Modic changes - An evidence-based, narrative review on its patho-physiology, clinical significance and role in chronic low back pain

Abstract

Objective: Lumbar degenerative spinal ailments are the most important causes for chronic low back pain. Modic changes (MC) are vertebral bone marrow signal intensity changes seen on MRI, commonly in association with degenerative disc disease (DDD). Despite being widely studied, majority of issues concerning MC are still controversial. The current narrative, evidence-based review comprehensively discusses the various aspects related to MC. Literature search: An elaborate search was made using keywords "Modic changes", "lumbar Modic changes", "Modic changes in lumbar spine", and "vertebral Endplate Spinal Changes", on pubmed and google (scholar.google.com) databases on the 3rd of March 2020. We identified crucial questions regarding Modic changes and included relevant articles pertaining to these topics for this narrative review. Results: The initial search using the keywords "Modic changes", "lumbar Modic changes", "Modic changes in lumbar spine", and "vertebral Endplate Spinal Changes" on pubmed yielded a total of 568, 412, 394 and 216 articles on "pubmed" database, respectively. A similar search using the aforementioned keywords yielded a total of 3650, 3548, 3726 and 21570 articles on "google scholar" database. The initial screening involved exclusion of duplicate articles, articles unrelated to MC, animal or other non-clinical studies, and articles in non-English literature based on abstracts or the titles of articles. This initial screening resulted in the identification of 405 articles. Full manuscripts were obtained for all these selected articles and thoroughly scrutinised at the second stage of article selection. All articles not concerning Modic changes, not pertaining to concerned questions, articles concerning other degenerative phenomena, articles discussing cervical or thoracic MC, case reports or animal studies, articles in non-English language and duplicate articles were excluded. Review articles, randomised controlled trials and level 1 studies were given preference. Overall, 69 articles were included in this review. Conclusion: Modic change (MC) is a dynamic phenomenon and its true etiology is still not definitely known. Disc/end plate injury, occult discitis and autoimmune reactions seem to trigger an inflammatory cascade, which leads to their development. Male sex, older age, diabetes mellitus, genetic factors, smoking, obesity, spinal deformities, higher occupational loads and DDD are known risk factors. There is no conclusive evidence on the causative role of MC in chronic low back pain (LBP) or any influence on the long term outcome in patients with LBP or lumbar disc herniations (LDH). Patients with MC have been reported to have less satisfactory outcome following conservative treatment or discectomy, although the evidence is still unclear.

Antibiotics should not be used for back/leg pain

“…The implication of Modic changes has engaged spine surgeons and radiologists for more than 30 years (Modic et al 2008a and b). The conclusion of the Danish long-term followup (Udby et al 2019) concurs with 2 recent reviews stating that "There is no conclusive evidence on the causative role of MC in chronic low back pain (LBP) or any influence on the long-term outcome in patients with LBP or lumbar disc herniations" (Viswanathan et al 2020) and "the association between MCs and LBP-related outcomes are inconsistent" (Herlin et al 2019).…”

“… 2019 ) concurs with 2 recent reviews stating that “There is no conclusive evidence on the causative role of MC in chronic low back pain (LBP) or any influence on the long-term outcome in patients with LBP or lumbar disc herniations” (Viswanathan et al. 2020 ) and “the association between MCs and LBP-related outcomes are inconsistent” (Herlin et al. 2019).…”

A definition and clinical grading of Modic changes

“…A recent evidence-based narrative review by Viswanathan et al 62 on MC pathology, clinical significance, and role in chronic pain describes the heterogenicity of MC nomenclature as a major issue and once again underlines the need for further research within the field.…”

Evidence for infection in intervertebral disc degeneration: a systematic review

“…Occult, or sub-clinical bacterial infection has been proposed to initiate and accelerate disc degeneration pathology. An infective aetiology has been proposed with several reviews linking microorganisms and disc degeneration [12,13] or MC [2,11,[14][15][16][17] though most investigations of infective disc degeneration are of small sample size and methods vary widely [16][17][18][19]. Two meta-analyses have implicated bacteria in disc pathophysiology.…”