Modic End Plate Changes of Spine With Classification

Q: Dear doctor, since 3 years I have been suffering from backache. On 24th February 2011, I took an MRI scan of lumbar spine. Its result is shown below:
At L1-L2, L2-L3 and L3-L4 no disc desiccation seen. Discs show no significant bulge/herniation. No evidence of significant primary canal / foraminal stenosis seen.
At L4-L5 disc desiccation seen with reduced disc height. Para-discal bone marrow appears hypointense on T1W , hyperintense on T2W images – suggestive of modic type I changes. Posterior disc protrusion causing significant spinal canal and bilateral foraminal stenosis with compression of the exiting nerve roots.
At L5-S1 no disc desiccation seen. Posterior annular disc bulge causing bilateral foraminal stenosis and mild spinal canal stenosis.
Vertebral alignment appears normal. No evidence of spondylolisthesis seen.
Vertebral bodies, pedicles, laminae, spinous processes and facetal articulation appear normal. Normal marrow signal intensity preserved.
Mid sagittal spinal canal measurement .
L1-L2–17 mm L2–14 mm
L2-L3–16 mm L3–14 mm
L3-L4–15 mm L4–13 mm
L4-L5–11 mm L5–13 mm
L5-S1–11 mm
Sir in this case, I am eagerly waiting your precious suggestions. Kindly inform me if surgery is its only remedy? We have so many doubts whether the operation would be success or not. Can you suggest any good doctor in Kerala?
-By Padma

Reply:

It is evident from your MRI that you are having a lot of back pain.

What Are Modic Changes?

Let us first know what these modic changes are. These are vertebral endplate and subchondral bone marrow changes due to the degeneration of discs. These are observed on MRI as signal intensity changes in vertebral body near the end plates of the affected discs.

With increasing age and repeated stress, wear and tear occurs in our back. This includes:

  • Wearing out of the cushions provided between two vertebrae
  • Shortening of the height between two vertebrae
  • Minor fractures in the bony areas (like trabeculae) of the vertebrae
  • Presence of signs of inflammations in the area, that is swelling etc.
  • Later on, fat tissue may get deposited
  • Inflammation finally leads to bone scarring

Pathologically, these changes are called modic changes and are grouped into 3 types.

i) Modic type 1 changes show signs of active inflammation. These signs are pain, presence of minor fractures and other breakages near the endplate area, accumulation of inflammatory fluid in the region leading to swelling. This stage is very painful and the pain usually correlates with the amount of inflammation.

ii) Modic type 2 is when the marrow gets substituted by yellow fat.

iii) Modic type 3 is the stage where all inflammation is finally replaced by bone scarring.

Since your MRI is showing modic type 1 changes, you have active inflammation in your back adjacent to end plates, which is giving you the pain.

Management of Backpain in Lumbar Vertebral Area

It won’t be proper to rush for surgery. Strong anti-inflammatory medication needs to be tried first.

It is something like you have many blisters there. Give yourself adequate rest. Don’t strain that part in any way. Avoid all movements that give you pain. You may also read here about the management of backache.

We are unable to suggest you a doctor at your place. However, it is advisable that you visit an orthopedician, preferably in a big hospital or institutional setup, not a solo clinic.

Hospitals are adequately equipped to meet emergencies. Also, there are people from other fields too, like neurology etc., who may be consulted during your treatment.

Your doctor may start with anti-inflammatory drugs first. This includes NSAIDs and corticosteroids.

He may consider giving you intradiscal injections of corticosteroids. 3 to 4 such injection are usually enough to take care of such inflammations.

Muscles relaxants are also given. SerratioPeptidase is a potent anti-inflammatory enzyme helpful in such conditions.

Surgery in this area is difficult and is suggested only when there is substantial herniation of the intervertebral disc tissue.

Take Care,

Buddy M.D.

Medical Advice (Q&As) on “Modic Degenerative Endplate Changes on MRI Spine – Type 1 2 3

  1. JOHN MCCULLEY

    HELLO, DO MODIC 1 CHANGES, WHICH ARE VERY PAINFUL, NATURALLY PROGRESS TO THE LESS PAINFUL MODIC II AND III TYPE? WHAT IS THE TEST FOR MODIC I CHANGES? CAN ANTIBIOTICS CURE THIS? THANKS, JOHN

    Reply
    1. Buddy M.D. Post author

      If no corrective measures are adopted at modic stage 1, it would naturally progress to stage 2.

      Corrective measures include rest of those parts, showing inflammatory changes, and anti- inflammatory medications.

      Antibiotics are not given. Patient requires anti-inflammatory drugs, even steroids. They should be given in time to arrest the progress of stage 1 to stage 2.

      Reply
  2. tom neirinckx

    Regarding modic 2–are the use of antibiotics a reasonable treatment? They are being used in England and Denmark. My MRI shows severe modic 1 and 2.

    Reply
    1. Buddy M.D. Post author

      You may try a course of antibiotics for your problem. Many clinical trials included antibiotics in their regimen and have proved their efficacy, though the role of antibiotics in backaches is still debatable.

      Modic 1 and, to some extent, Modic 2 type of changes are basically conditions characterized by inflammatory changes between the vertebrae.

      There is plenty of inflammatory fluid and tissue debris between the vertebrae. This material may work as a culture material for the growth of bacteria.

      A few anaerobic bacteria have been seen to grow in this here.

      Though the mainstay treatment for backaches is anti-inflammatory medications, a course of antibiotics may be tried under the supervision of a doctor.

      Reply
  3. Nurul Islam

    Sir,
    I had a long time back pain problem. Recently I took a MRI and reports findings are as bellow:

    Vertebra : Marginal osteophytes are seen at L1-L5 vertebral bodies. Type 2 end plate
    changes are seen at L1 & L2 bodies. Alignment is normal. Marrow signal intensity is normal.

    Disc : Dehydration of L1-L2, L2-L3 & L3-L4 discs are noted with reduced disc height between L1- L2.

    No canal stenosis or foraminal narrowing is seen.

    Visualized cord and conus appear normal.

    Para vertebral soft tissue appear normal.

    Impression : mild degenerative changes in lumber spine.

    Please help me giving suggestions. Thanks.

    Reply
    1. Buddy M.D. Post author

      Mild degenerative changes can be seen in your vertebral column. These suggest some wear and tear of the disc cushions and the vertebrae in the back.

      For now, you need to take rest till the pain subsides. You may be given pain killers for this.

      Once you are alright, avoid all activities that may lead to further wear and tear. Avoid excess weight lifting, wrong postures while sitting or working.

      Physiotherapy is suggested for strengthening the muscles of the back area, so that the burnt of all day work falls on the muscles and not on the vertebrae.

      Reply
  4. Drew Terry

    Hello, I have been dealing with back/right leg pain that I first noticed in 2002 but which didn’t really alter my activity level until 2008. Since then, I took driving jobs that took the pain away since standing for more than 45 minutes was out of the question, but sitting all day was okay. I can’t say it didn’t hurt, I could feel it, and some days were worse than others, but it wasn’t ever so painful that I couldn’t work through it. My doctor kept telling me that surgery should be my last option, and that I should continue to manage the pain by adapting what I do as long as it works. Well, this past April I left the driving job for a desk job that didn’t work out, but over the summer my back got worse to where now I can’t sit at the desk for 45 minutes without painkillers, and not much longer with them.

    I finally got an MRI two weeks ago, which I have included verbatim below. I am anxious because my appointment with the specialist is not until 12/5 and I haven’t really talked to anyone else who seems to really know much about the terms on here. My physical therapist, really nice, admitted she had no idea what Modic Type I changes were, so I pretty much stopped asking questions and she didn’t really offer to interpret anything else in the report.

    My G.P. would only say that it was “Significant.” And that was it, plus plenty of percocet.

    From what I’m reading, the Modic Type I changes seem to be quite serious, and the rest of it does seem pretty “significant” but I don’t know by how much and I’m too anxious to wait until 12/5 to find out.

    Anyone out there who would please be kind enough to briefly interpret what this report says I WOULD BE FOREVER GRATEFUL. THANK YOU.

    FINDINGS:

    There is convex right lumbar scoliosis centered at the L3 vertebral level. There is a trace anterolisthesis of L3 on L4. Modic Type I endplate change is seen at L4/L5. The tip of the conus medularris terminates at the L1 vertebral body level. Limited assessment of the paraspinal soft tissues is normal in appearance.

    At the L5/S1 level, there is a disc bulge and degenerative facet disease with a small superimposed right paracentral protrusion impinging the right S1 nerve root as it enters the lateral recess within the mildly narrowed spinal canal. There is moderate bilateral neural foraminal narrowing.

    At the L4/L5 level, there is a disc bulge and degenerative facet disease with moderate spinal canal narrowing and moderate/severe right and moderate left neural foraminal narrowing.

    At the L3/L4 level, there is a disc bulge and degenerative facet disease with moderate/severe spinal canal narrowing. There is a small right neural foraminal annular fissure with mild/moderate bilateral neural foraminal narrowing.

    At the L2/L3 level, there is a disc bulge and degenerative facet disease with moderate spinal canal narrowing and mild left and moderate right neural foraminal narrowing.

    At the L1/L2 level, there is a small disc bulge with mild spinal canal narrowing. The neural foramina are patent.

    IMPRESSION:

    1. Convex right lumbar scoliosis with advanced superimposed degenerative disc and facet disease. Current findings include L3/L4 moderate/severe spinal canal narrowing as well as L2/L3 and L4L5 moderate spinal canal narrowing.

    2. Multilevel neural foraminal narrowing including L4/L5 moderate/severe right neural foraminal narrowing. Additional findings include a L5/S1 small superimposed right paracentral protrusion abutting the right S1 nerve root as it enters the lateral recess within the mildly narrowed spinal canal. Additional levels of degenerative disease discussed above.

    END OF REPORT

    Reply
    1. Buddy M.D. Post author

      You have degenerative changes in your lower back. As you age up, the vertebra and the cushions between them start getting eroded by continuous friction between them. This degeneration is more if you are calcium deficient or adopt wrong postures in day to day activities.

      All foci of degeneration show some inflammation signs, that is pain and swelling. Your report shows that your back has inflammatory signs (This is modic type 1 changes).

      Due to swelling in between the affected vertebrae, the nerves coming out from between them is getting pressed and that’s giving you the pain.

      To alleviate pain, anti inflammatory medicines may be given. In severe cases, they may be even injected at the sites of severe inflammation.

      Apart from this, traction may be used in the affected limb. This would provide you relief for a long time.

      Once the pain is gone and you are alright, you need physiotherapy. Exercise under a physiotherapist to strengthen your back muscles. If back muscles are strong enough to handle all brunts of your daily work, they’ll not let the load come on the vertebral bones. This would prevent further degeneration.

      Reply
  5. becky eickleberry

    Findings:
    There are 5 lumbar type vertebral segments. Ileal lumbar ligaments
    are evident at the L5 level.

    There is grade 1 retrolisthesis of L4 on L5 with grade 1
    anterolisthesis of L5 on S1. No MR findings to suggest pars defects.
    No acute-appearing vertebral body height loss. Degenerative endplate
    changes are evident about the L3-4 level (Modic type I) and L4-5
    level (Modic type II). Bone marrow signal is otherwise unremarkable.
    L3: Mild bulging of the disc annulus and mild facet and ligamentum
    flavum hypertrophy impress upon the thecal sac without significant
    thecal sac or neural foraminal narrowing.

    L3-L4: An inferiorly directed right central extrusion extends
    approximately 0.8 mm inferiorly within the ventral epidural space. A
    smaller right subarticular and foraminal extrusion is nearly
    contiguous with the right central extrusion. These findings coupled
    with moderate facet and ligamentum flavum hypertrophy result in
    moderate narrowing of the thecal sac with a paucity of CSF signal.
    There is contact and suspected mass effect upon the descending right
    L4 nerve roots. There is moderate to severe narrowing of the right
    neural foramen.

    L4-L5: Loss of intervertebral disc space, a small diffuse disc
    osteophyte complex and moderate to advanced facet and ligamentum
    flavum hypertrophy contacting the descending L5 nerve roots. There is
    moderate narrowing of the neural foramina bilaterally with contact of
    the exiting nerve roots.

    L5-S1: Grade 1 anterolisthesis, uncovering of the intervertebral disc
    and an associated annular fissure and moderate facet and ligamentum
    flavum hypertrophy do not result in significant thecal sac or neural
    foraminal narrowing.

    The included intra-abdominal contents are unremarkable on the
    included sequences. Fatty atrophy within the posterior paraspinal
    musculature is more prominent distally.

    Reply
  6. Aimee west

    I’m 34 years old and having been dealing with lower back pain for 7 years. Just had my latest MRI which doesn’t show any disc buldge this time but not sure what other stuff means. The pain is worse and am wondering how much longer injections and meds will work. Here are my results.
    -2: Normal; no disc herniation or bulge. No central canal stenosis or neuroforaminal narrowing. L2-3: Mild disc space narrowing and desiccation. No disc herniation or bulge. No central canal stenosis or neuroforaminal narrowing. L3-4: Moderate disc space narrowing and desiccation. Modic 2 endplate signal changes. No disc herniation or bulges. No central canal stenosis or neuroforaminal narrowing. L4-5: Mild disc space narrowing and desiccation. Small Schmorls node. Small asymmetric left lateral disc osteophyte complex narrows the lateral recess and abuts the traversing nerve root on that side. There is no significant central canal stenosis. Mild left neural foraminal narrowing is present. L5-S1: Normal; no disc herniation or bulge. No central canal stenosis

    1. Multilevel spondylosis. 2. Mild left-sided neural foraminal narrowing at L4-5 with narrowing of the lateral recess on the same side.

    Reply
    1. Buddy M.D. Post author

      Till you have pain, injections and medications are essential to keep you moving. Once relived, you may start with some physiotherapy under a trained instruction. Patients in conditions similar to you have benefited with such sessions.

      Weight reduction, if overweight, helps a great deal.

      Reply

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