Modic Changes Associated with Greater Risk of Poor Outcome in Lower Back Pain
Patients with lower back pain who show Type 1 Modic changes may be at increased risk of experiencing poor treatment outcomes. This finding comes from a prospective study of 141 patients with lower back pain that was conducted in Denmark.
Modic changes—inflammatory changes in the end plates of the vertebrae that can be seen on magnetic resonance imaging (MRI)—were first recognized in 1988 and are associated with lower back pain. However, it is not clear whether or how well Modic changes correlate with treatment outcomes for lower back pain.
Patients in this study had been enrolled in a previous randomized clinical interventional study of lower back pain. They were classified as having either nonspecific lower back pain or radiculopathy based on their symptoms, a physical examination, and MRIs. To be included in the study, the patients had to have been out of work because of their back pain for 4 to 12 weeks. The outcome measures for the study were: change in back and leg pain, change in function, and whether they were able to return to work within the 1-year follow up of the study.
The patients were examined by MRI, including T1- and T2-weighted sequences, which identified Modic changes in 60% of them. Eighteen percent (18%) had Type I changes (which included both Type 1 and mixed Type 1/Type 2) and 42% had Type 2 changes. No patient had Type 3 changes. The MRIs were read by a radiologist who was given no clinical data on the patients.
Modic changes were the only variable that was found to be significantly and negatively associated with changes in pain score and function. Type 1 was negatively associated with both change of pain and change of function and was statistically significantly different from Type 2. Patients with Type 2 Modic changes did not significantly differ from patients with no Modic changes. Patients with Type 1 improved very little during the one-year follow up, the authors stated.
Type 1 Modic changes were also significantly associated with not being able to return to work, while there was no significant difference seen with Type 2 changes. Overall, the rate for not being able to return to work within the 1-year follow-up was 15% higher in patients with Modic changes compared with patients without Modic changes. Thirty-one percent (31%) of patients who were not able to return to work had Type 1 Modic changes, whereas these patients were only 18% of the patient group at baseline. Patients with Type 1 improved very little during the 1-year follow-up of the study, with a mean improvement in pain and function scores of 0.9 and 0.5 units, respectively.
The authors noted that the few patients who had morphologically normal discs had less improvement in function than patients with bulging, protruding, or herniated discs. Patients who had radiculopathy showed more improvement in pain scores than those without, but also had higher pain scores at baseline.
“The fact that degenerative manifestations were not associated with outcome—except for [Modic changes]—should not be interpreted as if these structural changes are not important at all. After all, cross-sectional studies have shown that lumbar degenerative manifestations visualized by MRI are associated with pain, though explaining less than half of the pain,” the authors noted. They concluded by recommending that patients with lower back pain who are out of work for more than 4 weeks undergo MRI, “if not for other reasons, then to identify Type 1 Modic changes.”
The importance of this paper is that it was able to use Modic findings as a predictive factor.