Modic Changes

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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). 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 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. Type 0- normal disc and vertebral body appearance, MC type I characterized by presence of bone marrow edema within vertebral body and hyper-vascularization, type II features fatty replacements of the red bone marrow within vertebral body and type III marked by 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.

Clinical Presentation

MC were found to be an independent predictor of intense and disabling low back pain episodes in women It may be advisable to attempt screening LBP clients for possible presence of MC and customize low back treatment for this subgroup early to avoid delays related to MRI availability.

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 since onset or later.
• failed exercise therapy attempts

Proposed risk factors for developing MC include:

• Body mass index (BMI) ranking of overweight or obese
• Advanced age
• Smoking

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

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.

Clinical Implicatins

client subgroup with MC is shown to be at moderate intensity on 6 month follow up despite treatment. This has implications on patient education, treatment and resource intensity planning, and risk /benefit ratio discussion when obtaining informed consent for physiotherapy.

In addition to anticipated extended duration and intensity of symptoms physiotherapists should consider 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 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 [27] (NRS) measures current back pain on a 0 to10 scale.
• The Roland Morris Disability Questionnaire [28] (RMQ) is a 23-item disability questionnaire with a 0 to 23 scale, measuring activity limitation.
• EuroQol [29,30] (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 their implications on practice should therefore be interpreted in broader context of particular client's physiotherapy goals.

Clinical Bottom Line- The Case

Kelly Wong, your potential client is a 51 year old, overweight (BMI- 29), otherwise healthy registered nurse (RN) working full time on Palliative Care Unit in the 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 this 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 fining 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 she loves caused her probshe likely caused her problems