Vertebral endplate changes are not associated with chronic low back pain among Southern European subjects: a case control study

The association of modic changes and chronic low back pain: A systematic review

Background

Modic changes (MC) have been proposed as a cause of low back pain (LBP). However, the proposition remains controversial. There is uncertainty over the existence or degree of association between the two and whether, if there is an association, it is a causal relationship. Previous systematic reviews of the evidence have had methodological flaws.

Aims

The aim was to synthesize the current evidence to test the hypothesis that there is an association between MC and LBP and if there is, to evaluate the strength of the association.

Methods

MEDLINE, EMBASE, and CINAHL were searched for all studies up to 31 December 2018 for cohort, case-control, and cross-sectional studies. Screening, quality assessment, and data extraction were conducted by two independent reviewers. Quality was assessed using the Joanna Biggs Institute tools for observational studies. The clinical heterogeneity among these studies ruled out pooling so a narrative review was undertaken.

Results

Fifteen studies met the inclusion criteria, varying in patient characteristics, characteristics of MC, coexisting spinal conditions, and outcomes. The quality of evidence was poor in six and moderate in seven. There was wide clinical heterogeneity amongst the studies. The inclusion ages varied from early teens to over 65s, pain duration varied from under 6 weeks to over three months, and characteristics of the MC chosen for the studies also differed. The results were inconsistent across the studies: the odds ratios varied from showing an inverse relationship [Kovacs] with an odds ratio 0.31 (95% confidence interval, 0.1-0.95) to a very strong positive association 121.4 (11.21-1315.08) [Nakamae]. There was no consistency in associations for: type of MC, lumbar levels affected, position in relation to the vertebra, and presence of co-existing spinal conditions. The associations were possibly spurious arising from potential biases suggested by incomplete reporting: publication bias, selective reporting, and post hoc analysis. Only one study at low risk of bias found a substantial association but it was a small study of a narrow group meaning its results may not be generalizable.

Discussion

The inconsistency of findings and the possibility that they were spurious means that no conclusions can be drawn about an association between MC and LBP. Future research should be designed as prospective cohort studies with adherence to reporting guidelines pertaining to observational studies and to MRI. Currently, clinicians should not look for the presence or absence of MC to guide their management of patients with LBP.

Detailed Subphenotyping of Lumbar Modic Changes and Their Association with Low Back Pain in a Large Population-Based Study: The Wakayama Spine Study

INTRODUCTION

To examine the association between the five types of Modic changes and low back pain (LBP) in a large population-based cohort.

METHODS

Of the 952 participants in the second Wakayama Spine Study, 814 (men, 246; women, 568; mean age, 63.6 years) were included in this study. Endplate changes on magnetic resonance imaging were classified according to the Modic classification system. Low back pain (LBP) was defined as continuous back pain for at least 48 h in the past month that is currently present. The prevalence of Modic changes in the lumbar region was assessed. Multivariate logistic regression analysis was conducted to determine the association between detailed subphenotype of Modic change and LBP comparing no Modic change in the lumbar spine and each level, respectively.

RESULTS

Modic changes throughout the lumbar spine were noted in 63.5% (n = 516) of all participants, with types I, I/II, II, II/III, and III observed in 7.8% (n = 63), 10.8% (n = 88), 40.0% (n = 326), 2.1% (n = 17), and 2.7% (n = 22), respectively. Modic types I/II were associated with LBP [odds ratio (OR): 3.26; 95% confidence interval (CI) 1.9, 5.5]. Furthermore, Modic type I/II changes at L2/3 and L4/5 were significantly associated with LBP (odds ratio: 2.77; 95% CI 1.04, 7.39 at L2/3; odds ratio: 2.86; 95% CI 1.39, 5.90 at L4/5).

CONCLUSIONS

Type I/II Modic changes in the lumbar region are significantly associated with LBP. To the best of our knowledge, this is the first large population-based study on the association between various Modic changes and LBP.

Association between types of Modic changes in the lumbar region and low back pain in a large cohort: the Wakayama spine study

PURPOSE

The clinical significance of Modic changes in low back pain (LBP) is yet to be clarified. Thus, this study aimed to examine the association between Modic changes and LBP after adjustment for confounding factors.

METHODS

We evaluated participants in the second Wakayama Spine Study. The degree of endplate changes as measured using magnetic resonance imaging was classified based on the Modic classification system. The prevalence of the types of Modic change in the lumbar region and at each level was assessed. Multivariate logistic regression analysis was conducted to determine the association between the types of Modic changes and LBP with adjustment for age, sex, body mass index, disc degeneration score, and disc displacement score. The LBP intensity was also compared according to the Visual Analogue Scale (VAS) score among the three types of Modic change.

RESULTS

Overall, 814 subjects were evaluated. Type II Modic changes were the most prevalent (41.9%). Only type I Modic changes were significantly associated with LBP (odds ratio): 1.84, 95% confidence interval [CI]: 1.1-2.9). The LBP VAS score was significantly higher in subjects with type I Modic change than that in those with no Modic change (23.9 ± 26.3 vs. 9.9 ± 19.4, p < 0.05).

CONCLUSION

Type I Modic changes in the lumbar region are significantly associated with LBP. Profiling Modic changes may be helpful to improve targeted treatment of LBP.

Modic changes-Their associations with low back pain and activity limitation: A systematic literature review and meta-analysis

BACKGROUND

Previous systematic reviews have reported positive associations between Modic changes (MCs) and low back pain (LBP), but due to their narrow scope and new primary studies, there is a need for a comprehensive systematic review. Our objectives were to investigate if MCs are associated with non-specific LBP and/or activity limitation and if such associations are modified by other factors.

METHODS

A protocol for this review was registered at PROSPERO prior to commencing the work (PROSPERO record: CRD42015017350). The MEDLINE, CINAHL and EMBASE databases were searched for relevant studies from first record to June 15th 2016. Prospective or retrospective cross-sectional cohort studies and case-control studies including people of all ages from general, working and clinical study populations were eligible for inclusion. Risk of bias assessment and data extraction for associations and potential modifiers were completed independently by pairs of reviewers. Meta-analysis was performed for homogeneous studies and presented as odds ratios (OR) with 95% CI.

RESULTS

In all, 5210 citations were identified and 31 studies were included. One study had low risk of bias. Fifteen studies (48%) reported statistically significant positive associations between MCs and LBP and one study found a statistically significant negative association. Meta-analysis performed for studies using concordant pain with provocative discography as the clinical outcome resulted in an OR of 4.01 (1.52-10.61). One of seven studies reported a statistically significant positive association between MCs and activity limitation. Lumbar disc level and disc degeneration were found to modify the association between MCs and LBP.

CONCLUSIONS

The results from this comprehensive systematic review indicate that the associations between MCs and LBP-related outcomes are inconsistent. The high risk of bias and the heterogeneity in terms of study samples, clinical outcomes and prevalence estimates of MCs and LBP may explain these findings. It is likely that new studies with low risk of bias will affect the direction and strength of these associations.

Modic Changes and Disc Degeneration of Nonfused Segments 27 to 45 Years After Harrington Instrumentation for Adolescent Idiopathic Scoliosis: Comparison to Healthy Controls

STUDY DESIGN

A case-control study.

OBJECTIVE

The aim of this study was to investigate the long-term prevalence of the Modic changes and disc degeneration in the nonfused segments of the surgically treated adolescent idiopathic scoliosis (AIS) patients and compare with age- and sex-matched healthy controls.

SUMMARY OF BACKGROUND DATA

No studies have looked at the association between Modic changes and low back pain in patients who underwent AIS surgery many years ago.

METHODS

Study subjects consisted of 194 patients with AIS who underwent spinal fusion with Harrington instrumentation between 1968 and 1987. Twenty-six patients (AIS group) underwent lumbar magnetic resonance imaging (MRI), whole spine X-ray, and patient-reported outcomes evaluations [Scoliosis Research Society-22 Patient Questionnaire (SRS-22), Oswestry Disability Index (ODI)]. The mean duration of follow-up observation was 36.1 years. The lowest fusion vertebra was used as follows: T12: 2 patients, L1: 4, L2: 11, L3: 6, L4: 2, L5: 1. Twenty-nine healthy age- and sex-matched individuals were selected as a control (CTR) group.

RESULTS

On the basis of MRI findings, a significantly higher percentage of subjects showed Modic changes in the AIS group (AIS group: 57.7%, CTR group: 13.8%). There were no significant differences in the percentage of subjects with disc degeneration rated Pfirrmann grade 4 or higher (AIS group: 61.5%, CTR group: 65.5%). SRS-22 scores for function and self-image were significantly lower in the AIS group. ODI was significantly worse in the AIS group. Modic changes in AIS group were found in the concave side of the curve in 61.9%. The magnitude of lumbar coronal curve was found to be a significant risk factor of Modic changes.

CONCLUSION

Modic changes were observed in 57.7% of AIS patients 27 years or more after spinal fusion with Harrington instrumentation. The magnitude of lumbar coronal curve was found to be a significant risk factor of Modic changes. Modic change occurred at a higher frequency in AIS patients than CTR individuals, with lower function and worse ODI scores.

LEVEL OF EVIDENCE

4.

Spinal fusion on adolescent idiopathic scoliosis patients with the level of L4 or lower can increase lumbar disc degeneration with sagittal imbalance 35 years after surgery

Introduction

The purpose of this study was to investigate the long-term incidence of lumbar disc degeneration and Modic changes in the non-fused segments of patients with adolescent idiopathic scoliosis (AIS) who previously underwent spinal fusion.

Methods

Study subjects consisted of 252 patients with AIS who underwent spinal fusion between 1968 and 1988. Of 252 patients, 35 subjects underwent lumbar spine MRI and whole spine X-ray examination. The mean patient age at the time of follow-up was 49.8 years, with an average follow-up period of 35.1 years. We classified the subjects into two groups based on the lowest fused vertebra: H group whose lowest fused vertebra was L3 or higher levels and L group whose lowest fused vertebra was L4 or lower levels.

Results

The L group had significantly advanced disc degeneration on MRI. There was no significant difference between two groups in Modic changes. The L group showed less lumbar lordosis than the H group (H group: 48.1 degrees; and L group: 32.1 degrees) and greater SVA (H group: 1.2 cm; and L group: 5.5 cm).

Conclusions

In AIS patients, 35 years after spinal fusion surgery on average, we evaluated lumbar disc degeneration and Modic changes of the non-fused segments. In patients with the lowest fusion level at L4 or lower, there were reduced lumbar lordosis, considerable SVA imbalance, and severe disc degeneration compared with those with the lowest fusion level at L3 or higher. The lowest fusion level at L3 or higher is recommended to reduce disc degeneration in midlife.

Antibiotic treatment In patients with chronic low back pain and Modic changes (the AIM study): study protocol for a randomised controlled trial

Background

A previous randomised controlled trial (RCT) of patients with chronic low back pain (LBP) and vertebral bone marrow (Modic) changes (MCs) on magnetic resonance imaging (MRI), reported that a 3-month, high-dose course of antibiotics had a better effect than placebo at 12 months’ follow-up. The present study examines the effects of antibiotic treatment in chronic LBP patients with MCs at the level of a lumbar disc herniation, similar to the previous study. It also aims to assess the cost-effectiveness of the treatment, refine the MRI assessment of MCs, and further evaluate the impact of the treatment and the pathogenesis of MCs by studying genetic variability and the gene and protein expression of inflammatory biomarkers.

Methods/design

A double-blinded RCT is conducted at six hospitals in Norway, comparing orally administered amoxicillin 750 mg, or placebo three times a day, over a period of 100 days in patients with chronic LBP and type I or II MCs at the level of a MRI-confirmed lumbar disc herniation within the preceding 2 years. The inclusion will be stopped when at least 80 patients are included in each of the two MC type groups. In each MC type group, the study is designed to detect (β = 0.1, α = 0.05) a mean difference of 4 (standard deviation 5) in the Roland Morris Disability Questionnaire score between the two treatment groups (amoxicillin or placebo) at 1-year follow-up. The study includes cost-effectiveness measures. Blood samples are assessed for security measures and for possible inflammatory mediators and biomarkers at different time points. MCs are evaluated on MRI at baseline and after 12 months. A blinded intention-to-treat analysis of treatment effects will be performed in the total sample and in each MC type group.

Discussion

To ensure the appropriate use of antibiotic treatment, its effect in chronic LBP patients with MCs should be re-assessed. This study will investigate the effects and cost-effectiveness of amoxicillin in patients with chronic LBP and MCs at the level of a disc herniation. The study may also help to refine imaging and characterise the biomarkers of MCs.

Trial registration

ClinicalTrials.gov, ID: NCT02323412. Registered on 21 November 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2306-8) contains supplementary material, which is available to authorized users.

Are Modic Changes Able to Help Us in Our Clinical Practice? A Study of the Modic Changes in Young Adults During Working Age

STUDY DESIGN

Modic changes [vertebral endplate spinal changes (VESC)] have been related to degenerative disk disease, and in past decades it was thought that their presence justified the surgical treatment, in particular spinal fusion.

OBJECTIVE

The aim of the present study is to investigate its prevalence and features in a population of young workers suffering from low back pain, and explore the eventual relationship with the treatment applied in each case.

BACKGROUND DATA

We conducted a retrospectively review of 450 magnetic resonance images from our hospital, in patients with low back pain or sciatica and age below 40.

MATERIALS AND METHODS

Age, sex, symptoms predominance, concurrence with other spine disease, VESC type, evolution, level/s of involvement and placement, affected disk location and extent of the disease, disk height, and status of the endplate were recorded. The applied treatment was divided in groups according to the degree of invasiveness of the procedure.

RESULTS

Prevalence of VESC was 13.05% predominant in patients over 30 years, and 100% associated to disk degenerative changes. Most frequent features were: type I (54%), lower lumbar region (98%), along with a decreased disk height (68%), and distortion of the disk endplates (98%, P<0.01). The patients with VESC presented a favorable outcome with conservative treatment, but were more frequently associated with invasive treatment, compared with non-VESC patients (P<0.024).

CONCLUSIONS

VESC prevalence increases with age, underlying the degenerative causative etiology. Surgical indication should not be stated on the basis of the VESC findings alone, the main factor for indicating surgery depends more on other associated degenerative spinal changes.

Type II Modic Changes May not Always Represent Fat Degeneration: A Study Using MR Fat Suppression Sequence

STUDY DESIGN

A radiological study of type II Modic changes (MCs).

OBJECTIVES

The aim of this study was to determine the characteristics of type II MCs on fat suppression (FS) magnetic resonance (MR) images and its association with radiological disc degeneration.

SUMMARY OF BACKGROUND DATA

Type II MCs are common endplate signal changes on MR images. On the basis of limited histological samples, type II MCs are thought to be stable fat degeneration. FS technique on MR, which can quantify fat content, may be an alternative to explore the pathology of MCs. To date, however, the characteristics of type II MCs on FS sequence have not been studied.

METHODS

Lumbar MR images conducted in a single hospital during a defined period were reviewed to include those with type II MCs and FS images. On FS images, signal status of type II MCs was visually classified as suppressed or not-suppressed. Signal intensity of vertebral regions with and without MCs was measured quantitatively on T2-weighted (T2W) and FS images to calculate fat content index and validate the visual classification. Using image analysis program Osirix, MCs size and adjacent disc degeneration were measured quantitatively. Paired t-tests and logistic regressions were used to determine the associations studied.

RESULTS

Sixty-four lumbar MRIs were included and 150 endplates with type II MCs were studied. Although signal of 37 (24.7%) type II MCs was suppressed on FS images, that of 113 (75.3%) was not suppressed. The discs adjacent to type II MCs had lower signal intensity (0.13 ± 0.003 vs. 0.14 ± 0.004, P < 0.001), lesser disc height (9.73 ± 1.97 vs. 11.07 ± 1.99, P < 0.001) and greater bulging area (80.0 ± 31.4 vs. 61.3 ± 27.5 for anterior bulging, 33.72 ± 21.24 vs. 27.93 ± 12.79 for posterior bulging, and 113.7 ± 39.9 vs. 89.2 ± 35.2 for total bulging, P < 0.05) than normal controls. Type II MCs that were not suppressed on FS image were associated with greater age [odds ratio (OR) = 1.11, P < 0.001], lower height (OR = 0.94, P < 0.05), and greater posterior bulging (OR = 1.05, P < 0.001) at the adjacent disc.

CONCLUSION

Signal of most type II MCs was not suppressed on FS MR images, suggesting that there are ongoing complicated pathologies. Type II MCs may not merely represent fat replacement.

LEVEL OF EVIDENCE

3.

Refined Phenotyping of Modic Changes: Imaging Biomarkers of Prolonged Severe Low Back Pain and Disability

Low back pain (LBP) is the world's most disabling condition. Modic changes (MC) are vertebral bone marrow changes adjacent to the endplates as noted on magnetic resonance imaging. The associations of specific MC types and patterns with prolonged, severe LBP and disability remain speculative. This study assessed the relationship of prolonged, severe LBP and back-related disability, with the presence and morphology of lumbar MC in a large cross-sectional population-based study of Southern Chinese.We addressed the topographical and morphological dimensions of MC along with other magnetic resonance imaging phenotypes (eg, disc degeneration and displacement) on the basis of axial T1 and sagittal T2-weighted imaging of L1-S1. Prolonged severe LBP was defined as LBP lasting ≥30 days during the past year, and a visual analog scale severest pain intensity of at least 6/10. An Oswestry Disability Index score of 15% was regarded as significant disability. We also assessed subject demographics, occupation, and lifestyle factors.In total, 1142 subjects (63% females, mean age 53 years) were assessed. Of these, 282 (24.7%) had MC (7.1% type I, 17.6% type II). MC subjects were older (P = 0.003), had more frequent disc displacements (P < 0.001) and greater degree of disc degeneration (P < 0.001) than non-MC subjects. In adjusted models, any MC (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.01-2.18), MC affecting whole anterior-posterior length (OR 1.62, 95% CI 1.04-2.51), and MC affecting 2/3 posterior length (OR 2.79, 95% CI 1.17-6.65) were associated with prolonged severe LBP. Type I MC tended to associate with pain more strongly than type II MC (OR 1.80, 95% CI 0.94-3.44 vs OR 1.36, 95% CI 0.88-2.09, respectively). Any MC (OR 1.47, 95% CI 1.04-2.10), type II MC (OR 1.56, 95% CI 1.06-2.31), MC affecting 2/3 posterior length (OR 2.96, 95% CI 1.27-6.89), and extensive MC (OR 1.95, 95% CI 1.21-3.15) were associated with disability. The strength of the associations increased with the number of MC.This large-scale study is the first to definitively note MC types and specific morphologies to be independently associated with prolonged severe LBP and back-related disability. This proposed refined MC phenotype may have direct implications in clinical decision-making as to the development and management of LBP. Understanding of these imaging biomarkers can lead to new preventative and personalized therapeutics related to LBP.

Degenerative disease of the lumbar spine

In the last 25 years, scientific research has brought about drastic changes in the concept of low back pain and its management. Most imaging findings, including degenerative changes, reflect anatomic peculiarities or the normal aging process and turn out to be clinically irrelevant; imaging tests have proven useful only when systemic disease is suspected or when surgery is indicated for persistent spinal cord or nerve root compression. The radiologic report should indicate the key points of nerve compression, bypassing inconsequential findings. Many treatments have proven inefficacious, and some have proven counterproductive, but they continue to be prescribed because patients want them and there are financial incentives for doing them. Following the guidelines that have proven effective for clinical management improves clinical outcomes, reduces iatrogenic complications, and decreases unjustified and wasteful healthcare expenditures.

ISSLS Prize Winner: Vertebral Endplate (Modic) Change is an Independent Risk Factor for Episodes of Severe and Disabling Low Back Pain

STUDY DESIGN

Longitudinal cohort study of twins representative of the general population.

OBJECTIVE

To assess the relationship between Modic change (MC) and severe, disabling low back pain (LBP), features of intervertebral disc degeneration (DD) and incident MC during 10-year follow-up.

SUMMARY OF BACKGROUND DATA

MC describes vertebral endplate and bone marrow lesions visible on magnetic resonance imaging (MRI). MC has been associated with DD. It remains unclear whether MC causes LBP independently or through association with DD. Moreover, association of MC with severe, disabling LBP is uncertain.

METHODS

Volunteers were recruited from the TwinsUK register to MRI and interview between 1996 and 2000 with a subset attending for follow-up a decade later. MC, DD (evaluated by loss of disc height and signal intensity, presence of disc bulge and anterior osteophytes) and Schmorl's nodes (SN) were determined on T2-weighted lumbar MR scans.

RESULTS

Complete data were available for 823 subjects at baseline and 429 at follow-up. Mean age at baseline was 54.0 years (range 32-70) with 96% females. The prevalence of MC was 32.2% at baseline and 48.7% at follow-up. Subjects with MC were older (P < 0.001) and more overweight (BMI: P = 0.026, weight: P < 0.001). At both baseline and follow-up, more subjects reporting severe LBP demonstrated MC (subjects with MC vs. without MC: 35.0% vs. 16.4% respectively, P < 0.001 at baseline; and 35.1% vs. 20.0% respectively, P < 0.001 at follow-up). In multivariable analyses, MC remained significantly associated with episodes of severe, disabling LBP (OR 1.58; 95% CI 1.04-2.41) after adjustment for age, BMI, DD, and SN at baseline. Loss of disc height and disc signal intensity were independently associated with prevalent MC at baseline, and disc height and disc bulge with incident MC during follow-up.

CONCLUSION

MC is an independent risk factor for episodes of severe and disabling LBP in middle-aged women. These observations support further work aimed at identifying the precise histology underlying MC.

LEVEL OF EVIDENCE

2.

Association between changes in lumbar Modic changes and low back symptoms over a two-year period

Background

The association of Modic changes (MC) with low back pain (LBP) is unclear. The purpose of our study was to investigate the associations between the extent of Type 1 (M1) and Type 2 (M2) MC and low back symptoms over a two-year period.

Methods

The subjects (n = 64, mean age 43.8 y; 55 [86%] women) were consecutive chronic LBP patients who had M1 or mixed M1/M2 on lumbar spine magnetic resonance imaging (MRI). Size and type of MC on sagittal lumbar MRI and clinical data regarding low back symptoms were recorded at baseline and two-year follow-up. The size (%) of each MC in relation to vertebral size was estimated from sagittal slices (midsagittal and left and right quarter), while proportions of M1 and M2 within the MC were evaluated from three separate slices covering the MC. The extent (%) of M1 and M2 was calculated as a product of the size of MC and the proportions of M1 and M2 within the MC, respectively. Changes in the extent of M1 and M2 were analysed for associations with changes in LBP intensity and the Oswestry disability index (ODI), using linear regression analysis.

Results

At baseline, the mean LBP intensity was 6.5 and the mean ODI was 33%. During follow-up, LBP intensity increased in 15 patients and decreased in 41, while ODI increased in 19 patients and decreased in 44. In univariate analyses, change in the extent of M1 associated significantly positively with changes in LBP intensity and ODI (beta 0.26, p = 0.036 and beta 0.30, p = 0.017; respectively), whereas the change in the extent of M2 did not associate with changes in LBP intensity and ODI (beta -0.24, p = 0.054 and beta -0.13, p = 0.306; respectively). After adjustment for age, gender, and size of MC at baseline, change in the extent of M1 remained significantly positively associated with change in ODI (beta 0.53, p = 0.003).

Conclusion

Change in the extent of M1 associated positively with changes in low back symptoms.

Systematic literature review of imaging features of spinal degeneration in asymptomatic populations

BACKGROUND AND PURPOSE

Degenerative changes are commonly found in spine imaging but often occur in pain-free individuals as well as those with back pain. We sought to estimate the prevalence, by age, of common degenerative spine conditions by performing a systematic review studying the prevalence of spine degeneration on imaging in asymptomatic individuals.

MATERIALS AND METHODS

We performed a systematic review of articles reporting the prevalence of imaging findings (CT or MR imaging) in asymptomatic individuals from published English literature through April 2014. Two reviewers evaluated each manuscript. We selected age groupings by decade (20, 30, 40, 50, 60, 70, 80 years), determining age-specific prevalence estimates. For each imaging finding, we fit a generalized linear mixed-effects model for the age-specific prevalence estimate clustering in the study, adjusting for the midpoint of the reported age interval.

RESULTS

Thirty-three articles reporting imaging findings for 3110 asymptomatic individuals met our study inclusion criteria. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age.

CONCLUSIONS

Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain. These imaging findings must be interpreted in the context of the patient's clinical condition.

Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK)

Background

There are few longitudinal cohort studies examining associations between incident MRI findings and incident spine-related symptom outcomes. Prior studies do not discriminate between the two distinct outcomes of low back pain (LBP) and radicular symptoms. To address this gap in the literature, we conducted a secondary analysis of existing data from the Longitudinal Assessment of Imaging and Disability of the Back (LAIDBACK). The purpose of this study was to examine the association of incident lumbar MRI findings with two specific spine-related symptom outcomes: 1) incident chronic bothersome LBP, and 2) incident radicular symptoms such as pain, weakness, or sensation alterations in the lower extremity.

Methods

The original LAIDBACK study followed 123 participants without current LBP or sciatica, administering standardized MRI assessments of the lumbar spine at baseline and at 3-year follow-up, and collecting information on participant-reported spine-related symptoms and signs every 4 months for 3 years. These analyses examined bivariable and multivariable associations between incident MRI findings and symptom outcomes (LBP and radicular symptoms) using logistic regression.

Results

Three-year cumulative incidence of new MRI findings ranged between 2 and 8%, depending on the finding. Incident annular fissures were associated with incident chronic LBP, after adjustment for prior back pain and depression (adjusted odds ratio [OR] 6.6; 95% confidence interval [CI] 1.2-36.9). All participants with incident disc extrusions (OR 5.4) and nerve root impingement (OR 4.1) reported incident radicular symptoms, although associations were not statistically significant. No other incident MRI findings showed large magnitude associations with symptoms.

Conclusions

Even when applying more specific definitions for spine-related symptom outcomes, few MRI findings showed large magnitude associations with symptom outcomes. Although incident annular fissures, disc extrusions, and nerve root impingement were associated with incident symptom outcomes, the 3-year incidence of these MRI findings was extremely low, and did not explain the vast majority of incident symptom cases.

Back pain's association with vertebral end-plate signal changes in sciatica

BACKGROUND CONTEXT

Patients with sciatica frequently experience disabling back pain. One of the proposed causes for back pain is vertebral end-plate signal changes (VESC) as visualized by magnetic resonance imaging (MRI).

PURPOSE

To report on VESC findings, changes of VESC findings over time, and the correlation between VESC and disabling back pain in patients with sciatica.

STUDY DESIGN/SETTING

A randomized clinical trial with 1 year of follow-up.

PATIENTS SAMPLE

Patients with 6 to 12 weeks of sciatica who participated in a multicenter, randomized clinical trial comparing an early surgery strategy with prolonged conservative care with surgery if needed.

OUTCOME MEASURES

Patients were assessed by means of the 100-mm visual analog scale (VAS) for back pain (with 0 representing no pain and 100 the worst pain ever experienced) at baseline and 1 year. Disabling back pain was defined as a VAS score of at least 40 mm.

METHODS

Patients underwent MRI both at baseline and after 1 year follow-up. Presence and change of VESC was correlated with disabling back pain using chi-square tests and logistic regression analysis.

RESULTS

At baseline, 39% of patients had disabling back pain. Of the patients with VESC at baseline, 40% had disabling back pain compared with 38% of the patients with no VESC (p=.67). The prevalence of type 1 VESC increased from 1% at baseline to 35% 1 year later in the surgical group compared with an increase from 3% to 11% in the conservative group. The prevalence of type 2 VESC decreased from 40% to 29% in the surgical group while remaining almost stable in the conservative group at 41%. The prevalence of disabling back pain at 1 year was 12% in patients with no VESC at 1 year, 16% in patients with type 1 VESC, 11% in patients with type 2 VESC, and 3% in patients with both types 1 and 2 VESC (p=.36). Undergoing surgery was associated with increase in the extent of VESC (odds ratio [OR], 8.6; 95% confidence interval [CI], 4.7-15.7; p<.001). Patients who showed an increase in the extent of VESC after 1 year did not significantly report more disabling back pain compared with patients who did not show any increase (OR, 1.2; 95% CI, 0.6-2.6; p=.61).

CONCLUSION

In this study, undergoing surgery for sciatica was highly associated with the development of VESC after 1 year. However, in contrast with the intuitive feeling of spine specialists, those with and those without VESC reported disabling back pain in nearly the same proportion. Therefore, VESC does not seem to be responsible for disabling back pain in patients with sciatica.

Appropriateness of lumbar spine magnetic resonance imaging in Spain

OBJECTIVES

To determine the minimum percentage of lumbar spine magnetic resonance imaging (LSMRI) which are inappropriately prescribed in routine practice.

METHODS

LSMRI performed prospectively on 602 patients in 12 Radiology Services across 6 regions in Spain, were classified as "appropriate", "uncertain" or "inappropriate" based on the indication criteria established by the National Institute for Clinical Excellence, the American College of Physicians and Radiology, and current evidence-based clinical guidelines. Studies on patients reporting at least one "red flag" were classified as "appropriate". A logistic regression model was developed to identify factors associated with a higher likelihood of inappropriate LSMRI, including gender, reporting of referred pain, health care setting (private/public), and specialty of prescribing physician. Before performing the LSMRI, the radiologists also assessed the appropriateness of the prescription.

RESULTS

Eighty-eight percent of LSMRI were appropriate, 1.3% uncertain and 10.6% inappropriate. The agreement of radiologists' assessment with this classification was substantial (k=0.62). The odds that LSMRI prescriptions were inappropriate were higher for patients without referred pain [OR (CI 95%): 13.75 (6.72; 28.16)], seen in private practice [2.25 (1.20; 4.22)], by orthopedic surgeons, neurosurgeons or primary care physicians [2.50 (1.15; 5.56)].

CONCLUSION

Efficiency of LSMRI could be improved in routine practice, without worsening clinical outcomes.