Measuring and reporting of vertebral endplate bone marrow lesions as seen on MRI (Modic changes): recommendations from the ISSLS Degenerative Spinal Phenotypes Group

Abstract

Purpose The positive association between low back pain and MRI evidence of vertebral endplate bone marrow lesions, often called Modic changes (MC), offers the exciting prospect of diagnosing a specific phenotype of chronic low back pain (LBP). However, imprecision in the reporting of MC has introduced substantial challenges, as variations in both imaging equipment and scanning parameters can impact conspicuity of MC. This review discusses key methodological factors that impact MC classification and recommends guidelines for more consistent MC reporting that will allow for better integration of research into this LBP phenotype. Methods Non-systematic literature review. ResultsThe high diagnostic specificity of MC classification for a painful level contributes to the significant association observed between MC and LBP, whereas low and variable sensitivity underlies the between-and within-study variability in observed associations. Poor sensitivity may be owing to the presence of other pain generators, to the limited MRI resolution, and to the imperfect reliability of MC classification, which lowers diagnostic sensitivity and thus influences the association between MC and LBP. Importantly, magnetic field strength and pulse sequence parameters also impact detection of MC. Advances in pulse sequences may improve reliability and prove valuable for quantifying lesion severity. Conclusions Comparison of MC data between studies can be problematic. Various methodological factors impact detection and classification of MC, and the lack of reporting guidelines hinders interpretation and comparison of findings. Thus, it is critical to adopt imaging and reporting standards that codify acceptable methodological criteria. Graphic abstractThese slides can be retrieved under Electronic Supplementary Material.Key points 1. Endplate bone marrow lesions, which are mainly identified using T1-and T2-weighted MRI ("Modic changes"), are the focus of a large and growing body of work. However, the specific methods for diagnosing these lesions can bias study findings. 2. The high diagnostic specificity of Modic classification for a painful level contributes to the significant association observed between Modic changes and LBP. Low and variable sensitivity underlies the between-and within-studies variability. Poor sensitivity may be owing to the presence of other pain generators, the limited MRI resolution, and the imperfect reliability of Modic classification. 3. Magnet strength and pulse sequence parameters can impact the detection of Modic changes. 4. Advanced pulse sequences may improve reliability and prove valuable for quantifying lesion severity. Fields AJ, Battié MC, Herzog RJ, Jarvik JG, Krug R, Link TM, Lotz JC, O'Neill CW, Sharma A; for the ISSLS Degenerative Spinal Phenotypes Group (2019) Measuring and reporting of vertebral endplate bone marrow lesions as seen on MRI (Modic changes); recommendations from the ISSLS Degenerative Spinal Phenotypes Group. Eur Spine J; SUGGESTED GUIDELINES FOR PRESENTATION OF MODIC CHANGE DATA MR unit...

Short tau inversion recovery MRI of Modic changes: a reliability study

“…However, the moderate agreement on the extent of the high STIR signal is not optimal. Moderate inter-observer agreement is common in spine imaging (36,41,49,50), but it implies lowered accuracy when associations with clinical factors are sought (37). More reliable conclusive MRI findings can be based on different observers’ separate evaluations followed by their joint conclusion (51).…”

“…Such data were included in articles on spondylarthritis (1)(2)(3)(4)(5), fractures (6), Modic changes (MCs) (7), hemangiomas (8), and pedicle screw loosening (9). However, all but one (6) of these reliability studies had only two observers, most (1,3-5,7-9) had small patient samples (n ¼ [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41], only one (8) included measurements (of signal intensities); the spondylarthritis studies were limited to lesion detection (1)(2)(3)(4)(5). Reliability estimates differed widely in these heterogeneous studies where radiologists and non-radiologists interpreted various fat-suppressed 1.5-T or 3-T series.…”

“…Mechanical, autoimmune, and infectious explanations for MCs have been proposed (20), and various treatments have been and are being tested (21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34). Reliable evaluation of the STIR findings is required to validate their relevance to symptoms and treatment (35)(36)(37).…”

Automatic Vertebral Body Segmentation Based on Deep Learning of Dixon Images for Bone Marrow Fat Fraction Quantification

“…We developed, trained, and validated a deep learning model on a total of 57 IDEAL image data sets to automatically segment lumbar vertebral bodies from water-fat MRI data. Our main findings were ( 1 ) deep learning-based automatic segmentation of vertebral bodies was feasible in 16 ± 1 s; ( 2 ) the deep learning model segmented vertebral bodies with high accuracy (97.8%), precision (98.3%), and sensitivity (99.3–99.4%) when compared with manual segmentations; ( 3 ) the deep learning model showed good performance compared with standard manual analysis (mean DSC = 0.849 across 24 subjects); ( 4 ) the automatically segmented ROIs provided reliable quantification of bone marrow fat fraction (Bland Altman analysis: low bias and limits of agreements lower than 10% difference of the mean ground truth values); and ( 5 ) the automatic segmentation and BMF quantification workflow is highly repeatable between scans within the same subjects (precision error of 1.6% and ICC of 1.00). While only lumbar vertebrae were analyzed in our study, if other vertebral bodies in the thoracic or sacral regions were present in the field of view, these would also get segmented by our deep learning framework, suggesting applications for segmentation of other vertebral regions with bone marrow fat.…”

Vertebral intraosseous plasma rich in growth factor (PRGF-Endoret) infiltrations as a novel strategy for the treatment of degenerative lesions of endplate in lumbar pathology: description of technique and case presentation

“…This novel approach illustrates the need to use standardized and accurate imaging and measurement techniques to evaluate improvements in the lumbar spine in order to correlate improvements in pain and functional outcomes with regeneration of paravertebral structures [28,29].…”