seen. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for a Modic change as a marker of a painful disc were 23.3%, 96.8%, 91.3% and 46.5% respectively. Modic changes, therefore, appear to be a relatively specific but insensitive sign of a painful lumbar disc in patients with discogenic low back pain. Received: 24 October 1997 Revised: 11 March 1998 Accepted: 21 April 1998     

Modic改变与腰痛关系的Meta分析

目的:探讨MRI上Modic改变与腰痛(low back pain,LBP)的相关性.方法:通过检索MEDLINE、EMBASE和Cochrane Controlled Clinical Trials Register等电子数据库,搜集符合要求的关于Modic改变的临床研究.提取的主要数据为(1)椎间盘造影术后发生疼痛(与原腰痛症状相似)的椎间盘数和其中发生Modic改变的椎间盘数;(2)椎间盘造影术后未发生疼痛(无腰痛和未发生与原腰痛症状相似的疼痛)的椎间盘数和其中发生Modic改变椎间盘数.将其带入Meta分析软件Review Manager 4.2(下载自Cochrane Libirary)中,在随机效应模型(Random-efiect model)下,用优势比(odds ratio,OR)计算结果,并进行敏感性分析.然后对Modic 改变的不同亚型进行对比分析.结果:经筛选,共6篇文献纳入Meta分析.6篇文献共纳入患者966例,椎间盘3026个.椎间盘造影术后疼痛组和无疼痛组相比,OR值为3.66(95%CI,1.46～9.15).椎间盘造影术后疼痛组1型Modic改变与2型Modic改变相比,OR值为1.31(95%CI,0.35～4.96).结论:和无腰痛患者相比,腰痛患者的Modic改变发生率更高;与2型Modie改变相比,尚没有证据表明1型Modic改变更易引起腰痛.     

腰椎疾病中Modic改变的相关研究进展

Modic改变(MCs)作为腰椎脊柱退变的影像特征受到越来越多的关注,随着研究的不断深入,发现不同腰椎疾病的患者多存在MCs,MCs与脊柱腰椎许多疾病逐渐联系起来.但目前的研究大多以终板MCs后引起的症状为主要方向.该文就椎体MCs与腰椎疾病的相关研究进展进行综述.     

腰痛患者下腰椎MRI上Modic改变与高信号区的发生情况及意义

目的:探讨腰痛患者下腰椎MRI上Modic改变与腰椎间盘局限性高信号区(high-intensity zone,HIZ)的发生情况及意义。方法:对511例腰痛患者(男263例,女248例;年龄20~70岁,平均48岁)腰椎MRI上L4/5和L5/S1节段的Modic改变和HIZ进行评估,统计两者及两者共存于同一节段的发生率。将有Modic改变和/或HIZ的椎间盘分为Modic组、Modic-HIZ组、HIZ组,比较3组的年龄、椎间盘高度、椎间盘退变程度、腰痛VAS和ODI评分。结果:511例患者中,190例(37.18%)209个节段有Modic改变,127例(24.85%)142个椎间盘有HIZ,18例(3.52%)18个节段出现Modic改变和HIZ共存的现象。HIZ组、Modic-HIZ组和Modic组分别为89例(124个节段)、18例(18个节段)、152例(191个节段),患者平均年龄分别为46.0±11.0岁、49.2±9.2岁和53.5±10.6岁,仅HIZ组和Modic组差异有统计学意义(P<0.05);椎间盘平均高度分别为9.93±2.46mm、8.73±2.45mm和7.57±2.21mm,组间两两比较差异有统计学意义(P<0.05);3组椎间盘退变分级均≥Ⅲ级,其中Ⅳ级+Ⅴ级退变率分别为48.39%、72.22%和75.92%,仅HIZ组与Modic组、Modic-HIZ组差异有统计学意义(P<0.05);腰痛VAS分别为8.39±0.32分、8.45±0.30分、8.61±0.54分,ODI评分分别为38.22±4.23分、38.45±4.16分、39.18±3.53分,3组间无统计学差异(P>0.05)。结论:腰痛患者下腰椎Modic改变和HIZ的发生率较高,但两者共存于同一节段的发生率低,当两者共存于同一节段时腰痛并不会明显加重。     

腰椎Modic改变的MRI定量与下腰痛相关性研究

目的：通过测定MRI T2正中矢状位像上腰椎终板Modic面积改变率分析Modic面积改变率大小与下腰痛程度的相关性。方法：2011年12月至2012年6月,对因下腰痛手术的70例患者进行疼痛和功能评分（JOA、VAS）和MRI检查,男39例,女31例;年龄29～72岁,平均（51.00±11.89）岁。70例中54例有腰椎终板Modic改变,将54例患者按Modic分型标准分为4型：Modic I型15例,ModicⅡ型21例,Modic Ⅲ型11例,Modic混和型7例（由于Modic混合型例数太少未纳入研究排除）.在MRI T2正中矢状位上测量各分型Modic改变面积及对应椎体的面积,两者面积比较得出Modic改变率,对于多节段Modic改变的求比率之和,观察JOA、VAS评分与Modic改变率之间的相关性。结果：ModicⅠ型改变率和JOA评分的相关系数r=-0.308,P=0.048<0.05,两者具有负相关性;与VAS评分的相关系数r=0.428,P=0.021<0.05,两者具有正相关性。ModicⅡ型改变率和JOA评分的相关系数r=-0.375,P=0.043<0.05,两者有负相关性;与VAS评分的相关系数r=0.352,P=0.041<0.05,两者具有正相关性。Modic Ⅲ型面积改变率与下腰痛程度无明显相关性（P>0.05）.结论：下腰痛患者中ModicⅠ、Ⅱ型面积改变率分别与下腰痛的疼痛程度有密切关系,ModicⅢ型面积改变率与下腰痛程度无明显相关性。     

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 × 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.     

腰椎退变性滑脱与终板Modic改变的相关性研究

目的 :观察腰椎退变性滑脱患者腰椎终板的Modic改变情况,分析退变性滑脱与终板Modic改变之间的关系。方法:回顾性分析108例腰椎退变性滑脱症患者的MRI资料,观察腰椎滑脱节段与非滑脱节段终板Modic改变各型的发生率及分布情况,分析终板Modic改变与腰椎滑脱的相关性。结果:108例腰椎退变性滑脱患者共540个椎体中,Ⅰ度滑脱149个,Ⅱ度滑脱17个;L1椎体滑脱10个,L2椎体26个,L3椎体41个,L4椎体46个,L5椎体43个。108例腰椎退变性滑脱患者共计1080个腰椎终板,351个终板存在Modic改变,其中ModicⅠ型172个(15.93%),Ⅱ型144个(13.33%),Ⅲ型3个(0.28%),混合型32个(2.96%);L1/2节段34个(3.15%),L2/3节段61个(5.65%),L3/4节段65个(6.02%),L4/5节段77个(7.13%),L5/S1节段114个(10.56%)。腰椎滑脱节段终板的Modic改变发生率为75.30%,非滑脱节段终板的Modic改变发生率为13.50%,差异有统计学意义(P0.05)。Spearman相关检验表明Modic改变和腰椎滑脱程度呈正相关(r=0.613,P0.05)。结论 :腰椎退变性滑脱患者滑脱节段终板的Modic改变多见,各型中以Ⅰ型多发,Modic改变的发生与滑脱程度呈正相关。     

不同术式治疗伴终板Modic改变的腰椎椎间盘突出症的疗效分析

目的 评估采用后路椎间盘镜下髓核摘除术(microendoscopic discectomy,MED)或后路椎间融合术(posterior lumbar interbody fusion,PLIF)治疗伴有终板Modic改变的腰椎椎间盘突出症患者的手术疗效.方法 回顾性分析2005年5月～2009年12月收治的73例伴...     

MRI上腰椎终板信号改变的影响因素分析———性别、体重、劳动量及吸烟与Modic改变的相关性

目的:探讨腰腿痛患者腰椎MRI上终板Modic改变的分布特点及其相关因素。方法:回顾性分析我院2009年2月～2010年10月收治的210例腰腿痛患者腰椎MRI中Modic改变的发生率及类型,并评估Modic改变与性别、体重、劳动量及吸烟等因素的相关性。结果:47例患者共58个椎间盘邻近椎板存在Modic改变,占入选患者的22.4%。其中男16例;女31例,ModicⅠ型、Ⅱ型和Ⅲ型的人数分别为16例、25例、6例,出现Modic改变的节段为L5/S1(28个)、L4/5(17个)、L3/4(9个)、L2/3(4个)。在肥胖人群中Modic改变的发生率高于正常体重和超重人群(P<0.05),重体力劳动者的发生率高于一般劳动者(P<0.05),劳动量和体重与ModicⅢ型改变有相关性(P<0.05),与其他分型无明显相关性(P>0.05)。吸烟与Modic改变无明显相关性(P>0.05)。结论:患者的性别、体重及劳动量等因素与Modic改变的发生具有相关性,生物力学损伤可能在Modic改变中发挥着重要作用。     

The prevalence of MRI-defined spinal pathoanatomies and their association with Modic changes in individuals seeking care for low back pain

Modic changes are of increasing interest, however their age and gender prevalence are not well described. To date, the associations between Modic changes and other common vertebral pathologies have only been described in small samples (n < 100). Our aim was, in a large dataset of people with low back pain, to (1) describe the prevalence of a range of spinal pathoanatomies, and (2) examine the association between Modic changes and stages of intervertebral disc (IVD) pathology. Common pathologies were coded from the lumbar spine MRIs from 4,233 consecutive people imaged while attending a publicly-funded secondary care outpatient facility in Denmark. Prevalence data were calculated by pathology and by vertebral level. Prevalence was also calculated by age and gender categories for Modic changes. The association between stages of IVD pathology (degeneration, bulge, herniation) and Modic changes at L4/5 and L5/S1 was expressed using prevalence ratios (PR) and 95% confidence intervals. The prevalence of Modic changes and IVD pathology were greater in L4/5 and L5/S1, compared with the upper lumbar spine. There was no significant gender difference in prevalence of Modic changes (p = 0.11). The prevalence of IVD disc pathology occurring concurrently with Modic changes ranged from 11.5 to 17.5% (Type 1), 8.5 to 12.7% (Type 2) and 17.1 to 25.6% (Type 1 and/or 2) while the prevalence occurring in the absence of Modic changes ranged from 0.5 to 6.3% (Type 1), 0.3 to 4.9 (Type 2), 0.8 to 9.7% (Type 1 and/or 2). The associated PR for IVD pathology occurring concurrently with Modic changes ranged from 1.8 to 29.2 (p < 0.05). The highest PR (29.2) was between degeneration and Modic changes, indicating that it is rare for Modic changes to occur without disc degeneration. Spinal pathoanatomy was common in this population, particularly IVD pathologies, and a consistent trend of a relatively greater prevalence in the lower lumbar spine was identified. Modic changes were more likely to be present among individuals with IVD pathology than without, which may implicate mechanical factors as being one aetiological pathway for Modic changes, although other hypotheses may equally explain this association.     

腰椎间盘突出症的误诊误治分析

1例误诊误治的腰椎间盘突出症患者,经胶原酶溶盘术后,疼痛加重.术后腰椎MRI示:“L3椎体以下水平椎管内见异常信号影填充,呈椎管内铸型样变.终丝马尾神经未见”,转入神经外科手术.术中可见病变位于L3～S1椎管髓外硬膜下,表面光滑,且与一支神经根相连,术后病理诊断:“神经鞘瘤并坏死”.通过分析该病例误诊误治的原因,提示:忽视临床症状和体征的重要性,忽视症状体征和影像学检查结果的吻合,对腰椎间盘突出症及其他腰腿痛疾病缺乏足够的认识是造成腰椎间盘突出症误诊误治的主要原因.