Modic Changes & Their Associations With Clinical Findings

Transcription

1 Modic Changes & Their Associations With Clinical Findings Per Kjaer Associate professer Department of Sports Science and Clinical Biomechanics, University of Southern Denmark

2 The Clinical Questions What are the mechanisms underlying the patient s pain? Could Modic Changes be the cause? Are there particular characteristics in a patient s history and physical examination findings?

3 Overview Definition of Modic changes Ætiology Definition of clinical findings Characteristics from history taking physical examination Conclusion

4 Type 1 Modic type 1 MRI Low T1-signal High T2-signal Histology Fibro-vascular tissue Fissured endplates Modic et al 1988 Blum et al 2009 Albert et al 2009 T1 T2

5 Type 2 Modic type 2 MRI High T1-signal High T2-signal Histology Fatty bone marrow Fissured endplates Modic et al 1988 T1 T2

6 Type 3 Modic type 3 MRI Low T1-signal Low T2-signal Histology Sclerosis Disc calcification Modic et al 1988 Karamouzian et al 2010 T1 T2

7 Suggested Causes Genetic Autoimmune Biomechanical Infectious Karppinen et al 2008 and 2009 Ma et al 2011 Rahme et al 2008 Albert et al 2008, 2009 and 2013 Hu et al 2009 Wedderkopp 2009

8 Biomechanical theory Normal disc Degenerated disc

9 Biomechanical theory Degenerated disc Degenerated disc

10 Infection theory Normal disc Disc disruption

11 Clinical Findings Information from patient s history Patient s interview Questionnaire Information from physical examination Movement Palpation Provocation test Pain threshold

12 No Disc degeneration or Modic Disc degeneration (DD) Modic changes & Disc degeneration

13 Study population and variables Backs on Funen Denmark 412 people from general population aged 40 MRI Disc degeneration (DD): reduced signal or height Modic changes (MC): one or more signal changes Questionnaire LBP history Work and lifestyle Functioning Physical examination

14 The 3 groups Neither MC nor DD 179 DD 141 MC & DD 73

15 Percentage Patient history Reporting LBP MC & DD DD only Neither Past week Past month Past year Seeking care Non-trivial LBP P<0.003

16 Percentage LBP history MC & DD DD only Any previous episodes LBP Previous disc herniation Neither p<0.01

17 Percentage Work and lifestyle MC & DD DD only Neither 10 0 Heavy phys work Vibrations Body mass index High level leisure Heavy smokers

18 Percentage Different definitions of functioning MC & DD DD only Neither 5 0 Downtime work Downtime leisure Sick leave Reduced sports Physical function p<0.01

19 Percentage Physical examination Flat back Pain on Lumbar movement PPT NMK Activation of LMM Lumbar pain tolerance p<0.03

20 And after that 54 citations in Web of Science, 463 hits in PubMed One conference proceeding and a paper Have reduced ROM in Flexion (clbp) One paper Bendix et al 2006 Hard work combined with overweight and smoking increased the probability of Modic Changes but not LBP One bachelor s thesis Lebouf-Yde et al 2008 Pain on return from lumbar flexion increased probability of Modic Changes Tang and Skrostrup 2008

21 And after that, cont 36 patients with chronic LBP in three subgroups Rannou et al 2007 The Modic subgroups had: and and higher serum hscrp level (Type 1) Longest duration of pain, longer period with morning stiffness, worst painful moments late night/morning, more pain during Valsalva maneuver Exacerbation of pain on hyperextension

22 Other factors Increasing the probability of having modic changes BMI Age Previous disc herniation Arena et al 2011, Kuisma et al 2008 Wang et al 2012, Albert et al 2008 Albert et al 2007

23 The Clinical Question What are the mechanisms behind the patients pain? Could Modic Changes be the cause? Are there particular characteristics in a patient s history and physical examination findings associated with Modic Changes? (Does the presence of Modic Changes have any consequence for the management of this patients pain?)

24 The answer As a group, the people with Modic Changes seem to be worse in terms of pain, disability and participation physical impairments Reduced and painful movements Positive pain provocation test Particular risk factors previous lumbar disc herniation Overweight, hard work and smoking On an individual level, we cannot know

25 Conclusion We can only cautiously suggest to an individual patient that he or she may have an increased probability of Modic Changes But 25 June 2009

26 Thank you for listening 26 June 2009

27 1. 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 (Phila Pa 1976) 2005, 30(10): Modic MT, Masaryk TJ, Ross JS, Carter JR: Imaging of Degenerative Disk Disease. Radiology 1988, 168(1): Blum A, Roch D, Loeuille D, Louis M, Batch T, Lecocq S, Witte Y: Bone marrow edema: definition, diagnostic value and prognostic value. Journal De Radiologie 2009, 90(12): Albert HB, Petersen H, Manniche C, Hoilund-Carlsen PF: PET imaging in patients with Modic changes. Nuklearmedizin 2009, 48(3): Karamouzian S, Eskandary H, Faramarzee M, Saba M, Safizade H, Ghadipasha M, Malekpoor AR, Ohadi A: Frequency of lumbar intervertebral disc calcification and angiogenesis, and their correlation with clinical, surgical, and magnetic resonance imaging findings. Spine (Phila Pa 1976) 2010, 35(8): Karppinen J, Daavittila I, Solovieva S, Kuisma M, Taimela S, Natri A, Haapea M, Korpelainen R, Niinimaki J, Tervonen O et al: Genetic factors are associated with Modic changes in endplates of lumbar vertebral bodies. Spine 2008, 33(11): Ma XL, Ma JX, Wang T, Tian P, Han C: Possible role of autoimmune reaction in Modic Type I changes. Medical Hypotheses 2011, 76(5): Rahme R, Moussa R: The Modic vertebral endplate and marrow changes: Pathologic significance and relation to low back pain and segmental instability of the lumbar spine. American Journal of Neuroradiology 2008, 29(5): Albert HB, Kjaer P, Jensen TS, Sorensen JS, Bendix T, Manniche C: Modic changes, possible causes and relation to low back pain. Med Hypotheses 2008, 70(2): Albert H, Pedersen H, Manniche C, Hoilund-Carlsen PF: PET imaging in patients with Modic changes. Nuklearmedizin 2009, 48(3): June 2009

28 11. Arndt J, Charles YP, Koebel C, Bogorin I, Steib JP: Bacteriology of degenerated lumbar intervertebral disks. Journal of spinal disorders & techniques 2012, 25(7):E Wedderkopp N, Thomsen K, Manniche C, Kolmos HJ, Secher Jensen T, Yde CL: No Evidence for Presence of Bacteria in Modic Type I Changes. Acta Radiologica 2009, 50(1): Adams MA, Dolan P: Intervertebral disc degeneration: evidence for two distinct phenotypes. J Anat 2012, 221(6): Albert HB, Lambert P, Rollason J, Sorensen JS, Worthington T, Pedersen MB, Norgaard HS, Vernallis A, Busch F, Manniche C et al: Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae? European Spine Journal 2013, 22(4): Kjaer P, Korsholm L, Bendix T, Sorensen JS, Leboeuf-Yde C: Modic changes and their associations with clinical findings. Eur Spine J 2006, 15(9): Bendix T, Sorensen PH, Sorensen JS: DOES MODIC CHANGES PRESENT WITH A SPECIFIC CLINICAL PICTURE? In: EuroSpine 2006: 2006; Istanbul, Turkey: Eur Spine J; 2006: S Leboeuf-Yde C, Kjaer P, Bendix T, Manniche C: Self-reported hard physical work combined with heavy smoking or overweight may result in so-called Modic changes. BMC Musculoskelet Disord 2008, 9: Rannou F, Ouanes W, Boutron I, Lovisi B, Fayad F, Mace Y, Borderie D, Guerini H, Poiraudeau S, Revel M: High-sensitivity C-reactive protein in chronic low pack pain with vertebral end-plate modic signal changes. Arthritis Rheum-Arthritis Care Res 2007, 57(7): Arana E, Kovacs FM, Royuela A, Estremera A, Asenjo B, Sarasibar H, Amengual G, Galarraga I, Alonso A, Casillas C et al: Modic changes and associated features in Southern European chronic low back pain patients. Spine Journal 2011, 11(5): Wang Y, Videman T, Battie MC: Modic changes: prevalence, distribution patterns, and association with age in white men. Spine Journal 2012, 12(5): June 2009