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Modic changes

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Modic changes are pathological changes in the bones of the spine, the vertebrae. These changes are situated in both the body of the vertebrae and in the end plate of the neighboring disc. Clinically, Modic Changes are often associated with constant lower back pain during the day, with peak pain occurring during the night and in the morning, coupled with back stiffness.[1][2]

Modic changes have been observed in approximately 6 % of the general adult population regardless of ethnicity.[3][4][5][6] Modic changes are rare in children and young adults. From the age of 25 to 40 years, there is a steep increase in their prevalence, which levels out about 40 years of age and is stable until 80+ years.[7] Modic changes are estimated to affect approximately 349 million of the adult population worldwide.[July 2021 est.][8]

Modic changes is a descriptive term used by radiologists in MRI evaluations. Conventional treatment including physiotherapy, chiropractic, acupuncture, and exercise for back pain, are ineffective in treating Modic changes. Conversely, long term antibiotic treatment has been shown to be an effective treatment if done effectively.

Signs and Symptomps

Several studies have shown a relationship between Modic changes in the spinal vertebrae and pain in the lower back. The last decade of studies on Modic changes have shown that Modic changes are associated with many treatment-resistant pain episodes and may result in patients entering a state of chronic low back pain. On average, individuals with Modic changes have had chronic pain for longer than individuals suffering from non-Modic changes back pain.[9][10]

Nightly Pain

Peak pain tends to occur late at night and morning and often late-night pain often results in poor and interrupted sleep.[11][12]

Morning pain and stiffness

Many individuals suffering from Modic changes, tend to have a high degree of morning stiffness in the back. The duration of the stiffness in the morning also tends to be longer compared to individuals with no Modic changes.[13][14]

Pain with lumbar hyperextension

Individuals with Modic changes experience exacerbation of pain when performing a hyperextension of the back.[15][16] A hyperextension of the back is the equivalent of performing an excessive backward bending of the back beyond its natural position.

Causes of back pain

In 20% of the patients we can identify an anatomical reason for the pain,[17] such as a lumbar disc herniation, or stenosis which is a reduction in the circumference of the spinal canal.

There might be reasons for back pain that cannot be identified on magnetic resonance imaging (MRI), for example muscular pain. But other areas like knee or hip pain do a lot better when it comes to diagnosing the exact reasons for the pain. The low percentage for back diagnosis might be due to the fact that the back is a much more complex and complicated structure.

Diagnosing modic changes

Modic changes are characterized on MRI (magnetic resonance imaging). The 3 Modic classifications were first described and defined by Dr. Michael Modic in 1988.

Normal bone contains internal scaffolding, called trabeculae. Red bone marrow, which produces blood cells, is located in the hollows between the trabeculae.

  • In Modic type 1 there is vascular development in the vertebral body, with findings of inflammation and edema, but no trabecular damage or marrow changes.
  • In Modic type 2 there are changes in bone marrow, with fatty replacement of formerly red, cellular marrow normally seen there. With Modic type 2 changes the marrow is substituted by visceral fat, the same kind of fat we have on our hips and bellies.
  • Modic Changes type 3 are less common, with fractures of the trabecular bone, along with trabecular shortening and widening.

Modic changes have been observed in dogs.[18]

Modic changes and pain

Many studies[which?] have examined the relationship between Modic changes in the vertebrae in the spine and pain in the lower back. There are inconclusive correlation between having Modic changes and experiencing pain in the lower back.

Studies[which?] have shown that patients with Modic changes are rather different from other patients with normal back pain. For example, 75 –80 % of patients with Modic changes have constant pain, which means they do not ever have a pain-free moment day or night. There might be fluctuations in the intensity, but no break from the pain.

Treatment

It is difficult to treat patients with Modic changes. Treatment that normally cures or help patients with normal back pain does not have effect on Modic changes or pain from Modic changes.

The recommended treatment for long lasting pain in the lower back is exercises, normally aided by the instruction of a qualified clinician. This is often followed by muscle strengthening and fitness training. This treatment does help the vast majority of normal back pain patients. But studies[which?] have shown that patients with Modic changes showed much higher pain score than patients with normal back pain, and most importantly that their pain increased with training. Other recent studies cited state no clinical difference between load reduction and rest or doing physio in relation to management or improvement of the condition. [19]

Research

The following section is controversial [20] with concerns over methodology and also potential conflicts of interest, in that some of the researchers are associated with a company which certifies clinicians to diagnose the condition for £200. It is true that a study has been published, and results are interesting. However, spinal clinicians and researchers are agreed that further studies are needed, specifically fully blinded randomised controlled trials, to confirm or refute claims made in the published study. At this stage patients with low back pain should not consent to anti-biotic treatment without proper assessment and investigation under the care of a qualified spine surgeon or physician.

Scientist Hanne Albert at a large back center in Europe, the Spine Centre of Southern Denmark led by Professor Claus Manniche, performed studies that have showed that 80% of patients with Modic changes type 1 are cured or much improved after a cheap and simple antibiotic treatment.[21]

However, a more recent double blind, placebo-controlled, multicenter study from 2019 shows no evidence for the effect of antibiotics on back pain with Modic changes.[22]

References

  1. ^ Jensen, Tue Secher; Karppinen, Jaro; Sorensen, Joan S.; Niinimäki, Jaakko; Leboeuf-Yde, Charlotte (November 2008). "Vertebral endplate signal changes (Modic change): a systematic literature review of prevalence and association with non-specific low back pain". European Spine Journal. 17 (11): 1407–1422. doi:10.1007/s00586-008-0770-2. PMC 2583186. PMID 18787845.
  2. ^ Arnbak, Bodil; Jurik, Anne G.; Jensen, Tue S.; Manniche, Claus (February 2018). "Association Between Inflammatory Back Pain Characteristics and Magnetic Resonance Imaging Findings in the Spine and Sacroiliac Joints". Arthritis Care & Research. 70 (2): 244–251. doi:10.1002/acr.23259. PMID 28426912. S2CID 21199975.
  3. ^ Mok, Florence P.S.; Samartzis, Dino; Karppinen, Jaro; Fong, Daniel Y.T.; Luk, Keith D.K.; Cheung, Kenneth M.C. (January 2016). "Modic changes of the lumbar spine: prevalence, risk factors, and association with disc degeneration and low back pain in a large-scale population-based cohort". The Spine Journal. 16 (1): 32–41. doi:10.1016/j.spinee.2015.09.060. PMID 26456851.
  4. ^ Kuisma, Mari; Karppinen, Jaro; Niinimäki, Jaakko; Ojala, Risto; Haapea, Marianne; Heliövaara, Markku; Korpelainen, Raija; Taimela, Simo; Natri, Antero; Tervonen, Osmo (May 2007). "Modic Changes in Endplates of Lumbar Vertebral Bodies: Prevalence and Association With Low Back and Sciatic Pain Among Middle-Aged Male Workers". Spine. 32 (10): 1116–1122. doi:10.1097/01.brs.0000261561.12944.ff. PMID 17471095. S2CID 37327051.
  5. ^ Jensen, Tue Secher; Karppinen, Jaro; Sorensen, Joan S.; Niinimäki, Jaakko; Leboeuf-Yde, Charlotte (November 2008). "Vertebral endplate signal changes (Modic change): a systematic literature review of prevalence and association with non-specific low back pain". European Spine Journal. 17 (11): 1407–1422. doi:10.1007/s00586-008-0770-2. PMC 2583186. PMID 18787845.
  6. ^ Kjaer, Per; Korsholm, Lars; Bendix, Tom; Sorensen, Joan S.; Leboeuf-Yde, Charlotte (September 2006). "Modic changes and their associations with clinical findings". European Spine Journal. 15 (9): 1312–1319. doi:10.1007/s00586-006-0185-x. PMC 2438570. PMID 16896838.
  7. ^ Albert, Hanne B.; Briggs, Andrew M.; Kent, Peter; Byrhagen, Andreas; Hansen, Christian; Kjaergaard, Karina (August 2011). "The prevalence of MRI-defined spinal pathoanatomies and their association with Modic changes in individuals seeking care for low back pain". European Spine Journal. 20 (8): 1355–1362. doi:10.1007/s00586-011-1794-6. PMC 3175840. PMID 21544595.
  8. ^ "World". The World Factbook. Central Intelligence Agency. 26 May 2022. Retrieved 6 June 2022.
  9. ^ Bailly, F.; Maigne, J.-Y.; Genevay, S.; Marty, M.; Gandjbakhch, F.; Rozenberg, S.; Foltz, V. (March 2014). "Inflammatory pain pattern and pain with lumbar extension associated with Modic 1 changes on MRI: a prospective case–control study of 120 patients". European Spine Journal. 23 (3): 493–497. doi:10.1007/s00586-013-3036-6.
  10. ^ Arnbak, Bodil; Jurik, Anne G.; Jensen, Tue S.; Manniche, Claus (February 2018). "Association Between Inflammatory Back Pain Characteristics and Magnetic Resonance Imaging Findings in the Spine and Sacroiliac Joints". Arthritis Care & Research. 70 (2): 244–251. doi:10.1002/acr.23259.
  11. ^ Bailly, F.; Maigne, J.-Y.; Genevay, S.; Marty, M.; Gandjbakhch, F.; Rozenberg, S.; Foltz, V. (March 2014). "Inflammatory pain pattern and pain with lumbar extension associated with Modic 1 changes on MRI: a prospective case–control study of 120 patients". European Spine Journal. 23 (3): 493–497. doi:10.1007/s00586-013-3036-6.
  12. ^ Arnbak, Bodil; Jurik, Anne G.; Jensen, Tue S.; Manniche, Claus (February 2018). "Association Between Inflammatory Back Pain Characteristics and Magnetic Resonance Imaging Findings in the Spine and Sacroiliac Joints". Arthritis Care & Research. 70 (2): 244–251. doi:10.1002/acr.23259.
  13. ^ Bailly, F.; Maigne, J.-Y.; Genevay, S.; Marty, M.; Gandjbakhch, F.; Rozenberg, S.; Foltz, V. (March 2014). "Inflammatory pain pattern and pain with lumbar extension associated with Modic 1 changes on MRI: a prospective case–control study of 120 patients". European Spine Journal. 23 (3): 493–497. doi:10.1007/s00586-013-3036-6.
  14. ^ Arnbak, Bodil; Jurik, Anne G.; Jensen, Tue S.; Manniche, Claus (February 2018). "Association Between Inflammatory Back Pain Characteristics and Magnetic Resonance Imaging Findings in the Spine and Sacroiliac Joints". Arthritis Care & Research. 70 (2): 244–251. doi:10.1002/acr.23259.
  15. ^ Bailly, F.; Maigne, J.-Y.; Genevay, S.; Marty, M.; Gandjbakhch, F.; Rozenberg, S.; Foltz, V. (March 2014). "Inflammatory pain pattern and pain with lumbar extension associated with Modic 1 changes on MRI: a prospective case–control study of 120 patients". European Spine Journal. 23 (3): 493–497. doi:10.1007/s00586-013-3036-6.
  16. ^ Arnbak, Bodil; Jurik, Anne G.; Jensen, Tue S.; Manniche, Claus (February 2018). "Association Between Inflammatory Back Pain Characteristics and Magnetic Resonance Imaging Findings in the Spine and Sacroiliac Joints". Arthritis Care & Research. 70 (2): 244–251. doi:10.1002/acr.23259.
  17. ^ ???
  18. ^ Gendron, Doherr, Gavin; et al. (2012). "Magnetic Resonance Imaging Characterization of Vertebral Endplate Changes in the Dog". Veterinary Radiology & Ultrasound. 53 (1): 50–56. doi:10.1111/j.1740-8261.2011.01861.x. PMID 21992691.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ Jensen, Rikke Krüger (23 September 2011). "Rehabilitation of Patients with Modic Changes in the Lumbar Spine - a Randomized Controlled Trial".
  20. ^ "Back pain breakthrough crippled by doubt". 2013-06-16.
  21. ^ Albert HB, Sorensen JS, Christensen BS, Manniche C (2013). "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". European Spine Journal. 22 (4): 697–707. doi:10.1007/s00586-013-2675-y. PMC 3631045. PMID 23404353.
  22. ^ Bråten LCH (Aug 2019). "Efficacy of antibiotic treatment in patients with chronic low back pain and Modic changes (the AIM study): double blind, randomised, placebocontrolled, multicentre trial."". BMJ. 367: l5654. doi:10.1136/bmj.l5654. PMC 6812614. PMID 31619437.

Bibliography

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