PREVIEW ONLY...Modic changes: What are they? Vertebral endplate signal changes seen on MRI Three types* •Type 1 •Type 2 •Type 3 * Modic MT, 1988 PREVIEW ONLY These notes are

19/09/2013

1

PREVIEW ONLY

These notes are a preview.

Slides are limited.

Full notes available after purchase from

www.worldhealthwebinars.com.au

This webinar will begin in the next few minutes

Live webinar technical support

Please call 1800 006 293 – then press 1

You will need to tell tech support that you are a webinar attendee and do not have an email account with Citrix.

Be sure to convert to your own time zone at www.worldhealthwebinars.com.au

Modic changes and low back pain

Presented by: Tue Secher Jensen, Senior researcher, MSc (Clin. Biomech.), PhD

Will commence LIVE from Denmark, at 7:00pm AEST

19/09/2013

2

Dr Matthew Bulman BHsc, MChiro

World Health Webinars (Australia) Chiropractic Program Coordinator

World Health Webinars (Australia) Host

Editor of the Chiropractic and Osteopathic College of Australasia NEWS

Owner of The Runner’s Clinic, Sydney

Need technical support?

Please call 1800 006 293, then press 1

You will need to tell them that you are a webinar attendee and do not have an email account with Citrix.

Click red button to minimise

You will be muted

during every webinar.

Make as much noise

as you like :)

Dodgy computer

speakers? Select

Telephone and call in

toll - FREE to hear the

presentation

Questions? We’ll

answer them all at

the end

Tue Secher Jensen

Full time senior researcher at the Spine Centre

of Southern Denmark and the Nordic Institute of

Chiropractic and Clinical Biomechanics

The main focus of research is medical imaging

and its role in spinal pain conditions with a focus

on magnetic resonance imaging (MRI).

Involved in development of clinical guidelines

and implementation research

Member of the Danish Chiropractic Council

(2005 - present)

19/09/2013

3

Are modic changes clinically relevant?

Are Modic changes clinically relevant?

Clinical implications

• Diagnosis

• Treatment

• Prognosis

Subjects of this talk

Introduction

• MRI crash course

• EBM tools

Modic changes and low back pain

• What are Modic changes?

• Why are Modic changes?

• How common are they?

• Are they associated with LBP?

• Can we treat Modic changes?

Q&A

19/09/2013

4

MRI ”crash course”

What can you see on MRI? PREVIEW ONLY


Slides are limited.




What can you see on MRI?


What can you see on MRI? PREVIEW ONLY


Slides are limited.



19/09/2013

5

Normal disc

Vertebra

CSF

Herniation

Degen. disc

T1-weighted T2-weighted

Spinal cord / nerve roots

Short EBP intro

Odds ratio (OR)

PREVIEW ONLY


Slides are limited.



19/09/2013

6

Odds ratio (OR)

Odds ratio (OR)

Odds ratio (OR)

PREVIEW ONLY


Slides are limited.



19/09/2013

7

Odds ratio (OR)

Modic changes: What are they?

Vertebral endplate signal changes seen on MRI

Three types*

• Type 1

• Type 2

• Type 3

* Modic MT, 1988

PREVIEW ONLY


Slides are limited.




Modic type 1

• Histology

• Fibro-vascular tissue

• Fissured endplates

• MRI

• Low T1-signal

• High T2-signal

* Modic MT, 1988

19/09/2013

8


Modic type 2

• Histology

• Fatty bone marrow

• Fissured endplates

• MRI

• High T1-signal

• High T2-signal

* Modic MT, 1988


Modic type 3

• Histology

• Sclerosis

• MRI

• Low T1-signal

• Low T2-signal

* Modic MT, 1988

PREVIEW ONLY


Slides are limited.



Modic changes: Why are they?

Autoimmune

Biomechanical

Infection

1 Albert HB et al, 2008

19/09/2013

9

Modic changes: Why are they?

Autoimmune

Biomechanical

Infection

PREVIEW ONLY


Slides are limited.



Biomechanical theory


19/09/2013

10


Experimental studies1

General population and patients2,3

• Disc degeneration

• Disc herniation

• Disc bulge

Genetics4,5

• IL1A

• MMP3

1 Adams M et al 2,3 Jensen / Albert, 2010/13 4,5 Karppinen J et al, 2008/9

PREVIEW ONLY


Slides are limited.



Infection theory

Normal disc Disc disruption

Infection theory

40% of disc herniations are infected

• 80 % of infected discs develop new Modic type 1

• 40% of non-infected discs develop new Modic type 1

Albert HB et al, 2013

19/09/2013

11

Prevalence of Modic changes

Clinical >> non-clinical

Jensen TS et al, 2008

PREVIEW ONLY


Slides are limited.



Prevalence

Increases with age

Jensen TS et al, 2008

Prevalence

Modic changes are common in adult patients with LBP

Albert H et al, 2008

PREVIEW ONLY


Slides are limited.



19/09/2013

12

Association with LBP

Vertebral endeplate and pain

• Nociceptors in the endplate1,2

Association with LBP + Number of individuals * Number of levels

PREVIEW ONLY


Slides are limited.



Association with LBP

Update of systematic review from 2008*

• 17 studies identified

Statistically positive association in 12 of 17

studies

• Odds ratios: 2.0 – 27.9

Meta-analysis (discography studies only,

n=9)

• Overall odds ratio: 5.4 (2.4 – 12.2)

19/09/2013

13

Natural course (endplate)

Type of Modic changes

Persistent LBP, n=1056 (1 year follow-up)1

• 20 % disappear

• 40 % change type

• 40 % remain the same

Size of Modic changes

The bigger they are, the more likely they are to persist1

Natural course (patient)

Baseline (n=74)

Modic Type I Modic Type 2

77% (n=74)

23% (n=22)

1 year (n=74)

Jensen RK et al., 2012

PREVIEW ONLY


Slides are limited.




Baseline (n=74)

Modic Type I

77% (n=74)

23% (n=22)

1 year (n=74)

74% (n=55)

26% (n=19)

19/09/2013

14


Baseline (n=74)

Modic Type I Modic Type 2

45% (n=10)

55% (n=12)

77% (n=74)

23% (n=22)

1 year (n=74)

74% (n=55)

26% (n=19)

Jensen RK et al., 2012


Baseline (n=74)

PREVIEW ONLY


Slides are limited.



Case 1

40 year-old woman with LBP

Two MRI scans four years apart

19/09/2013

15

Case 1

Age 40

T1 T2

PREVIEW ONLY


Slides are limited.



Case 1

Age 40

Age 44

T1 T2 T1 T2

Case 2

50 year old woman

Initial presentation

• Disc herniation and sciatica

19/09/2013

16

Case 2

T1 T2

Baseline

PREVIEW ONLY


Slides are limited.



Case 2

Baseline After 1 year

T1 T2 T1 T2

Treatment and prognosis

Only three RCTs

• Intradiscal steroid1

• Good effect at 3 and 6 months

• Exercise vs. Rest2

• No effect at 10 weeks and 12 months

• Antibiotics3


1 Cao P et al, 2011 2 Jensen RK et al, 2012 3 Albert HB et al, 2013

19/09/2013

17

Treatment

Only three RCTs

• Intradiscal steroid1


• Exercise vs. Rest2

• No effect at 10 weeks and 12 months

• Antibiotics3


1 Cao P et al, 2011 2 Jensen RK et al, 2012 3 Albert HB et al, 2013

PREVIEW ONLY


Slides are limited.



Treatment

Future RCTs on Modic changes (ClinicalTrials.gov)

• Intradiscal steroid

• Bisphosphonate

• Nucleus replacement

Treatment effect modification

Epidural steroid injections

Intradiscal steroid injections

Disc replacement

Fusion surgery

Exercise/conservative treatment

Discectomy

PREVIEW ONLY


Slides are limited.



19/09/2013

18

Treatment effect modification

Epidural steroid injections

Intradiscal steroid injections

Disc replacement

Fusion surgery

Exercise/conservative treatment

Discectomy1,2

Conclusions

Prevalence of Modic changes

• Adults >> children

• LBP patients >> non-clinical populations

Positive association between Modic changes and

LBP

Conclusions

Natural course:

• The bigger they are the more likely they are to

persist

• Persistent Type 1 changes associated with poor

clinical outcome

Promising results for treatment

PREVIEW ONLY


Slides are limited.



19/09/2013

19


Clinical value

Diagnosis

Treatment

Prognosis


X

PREVIEW ONLY


Slides are limited.



Live Q & A With Tue Secher Jensen

19/09/2013

20

Coming up October 15

Facebook, Twitter, LinkedIn, Google +

Live Q & A With Tue Secher Jensen

19/09/2013

21

Thank you

From Tue Secher Jensen &

World Health Webinars Australia http://worldhealthwebinars.com.au

Documents

PREVIEW ONLY...Modic changes: What are they? Vertebral endplate signal changes seen on MRI Three types* •Type 1 •Type 2 •Type 3 * Modic MT, 1988 PREVIEW ONLY These notes are