Association of accelerated switch from vertebral end‐plate Modic I to Modic 0 signal changes with clinical benefit of intradiscal corticosteroid injection for chronic low back pain

Abstract

Modic I vertebral end-plate signal changes detected by magnetic resonance imaging (MRI) are associated with chronic low back pain. Typically, Modic I signal changes in untreated patients switch to nonModic I signal changes within 3 years, which reflect spontaneous healing. Recent findings suggest that Modic I signal changes may be related to local inflammatory changes, providing a rationale for treatment with intradiscal injections of antiinflammatory drugs. In the present report, we describe a 31-year-old man with 1-year history of chronic low back pain associated with vertebral end-plate Modic I signal changes, who received 1 intradiscal corticosteroid injection in L5-S1. Local treatment led to rapid pain relief and was associated with an accelerated switch from Modic I to Modic 0 signal changes, as seen on lumbar MRI at 1-month followup. This is the first report of an effective local treatment for both the symptoms and the structural changes of chronic low back pain that are associated with Modic I signal changes. Additionally, this case reinforces the hypothesis that local inflammation has a pathogenic role.De Roos et al (1) and Modic et al (2) described changes of the vertebral end-plate bone marrow magnetic resonance imaging (MRI) signal anecdotally present in an asymptomatic population but specifically observed in patients with nonspecific chronic low back pain (3-5). Modic 0 signal changes are the normal vertebral body signal. Modic I signal changes correspond to vertebral end-plate edema. Modic II signal changes are characterized by disruption of the end-plates as well as fatty degeneration of the adjacent bone marrow. Modic III signal changes are characterized as sclerosis that is evident on radiography. Modic II and Modic III signal changes, which are assumed to correspond to stages of spontaneous healing, usually occur within 1-3 years after Modic I signal change (6). Recent findings suggest that Modic I signal change may be related to low-grade systemic inflammation (7), along with local inflammatory changes. Biopsy studies have shown replacement of vertebral end-plate bone marrow with richly vascularized fibrous tissue (2), increased levels of interleukin-6 (IL-6) (8), and a higher number of tumor necrosis factor ␣ (TNF␣) immunoreactive cells (9).The hypothesis that a local inflammatory reaction occurs in the subchondral bone marrow adjacent to the end-plate has provided a rationale for local injection of corticosteroids to treat nonspecific chronic low back pain associated with vertebral end-plate Modic I signal changes. In a recent open study assessing the association of severity of inflammatory end-plate changes identified on MRI and clinical response to intradiscal corticosteroid injection in nonspecific chronic low back pain, the reduction in pain score at 1 month was significantly higher in patients exhibiting Modic I signal changes than in those with Modic II signal changes (10). This finding suggests that intradiscal injection of corticosteroids could be an appropriate treatment for patient...

Modic I changes size increase from supine to standing MRI correlates with increase in pain intensity in standing position: uncovering the “biomechanical stress” and “active discopathy” theories in low back pain

“…Furthermore, treatment with intradiscal steroid injections was found to be effective in pain reduction and regression of Modic I changes. Altogether, these data support the role of biomechanically and/ or biochemically induced local inflammation in the pathogenesis of Modic I changes and related symptoms [1].…”

“…Among the Modic endplate changes, MC type I are the most frequently associated with low back pain, but, despite the long debate, the exact relationship remains controversial. Several authors define Modic changes as specific indicators of "discogenic" low back pain with a strong association, while others say that Modic changes are also prevalent in the asymptomatic population [1,35].…”

“…Degenerative disc disease of the spine causing low back pain is a leading cause of morbidity and chronic disability [1]. MRI is the preferred imaging technique to evaluate the degenerative changes of the spine [2,3], showing high sensitivity and specificity in the diagnosis of conditions like disc herniation, spinal stenosis, and spondylodiscitis [4][5][6][7].…”

Efficacy of zoledronic acid for chronic low back pain associated with Modic changes in magnetic resonance imaging

“…Intradiscal glucocorticoid injection is therefore a logical treatment choice in cases of inflammation and consequently published case studies on intradiscal steroids into discs with M1 show improvement in symptoms in the short term [31,32] and even normalization of M1 changes in MRI [32]. Similarly, in some cases patients with M1 had a greater medium-term improvement in disability when treated with epidural steroid injections [33].…”

Intradiscal Glucocorticoid Injection for Patients With Chronic Low Back Pain Associated With Active Discopathy

“…Open-label studies have suggested that GC IDI could provide shortterm relief in patients with Modic-associated chronic LBP and that Modic 1 changes could be predictive of a better response to GC IDI than other Modic types (15)(16)(17)(18). Accelerated switching from Modic 1 to a normal vertebral endplate subchondral bone MRI signal after GC IDI has also been reported (19). A double-blind, randomized, controlled study of 120 patients with Modic-associated chronic LBP receiving GC IDI showed reduced LBP intensity at 3 and 6 months.…”