Do vertebral endplate signal changes (modic changes) hurt? A systematic review

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1 Do vertebral endplate signal changes (modic changes) hurt? A systematic review Poster No.: C-2418 Congress: ECR 2010 Type: Scientific Exhibit Topic: Musculoskeletal Authors: T. S. Jensen 1, P. Kent 1, J. Karppinen 2, J. S. Sorensen 1, J. Keywords: DOI: Niinimäki 2, C. Leboeuf-Yde 1 ; 1 Ringe/DK, 2 Oulu/FI Systematic review, Modic changes, low back pain /ecr2010/C-2418 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 11

2 Purpose Low back pain (LBP) is a common condition in the general population. In the Nordic countries, approximately 50% of adults will have experienced LBP within the last year. [12] The majority of patients with LBP (up to 80%) will be given the diagnosis of "nonspecific" low back pain (NSLBP) based on the lack of pathoanatomical findings. [5,19] However, it is likely that LBP is not one condition, but the predominant symptom of a number of, as yet, unidentified disorders in one or several of the potentially painful structures in the spine. One of these potentially painful structures is the vertebral endplate. The awareness that vertebral endplate signal changes (Modic changes), see Figures 1 and 2, are a possible source of LBP comes from a recent systematic review published by this group, which investigated the association between Modic changes and LBP.[7] The purposes of this study were to bring the systematic review up to date and to quantify the association between vertebral endplate signal changes (Modic changes) and non-specific low back pain (NSLBP). Images for this section: Page 2 of 11

3 Fig. 1 Page 3 of 11

4 Fig. 2 Page 4 of 11

5 Methods and Materials MEDLINE, EMBASE, and SveMED databases were searched for the period 1984 to November An additional search was made in MEDLINE from November 2007 to June The following terms (and synonyms) were used as search criteria: MRI Vertebral endplate Lumbar spine For the purpose of inclusion of relevant articles we defined Modic changes as "signalchanges seen on MRI in the vertebral bone, extending from the endplate".[8] Articles were included which investigated the association between Modic changes and NSLBP and reported sufficient data to construct two-by-two tables. Articles on specific low back pain conditions (e.g. spondylodiscitis, malignancy, spondyloarthropathy) were excluded. A standardised data collection and quality assessment were performed.[7] To estimate the association between VESC and NSLBP, two-by-two tables were created and exact odds ratios were calculated with 95% confidence intervals (CI). Meta-analysis was performed on homogeneous studies. Results In all, 1178 (Medline), 964 (Embase), and 15 (SveMed) abstracts and articles were retrieved. Of these, 13 full text articles met the inclusion criteria. [1-3,6,9-11,13,14,17,18,20,21] A statistically significant positive association between VESC and NSLBP was found in 10 of 13 studies from the general, working, and clinical populations with odds ratios ranging from 2.0 to 27.9 (Figure 1). The remaining three studies showed statistically insignificant associations. A meta-analysis was not performed on the included 13 studies because of heterogeneity in relation to study sample, outcome of LBP, and age. The eight studies that used provocative discography as an outcome for LBP were homogenous in relation to study sample and age distribution. Of the total number of discs included (n=4457) in the eight studies, 447 (10%) were reported to have adjacent Modic changes. The median prevalence of pain on discography was more than twice as high for discs with adjacent Modic changes as compared to discs without Modic changes (Figure 2). A meta-analysis of the eight discography studies included in the Page 5 of 11

6 review showed a pooled odds ratio between Modic changes and pain on discography of 4.50 (CI ) (Figure 3). Images for this section: Fig. 1 Page 6 of 11

7 Fig. 2 Page 7 of 11

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9 Conclusion The results from this systematic review show that Modic changes in the lumbar spine are associated with pain and therefore should be noted routinely in MRI reports. References 1. Albert HB, Manniche C: Modic changes following lumbar disc herniation. Eur Spine J 2007, 16: Braithwaite I, White J, Saifuddin A, Renton P, Taylor BA: Vertebral endplate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography. Eur Spine J 1998, 7: Cvitanic OA, Schimandle J, Casper GD, Tirman PF: Subchondral marrow changes after laser diskectomy in the lumbar spine: MR imaging findings and clinical correlation. AJR Am J Roentgenol 2000, 174: de Roos A, Kressel H, Spritzer C, Dalinka M: MR imaging of marrow changes adjacent to end plates in degenerative lumbar disk disease. AJR Am J Roentgenol 1987, 149: Deyo RA, Rainville J, Kent DL: What can the history and physical examination tell us about low back pain? JAMA 1992, 268: Ito M, Incorvaia KM, Yu SF, Fredrickson BE, Yuan HA, Rosenbaum AE: Predictive signs of discogenic lumbar pain on magnetic resonance imaging with discography correlation. Spine 1998, 23: Jensen TS, Karppinen J, Sorensen JS, Niinimaki J, Leboeuf-Yde C: Vertebral endplate signal changes (Modic change): a systematic literature review of prevalence and association with non-specific low back pain. Eur Spine J 2008, 17: Jensen TS, Sorensen JS, Kjaer P: Intra- and interobserver reproducibility of vertebral endplate signal (modic) changes in the lumbar spine: the Nordic Modic Consensus Group classification. Acta Radiol 2007, 48: Kjaer P, Leboeuf-Yde C, Korsholm L, Sorensen JS, Bendix T: Magnetic resonance imaging and low back pain in adults: a diagnostic imaging study of 40-year-old men and women. Spine 2005, 30: Kokkonen SM, Kurunlahti M, Tervonen O, Ilkko E, Vanharanta H: Endplate degeneration observed on magnetic resonance imaging of the lumbar spine: correlation with pain provocation and disc changes observed on computed tomography diskography. Spine 2002, 27: Kuisma M, Karppinen J, Niinimaki J, Ojala R, Haapea M, Heliovaara M et al.: Modic changes in endplates of lumbar vertebral bodies: prevalence Page 9 of 11

10 and association with low back and sciatic pain among middle-aged male workers. Spine 2007, 32: Leboeuf-Yde C, Klougart N, Lauritzen T: How common is low back pain in the Nordic population? Data from a recent study on a middle-aged general Danish population and four surveys previously conducted in the Nordic countries. Spine 1996, 21: Lei D, Rege A, Koti M, Smith FW, Wardlaw D: Painful disc lesion: can modern biplanar magnetic resonance imaging replace discography? J Spinal Disord Tech 2008, 21: Lim CH, Jee WH, Son BC, Kim DH, Ha KY, Park CK: Discogenic lumbar pain: association with MR imaging and CT discography. Eur J Radiol 2005, 54: Modic MT, Masaryk TJ, Ross JS, Carter JR: Imaging of degenerative disk disease. Radiology 1988, 168: Modic MT, Steinberg PM, Ross JS, Masaryk TJ, Carter JR: Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology 1988, 166: O'Neill C, Kurgansky M, Kaiser J, Lau W: Accuracy of MRI for diagnosis of discogenic pain. Pain Physician 2008, 11: Schenk P, Laubli T, Hodler J, Klipstein A: Magnetic resonance imaging of the lumbar spine: findings in female subjects from administrative and nursing professions. Spine 2006, 31: Spengler DM, David DP: Industrial low back pain: A practical approach. In Industrial Low Back Pain: A Comprehensive Approach. Edited by Wiesel SW. Charlottesville, VA: The Michie Co.; 1985: Thompson KJ, Dagher AP, Eckel TS, Clark M, Reinig JW: Modic changes on MR images as studied with provocative diskography: clinical relevance--a retrospective study of 2457 disks. Radiology 2009, 250: Weishaupt D, Zanetti M, Hodler J, Min K, Fuchs B, Pfirrmann CW et al.: Painful Lumbar Disk Derangement: Relevance of Endplate Abnormalities at MR Imaging. Radiology 2001, 218: Personal Information T. S. Jensen 1, P. Kent 1, J. Karppinen 2, J. S. Sorensen 1, J. Niinimäki 2, C. Leboeuf-Yde 1 1 The Spine Centre of Southern Denmark, Ringe, Denmark 2 Oulu University Hospital, Oulu, Finland Contact: Page 10 of 11

11 Tue Secher Jensen, MSc (Clin. Biomech.), Ph.D. The Spine Centre of Southern Denmark Lindevej 5, 5750 Ringe Denmark Direct phone: Mobile: Page 11 of 11