Modic changes (MCh) are pathological changes in the bone marrow and the endplates of adjacent vertebrae characterized by bone marrow edema, fatty degeneration or osteosclerosis that are revealed by high-power field magnetic resonance imaging (MRI). The dominant disease pattern is a persistent back pain syndrome with varying intensity. It leads to difficulties in the interpretation of clinical data, evaluation of MRI data and treatment. The article presents a modern conception of the pathogenesis, classification, clinical implications and treatment of MCh based on national and foreign sources as well and the author's view on the osteogenic mechanism of the pathogenesis and treatment of MCh using intraosseous blockades.

MS EDSS state, convert from RRMS to SPMS or die. Patients have a fixed annual probability of relapse and death. RRMS patients with EDSS score Ͻ7 were eligible for disease modifying therapies (DMTs). Patients with SPMS or EDSS score Ն7 received best supportive care. Transition probabilities were based on natural history of RRMS. Efficacy (i.e. on relapse rates and disability progression) was obtained from a mixed treatment comparison of published results. Health utilities were obtained from Orme et al (2007). Resources use (physician consultations; ambulatory care; hospitalization, other drugs, services, DMT monitoring and administration) were validated by an experts' panel and valued using Brazilian official lists. Annual discount rate of 5% was applied both to costs and outcomes. Probabilistic sensitivity analysis (PSA) was performed. RESULTS: Adopting WHO threshold, base case analysis showed fingolimod is more effective and less costly (dominant) versus IFN-␤-1a 44mcg (incremental costs: -26,567BRL; QALY: 0.223) and cost-effectiveness versus IFN-␤-1a 30mcg; IFN-␤-1a 22mcg and IFN-␤-1b 300mcg, with ICER (BRL/QALY): 29,306; 6,725 and 52,626, respectively (Ͻ3 GDP/capita or BRL 57,000.00; 1USD ϭ 2.055BRL). PSA has confirmed the consistency of base case results. CONCLUSIONS: In the treatment of patients with RRMS, fingolimod provides superior effectiveness and represents good value for money in comparison with the most common first line therapies by the health care payer in Brazil.

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