Modic changes

Original Editor - Jaroslaw Pospiech Top Contributors - Jaroslaw Pospiech

Definition and Introduction

Modic changes (MC) are bone marrow lesions seen within a vertebral body on magnetic resonance imaging (MRI), suggestive of being associated with low back pain (LBP). [1] Their presence in clients receiving physiotherapy for low back pain may be of significance when discussing prognosis and benefits of exercise therapy.

Pathological Process

Research on the subject has been published since 1988 when MC were first identified by Dr. Michael Modic. Subsequent publications on the subject provided incremental gains in understanding of this new diagnostic entity. Though causes and mechanisms responsible for formation of MC are still poorly understood, progress is being made in linking his spinal phenotype with disc degeneration and LBP. This is significant because currently the value of MRI in management of LBP remains low due to lack of phenotypical features strongly correlating with clinical symptoms.

Modic changes classification consists of 4 types[2]:

  • Type 0 - normal disc and vertebral body appearance,
  • Type I - presence of bone marrow edema within vertebral body and hyper-vascularization,
  • Type II - fatty replacements of the red bone marrow within vertebral body.
  • Type III - subchondral bone sclerosis.

Same authors postulated that the types form a continuum along which the disease process will progress. Estimate of 18-24 months was provided for transition form type I to type II though others feel that much larger longitudinal studies are required to support this idea.

Fig 1. Modic changes. Modic type I change: hyperintense on T2WI (A↘), hypointense on T1WI (B↘) at inferior endplate of L4. Modic type II change: hyperintense on T2WI (C upper↘), hyperintense on T1WI (D upper↘) at superior endplate of L3. Modic type III change: hypointense on T2WI (C inferior↘), hypointense on T1WI (D inferior↘) at superior endplate of L4.[2]


Clinical Presentation

MC were found to be an independent predictor of intense and disabling low back pain episodes in women.[3]

The subgroup of LBP clients with MC seeking physiotherapy care may more often report:

  • Constant and nocturnal pain
  • Higher level of functional impairment
  • Lack of improvement at week 4 or later since onset
  • Failed exercise therapy attempts

Proposed risk factors for developing MC include:

  • Body mass index (BMI) ranking of overweight or obese[1][4]
  • Advanced age[1][2]
  • Smoking[1]

Prevalence of MC in clinical population was reported as 18-62%[5]

Physical examination findings may not be useful for differentiating between clients with and without MC and characteristic of degenerative disk disease.

Diagnostic Procedures

MRI is the method of diagnosing MC, however x-ray imaging is helpful in differentiating from spondyloarthropathy.[5]

Clinical Implications

LBP client subgroup with MC has shown to be still experiencing a moderate pain intensity on 6 month follow up despite treatment.[6] It may be advantageous to our patients if knowledge of association between MC and more persistent and disabling pain influences education, physiotherapy goal setting, resource intensity planning, as well as risk/benefit ratio discussion when obtaining informed consent for physiotherapy intervention.

In addition to anticipated extended duration and intensity of symptoms physiotherapists could benefit from considering a possibility that a mainstay non invasive treatment for LBP may not be more effective than activity reduction and rest. A single randomized controlled trial[7] evaluated comparative effects of rest and exercise in treatment off LPB with MC concluding that here was no statistically significant difference between groups on following outcome measures:

  • The numerical rating scale (NRS) measures current back pain on a 0 to 10 scale.
  • The Roland Morris Disability Questionnaire (RMQ) is a 23-item disability questionnaire with a 0 to 23 scale, measuring activity limitation.
  • EuroQol (EQ-5D) is a standardized instrument measuring health status-related quality of life consisting of a health status index (EQindex 0 to 1 scale) and a visual analogue scale (EQVAS 0 to 100 scale).
  • The global assessment transition questionnaire measures the patients' perceptions of the overall change in their back pain since the beginning of the study on a 7-point Likert scale.
  • Days lost from work due to pain.

Conversely, the study did not produce any evidence of harm due to standard exercise therapy and recommendation to maintain normal physical activity level when possible.

The results of this high quality study and its implications on practice should therefore be interpreted in broader context of a specific client's physiotherapy goals.

Clinical Bottom Line - The Case

Kelly Wong, your potential client is a 51 year old female, overweight (BMI - 29), otherwise healthy registered nurse (RN), working full-time at the Palliative Care Unit in a local hospital. You had the pleasure to meet her 4 weeks ago when in addition to standard pharmacological treatment, she received referral to physiotherapy and requisition for MRI from her general practitioner. Kelly shared with you that she had experienced LBP twice before in last 10 years with most recent onset 4 months ago. She decided to access healthcare due to symptom intensity and duration exceeding those she recalls form past flare ups. Kelly feels positive about her progress with physiotherapy treatment and attends her appointments regularly. Despite her undeniable compliance with your recommendations you were not able to document any significant changes on any of the standardized outcome measures you use with this client.

She just had a neurosurgical consult at which she was informed that her MRI confirmed DDD without neurological tissue compromise at L4-5 level. Her neurologist noted MC in both L4 and L5 vertebral bodies and briefly discussed significance of this finding with Kelly. She was relieved by the fact that surgery was not necessary but very concerned to find out that MC put her at greater risk of more significant symptoms and disability. She was advised to continue with current treatment and report any worsening or new symptoms.

Kelly's main concern at the moment is that her gratifying but physically taxing profession has caused her back problems and continues to damage her spine. She fears that she has no choice but to retrain and find a sedentary role, risking a considerable loss of income.

Kelly anxiously awaits your opinion.

What should we tell our client having updated our professional expertise with above review of existing scientific literature on the subject of LBP with MC? The message may be one of guarded optimism when it comes to addressing Kelly's main concern and it could sound somewhat like this:

" While it is true that your MRI findings of inflammatory process in vertebral bodies on top and bottom of the involved inter-vertebral disc explain well a slower response to treatment, higher pain intensity and duration than you experienced in the past, it is also true that the type of profession and physical activity level were not indicted as risk factors for developing or worsening this condition. There are reports of similar percentage of the type of problems you, unfortunately, have to deal with, being diagnosed in workers performing physically challenging and sedentary roles. Continuing with as many of normal activities as possible is still recommended for best long term outcomes. As your physiotherapist I would like to support you in your realistic and attainable goal of continuing in your RN role by:

  • carefully monitoring your functional status and symptoms, and communicating regarding safe sustainable level of work with your employer
  • promptly bringing any relevant changes or concerns to your doctor's attention
  • supervising and adjusting the mode and intensity of your non-aggravating therapeutic and conditioning exercises to maximize their beneficial physical and psychological effects
  • completing an ergonomic evaluation of your workplace and collaborating with you and your employer on implementing changes to minimize a number of aggravating tasks, while being able to effectively complete your work assignments
  • performing spinal mobilizations and soft tissue massage to provide temporary relief of symptoms at times of aggravation
  • helping to achieve self-reliance and independence with managing your low back pain
  • linking you with community and internet resources shown effective in assisting with attaining healthy body mass index.

Do you have any questions?"

Resources

What are Modic changes?

References

[1][2][4]
  1. 1.0 1.1 1.2 1.3 1.4 Mok FP, Samartzis D, Karppinen J, Fong DY, Luk KD, Cheung KM. 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. 2016 Jan 1;16(1):32-41.
  2. 2.0 2.1 2.2 2.3 Xia W, Liu C, Duan S, Xu S, Wang K, Zhu Z, Liu H. The influence of spinal-pelvic parameters on the prevalence of endplate Modic changes in degenerative thoracolumbar/lumbar kyphosis patients. PloS one. 2018 May 15;13(5):e0197470.
  3. Määttä JH, Wadge S, MacGregor A, Karppinen J, Williams FM. ISSLS prize winner: vertebral endplate (Modic) change is an independent risk factor for episodes of severe and disabling low back pain. Spine. 2015 Aug 1;40(15):1187-93.
  4. 4.0 4.1 Määttä JH, Wadge S, MacGregor A, Karppinen J, Williams FM. ISSLS prize winner: vertebral endplate (Modic) change is an independent risk factor for episodes of severe and disabling low back pain. Spine. 2015 Aug 1;40(15):1187-93.
  5. 5.0 5.1 Zhang YH, Zhao CQ, Jiang LS, Chen XD, Dai LY. Modic changes: a systematic review of the literature. European Spine Journal. 2008 Oct 1;17(10):1289-99.
  6. Fayad F, Lefevre-Colau MM, Rannou F, Quintero N, Nys A, Macé Y, Poiraudeau S, Drapé JL, Revel M. Relation of inflammatory modic changes to intradiscal steroid injection outcome in chronic low back pain. European Spine Journal. 2007 Jul 1;16(7):925-31.
  7. Jensen RK, Leboeuf-Yde C, Wedderkopp N, Sorensen JS, Manniche C. Rest versus exercise as treatment for patients with low back pain and Modic changes. A randomized controlled clinical trial. BMC medicine. 2012 Dec;10(1):22.