Modic changes

Modic changes are pathological changes in the bones of the spine, the vertebrae. These changes are situated in both the body of the vertebrae and in the end plate of the neighboring disc. It is important to understand that Modic changes do not represent an illness, but are a simple descriptive term used by radiologists in MRI diagnostics to describe common degenerative processes quite often seen with ageing. Because Modic changes are not an illness, dedicated treatment is not required and there is currently no evidence for a specific therapy beyond common therapies against backpain. In general, theses changes resolve spontaneously and it lies at the center of the Modic classification that it contains three different stages from active inflammation over fatty bone marrow transformation to a spontaneously healed state with calcifications.

Causes of back pain

In 20% of the patients we can identify an anatomical reason for the pain,[1] such as a lumbar disc herniation, or stenosis which is a reduction in the circumference of the spinal canal.

There might be reasons for back pain that cannot be identified on magnetic resonance imaging (MRI), for example muscular pain. But other areas like knee or hip pain do a lot better when it comes to diagnosing the exact reasons for the pain. The low percentage for back diagnosis might be due to the fact that the back is a much more complex and complicated structure.

Diagnosing modic changes

Modic changes are characterized on MRI (magnetic resonance imaging). The 3 Modic classifications were first described and defined by Dr. Michael Modic in 1988.

Normal bone contains internal scaffolding, called trabeculae. Red bone marrow, which produces blood cells, is located in the hollows between the trabeculae.

  • In Modic type 1 there is vascular development in the vertebral body, with findings of inflammation and edema, but no trabecular damage or marrow changes.
  • In Modic type 2 there are changes in bone marrow, with fatty replacement of formerly red, cellular marrow normally seen there. With Modic type 2 changes the marrow is substituted by visceral fat, the same kind of fat we have on our hips and bellies.
  • Modic Changes type 3 are less common, with fractures of the trabecular bone, along with trabecular shortening and widening.

Modic changes have been observed in dogs.[2]

Modic changes and pain

Many studies have examined the relationship between Modic changes in the vertebrae in the spine and pain in the lower back. There are inconclusive correlation between having Modic changes and suffering from pain in the lower back.

Studies have shown that patients with Modic changes are rather different from other patients with normal back pain. For example, 75 –80 % of patients suffering from Modic changes have constant pain, which means they do not ever have a pain-free moment day or night. There might be fluctuations in the intensity, but no break from the pain.

Treatment

It is difficult to treat patients with Modic changes. Treatment that normally cures or help patients with normal back pain does not have effect on Modic changes or pain from Modic changes.

The recommended treatment for long lasting pain in the lower back is exercises, normally aided by the instruction of a qualified clinician. This is often followed by muscle strengthening and fitness training. This treatment does help the vast majority of normal back pain patients. But studies have shown that patients with Modic changes showed much higher pain score than patients with normal back pain, and most importantly that their pain increased with training. Other recent studies cited state no clinical difference between load reduction and rest or doing physio in relation to management or improvement of the condition. [3]

Since radiologists very frequently use the Modic classification in their reports and this leads to unsettledness in a lot of patients reading their reports, businessmen in Denmark and Norway founded private "Modic clinics" to exploit these unsecure patients. The entry-procedure into these private clinics begins with a payment of approx. 50 $ for a re-reading of the patients MRI. As stated above, there is currently no special therapy "against a radiology image-classification" and such a therapy is, with today's state of research, not necessary. Common physiotherapy exercises, aquajogging, warmth and, above all, the natural course of these Modic changes will, in most cases, after some time lead to pain relief.

Research

The following section is controversial [4] with concerns over methodology and also potential conflicts of interest, in that some of the researchers are associated with a company which certifies clinicians to diagnose the condition for £200. It is true that a study has been published, and results are interesting. However, spinal clinicians and researchers are agreed that further studies are needed, specifically fully blinded randomised controlled trials, to confirm or refute claims made in the published study. At this stage patients with low back pain should not consent to anti-biotic treatment without proper assessment and investigation under the care of a qualified spine surgeon or physician.

Scientist Hanne Albert at a large back center in Europe, the Spine Centre of Southern Denmark led by Professor Claus Manniche, performed studies that have claimed that 80% of patients with Modic changes type 1 are cured or much improved after a cheap and simple antibiotic treatment.[5]

However, a more recent double blind, placebo-controlled, multicenter study from 2019 shows no evidence for the effect of antibiotics on back pain with Modic changes.[6]

References
  1. ???
  2. Gendron, Doherr, Gavin; et al. (2012). "MAGNETIC RESONANCE IMAGING CHARACTERIZATION OF VERTEBRAL ENDPLATE CHANGES IN THE DOG". Veterinary Radiology & Ultrasound. 53 (1): 50–56. doi:10.1111/j.1740-8261.2011.01861.x. PMID 21992691.CS1 maint: multiple names: authors list (link)
  3. http://www.clinicaltrials.gov/ct2/show/NCT00454792
  4. "Back pain breakthrough crippled by doubt". 2013-06-16.
  5. Albert HB, Sorensen JS, Christensen BS, Manniche C (2013). "Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy". European Spine Journal. 22 (4): 697–707. doi:10.1007/s00586-013-2675-y. PMC 3631045. PMID 23404353.
  6. Bråten LCH (Aug 2019). "Efficacy of antibiotic treatment in patients with chronic low back pain and Modic changes (the AIM study): double blind, randomised, placebocontrolled, multicentre trial."". BMJ. 367: l5654. doi:10.1136/bmj.l5654. PMC 6812614. PMID 31619437.

Bibliography
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