Modic positive patients reported higher levels of clinically relevant improvement 2 weeks, 3 and 6 months compared to Modic negative patients. However, at 1 year Modic I patients were significantly less likely to report ‘improvement’, suggesting they may be prone to relapse.

76.5% of Modic positive patients reported ‘improvement’ compared to 53.3% of Modic negative patients (P = .09) at 2 weeks. Modic positive patients had larger decreases in leg pain (P = .02) and disability scores (P = .012) at 2 weeks. Modic positive patients had larger reductions in disability levels at 3 (P = .049) and 6 months (P = .001). A significant difference (P = .001) between patients with Modic I vs. Modic II was found at 1 year, where Modic II patients did significantly better.

This prospective outcomes study includes 72 MRI confirmed symptomatic LDH patients treated with SMT. Numerical rating scale (NRS) pain and Oswestry disability data were collected at baseline. NRS, patient global impression of change to assess overall improvement, and Oswestry data were collected at 2 weeks, 1, 3, 6 months and 1 year. MRI scans were analyzed for Modic change present/absent and classified as Modic I or II when present. Chi-squared test compared the proportion of patients reporting relevant 'improvement' between patients with and without Modic changes and those with Modic I vs. II. NRS and Oswestry scores were compared at baseline and change scores at all follow-up time points using the unpaired Student t test.

The purpose of this study was to determine if there is a difference in outcomes between Modic positive and negative lumbar disc herniation (LDH) patients treated with spinal manipulative therapy (SMT).

Modic changes describe and categorize three degenerative changes in the vertebral endplates and subchondral bone.These changes are visible on magnetic resonance (MR) imaging, and there is a high interobserver reliability of diagnosis.Modic type I is characterized by low signal intensity on T1-weighted sequences and high signal intensity on T2-weighted sequences. This corresponds to bone marrow edema.Modic type II appears as high signal intensity on T1-weighted images and either high signal or intermediate signal intensity on T2-weighted images, the same as fat. Modic type III has low signal intensity on both T1 and T2 weighted sequences and would appear as sclerosis on routine radiographs.The incidence of Modic changes and the number of affected levels increases with age and is common in the lumbar spine.The natural course of MC is progressive with the most common pattern being that type I eventually converts to type II.

Reverse transformation of Modic type 2 changes to Modic type 1 changes during sustained chronic low-back pain severity. Report of two cases and review of the literature.

Is the development of Modic changes associated with clinical symptoms? A 14-month cohort study with MRI.

The link between MC and chronic low-back pain (LBP) has been established by many studies, particularly Modic type I, but the strength of this relationship varies greatly between different authors.Furthermore there is a high prevalence of MC and other degenerative changes in asymptomatic individuals.

Mitra et al found that there is a relationship between the evolution of Modic type I (conversion to Modic type II or extension in size) and a change in symptoms, but this relationship does not reach a significant statistical level.Other studies have found statistically significant associations between the presence of Modic changes and degenerative disc disease, disc herniation at the same level as the Modic changes, Modic I and low back pain as well as a change in size of the MC type I and a change in intensity of LBP and disability.

The association of combination of disc degeneration, end plate signal change, and Schmorl node with low back pain in a large population study: the Wakayama Spine Study.

The study on the relationship between modic change and disc height together with lumbar hyperosteogeny.

The association between Modic changes and pain during 1-year follow-up in patients with lumbar radicular pain.

There are many studies evaluating the influence of the presence of MC on the outcomes from different therapeutic interventions on the spine, but the results are controversial.Fayad et al found that intradiscal steroid injection produces a reduction of pain particularly in patients with Modic type I changes (inflammatory pattern) compared to patients with Modic type II changes, and suggested that steroid injection may be an efficient short-term treatment for patients suffering from LBP with inflammatory MC on MRI.Zhuang et al also demonstrated the efficacy of the intradiscal steroid injection on the outcomes of patients presenting with MC, but did not find any difference in postoperative efficacy between different Modic types.In 2014, Shan et al published a study in which they described the relationship between MC and the likelihood of resorption of disc herniations at a lumbar level.They discovered that MC are associated with less probability of resorption of LDH and that these patients are less likely to improve with conservative treatment (rehabilitation programs). However, spinal manipulation to the level of the disc herniation was not one of the conservative treatments included in that study.

Spontaneous Resorption of Lumbar Disc Herniation is Less Likely When Modic Changes are Present.

Spontaneous Resorption of Lumbar Disc Herniation is Less Likely When Modic Changes are Present.

Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae?.

The role of spinal manipulation therapy (SMT) as a conservative treatment for symptomatic, lumbar disc herniation has been controversial over many years, but in 2014 Leemann et al published a study, which showed a high degree of clinically significant improvement in patients with leg and back pain due to a disc herniation who were treated with high velocity, low amplitude SMT to the level of herniation with no adverse events.Another study by Peterson et al compared two groups of patients with symptomatic lumbar disc herniation, one treated with high-velocity, low-amplitude spinal manipulation and the other treated with imaging-guided nerve root injection.The results showed improvement in a large percentage of patients, with no significant differences between the two treatment groups.

Several studies have confirmed the fact that MC are linked with disc herniation at the same spinal level and not only seen in patients with non-specific LBP.Patients with this combination of lumbar disc herniation and Modic changes may actually have two sources for their specific low back pain. However, to date only 1 study has investigated whether or not there is a difference in treatment outcomes comparing patients with MRI confirmed symptomatic lumbar disc herniations with and without Modic changes.The treatment in that study involved imaging-guided lumbar nerve root blocks and patients with Modic changes reported significantly worse outcomes compared to patients without Modic changes at 1 month post injection. While two studies have shown that spinal manipulative therapy appears to have a good effect on lumbar disc herniation (LDH) patients, and that most of the LDH patients undergoing this treatment are going to improve in the short- and in the long-term, neither study looked at whether or not there is a difference in outcome between LDH patients with Modic changes compared to those without Modic changes when treated with SMT.Therefore the purposes of this study were to determine if there was a difference in outcomes between Modic positive and negative lumbar disc herniation patients treated with SMT as well as to compare treatment outcomes depending on the specific Modic type.

The primary outcome was the proportion of patients that reported a clinically relevant improvement in the PGIC scale. The patients were categorized as improved if they answered with a 1 or a 2 (much better, better) on the PGIC scale, and as not improved if they responded with a 3, 4, 5, 6 or a 7 (slightly better through much worse. The percentage of improved and not improved patients was assessed for each time point, and then compared first for the presence/absence of Modic changes (both I and II together), and then with the single Modic categories (0 = absence of MC; 1 = MC type I; 2 = MC type II). These relationships were calculated using the chi-square test. Using the unpaired Students t test the change scores for the NRS (back and leg) and Oswestry questionnaire for patients with and without MC were compared for significant differences (P < .05) at all follow-up time points. The unpaired Student’s t test was also used for comparing NRS and Oswestry change scores for patients with MC type I and type II at the different follow-up time points. Comparisons were always made referring to the baseline scores. Mean scores for NRS (back and leg) were also calculated comparing patients with and without MC at different time points using the unpaired t test.

The specific MRI findings for the MC type I are low signal intensity on T1-weighted images, and high signal intensity in T2-weighted images ( Fig 1 ). This combination represents a bone marrow edema. For the MC type II, the findings are high signal on T1- and iso-/high signal intensity on T2-weighted slices, typical findings for the fatty transformation of the bone marrow ( Fig 2 ).

B, T1-weighted sagittal MRI slice of the same patient now showing high signal intensity at the adjacent L4-5 vertebral bodies indicating Modic type II changes.

A, T2-weighted sagittal MRI slice with disc herniations at both the L4-5 and L5-S1 levels. High signal intensity is noted at the adjacent L4-5 vertebral bodies.

Fig 2 A, T2-weighted sagittal MRI slice with disc herniations at both the L4-5 and L5-S1 levels. High signal intensity is noted at the adjacent L4-5 vertebral bodies.

B, T1-weighted sagittal MRI slice of the same patient showing low signal intensity in the vertebral bodies adjacent to the L5-S1 disc herniation consistent with Modic type I changes.

A, T2-weighted sagittal MRI slice of the lumbar spine with a disc herniation at L5-S1 and increased signal intensity in the adjacent vertebral bodies.

Fig 1 A, T2-weighted sagittal MRI slice of the lumbar spine with a disc herniation at L5-S1 and increased signal intensity in the adjacent vertebral bodies.

Seventy two patients whose MRI scans were available on the treating practice computer system, presenting with a symptomatic lumbar disc herniation whose clinical findings were consistent with the side and level of the herniation seen on the MR image and with follow-up questionnaires filled via telephone interviews at the different time points were included. All of the patients underwent MR scans including axial and sagittal slices. The evaluation was based on T1 and T2-weighted slices. The MR images were evaluated without the knowledge of the clinical outcomes by three different persons, two master students in Chiropractic Medicine specifically trained to recognize and categorize abnormalities on lumbar spine MRI scans and the supervisor (radiologist and chiropractor). The readings were done independently to assess inter-rater reliability of the detection and categorization of Modic changes and then a consensus reading was done for ease of statistical analysis. The reliability data are not part of this current study. The aim of the MRI evaluation of the levels from L1-L2 to L5-S1 was to detect the disc herniation(s) level(s), the absence/presence of MC and, if present, to categorize them as Modic change type I or II (the MC type III was not considered) and to identify the spinal level (the same or different) compared to the location of the LDH. If mixed MC I and II were present, MC I was prioritized.

The primary outcome was the proportion of patients reporting clinically relevant improvement on the 7-point PGIC scale, whereas the secondary outcomes were the NRS and Oswestry scores, change scores and the worsening of the patient's condition.

Prior to the first treatment, demographic information about the patients was provided from the doctor of chiropractic including patient's age, sex and duration of complaint.

The PGIC uses a categorical scale with a range of 1-7 (much better, better, slightly better, unchanged, slightly worse, worse, much worse). Clinically relevant improvement has been considered only when the patients reported much better or better. Slightly better was not considered an improvement in the patient's condition. Slightly worse, worse and much worse were all considered worsening of the condition, consistent with previous studies.

Patients presenting with an MRI confirmed symptomatic lumbar disc herniation completed baseline pain and disability questionnaires prior to being treated with high velocity, low amplitude spinal manipulation. They were also asked to complete questionnaires about pain and disability levels and about their impression of overall improvement at different time points after the start of treatment via telephone interview. Pain level data, collected using the numerical rating scale (NRS) of 0 to 10 (0 = no pain and 10 = the worst pain imaginable), 1 for the back pain and 1 for the leg pain, and disability data from the Oswestry pain and disability questionnaire (OPDQ) were collected prior to treatment. Pain data (NRS), overall improvement data using the patient's global impression of change scale (PGIC) and Oswestry follow-up data were also collected at 2 weeks, 1, 3 and 6 months as well as 1 year after the first treatment by telephone interview by a research assistant at the Orthopaedic University Hospital who was unknown to the patients. As patients were not always available during the limited time frames allowed for the follow-up data collection phone calls, they were only excluded if 3 consecutive data collection time points were missed. Thus slightly varying numbers of patients are included at the different data collection time points in this study.

The specific spinal manipulation was performed depending on the location of the disc herniation, intraforaminal or paramedian, as seen on the MR images, and fully described in the outcomes study by Leemann et al.

The study received ethics approval from the Orthopaedic University Hospital Balgrist and the Canton of Zürich ethics committees (EK (22/2009), and all patients signed an informed consent to participate in the study.

All included patients were treated with high-velocity, low-amplitude spinal manipulation to the specific level of their disc herniation.

Patients presenting with pathologies of the lumbar spine that are contraindications to the chiropractic spinal manipulation, such as tumors, infections, inflammatory spondylarthropathies, acute fractures, Paget’s disease, severe osteoporosis were excluded, and also excluded were those patients with previous spinal surgery, signs of cauda equina syndrome, body mass index over 30, spondylolisthesis, neurogenic claudication and pregnancy.

The inclusion criteria for this study were the same as for the previous study by Leemann et al and were patient's age between 18 and 65 years, back pain and moderate to severe leg pain following a dermatomal pattern, and at least one of the following criteria: a) reduced straight leg raise test, b) deficit in detection of cold temperature, c) decreased response to pinprick, d) reduced muscle strength in a corresponding myotome, e) decreased or absent deep tendon reflex corresponding to the involved segment.An MR scan demonstrating the level and side of the LDH, consistent with the clinical findings was also required.

The patients that were included in the study presented with symptoms and signs of a lumbar disc herniation, such as back pain and leg pain following a dermatomal pattern with or without myotome or reflex changes and with at least 1 other positive orthopedic test for LDH. When these clinical findings were consistent with the abnormal findings on the MR images concerning spinal level and side of the herniation they were included in the study.

This study is a prospective outcomes study on adult patients presenting with a symptomatic, MRI-confirmed lumbar disc herniation and treated with high velocity, low amplitude spinal manipulation at a single practice in Zürich, Switzerland. It is a follow-up study from the publication by Leemann et alThe demographic information and the clinical outcomes were available on the University Chiropractic Medicine Department research database. The MR images regarding the patients were available on the database of this chiropractic practice.

The percentage of patients presenting with Modic changes and showing them at the same level of the disc herniation was 97.5%, and the most common location for MC was L5-S1 (with a percentage of 51%), as shown in the Fig 3

On Table 4 the patients were divided into two categories, those presenting MC type I and those presenting MC type II. There was no significant difference in the age of patients with MC type I or type II. Comparing duration of complaints of the two categories, the MC I patients showed a shorter onset time of symptoms compared to MC II patients, although this did not reach statistical significance. Looking at the baseline values for NRS back pain, NRS leg pain and Oswestry scores, there were no significant differences between patients with MC I and patients with MC II. The NRS change scores for back pain revealed no statistically significant differences between the two groups of patients, whereas the NRS change scores for leg pain at 1 month, 3 months and at 1 year showed a tendency for MC II patients to do better, although the results did not reach statistical significance. The Oswestry change scores at all follow-up time points showed no significant differences.

The chi-square test was also used to compare patients with MC type I, MC type II and patients without MC at all data collection time points ( Table 2 ). While there were no significant differences in the proportion of patients reporting “improvement” at 2 weeks, 3 months and 6 months between the 3 groups, a highly significant difference in outcomes was noted at 1 year as patients with Modic type II did significantly better and the proportion of patients with Modic type I reporting improvement significantly decreased compared to the earlier time points ( Table 2 ). A similar trend was also noted at 1 month, where patients without Modic changes improved in 64.5% of the cases, whereas only 46.7% of the patients with MC type I improved but 82.6% of patients with MC type II (P = .067) reported clinically relevant improvement. When looking at the actual seven categories of PGIC responses and comparing these with the three categories of Modic changes, a significant difference was only found at the 1 year data collection time point (P = .013) consistent with the results reported above.

Proportion of Patients With Modic Type I, Modic Type II and no Modic Changes Reporting Clinically Relevant ‘Improvement’ at the Various Data Collection Time Points

Table 2 Proportion of Patients With Modic Type I, Modic Type II and no Modic Changes Reporting Clinically Relevant ‘Improvement’ at the Various Data Collection Time Points

At two weeks, 76.5% of patients with MC and 53.3% of the MC negative patients reported clinically relevant “improvement” (P = .09). The proportion of Modic positive and negative patients reporting “improvement” at the other data collection time points were quite similar other that at 1 year where there was a tendency for a higher proportion of the Modic negative patients to report “improvement”.

From the University Chiropractic Medicine Department research database were included 72 consecutive, MRI confirmed, symptomatic lumbar disc herniation patients whose treatment outcome data were complete up to 1 year and whose MR images were available on the chiropractic practice computer system. Of these 72 patients, 40 presented with MC. Of the patients presenting with MC, 16 were categorized as MC type I, and 24 as MC type II. The age range was between 23 and 70 years old, with a mean age of 41.9 (SD = 11.35) years. The sex distribution was the following: 76.4% of the patients were males, and 23.6% were females.

Discussion

4 Nguyen C

Poiraudeau S

Rannou F Vertebral subchondral bone. , 5 Thompson KJ

Dagher AP

Eckel TS

Clark M

Reinig JW Modic changes on MR images as studied with provocative diskography: clinical relevance--a retrospective study of 2457 disks. , 13 Braithwaite I

White J

Saifuddin A

Renton P

Taylor BA Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography. , 14 Jensen TS

Karppinen J

Sorensen JS

Niinimäki J

Leboeuf-Yde C Vertebral endplate signal changes (Modic change): a systematic literature review of prevalence and association with non-specific low back pain. , 15 Mitra D

Cassar-Pullicino VN

McCall IW Longitudinal study of vertebral type-1 end-plate changes on MR of the lumbar spine. , 17 Järvinen J

Karppinen J

Niinimäki J

et al. Association between changes in lumbar Modic changes and low back symptoms over a two-year period. , 18 Schistad EI

Espeland A

Rygh LJ

Roe C

Gjerstad J The association between Modic changes and pain during 1-year follow-up in patients with lumbar radicular pain. , 19 Kerttula L

Luoma K

Vehmas T

Grönblad M

Kääpä E Modic type I change may predict rapid progressive, deforming disc degeneration: a prospective 1-year follow-up study. 32 Leemann S

Peterson CK

Schmid C

Anklin B

Humphreys BK Outcomes of acute and chronic patients with magnetic resonance imaging-confirmed symptomatic lumbar disc herniations receiving high-velocity, low-amplitude, spinal manipulative therapy: a prospective observational cohort study with one-year follow-up. , 33 Peterson CK

Leemann S

Lechmann M

Pfirrmann C

Hodler J

Humphreys BK Symptomatic magnetic resonance imaging-confirmed lumbar disk herniation patients: a comparative effectiveness prospective observational study of 2 age- and sex-matched cohorts treated with either high-velocity, low-amplitude spinal manipulative therapy or imaging-guided lumbar nerve root injections. , 36 Peterson CK

Schmid C

Leemann S

Anklin B

Humphreys BK Outcomes from magnetic resonance imaging-confirmed symptomatic cervical disk herniation patients treated with high-velocity, low-amplitude spinal manipulative therapy: a prospective cohort study with 3-month follow-up. The purpose of this study was to compare the treatment outcomes of patients with and without Modic changes who presented with MRI-confirmed, symptomatic lumbar disc herniation, who were treated with high-velocity, low amplitude spinal manipulation. This is the first study to investigate the role that MCs may have in relationship to the outcomes from the specific treatment of high velocity, low amplitude, spinal manipulation in a group of LBP patients with a very specific diagnosis. Both the disc herniation and the MCs are known to act as pain generators in the lumbar spine.Although the radiculopathy can be explained only through the disc herniation, the low back pain can be generated from both, meaning that patients presenting with both the disc herniation and the MC are more likely to have two sources for their pain. Since the spinal manipulation is thought to have a positive effect on the signs and symptoms of patients with lumbar disc herniations, but not on MCs, we would have expected that patients with MC and disc herniation would have reported less improvement after the treatment as compared to patients with disc herniation but without MC.The percentage of patients reporting clinically relevant “improvement” in this study increased over time in both categories of patients (MC positive and MC negative), but surprisingly, at two weeks after treatment the percentage of MC positive patients reporting clinically relevant ‘improvement’ was over 23% higher compared to the MC negative group, although the p-value was only close to significance (P = .09). A larger sample size would likely have found this statistically significant. At all of the other follow-up time points there was no significant difference between the two categories of patients, meaning that the subjective “improvement” reported by the patients was not significantly different due to the presence or absence of MC as most patients improved.

When comparing outcomes for patients with Modic type I, Modic type II and no Modic changes it was surprising that a high proportion of Modic I patients reported clinically relevant ‘improvement’ at the 2 week time point with even higher proportions of improved patients at the 3 and 6 month data collection time points. However, at the 1 month and 1 year data collection periods there were marked decreases in the proportion of Modic I patients reporting ‘improvement’ (particularly at 1 year) suggesting that patients with Modic type I are more prone to relapses and recovery periods during the course of treatment as compared to Modic type II patients and those without Modic changes whereas both of these groups showed a more steady increase in the proportion of ‘improved’ patients over the course of the study.

For the secondary outcomes of this study (NRS back, NRS leg and Oswestry change scores), the results showed no significant differences between patients with and without MC for the NRS back pain change scores at any time point. However, the NRS leg pain change scores at two weeks as well as the Oswestry change scores at 2 weeks, 3 months and 6 months showed significantly higher change scores in patients with Modic changes, meaning that they reported lower mean NRS leg pain scores and lower pain and disability levels in the Oswestry questionnaire after the treatments as compared to patients without MC. This supports the results reported above where a higher proportion of MC positive patients reported clinically relevant ‘improvement’ at 2 weeks compared to MC negative patients.

34 Peterson CK

Pfirrmann C

Hodler J Are Modic changes related to outcomes in lumbar disc herniation patients treated with imaging-guided lumbar nerve root blocks?. These results are different from those reported in the study evaluating the influence that MCs may have on the treatment outcomes of patients with imaging confirmed lumbar disc herniations who were treated with nerve root injections.In that study patients with MCs reported worse outcomes at the last data collection time point of 1 month post injection compared to patients without MCs.

34 Peterson CK

Pfirrmann C

Hodler J Are Modic changes related to outcomes in lumbar disc herniation patients treated with imaging-guided lumbar nerve root blocks?. It is not possible to assess if the results from this current study were due to natural history or if the high-velocity, low-amplitude spinal manipulative therapy could have had a role on the MC-caused pain. Although the current literature strongly supports that MCs are pain generators in themselves, this is only the second study to investigate the role that these MCs may have on the outcomes from a very specific treatment in a homogeneous group of patients with their LBP symptoms due to a confirmed lumbar disc herniation.Because the results of these two studies are different, one can speculate that perhaps the direct thrust into the motion segment affected by the lumbar disc herniation is an active, local, treatment which alters the neurobiomechanical functioning of that motion segment (i.e. the mechanoreceptors) of the spine whereas the imaging-guided nerve root block treatment is passive with no movement induced to the motion segment during the treatment and thus probably not altering the intersegmental motion. Precisely how this may impact on the MCs, if at all, is obviously unknown at this time. Certainly more research is needed to clarify the role of spinal manipulative therapy in non-specific LBP patients who also have MCs.

9 Hutton MJ

Bayer JH

Powell JM Modic vertebral body changes: the natural history as assessed by consecutive magnetic resonance imaging. , 10 Jensen RK

Leboeuf-Yde C

Wedderkopp N

Sorensen JS

Jensen TS

Manniche C Is the development of Modic changes associated with clinical symptoms? A 14-month cohort study with MRI. , 11 Kuisma M

Karppinen J

Niinimäki J

et al. A three-year follow-up of lumbar spine endplate (Modic) changes. , 12 Marshman LA

Trewhella M

Friesem T

Bhatia CK

Krishna M Reverse transformation of Modic type 2 changes to Modic type 1 changes during sustained chronic low-back pain severity. Report of two cases and review of the literature. , 15 Mitra D

Cassar-Pullicino VN

McCall IW Longitudinal study of vertebral type-1 end-plate changes on MR of the lumbar spine. , 17 Järvinen J

Karppinen J

Niinimäki J

et al. Association between changes in lumbar Modic changes and low back symptoms over a two-year period. , 18 Schistad EI

Espeland A

Rygh LJ

Roe C

Gjerstad J The association between Modic changes and pain during 1-year follow-up in patients with lumbar radicular pain. Comparing MC negative patients with MC type I patients and MC type II patients at the two weeks follow-up time point had very similar results: both the MC type I and the MC type II groups showed a greater percentage of improved patients compared to the MC negative group but again this did not reach statistical significance. Comparing these three groups for any of the seven categories of the PGIC scale found no significant differences other than at the 1 year time period as expected from the other results. This means that the percentage of patients reporting improvement, no change or worsening of the condition was not influenced by the presence or absence of MC, nor by different MC types for most data collection time points. These results are somewhat surprising, due to the fact that it is currently known that the MC type I tends to cause more pain than the type II, due to its inflammation component.The fact that MC positive and MC negative patients did not report significant differences in the PGIC scale until the 1 year time point supports the above stated need for more research to find out the exact role of MC in causing and perpetuating pain and disability. However, it does appear that Modic I patients are prone to relapses or recurrences of pain and this may be due to the influence of the inflammatory component. It would be interesting to follow the Modic I patients over a longer period of time than just 1 year to try to identify further relapses or determine if the condition stabilizes.

5 Thompson KJ

Dagher AP

Eckel TS

Clark M

Reinig JW Modic changes on MR images as studied with provocative diskography: clinical relevance--a retrospective study of 2457 disks. , 9 Hutton MJ

Bayer JH

Powell JM Modic vertebral body changes: the natural history as assessed by consecutive magnetic resonance imaging. , 10 Jensen RK

Leboeuf-Yde C

Wedderkopp N

Sorensen JS

Jensen TS

Manniche C Is the development of Modic changes associated with clinical symptoms? A 14-month cohort study with MRI. , 11 Kuisma M

Karppinen J

Niinimäki J

et al. A three-year follow-up of lumbar spine endplate (Modic) changes. , 12 Marshman LA

Trewhella M

Friesem T

Bhatia CK

Krishna M Reverse transformation of Modic type 2 changes to Modic type 1 changes during sustained chronic low-back pain severity. Report of two cases and review of the literature. , 17 Järvinen J

Karppinen J

Niinimäki J

et al. Association between changes in lumbar Modic changes and low back symptoms over a two-year period. , 18 Schistad EI

Espeland A

Rygh LJ

Roe C

Gjerstad J The association between Modic changes and pain during 1-year follow-up in patients with lumbar radicular pain. Looking at the different MC types, there were no significant differences between MC type I and MC type II patients for NRS back, NRS leg and Oswestry change scores at all follow-up time points, revealing no differences in treatment outcomes between these two groups of patients. This could also be somehow surprising, because of the pain generating inflammatory component of MC type I, but many studies have already evaluated the temporal course of MC, establishing that MC types change over time, and that both types (MC I and II) could act as pain sources as there is a continuum from type I to type II.Furthermore, patients with Modic type II may still have some inflammatory elements that do not appear unless STIR MRI (fluid sensitive) images are routinely used.

Also surprising was the fact that there were no significant differences between the baseline scores for NRS back, NRS leg and for the Oswestry Questionnaire of patients with MC and patients without MC, and the baseline scores were also similar between patients without MC, patients with MC type I and patients with MC type II. Therefore, the influence of Modic changes, particularly type I on these patients’ symptoms was minimal at baseline as it is likely that the majority of their presenting signs and symptoms overwhelmingly originated from the disc herniation. Certainly an inclusion criteria into this study was that the clinical presentation must match the level of disc herniation visualized on the MRI scans.

7 Han C

Ma X

Ma J

Wang T

Wang P Distribution characteristics of Modic changes of lumbar endplate and its relationship with low back pain. , 8 Villarreal-Arroyo M

Mejia-Herrera JC

Larios-Forte MC Incidence of Modic degenerative changes in patients with chronic lumbar pain at Monterrey Regional ISSSTE Hospital. , 19 Kerttula L

Luoma K

Vehmas T

Grönblad M

Kääpä E Modic type I change may predict rapid progressive, deforming disc degeneration: a prospective 1-year follow-up study. , 20 Luoma K

Vehmas T

Grönblad M

Kerttula L

Kääpä E Relationship of Modic type 1 change with disc degeneration: a prospective MRI study. , 21 Ma Z

Ding WY

Shen Y

Sun YP

Yang DL

Xu JX The study on the relationship between modic change and disc height together with lumbar hyperosteogeny. , 23 Jensen TS

Kjaer P

Korsholm L

et al. Predictors of new vertebral endplate signal (Modic) changes in the general population. The results of this current study also showed a strong association between disc herniation at a lumbar level and Modic changes at this same level, supporting previous research that these degenerative changes are more likely to occur together at the same level, most commonly in the lower lumbar segments.

7 Han C

Ma X

Ma J

Wang T

Wang P Distribution characteristics of Modic changes of lumbar endplate and its relationship with low back pain. , 8 Villarreal-Arroyo M

Mejia-Herrera JC

Larios-Forte MC Incidence of Modic degenerative changes in patients with chronic lumbar pain at Monterrey Regional ISSSTE Hospital. , 19 Kerttula L

Luoma K

Vehmas T

Grönblad M

Kääpä E Modic type I change may predict rapid progressive, deforming disc degeneration: a prospective 1-year follow-up study. , 20 Luoma K

Vehmas T

Grönblad M

Kerttula L

Kääpä E Relationship of Modic type 1 change with disc degeneration: a prospective MRI study. , 21 Ma Z

Ding WY

Shen Y

Sun YP

Yang DL

Xu JX The study on the relationship between modic change and disc height together with lumbar hyperosteogeny. , 23 Jensen TS

Kjaer P

Korsholm L

et al. Predictors of new vertebral endplate signal (Modic) changes in the general population. Comparing the age of patients with and without MC, we found a significant difference between these two groups of patients, with the MC positive patients being slightly older than the MC negative patients. This association between advanced age and degenerative changes was already established by many studies.There was no difference between the age of patients presenting with MC type I and MC type II however.

5 Thompson KJ

Dagher AP

Eckel TS

Clark M

Reinig JW Modic changes on MR images as studied with provocative diskography: clinical relevance--a retrospective study of 2457 disks. , 9 Hutton MJ

Bayer JH

Powell JM Modic vertebral body changes: the natural history as assessed by consecutive magnetic resonance imaging. , 10 Jensen RK

Leboeuf-Yde C

Wedderkopp N

Sorensen JS

Jensen TS

Manniche C Is the development of Modic changes associated with clinical symptoms? A 14-month cohort study with MRI. , 11 Kuisma M

Karppinen J

Niinimäki J

et al. A three-year follow-up of lumbar spine endplate (Modic) changes. , 12 Marshman LA

Trewhella M

Friesem T

Bhatia CK

Krishna M Reverse transformation of Modic type 2 changes to Modic type 1 changes during sustained chronic low-back pain severity. Report of two cases and review of the literature. , 17 Järvinen J

Karppinen J

Niinimäki J

et al. Association between changes in lumbar Modic changes and low back symptoms over a two-year period. , 18 Schistad EI

Espeland A

Rygh LJ

Roe C

Gjerstad J The association between Modic changes and pain during 1-year follow-up in patients with lumbar radicular pain. Although it did not reach statistical significance, a tendency was shown by patients with MC of presenting with a more acute onset of symptoms, whereas patients without MC presented with a more chronic course of symptoms. This difference between these two categories of patients could be explained by the fact that MC may represent a separate pain source in these patients. Similarly, when comparing patients with MC type I and those with MC type II, the results revealed that patients with MC type I showed a shorter onset of symptoms, whereas those with MC type II presented with a longer duration of complaints. This tendency did not reached statistical significance, but it supports the hypotheses that MCs commonly occur at the same levels as herniated discs (most likely initiated by the disc herniation in many patients) and that the Modic types change over time, with the most common pattern being that of MC type I changing to MC type II over time.