Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy

Purpose

Modic type 1 changes/bone edema in the vertebrae are present in 6 % of the general population and 35–40 % of the low back pain population. It is strongly associated with low back pain. The aim was to test the efficacy of antibiotic treatment in patients with chronic low back pain (>6 months) and Modic type 1 changes (bone edema).

Methods

The study was a double-blind RCT with 162 patients whose only known illness was chronic LBP of greater than 6 months duration occurring after a previous disc herniation and who also had bone edema demonstrated as Modic type 1 changes in the vertebrae adjacent to the previous herniation. Patients were randomized to either 100 days of antibiotic treatment (Bioclavid) or placebo and were blindly evaluated at baseline, end of treatment and at 1-year follow-up.

Outcome measures

Primary outcome, disease-specific disability, lumbar pain. Secondary outcome leg pain, number of hours with pain last 4 weeks, global perceived health, EQ-5D thermometer, days with sick leave, bothersomeness, constant pain, magnetic resonance image (MRI).

Results

144 of the 162 original patients were evaluated at 1-year follow-up. The two groups were similar at baseline. The antibiotic group improved highly statistically significantly on all outcome measures and improvement continued from 100 days follow-up until 1-year follow-up. At baseline, 100 days follow-up, 1-year follow-up the disease-specific disability-RMDQ changed: antibiotic 15, 11, 5.7; placebo 15, 14, 14. Leg pain: antibiotics 5.3, 3.0, 1.4; placebo 4.0, 4.3, 4.3. Lumbar pain: antibiotics 6.7, 5.0, 3.7; placebo 6.3, 6.3, 6.3. For the outcome measures, where a clinically important effect size was defined, improvements exceeded the thresholds, and a trend towards a dose–response relationship with double dose antibiotics being more efficacious.

Conclusions

The antibiotic protocol in this study was significantly more effective for this group of patients (CLBP associated with Modic I) than placebo in all the primary and secondary outcomes.     

Relation of inflammatory modic changes to intradiscal steroid injection outcome in chronic low back pain

The purpose of this study was to analyze the association between the severity of inflammatory endplate changes (Modic) on MRI and the clinical response to intradiscal injection of corticosteroids (IDIC) in chronic low back pain (LBP). A total of 74 patients with LBP and inflammatory Modic changes who showed no response to 3-month conservative treatment received lumbar IDIC. Two spine specialists and a radiologist assessed independently the endplate marrow changes of the injected discs. We classified patients with a pure edema endplate changes on MRI as Modic type I (n = 37); those with a mixture of Modic type I and type II changes but predominantly edema changes as Modic I-2 (n = 25) and those with predominantly fatty changes as Modic II-1 (n = 12). The primary outcome was the change in LBP intensity between baseline and 1 month after IDIC, as measured on a visual analog scale (range 0-100 mm). At 1 month, reduction in pain score was significantly higher in the Modic I and Modic I-2 groups than in the Modic II-1 group (30.2 +/- 26.6 and 29.4 +/- 21.5 vs 5.3 +/- 25.5; P = 0.009 and P = 0.017, respectively). At 3 and 6 months, IDIC tended to be more effective in the Modic I and Modic I-2 groups but not significantly. No complications such as infection or hematoma were reported. IDIC could be a short-term efficient treatment for patients with chronic LBP and predominantly inflammatory endplate changes when conservative treatments have failed.     

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。     

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.     

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.     

Inflammatory pain pattern and pain with lumbar extension associated with Modic 1 changes on MRI: a prospective case–control study of 120 patients

Purpose

To compare, in a case–control study, clinical characteristics of patients with low back pain (LBP) with and without Modic 1 signal changes on MRI.

Methods

Patients with chronic non-specific LBP and a recent (<6 months) MRI were prospectively screened and included in Modic 1 group or control group. Patients in control group were age- and gender-matched with patients with Modic 1 group. Pain characteristics, including night pain and worse pain on waking and morning stiffness, were recorded. The presence of at least one of these three characteristics indicated an inflammatory pain pattern. Patients were evaluated by questionnaires and physical examination (including lumbar range of motion). Data were analyzed by univariate and multivariate analyses.

Results

120 patients were included (60 in each group). The groups did not differ in sedentary work (p = 0.25), morning stiffness for >60 min (p = 0.19), waking at night (p = 0.08), worse pain on waking (p = 0.09), back stiffness (p = 0.12), or pain with flexion (p = 0.87). Modic 1 patients more frequently exhibited an inflammatory pain pattern (p = 0.006), worse pain with lumbar extension (p < 0.005) and responded better to oral steroids (p = 0.004) than did controls. On multivariate analysis, Modic 1 changes were associated with sedentary work [odds ratio 0.22 (95 % confidence interval 0.05–0.93)], pain with lumbar extension [11.2 (3.1–40.4)] and an inflammatory pain pattern [4.5 (1.2–16.9)].

Conclusions

Characteristics of patients with LBP and Modic 1 changes on MRI consist of an inflammatory pain pattern and pain with lumbar extension. Level of evidence 3b.     

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.     

Obesity in children with low back pain: implications with imaging phenotypes and opioid use

BACKGROUND CONTEXTLow back pain (LBP) is common in children and adolescents, carrying substantial risk for recurrence and continuation into adulthood. Studies have linked obesity to the development of pediatric LBP; however, its association with lumbar spine degeneration, alignment parameters, and opioid use remains debated.PURPOSEConsidering the increasing prevalence of pediatric obesity and LBP and the inherent issues with opioid use, this study aimed to assess the association of obesity with lumbar spine degeneration, spinopelvic alignment, and opioid therapy among pediatric patients.STUDY DESIGN/SETTINGA retrospective study of pediatric patients presenting to a single institute with LBP and no history of spine deformity, tumor, or infection was performed.PATIENT SAMPLEA totasl of 194 patients (mean age: 16.7±2.3 years, 45.3% male) were included, of which 30 (15.5%) were obese.OUTCOME MEASURESPrevalence of imaging phenotypes and opioid use among obese to nonobese pediatric LBP patients. Magnetic resonance and plain radiographic imaging were evaluated for degenerative phenotypes (disc bulging, disc herniation, disc degeneration [DD], high-intensity zones [HIZ], disc narrowing, Schmorl's nodes, endplate phenotypes, Modic changes, spondylolisthesis, and osteophytes). Lumbopelvic parameters including lumbar lordosis, pelvic tilt, sacral slope, pelvic incidence and pelvic incidence-lumbar lordosis (PI–LL) mismatch were also examined.METHODSDemographic and clinical information was recorded, including use of opioids. The associations between obesity and lumbar phenotypes or opiod use were assessed by multiple regression models.RESULTSBased on multivariate analysis, obesity was significantly associated with the presence of HIZ (adjusted OR: 5.36, 95% CI: 1.30 to 22.09). Further analysis demonstrated obesity (adjusted OR: 3.92, 95% CI: 1.49 to 10.34) and disc herniation (OR: 4.10, 95% CI: 1.50 to 11.26) were associated with opioid use, independent of duration of symptoms, other potential demographic determinants, and spinopelvic alignment.CONCLUSIONSIn pediatric patients, obesity was found to be significantly associated with HIZs of the lumbar spine, while disc herniation and obesity were associated with opioid use. Spinopelvic alignment parameters did not mitigate any outcome. This study underscores that pediatric obesity increases the risk of developing specific degenerative spine changes and pain severity that may necessitate opioid use, emphasizing the importance of maintaining healthy body weight in promoting lumbar spine health in the young.     

Is the development of Modic changes associated with clinical symptoms? A 14-month cohort study with MRI

Purpose

Modic changes (MCs) have been suggested to be a diagnostic subgroup of low back pain (LBP). However, the clinical implications of MCs remain unclear. For this reason, the aims of this study were to investigate how MCs developed over a 14-month period and if changes in the size and/or the pathological type of MCs were associated with changes in clinical symptoms in a cohort of patients with persistent LBP and MCs.

Methods

Information on LBP intensity and detailed information from MRI on the presence, type and size of MCs was collected at baseline and follow-up. Changes in type (Type I, II, III and mixed types) and size of MCs were quantified at both time points according to a standardised evaluation protocol. The associations between change in type, change in size and change in LBP intensity were calculated using odds ratios (ORs).

Results

Approximately 40 % of the MCs followed the expected developmental path from Type I (here Type I or I/II) to Type II (here Type II or II/III) or Type I to Type I/II. In general, the bigger the size of the MC at baseline, the more likely it was that it remained unchanged in size after 14 months. Patients who had MC Type I at both baseline and 14-month follow-up were less likely to experience an improvement in their LBP intensity as compared to patients who did not have Type I changes at both time points (OR 7.2, CI 1.3–37). There was no association between change in size of MCs Type I and change in LBP intensity.

Conclusions

The presence of MCs Type I at both baseline and follow-up is associated with a poor outcome in patients with persistent LBP and MCs.     

Retrolisthesis and lumbar disc herniation: a preoperative assessment of patient function.

BACKGROUND CONTEXT: Retrolisthesis is relatively rare but when present has been associated with increased back pain and impaired back function. Neither the prevalence of this condition in individuals with lumbar disc herniations nor its possible relation to preoperative back pain and dysfunction has been well studied. PURPOSE: The purposes of this study were as follows: (1) to determine the prevalence of retrolisthesis (alone or in combination with other degenerative conditions) in individuals with confirmed L5-S1 disc herniation who later underwent lumbar discectomy; (2) to determine if there is any association between retrolisthesis and degenerative changes within the same vertebral motion segment; and (3) to determine the relation between retrolisthesis (alone or in combination with other degenerative conditions) and preoperative low back pain, physical function, and quality of life. STUDY DESIGN/SETTING: Cross-sectional study. PATIENT SAMPLE: A total of 125 individuals were identified for incorporation into this study. All patients had confirmed L5-S1 disc herniation on magnetic resonance imaging (MRI) and later underwent L5-S1 discectomy. All patients were enrolled in the Spine Patient Outcomes Research Trial (SPORT) study; data were obtained from the multi-institutional database comprised of SPORT patients from across the United States. OUTCOME MEASURES: Retrolisthesis, degenerative change on MRI, and Modic changes. METHODS: MRI scans of the lumbar spine were assessed at spinal level L5-S1 for all 125 patients. Retrolisthesis was defined as posterior subluxation of 8% or more. Disc degeneration was defined as any loss of disc signal on T2 imaging. Modic changes were graded 1 to 3 and collectively classified as vertebral endplate degenerative changes. The presence of facet arthropathy and ligamentum flavum hypertrophy was classified jointly as posterior degenerative changes. RESULTS: The overall incidence of retrolisthesis at L5-S1 in our study was 23.2%. Retrolisthesis combined with posterior degenerative changes, degenerative disc disease, or vertebral endplate changes had incidences of 4.8%, 16%, and 4.8% respectively. The prevalence of retrolisthesis did not vary by sex, age, race, smoking status, or education level when compared with individuals with normal sagittal alignment. However, individuals with retrolisthesis were more likely to be receiving workers' compensation than those without retrolisthesis. Increased age was found to be associated with individuals having vertebral endplate degenerative changes (both alone and in conjunction with retrolisthesis) and degenerative disc disease. Individuals who had retrolisthesis with concomitant vertebral endplate degenerative changes were more often smokers and had no insurance. The presence of retrolisthesis was not associated with an increased incidence of having degenerative disc disease, posterior degenerative changes, or vertebral endplate changes. No statistical significance was found between the presence of retrolisthesis on the degree of patient preoperative low back pain and physical function. Patients with degenerative disc disease were found to have increased leg pain compared with those patients without degenerative disc changes. CONCLUSIONS: We found no significant relationship between retrolisthesis in patients with L5-S1 disc herniation and worse baseline pain or function. It is possible that the contribution of pain or dysfunction related to retrolisthesis was far overshadowed by the presence of symptoms caused by the concomitant disc herniation. It remains to be seen whether retrolisthesis will affect outcome after discectomy in these patients.     

Predictors of new vertebral endplate signal (Modic) changes in the general population

Vertebral endplate signal changes (VESC), also known as Modic changes, have been reported to be associated with low back pain (LBP). However, little is known about predisposing factors for the development of new VESC. The aim of this study was to investigate the predictive value of lifestyle factors and disc-related magnetic resonance imaging (MRI) findings in relation to the development of new VESC. This prospective observational study included 344 people from the Danish general population who had an MRI and completed LBP questionnaires at the age of 40 and again at 44 years. Potential predictors of new VESC were female gender, disc-related MRI findings (disc degeneration, disc bulges, disc herniation, and other endplate changes) and lifestyle factors [high physical work or leisure activity, high body mass index (BMI), and heavy smoking]. Bivariate and multivariate logistic regressions were used to identify predictors of new VESC. New VESC at the age of 44 appeared in 67 of the 344. The majority (84%) of these new signal changes were type 1 VESC and almost half (45%) were only in the endplate and did not extend into the vertebral body. In the multivariate analysis, lumbar disc levels with disc degeneration, bulges or herniations at 40 were the only predictors of new VESC at age 44. Therefore, the development of new VESC at the age of 44 appears to be based on the status and dynamics of the disc, rather than being the result of gender or lifestyle factors such as smoking and physical load.     

MRI features of the psoas major muscle in patients with low back pain

Purpose

The purpose was to investigate the changes of the psoas major muscles (PM) cross-sectional area (CSA) and fat infiltration in the PM and to investigate the association between the morphology of the PM and expression of the degenerative changes of lumbar spine in patients with low back pain (LBP).

Methods

T2-weighted scans for measurements of the CSA and analysis of fat infiltration were performed on 42 patients and 49 controls using a 1.5 Tesla MR system. For a quantitative analysis of fat tissue infiltration a 4-grade visual scale was used.

Results

Patients had bigger CSA of the PM than controls at the levels of L3/L4 and L4/L5 intervertebral disc (P < 0.05). Patients with apparent degenerative changes of the lumbar spine had smaller CSA of the PM compared to the patients without apparent changes at the levels of L3/L4 and L4/L5 (P < 0.05). At the levels of L4/L5 and L5/S1 patients with present Modic changes in the lumbar vertebral bodies showed smaller CSA of the PM compared to the patients without Modic changes (P < 0.05). However, CSA of the PM in the patients with degenerative changes of lumbar spine and Modic changes was still bigger than the one of the controls. At all analyzed levels correlation between CSAs of the PM and fat infiltration of the lumbar paraspinal muscles was negative.

Conclusion

Results suggest increased activity of the PM in LBP patients but PM also remains active regardless of the presence of degenerative and Modic changes of the lumbar spine.     

Is diabetes mellitus a risk factor for modic changes?: A novel model to understand the association between intervertebral disc degeneration and end-plate changes

ObjectiveMechanical failure and inflammatory response are two mechanisms proposed for the development of Modic changes, even though they have not been clearly demonstrated, yet. Diabetes mellitus (DM) harbors micro- and macroangiopathy due to the irreversible glycation of proteins, increased oxidative stress, and inflammation. In this study, we aimed to identify whether DM was associated with Modic changes in terms of inflammatory process.MethodsWe conducted a cross-sectional study using our prospectively collected retrospective database of patients with DM who had visited the outpatient clinics at a university hospital. In 3999 patients with DM, 266 had spinal MRI due to cervical, thoracic or low back pain. We included patients, who had lumbar spine MRIs due to low back and/or leg pain and blood draw for HbA1c simultaneously. We analyzed 48 symptomatic patients with DM. We had also symptomatic patients without DM as control group.ResultsSevere intervertebral disc degeneration was significantly associated with Modic changes. Severe intervertebral disc degeneration had no significant association with serum HbA1c percentage and DM duration. Patients with Modic changes at any lumbar level had significantly higher HbA1c percentages, and longer duration of DM than those without Modic changes. Symptomatic patients with DM had higher rates of Modic changes compared to symptomatic ones without DM.ConclusionsSeverity and duration of DM were both closely associated with Modic changes, whereas the association of severity and duration of DM with severe intervertebral disc degeneration remained unclear.     

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 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.     

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.     

Disc degeneration of cervical spine on MRI in patients with lumbar disc herniation: comparison study with asymptomatic volunteers

An association between progression of cervical disc degeneration and that of lumbar disc degeneration has been considered to exist. To date, however, this association has not yet been adequately studied. Age-related changes in the cervical intervertebral discs were evaluated by magnetic resonance imaging (MRI) in patients with lumbar disc herniation, and compared with the MRI findings of healthy volunteers without lower back pain. The purpose of this study was to clarify whether the prevalence of asymptomatic cervical disc degeneration is higher in patients with lumbar disc herniation than in healthy volunteers. The study was conducted on 51 patients who were diagnosed as having lumbar disc herniation and underwent cervical spine MRI. The patients consisted of 34 males and 17 females ranging in age from 21–83 years (mean 46.9 ± 14.5 years) at the time of the study. The control group was composed of 113 healthy volunteers (70 males and 43 females) aged 24–77 years (mean 48.9 ± 14.7 years), without neck pain or low back pain. The percentage of subjects with degenerative changes in the cervical discs was 98.0% in the lumbar disc herniation group and 88.5% in the control group (p = 0.034). The presence of lumbar disc herniation was associated significantly with decrease in signal intensity of intervertebral disc and posterior disc protrusion in the cervical spine. None of the MRI findings was significantly associated with the gender, smoking, sports activities, or BMI. As compared to healthy volunteers, patients with lumbar disc herniation showed a higher prevalence of decrease in signal intensity of intervertebral disc and posterior disc protrusion on MRI of the cervical spine. The result of this study suggests that disc degeneration appears to be a systemic phenomenon.