Modic change treatment options.

We have spent a lot of time with the different podcasts discussing findings seen on MRI.  We have talked a lot about modic changes.  These changes are called Modic changes due to Dr, Michael Modic first classifying changes seen on MRI in 1988.  He specifically looked at changes to the top and bottom of the vertebra and this is called the endplates of the vertebra.  The findings we see with modic changes can be seen on MRI in any bone, but would not be called modic changes in any other bone besides the endplates of the vertebrae.

As a refresher for modic changes we have 3 types.  The first type of modic change is the fluid and inflammation seen in bone with a new injury.  When bone is damaged, we get an inflammatory response and increase in fluid.  This increase in fluid in bone is seen on MRI.  The T1 view will show fluid as dark. The T2 will show fluid as white.  The STIR view will show fluid as white.  This is the confirmation of a type 1 modic change. 

After the bone is damage there is the inflammatory stage.  Following the inflammatory stage, the bone will often go back to a normal makeup.  On occasion the bone will be damage enough that the bone will have an increased fat component following injury.  This increased fatty presence in the bone can also be seen on MRI and is called a type 2 modic change.  Fat will look bright on a T1.  Fat will also look bright on a T2, but will look dark on a STIR view given the fat suppression of a T2.  This is the method to confirm a type 2 modic change.

Damage bone will typically continue to degenerate over time.  The bone once damage will often have the inflammatory period which often changes to a fatty marrow replacement.  Over time the bone will continue to degenerate and turn hard or sclerotic.  This hardening or sclerosis will be seen on MRI and is called a type 3 modic change.  The type 3 modic change or hardening of the bone will be seen with a decrease in T1, T2 and STIR views. 

As we have talked about in the past podcasts the modic changes are one part of the picture when time dating an injury.  Studies have shown that modic changes typically progress from a type 1 to type 3.  Typically a type 1 modic change is seen with a new injury and typically lasts a couple months.  This can be very helpful with causation on injury cases.  A type 2 modic change typically appears months after a new injury and can last years.  This can also be helpful with causation on an injury case.  Type 3 modic changes are typically years old and can also help with causation on an injury case. 

I want to discuss treatment for this type of injury today and not just cover causation for injuries cases.  Todays study will be Transforaminal Epiduroscopic Basivertebral Nerve Laser Ablation for Chronic Low Back Pain Associated with Modic Changes: A Preliminary Open-Label Study published in 2018 by Hyeun (high oon) Sung Kim et al.  This was published in the Pain and Research Management Journal.

They reported that low back pain is a serious problem in society and a large cause of disability.  They showed that the expense for treating low back pain is over $100 Billion dollars per year.  This study showed that MRIs can often clearly identify pathologies seen with low back pain.  This is an important topic to discus for a moment.  I try to tell patient’s all the time that MRIs can not see pain.  They can see different pathologies and others they can’t see.  Just because we see disc damage or bone damage on an MRI doesn’t mean we know that is the cause of their pain.  Just because we don’t see pathology on an MRI doesn’t mean that they have no problems.  There are a lot of pain generators in the spine that we can’t see evidence of injury on an MRI.  Take facet problems as discussed on the last podcast.  We typically will not see any biomechanical injuries on an MRI as well.    This study went on to say quote “the importance of these pathologies is still controversial” end quote. 

They reported that patients with prolonged back pain showed modic changes up to 59% of the time.  They showed that clinically patients with prolonged low back pain and modic changes often will have nocturnal pain.  They showed that patients with modic changes will have back pain within a given year 90% of the time.  This shows that the presence of modic changes is associated with back pain. 

They reported that most causes of low back pain have been shown to get better spontaneously or with conservative care in general, but not typically with modic changes.  Their study was designed to assess pain coming from vertebrae when modic changes are present.  The basivertebral nerve goes to the vertebrae and quote “have a rich supply of small free nerve endings” end quote.  They went on to show that inflammation will quote “likely trigger the inflammatory pain” end quote. 

This study reported that these modic changes quote “involve damage and microfractures to the vertebral endplates resulting in the development of edema and inflammation of the adjacent vertebrae” end quote.  This study attempted to look at ablation or burning of the basivertebral nerve would be a successful treatment for patients with a type 1 or type 2 modic change.  They took patients with low back pain that lasted over 6 months and had already tried a minimum of 3 months conservative care.  They excluded patient without modic changes, spondylolisthesis, scoliosis, history of spinal infections, prior spinal malignancy, patient with radicular complaints. 

They had 14 patients that fit the criteria for possible chronic low back pain related to modic changes or vertebral endplate damage.  These 14 patients all had pain scales rated at 6-10 out of 10.  The mean pain scale was 7.79 prior to treatment.  They then did a laser basivertebral nerve ablation for these 14 patients.  They followed up 1 week after treatment and 13 out of the 14 had pain ranging from a 1 to a 3.   One patient had pain at a 6/10.  The average pain after 1 week was 1.93. 

They followed up again with the patients in 3 months and the average pain was 2.21.  They again followed up after a year and the average pain was 2.36.  They only had the one patient that did not have great results.  All other patients at 1 week, 3 months and one year had pain down to 1-3/10.  They reported that 95% of patients had excellent outcomes with chronic low back pain and basivertebral nerve ablation treatments.  They reported that 5% had fair outcomes with this treatment.  They reported that there were no complications with treatments.  They did reported that the small sample size is one inadequacy of their study. 

This is a very important study for us to review.  The basivertebral nerve has been shown to be a cause of low back pain.  This treatment appears to be a great option for people with low back pain and endplate damage seen on the MRI.  This is seen all the time with patients I have in my office after a MVC.  It is also patients that I do IMEs for.

Real world example

I did an IME for a new patient this week.  He was in a significant MVC around 3 years ago.  He has been having really bad low back pain since the MVC.  He went to the emergency room, chiropractic care, physical therapy and had MRI of his low back.   I asked him if he knew what was wrong with his low back that he would have ongoing low back pain for 3 years.  He reported that he was told he had a disc herniation in his low back and this was the cause for the low back pain. 

I was able to review an MRI taken one month after the MVC.  This MRI did show some disc damage.  The L4-5 and L5-S1 discs did extend beyond the normal healthy disc space.  The discs extended circumferentially and not focally in any direction.  There were mild to moderate bone spurs surrounding the disc bulges.  There was a loss of disc space height at these 2 levels.  The disc had a decreased signal or desiccation on T2.   

If you have listened to my podcasts about new vs. old disc damage it should be evident that his disc damage appears old and not related to a MVC 1 month prior.  His MRI did show type 1 modic changes around the L4-5 and the L5-S1 discs.  These modic changes signify new inflammation in the bone surrounding these degenerative disc bulges. 

The disc damage doesn’t appear new and was not likely caused by the MVC.  The damage to the bones surrounding the disc does appear new and is likely related to the MVC.  As seen in today’s study the damage to the bone that is seen as a modic change is quote “microfractures to the vertebral endplates”.  These microfractures have been shown to cause damage to quote “the bony endplates have a rich supply of small free nerve endings and will likely trigger the inflammatory pain” end quote. 

It is likely that his ongoing chronic pain is mediated by the basivertebral nerve and damage to the vertebral bodies.  This has not been mentioned to him with 3 years of treatment.  The radiologist did not report any modic changes on the MRI.  I do not know if the modic changes and damage to the vertebra are the cause for his ongoing low back pain, but it is the most likely possibility.  My future care section in the report covered how important future care and possible basivertebral nerve ablation might be for him.