Are Modic Vertebral End-Plate Signal Changes Associated with Degeneration or Clinical Outcomes in the Cervical Spine?

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.

Evaluating Nonoperative Treatment for Low Back Pain in the Presence of Modic Changes: A Systematic Review

OBJECTIVE

The objective of this study was to summarize and assess the current literature evaluating nonoperative treatments for patients with Modic changes (MCs) and low back pain (LBP).

METHODS

A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The PubMed database was searched from its inception until May 1, 2022 for studies evaluating MC and clinical outcomes. Key findings, treatment details, and patient information were extracted from included studies. Study quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

Eighteen studies were included in this review, encompassing a total of 2452 patients, 1713 of whom displayed baseline MC. Seventy-eight percent of studies were high quality. Of included studies, 2 evaluated antibiotics, 5 evaluated steroid injections, 6 evaluated conservative therapies, and 5 evaluated other treatment modalities. Antibiotics and bisphosphonates improved treatment in patients with MC. Patients with MC without disc herniation benefited from conservative therapy, while those with Type I Modic changes and disc herniation experienced poorer improvement. Significant variability exists in reported outcomes following steroid injections.

CONCLUSIONS

Nonoperative therapy may provide patients with MC with significant benefits. Patients may benefit from therapies not traditionally utilized for LBP such as antibiotics or bisphosphonates, but conservative therapy is not recommended for patients with concomitant MC and disc herniation. The large variation in follow-up times and outcome measures contributes to significant heterogeneity in studies and inability to predict long-term patient outcomes. More long-term studies are needed to assess nonoperative treatments for LBP in patients with MC.

Evaluating the Impact of Modic Changes on Operative Treatment in the Cervical and Lumbar Spine: A Systematic Review and Meta-Analysis

Modic changes (MCs) are believed to be potential pain generators in the lumbar and cervical spine, but it is currently unclear if their presence affects postsurgical outcomes. We performed a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies evaluating cervical or lumbar spine postsurgical outcomes in patients with documented preoperative MCs were included. A total of 29 studies and 6013 patients with 2688 of those patients having preoperative MCs were included. Eight included studies evaluated cervical spine surgery, eleven evaluated lumbar discectomies, nine studied lumbar fusion surgery, and three assessed lumbar disc replacements. The presence of cervical MCs did not impact the clinical outcomes in the cervical spine procedures. Moreover, most studies found that MCs did not significantly impact the clinical outcomes following lumbar fusion, lumbar discectomy, or lumbar disc replacement. A meta-analysis of the relevant data found no significant association between MCs and VAS back pain or ODI following lumbar discectomy. Similarly, there was no association between MCs and JOA or neck pain following ACDF procedures. Patients with MC experienced statistically significant improvements following lumbar or cervical spine surgery. The postoperative improvements were similar to patients without MCs in the cervical and lumbar spine.

Associations between clinical neck symptoms and various evaluations ofcervical intervertebral disc degeneration by magnetic resonance imaging

PURPOSE

Magnetic resonance imaging (MRI) is widely used to evaluate intervertebral disc degeneration. Recently, various evaluations of cervical disc degeneration using MRI have been conducted, but there is no gold standard. The purpose of this study was to compare the reproducibilities of previously reported classifications for evaluating cervical disc degeneration by MRI and their associations with clinical symptoms.

PARTICIPANTS AND METHODS

A total of 582 subjects underwent conventional MRI of the cervical spine. Disc degeneration was assessed in each intervertebral disc from C2/3 to C7/T1 using five different classifications: Matsumoto's grading system, Miyazaki's grading system, Nakashima's grading system, Jacobs' grading system, and Suzuki's grading system. MR images of 30 participants were used, and Cohen's kappa coefficient of agreement of each classification was calculated for intra-observer and inter-observer reliabilities. These five classifications of disc degeneration and changes of vertebral endplates were measured, and associations with clinical symptoms were assessed.

RESULTS

Kappa (κ) values of intra-observer agreement were higher for Jacobs' classification, whereas those of inter-observer agreement were higher for Nakashima's and Jacobs' classifications than for other classifications. The prevalences of neck pain and shoulder stiffness were 27.4% and 41.9%, respectively. There were no associations for any classifications of disc degeneration and Modic types with neck pain or shoulder stiffness. Only the presence of Schmorl's nodes was associated with neck pain.

CONCLUSION

At present, there is no specific classification for cervical disc degeneration associated with clinical symptoms. Vertebral endplate changes might be associated with clinical symptoms. It may be necessary to create a new classification for better reproducibility of the evaluation of cervical disc degeneration.

Cervical disc degeneration: important considerations for the manual therapist

Cervical disc degeneration (CDD) is a progressive, age-related occurrence that is frequently associated with neck pain and radiculopathy. Consistent with the majority of published clinical practice guidelines (CPG) for neck pain, the 2017 American Physical Therapy Association Neck Pain CPG recommends cervical manipulation as an intervention to address acute, subacute, and chronic symptoms in the 'Neck Pain With Mobility Deficits' category as well for individuals with 'Chronic Neck Pain With Radiating Pain'. While CPGs are evidence-informed statements intended to help optimize care while considering the relative risks and benefits, these guidelines generally do not discuss the mechanical consequences of underlying cervical pathology nor do they recommend specific manipulation techniques, with selection left to the practitioner's discretion. From a biomechanical perspective, disc degeneration represents the loss of structural integrity/failure of the intervertebral disc. The sequelae of CDD include posterior neck pain, segmental hypermobility/instability, radicular symptoms, myelopathic disturbance, and potential vascular compromise. In this narrative review, we consider the mechanical, neurological, and vascular consequences of CDD, including information on the anatomy of the cervical disc and the mechanics of discogenic instability, the anatomic and mechanical basis of radiculitis, radiculopathy, changes to the intervertebral foramen, the importance of Modic changes, and the effect of spondylotic hypertrophy on the central spinal canal, spinal cord, and vertebral artery. The pathoanatomical and biomechanical consequences of CDD are discussed, along with suggestions which may enhance patient safety.

Cervical Disc Degeneration and Vertebral Endplate Defects After the Fused Operation

STUDY DESIGN

Longitudinal study of cervical MR in patients with degenerative disc disease (DDD).

OBJECTIVE

To evaluate the evolution of the degenerative changes in the C2-D1 cervical segments and to assess the association magnetic resonance imaging (MRI) parameters with clinical symptoms after surgical treatment in patients with DDD.

SUMMARY OF BACKGROUND DATA

The evolution of degenerative changes in the cervical spine is poorly understood. Endplate defects can be of great importance in progressive disc degeneration (DD). Clarification of this predictor may be important in determining the treatment tactics in patients with DDD.

METHODS

The study included patients who had 2-years' follow-up after cervical fusion for spondylotic radiculo- with/without myelopathy. Demographic data (age, sex, surgical data) were assessed; clinical data (visual analogue scale [VAS] neck, VAS arm, Neck Disability Index [NDI]) and cervical MRI (DD grades by Pfirrmann, Modic changes (MC), total endplate scores (TEPS) were compared to preoperative data.

RESULTS

The median follow-up term was 26.5 (18.9-33.1) months. All patients reported a decrease neck pain and arm pain at follow-up (P < 0.001). There was observed the change in MC types (P < 0.001) and an increase of TEPS (P < 0.05). 71.7% discs remained unchanged during the follow-up, but a significant number of discs went from Grade 2 to Grade 3 and from Grade 3 to Grade 4 by Pfirrmann (P < 0.001). Clinical scores (VAS neck, VAS arm, NDI) had no correlation with MRI changes (P > 0.05). DD was associated with TEPS (odds ratio [OR] 2.05-5.47, P < 0.05) and patients' age (OR 1.11-2.33, P < 0.05) at all cervical levels; with MC types, but only at C4-C5 and C6-C7 levels (OR = 2.91 and 2.79, respectively, P < 0.05). Receiver-operating characteristic analysis showed a TEPS threshold value of 7, above which the probability of DD significantly higher.

CONCLUSION

During 2 years' follow-up the significant increase of DD grades by Pfirrmann was observed at C4-C6 levels (P < 0.001). A significant association DD with TEPS and age at all cervical levels was determined.Level of Evidence: 3.

Association between Modic changes, disc degeneration, and neck pain in the cervical spine: a systematic review of literature

BACKGROUND

The contribution of Modic changes (MCs) in relation to spinal pain and degenerative changes has been evaluated frequently. However, most studies focus on lumbar spine. The association between MCs, neck pain, and cervical disc degeneration is not clear.

PURPOSE

The objective of this study was to review current literature on the association between MCs, cervical disc degeneration, and neck pain.

STUDY DESIGN

A systematic review METHODS: A literature search was performed in PubMed, Embase, and Web of Science using a sensitive search string combination. Studies were selected by predefined selection criteria and risk of bias was assessed using a validated Cochrane Checklist adjusted for this purpose.

RESULTS

Fourteen articles that associated MCs with neck pain and/or cervical disc degeneration were included in the present study. Ten articles showed low risk of bias and four showed intermediate risk of bias. The prevalence of MCs in cervical spine varied from 5% to 40% and type II was predominant. Patients with MCs were reported to experience more neck pain and disability. Cervical disc degeneration was detected more frequently in patients with MCs.

CONCLUSIONS

Modic changes were found to be associated with neck pain and with disc degeneration. Therefore, the large variation in prevalence that is reported is highly dependent on the nature of the studied population.

The Impact of Modic Changes on Preoperative Symptoms and Clinical Outcomes in Anterior Cervical Discectomy and Fusion Patients

Objective

To assess the impact of Modic changes (MC) on preoperative symptoms, and postoperative outcomes in anterior cervical discectomy and fusion (ACDF) patients.

Methods

We performed a retrospective study of prospectively collected data of ACDF patients at a single institution. Preoperative magnetic resonance imagings were used to assess the presence of MC. MC were stratified by type and location, and compared to patients without MC. Associations with symptoms, patient-reported measures, and surgical outcomes were assessed.

Results

A total of 861 patients were included, with 356 patients with MC (41.3%). MC more frequently occurred at C5–6 (15.1%), and type II was the most common type (61.2%). MC were associated with advanced age (p < 0.001), more levels fused (p < 0.001), a longer duration of symptoms, but not with specific symptoms. MC at C7–T1 resulted in higher postoperative disability (p < 0.001), but did not increase risk of adjacent segment degeneration or reoperation.

Conclusion

This study is the first to systematically examine the impact of cervical MC, stratified by type and location, on outcomes in ACDF patients. Patients with MC were generally older, required larger fusions, and had longer duration of preoperative symptoms. While MC may not affect specific outcomes following ACDF, they may indicate a more debilitating preoperative state for patients.

Progress of the Anterior Transpedicular Screw in Lower Cervical Spine: A Review

The anterior transpedicular screws (ATPS) fixation is a valuable discovery in the field of lower cervical spine (LCS) reconstruction, as it has the advantages of both anterior and posterior approaches. In recent years, with in-depth research on ATPS fixation related to anatomy, biomechanical tests, and clinical applications, its firm stability and excellent biomechanical properties have been recognized by more and more surgeons. Although ATPS fixation has been gradually applied in clinic settings under the promotion of emerging distinctive instruments, its long-term efficacy still needs to be further clarified due to the lack of large sample size studies and long-term follow-up. Nevertheless, it is believed that with the maturity of digital devices and the development of precision medicine, ATPS fixation has a promising prospect.