Modic changes

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Welcome back to the Forensic Chiropractor podcast.

I was looking at all the podcasts that I have done so far online.  I noticed that my episode about modic changes was my most popular podcast by a long ways.  This made me want to cover modic changes again.

As a refresher before we get into a new research article I want to go over what modic changes are.  Dr. Modic was the doctor that was able to get his name placed on a phenomenon doctors started seeing on MRI.  MRI was not available to health care providers until the mid 1980s.  So in a lot of ways MRIs and modic changes are fairly new.  Modic changes are a way to describe changes to the top or bottom of a vertebra also know as an endplate.  These changes can be seen on MRI in any bone, but would not be called a modic change unless in vertebral endplates.  If you have the same findings on different bones the same concepts work, but they should not be called modic changes. 

There are 3 types of modic changes.  A type 1 modic change is when the bone signal changes due to inflammation or edema.  Edema is an increase of fluid in the bone.  On a typical MRI of the spine, we have 3 views.  We have a T1, T2 and STIR view.  I have covered what these different views are in prior podcasts.   The important thing to remember for modic changes is that we can see the difference between fluid, fat and hard sclerotic bone on MRI.  A type 1 modic change will have increased fluid and will appear bright on a STIR and T2 view, but dark on a T1. 

A type 1 modic change is edema and increased fluid and almost always associated with new injury to an area.  This is seen all the time on MRIs when there are fractures to any bone.  If you listened to podcast 18 you heard that modic changes have been shown to be microfractures of the vertebra.  That was from the 2018 study published by HIGH OON et al.  Edema in bone is a good indication of a new injury and is another indication of a new injury. 

A type 2 modic change is when the marrow of vertebral endplates changes and has an increase of fat tissue.  The fat tissue is seen different that normal boney marrow.  A type 2 modic change would have an increase T2 view and a decreased STIR and T1 view.  Although everyone is different a type 2 modic change will typically occur after the edema is gone.  This can take weeks to years.  In some cases, the edema resolves and there are no type 2 modic changes.   In general, a type 2 modic change is not typically seen as a brand new injury, but is associated with pain. 

The 2018 Study by High OON et al. showed that type 1 and type 2 modic changes cause pain mediated by the basi vertebral nerve.  This nerve pain was shown to be very intense pain that responded very well to a basi vertebral nerve ablation. 

A type 3 modic change is when the marrow of the vertebral endplates becomes hard or sclerotic.  This is typically seen years after an injury and is typically seen with lots of degenerative bone spurring.  A type 3 modic change will appear dark on the T1, T2 and STIR views. 

The study I chose for this podcast is Pathobiology of Modic Changes published in the European Spine Journal November 2016 by Stefan Dudli et al.  This study was published a few years prior to the last modic change study I reviewed.  Although this is older than the prior study there is still really useful information. 

Today’s study showed that there is not a lot of research about caused for modic changes.  They did show that regardless of the causes patients with Modic changes have a high association for low back pain.  This study was based on a literature review.  They showed that modic changes or endplate changes share many of the same characteristics with other bones.  They showed that 43% of patients with low back pain also had modic changes.  They showed that patients without low back problems have a 6% chance of having modic changes. 

This study showed that more often than not modic changes were seen with degenerative discs and disc herniations.  This study showed that modic changes create a different type of low back pain compared to patients without modic changes.  As a side note this finding matches the 2018 study showing that modic changes are microfracture that likely damage the basivertebral nerve.

This study showed that low back pain with modic changes has a poor outcome with conservative treatment.  In fact they didn’t show any treatments that were effective.  My last podcast did show that the basivertebral nerve ablation was effective treatment for low back pain patients with modic changes.  Today’s study showed that patients with modic changes had worse outcomes after discectomy.  Likely due to basivertebral nerve pain and not radiculopathy or discogenic pain. 

Today’s study showed that the larger the modic changes typically the larger the disc damage.  They showed that modic changes are not related to age changes in marrow.  They also showed that degenerative discs are not alone the causes of modic changes.  This means that modic changes are not age-related changes and do not come from degenerative discs.  They are often seen with degenerative discs, but not likely caused by the degenerative discs.  In my opinion this makes sense.  The damage or injury to the spine is often significant enough to damage the vertebra and the disc.  This leads to modic changes in the vertebra and damage to the disc later seen as a degenerative disc bulge.  This study went on to show that endplate damage promotes degenerative discs.  They went on to show that disc herniation can predispose people to modic changes and that disc damage should be considered a predisposing factor to modic changes rather than an incidental finding. 

This study showed that the more severe the endplate damage is the more likely the low back pain will be chronic.  This means that severe modic changes indicate chronic low back pain.  They reported that this is likely due to inability to remove the inflammatory stimulus leading to chronic pain.  We covered some of this in the last podcast about centralization. 

This study suggested that there may be 2 causes for modic changes. The first is occult discitis.  That is a hidden inflammation in the disc.   The second is an autoimmune reaction of bone marrow to disc cells.  Either ways these suggested caused for modic changes include bone or disc damage as the cause.

They concluded that the propensity to develop modic changes depends on 3 factors.  First structural disruption of the disc or endplate.  Second the inflammatory potential of the disc.  Third is the bone marrows response to inflammatory stimuli.  This is consistent with what I see in practice.  Patients with new trauma with bone or disc damage often have type 1 modic changes.  Although not all do.  That is likely to the their bone marrows response to inflammation. 

When it comes to treatments they reported that there are not a lot of treatments available for modic changes.  Once again this study came out prior to the 2018 study showing basi vertebral nerve ablations as an effective treatment. 

This study concluded that modic changes need either bone or disc damage with persistent stimulus.  This shows that modic changes start with damage.    This damage caused changes to the bone marrow.  They reported that modic changes are more than just coincidental imaging findings.

This study showed a couple really important things.  Modic changes are caused by tissue damage and are not age related and not incidental findings.  Modic changes are a different type of low back pain that can be difficult to treat.  They showed that this endplate damage leads to a cascade of degenerative changes in the disc and vertebra.  Not that degenerative changes caused the modic changes, but that the modic changes led to the degenerative changes. 

Real World

I had a patient low back pain after a MVC.   I took x-rays that showed a pars fracture in the lumbar spine.  The vast majority of pars fractures are old and not related to any new injury.  Given the onset of low back pain post MVC it seemed likely that these fractures were new and related to the MVC.  I had high suspicion of disc damage and radiculopathy in the lumbar spine as well so an MRI was ordered.  The MRI came back with a new disc herniation at L5-S1.  I say new because it had the classic findings of a new disc herniation.  It had a focal herniation with no loss of disc space height.  It had increased signal in the herniation.  There were no degenerative osseous changes surrounding the disc.  ttt MRI also showed the pars fracture with high signal on T1 and STIR and low signal on a T1.  This is clearly an active inflammatory and edema state around the fracture.   If this was around the endplate, we would call it a type 1 modic change.  This is a clear indication that the fracture is new and related to the MVC. 

In deposition I was asked if I knew that the vast majority of pars fractures are old and unrelated to new trauma.  I said of course I do.  The attorney then asked if I still thought the patients’ pars fracture was new and related to the MVC.  I said that I did and that the explanation was in the notes.  It appeared that the attorney did not read any of my notes.  He asked me to explain.  I went to my interpretation of the MRI.  I was able to show him that there is clear edema and inflammation around the fracture and that with the increased T2 and STIR views and a decreased T1 view there is no other explanation than new damage. 

This was a strange deposition for me since the attorney really wanted to learn more about what I was saying.  I asked him if I could show him the MRI.   We looked at the MRI and I was able to show him what fluid looks like on the different views and what bone, muscle and other anatomy looks like on the MRI.  Then I was able to show him the other pars that did not have the edema and fracture.  Then showed him the fracture with the edema.  After a moment and a few more questions it seemed to make sense to this attorney.  Then he moved on to talk about other aspects of the case.

This is a great real world example of using MRI and the understanding of what we are looking at to help time date an injury.  This was not a modic change example, but same concept.   I have done this same concept over and over for new disc herniations with type 1 modic changes surrounding them. 

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