Prevalence of Modic changes related to lower back pain

Issue: Issue 6 2005

EuroSpine 2005 [icon] Modic changes on MRI, especially Type 1, relate closely to lower back pain, and Modic changes increase dramatically after a lumbar disc herniation, according to a study.

Danish researchers reported that 60% of patients with Modic changes on MRI experienced low back pain; 20% of patients without Modic changes had pain (P<.0001). Overall, MRIs taken at baseline revealed Modic changes for 26% of patients, but this number increased to 49% at 14-month follow-up. Type 1 Modic changes were at a larger risk for correlating to pain than Type 2 Modic changes, but this was not statistically significant.

Modic changes are signs of signal intensity in the vertebral endplate associated with degenerative disc disease.

“[The results were] very surprising to us … what is happening at the 14th month is almost a threefold increase in Type 1 changes, a slight increase in the Type 2 and a slight increase in the Type 3 changes,” said Hanne Albert, PhD, PT, MPH, of the University of Southern Denmark, who presented the results at the 2005 Annual Congress of the Spine Society of Europe (EuroSpine 2005).

“If you have Modic changes on the MRI, the risk of having lumbar pain was more than sixfold, an odds ratio (OR) of 6.1,” she said.

Lower back pain patients

The study involved 181 patients, aged 18 to 85 years, treated at the Back Centre Funen, a University of Southern Denmark specialist center. At 14-month follow-up, 166 patients remained.

Modic Type 1 changes are seen on a T1-weighted MRI as areas of low signal intensity extending from the vertebral endplates.

Courtesy of Hanne Albert

All patients had radicular pain of dermatonal distribution below the knee and a current leg pain intensity of 3 that lasted for two to 52 weeks. Patients were randomized into two active conservative treatment regimes for eight weeks.

A radiologist evaluated the MRIs at baseline and at 14 months, using a validated evaluation protocol, according to the abstract. At baseline, 65% of patients had three or four positive root compression signs, and 30% had two positive root compression signs.

To determine the relationship between a previous herniation and Modic changes on MRI, Albert and her colleague, Claus Manniche, MD, used a classification from the American Society of Radiologists, separating disc herniations into types. “Of the patients who had normal discs, not one single person developed Modic changes,” Albert said.

However, of those patients with lesions, 47% of patients with a bulge, 56% of focal protrusion patients, 31% of broad-based protrusion patients, 56% of extrusion patients and 63% of sequestrian patients developed Modic changes at follow-up.

Researchers found that the patients with Modic changes at baseline developed new Type I changes after herniation. In the 12 months after treatment ended, 12 patients had surgery, mainly for new herniations. Nine patients developed Modic changes; less than 50% of patients who did not have surgery developed Modic changes (OR 3.5, P<.055).

During the 14-month follow-up, Albert and Manniche also tested pain at forward and backward bending and conducted the springing tests, concluding that these may be clinical tests to detect Modic changes.

They found that patients with a previous herniation had an OR of 4.0 Modic change if the springing test was positive (P<.0003) and a 1.7 OR for Modic changes if pain at forward and backward bending test, which was not statistically significant.

Patients with a previous herniation and low back pain presented with a 14.0 OR in the springing test and a 7.1 OR in the pain at forward and backward bending test. This was highly significant.

For more information:

Albert HB, Manniche C. Modic changes, the prevalence and relationship to lumbar disc herniation. A possible new pathogenesis of low back pain. #12. Presented at EuroSpine 2005. Sept. 21-24, 2005. Barcelona.