Association of Modic changes with health-related quality of life among patients referred to spine surgery

Modic Changes of the Cervical and Lumbar Spine and Their Effect on Neck and Back Pain: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic Review.

OBJECTIVES

To systematically review the current literature and perform a meta-analysis on patients with cervical or lumbar spine Modic changes to determine if their baseline axial back pain and disability are comparable to patients without Modic changes.

METHODS

A systematic review of the PubMed database was conducted in accordance with PRISMA guidelines. A meta-analysis was performed to compare the mean differences in back pain, leg pain, and disability based on the presence of cervical or lumbar spine Modic changes. A subgroup analysis of the different types of Modic changes was conducted to determine if Modic type affected back pain or disability.

RESULTS

- After review of 259 articles, 17 studies were included for meta-analysis and ten studies were included for qualitative synthesis. In the lumbar spine, 10 high-quality studies analyzed Visual Analog Scale (VAS) back pain, 10 evaluated VAS leg pain, and 8 analyzed Oswestry Disability Index. VAS back pain (mean difference (MD), -.38; 95% CI, -.61 - .16) and Oswestry disability index (MD -2.52; 95% CI, -3.93 - -1.12) were significantly lower in patients without Modic changes. Modic change subtype was not associated with differences in patient-reported outcomes. Patients with cervical spine Modic changes did not experience more severe pain than those without MC.

CONCLUSIONS

Modic changes in the lumbar spine are not associated with clinically significant axial low back pain severity or patient disability. Similar to the lumbar spine, Modic changes in the cervical spine are not associated with symptom severity, but they are associated with pain duration.

The impact of degenerative disc disease on regional volumetric bone mineral density (vBMD) measured by quantitative computed tomography

BACKGROUND CONTEXT

It has been reported that degenerative disc disease (DDD) is associated with higher spinal bone mineral density (BMD) based on previous studies that used dual X-ray absorptiometry (DXA). However, DDD is often associated with proliferative bone changes and can lead to an overestimation of BMD measured with DXA. Trabecular volumetric BMD (vBMD) in the vertebral body measured with quantitative computed tomography (QCT) is less affected by those changes and can be a favorable alternative to DXA for patients with degenerative spinal changes.

PURPOSE

The purpose of this study is to investigate the effect of DDD on regional trabecular vBMDs in the vertebral body measured by QCT.

STUDY DESIGN/SETTING

Cross-sectional observational study at a single academic institution.

PATIENTS SAMPLE

Consecutive patients undergoing posterior lumbar spinal fusion between 2014 and 2017 who had a routine preoperative CT scan and magnetic resonance imaging (MRI) within a 90-day interval.

OUTCOME MEASURES

Regional trabecular vBMDs in the vertebral body by QCT.

METHODS

QCT measurements were conducted in L1-S1 vertebral trabecular bone. Any apparent sclerotic lesions that might affect vBMD values were excluded from the region of interest. The vBMDs of each level were defined as the average vBMD of the upper and lower vertebrae. To evaluate DDD, Pfirrmann grade, Modic grade, total end plate score, and vacuum phenomenon were documented. Univariate regression analysis and multivariate analyses with a linear mixed model adjusted with individual variability of segmental vBMDs were conducted with vBMD as the response variable.

RESULTS

Of 143 patients and 715 disc levels, 125 patients and 596 discs met our inclusion criteria. Mean vBMD (±standard deviation [SD]) of all levels was 119.0±39.6 mg/cm³. After adjusting for all covariates, Pfirrmann grade was not an independent contributor to vBMD, but the presence of any Modic change (type 1, β=6.8, p≤.001; type 2, β=6.7, p<.001; type 3, β=43.6, p<.001), high TEPS (score 10-12, β=14.2, p<.001), or vacuum phenomenon (β=9.0, p<.001) was shown to be independent contributors to vBMD.

CONCLUSIONS

Our results showed that the presence of certain end plate lesions (Modic changes and high TEPS) on MRI was significantly associated with increased regional QCT-vBMDs in the vertebral body, but no significant association was observed with disc nucleus pathology, unless it was associated with a vacuum phenomenon. When end plate lesions with Modic changes and high TEPS are present at the measuring level, care must be taken to interpret vBMD values, which might be overestimations even if the trabecular area appears normal.

Osteoclast activators are elevated in intervertebral disks with Modic changes among patients operated for herniated nucleus pulposus

PURPOSE

Modic changes (MC) are associated with low back pain (LBP). Inflammation is considered as a key factor that triggers symptoms in especially type I MC, but so far of the potential inflammatory candidates only TNFα has been linked to MC. The objective of the study was to analyze a set of inflammatory mediators in human surgical disk samples and quantify their association with MC in the adjacent vertebral bodies.

METHODS

The study sample consisted of 51 intervertebral disk tissue specimens; 20 'No MC' disks, 19 'Type I MC' disks, and 12 'Type II MC' disks. mRNA expression of 46 cytokines was quantified from isolated RNA. Tissue samples were stained using hematoxylin and eosin, toluidine blue, Herovici, CD68 and CD163.

RESULTS

No significant differences were found in the amount of macrophages or presence of chondrocyte conglomerates between the MC groups. Of the multiple genes tested, statistically significant associations were observed for M-CSF1 (p = 0.028), RANKL (p = 0.035), RUNX1 (p = 0.032), and RUNX2 (p = 0.047) that were increased in 'Type II MC,' while OSCAR (p = 0.042) was increased in 'Type I MC' group compared to 'No MC.'

CONCLUSIONS

Since these cytokines are related to differentiation and proliferation of osteoclasts, our data suggest that the stimulation of vertebral osteoclasts by factors secreted by disk tissue is involved in the pathophysiology of MC.