degenerative marrow (modic) changes on cervical spine mri scans prevalence, inter- and...

Degenerative Marrow (Modic) ChangesDegenerative Marrow (Modic) Changeson Cervical Spine MRI Scanson Cervical Spine MRI Scans

Prevalence, Inter- and Intra-examiner Reliability and Link to Prevalence, Inter- and Intra-examiner Reliability and Link to Disc HerniationDisc Herniation

Eugen Mann, final year medical student (current Radiol Resident)Cynthia Peterson, RN, DC, DACBR, M.Med.EdJürg Hodler, MD, MBA

Published in SPINE 2011;36:1081-1085

Department of Radiology, Orthopaedic University Hospital Balgrist Zürich, Switzerland

Department of Radiology, Orthopaedic University Hospital Balgrist. Zürich SwitzerlandDepartment of Radiology, Orthopaedic University Hospital Balgrist. Zürich Switzerland 22

BACKGROUND

Types I, II and III were first described by Dr. Michael ModicTypes I, II and III were first described by Dr. Michael Modic I = low SI on T1 and high SI on T2I = low SI on T1 and high SI on T2 II = high SI on T1 and either isointense or high on T2II = high SI on T1 and either isointense or high on T2 III = low SI on both T1 and T2 (sclerosis on x-rays)III = low SI on both T1 and T2 (sclerosis on x-rays)

Most of the literature focuses on the lumbar spineMost of the literature focuses on the lumbar spine

Type I changes (at least) appear linked with painType I changes (at least) appear linked with pain

Appears to be a genetic predisposition to Modic changesAppears to be a genetic predisposition to Modic changes

Jensen et al found a link between new Modic changes (type Jensen et al found a link between new Modic changes (type I) and disc herniation in the lumbar spineI) and disc herniation in the lumbar spine


MODIC TYPE I


MODIC TYPE II + HERNIATION


RATIONALE FOR STUDY

Only one previous study on Modic changes Only one previous study on Modic changes in the cervical spine.in the cervical spine. Prevalence study only. Prevalence study only. Appears different from findings in lumbar Appears different from findings in lumbar

spine. Type I were most prevalent.spine. Type I were most prevalent. Experience suggested that disc herniations and Experience suggested that disc herniations and

Modic changes were often seen at the same Modic changes were often seen at the same level. Is this true?level. Is this true?


METHODS

Cervical MRI scans of 500 consecutive pts age 50 and over Cervical MRI scans of 500 consecutive pts age 50 and over were retrospectively evaluated by a final year medical were retrospectively evaluated by a final year medical student trained specifically in MRI diagnosis of Modic student trained specifically in MRI diagnosis of Modic changes and disc herniations.changes and disc herniations.

200 of these same scans were independently evaluated by 200 of these same scans were independently evaluated by a radiologist for inter-examiner reliability.a radiologist for inter-examiner reliability.

100 of the 200 scans were re-evaluated one month later by 100 of the 200 scans were re-evaluated one month later by the same radiologist for intra-examiner reliability.the same radiologist for intra-examiner reliability.

Age and gender of the patients was recordedAge and gender of the patients was recorded


Motion segments C3/4 – C6/7 were assessed for:Motion segments C3/4 – C6/7 were assessed for:

Presence/Absence of Modic changes at segmental levelsPresence/Absence of Modic changes at segmental levels

Type of Modic change if present (Types I and II only)Type of Modic change if present (Types I and II only)

Presence/Absence of disc herniation at segmental levelsPresence/Absence of disc herniation at segmental levels

Category of disc herniation if presentCategory of disc herniation if present

Type I = diffuse or broad-based without cord or root Type I = diffuse or broad-based without cord or root compression (Bulge)compression (Bulge)

Type II = focal protrusion usually with cord or nerve root Type II = focal protrusion usually with cord or nerve root compromisecompromise

METHODS (cont)


EXCLUSION CRITERIA

Recent fracturesRecent fractures Surgical fusionsSurgical fusions Acute Schmorl‘s nodesAcute Schmorl‘s nodes Spinal infectionsSpinal infections TumoursTumours Inflammatory arthropathyInflammatory arthropathy Haemodialysis spondyloarthropathyHaemodialysis spondyloarthropathy Congenital block vertebraCongenital block vertebra


STATISTICAL ANALYSIS

Descriptive statistics for prevalence dataDescriptive statistics for prevalence data Number of patientsNumber of patients Number of motion segmentsNumber of motion segments Age and genderAge and gender

Risk ratios (95% CI) for association between disc Risk ratios (95% CI) for association between disc herniations and Modic changesherniations and Modic changes

Kappa statistics for reliability dataKappa statistics for reliability data SPSS and CIA were used for data analysisSPSS and CIA were used for data analysis (Thanks to Prof. Jennifer Bolton for her help with (Thanks to Prof. Jennifer Bolton for her help with

the risk ratio calculations.)the risk ratio calculations.)


RESULTS

PrevalencePrevalence Association with disc herniationAssociation with disc herniation Reliability of diagnosisReliability of diagnosis

Inter-observer reliabilityInter-observer reliability Intra-observer reliabilityIntra-observer reliability


RESULTS 1Prevalence

426 patients met inclusion criteria (85.2%)426 patients met inclusion criteria (85.2%)

Mean age = 61.7 (SD = 9.12)Mean age = 61.7 (SD = 9.12)

Male:Female ratio = 48:52Male:Female ratio = 48:52

172 out of 426 pts had Modic changes at one or more levels 172 out of 426 pts had Modic changes at one or more levels

(40.4%).(40.4%). 30% = Modic I30% = Modic I

70% = Modic II70% = Modic II

51% of Modic changes were seen in females51% of Modic changes were seen in females

No significant age difference between pts with and without No significant age difference between pts with and without

Modic changesModic changes


C6/7 was most common level for Modic changes, followed C6/7 was most common level for Modic changes, followed by C5/6.by C5/6.

245 out of 1704 motion segments had Modic changes 245 out of 1704 motion segments had Modic changes (14.4%).(14.4%). 74 motion segments = Type I74 motion segments = Type I 171 motion segments = Type II171 motion segments = Type II

Disc herniations type I and II were noted in 333 pts (78.2%)Disc herniations type I and II were noted in 333 pts (78.2%) 242 pts (56.8%) had DH at more than 1 level242 pts (56.8%) had DH at more than 1 level Of 1704 motion segments, 226 (13.3%) had disc bulge and Of 1704 motion segments, 226 (13.3%) had disc bulge and

493 (28.9%) had true herniation.493 (28.9%) had true herniation. C5/6 followed by C6/7 were most commonly involvedC5/6 followed by C6/7 were most commonly involved


RESULTS 2Modic changes and disc

herniation

Only Type II disc herniations were considered. Only Type II disc herniations were considered. Modic I and II were pooledModic I and II were pooled

RR = 2.42 (95% CI = 1.93 – 3.04) overall for both RR = 2.42 (95% CI = 1.93 – 3.04) overall for both Modic changes and disc herniation at the same Modic changes and disc herniation at the same level.level.

Highest RR was at the C4/5 level (RR = 3.3. 95% Highest RR was at the C4/5 level (RR = 3.3. 95% CI = 1.8 – 6.05)CI = 1.8 – 6.05)


RESULTS 3Reliability of diagnosis

Inter-Examiner reliability of identifying and Inter-Examiner reliability of identifying and categorizing Modic changescategorizing Modic changes K = 0.54 (95% CI = 0.43 – 0.65) ModerateK = 0.54 (95% CI = 0.43 – 0.65) Moderate 73%73%

Intra-Examiner reliabilityIntra-Examiner reliability K = 0.89 (95% CI = 0.72 – 0.92) Almost perfectK = 0.89 (95% CI = 0.72 – 0.92) Almost perfect 89%89%


DISCUSSION

Reliability between experienced and novice Reliability between experienced and novice

reader is acceptable.reader is acceptable.

A large percentage of pts over age 50 have Modic A large percentage of pts over age 50 have Modic

changes at this Hospital.changes at this Hospital.

Modic type II changes were predominate.Modic type II changes were predominate.

Similar to findings in the lumbar spineSimilar to findings in the lumbar spine

However….Did we miss the Modic I pts because However….Did we miss the Modic I pts because

these happen earlier?these happen earlier?


DISCUSSION (cont)

No age difference found between those with and without No age difference found between those with and without

Modic changes may be due to excluding pts under age Modic changes may be due to excluding pts under age

50.50.

High prevalence of DH in this population likely due to High prevalence of DH in this population likely due to

type of Hospitaltype of Hospital

Patients with Disc herniations are 2.42 times more likely Patients with Disc herniations are 2.42 times more likely

to also have Modic changes at the same level.to also have Modic changes at the same level.

However, the majority of DH pts did not have Modic However, the majority of DH pts did not have Modic

changeschanges

Genetic predisposition?Genetic predisposition?


FURTHER STUDIES

Look at patients younger than age 50Look at patients younger than age 50

Compare pain and disability levels between patients Compare pain and disability levels between patients

with Modic I vs. Modic II in the cervical spinewith Modic I vs. Modic II in the cervical spine

How do these patients respond to chiropractic care? How do these patients respond to chiropractic care?

Or to other treatments? Or to other treatments?

Currently collecting data for nerve root injections.Currently collecting data for nerve root injections.

The Evolution of Degenerative Marrow (Modic) Changes on

Cervical Spine MRI Scans

Eugen Mann, M.D.(current Radiol Resident)Eugen Mann, M.D.(current Radiol Resident) Cynthia Peterson, RN, DC, DACBR, Cynthia Peterson, RN, DC, DACBR,

M.Med.EdM.Med.Ed Jürg Hodler, MD, MBAJürg Hodler, MD, MBA Christian Pfirrmann, MD, MBAChristian Pfirrmann, MD, MBA


Purpose of Study

Evaluate the course and development of Evaluate the course and development of Modic changes in the cervical spine in Modic changes in the cervical spine in neck pain patietns and compare the neck pain patietns and compare the findings with similar studies done on the findings with similar studies done on the lumbar spine.lumbar spine.


METHODS

From the original 500 patients in the From the original 500 patients in the previous study, 64 had follow-up MRI previous study, 64 had follow-up MRI scans (after applying the exclusion scans (after applying the exclusion criteria).criteria).

Retrospective analysis of sagittal and axial Retrospective analysis of sagittal and axial T1 and T2-weighted cervical MRI scans. T1 and T2-weighted cervical MRI scans.

Presence or absence of Modic changes and Presence or absence of Modic changes and type (Modic 1 and 2 only) recorded as well type (Modic 1 and 2 only) recorded as well as segmental level/s. as segmental level/s.

Age and gender also recordedAge and gender also recordedDepartment of Radiology, Orthopaedic University Hospital Balgrist. Zürich SwitzerlandDepartment of Radiology, Orthopaedic University Hospital Balgrist. Zürich Switzerland 2323

Statistical Analysis

Descriptive statisticsDescriptive statistics Prevalence rates in relation to the number of Prevalence rates in relation to the number of

affected segmental levels.affected segmental levels. Prevalence rates in relation to MC type, gender Prevalence rates in relation to MC type, gender

and mean age.and mean age.


Results Baseline MRI:Baseline MRI:

37/64 patients (58%) had Modic changes on 1st 37/64 patients (58%) had Modic changes on 1st MRI study.MRI study.

This corresponded to 21.9% of motion This corresponded to 21.9% of motion segments.segments.

Follow-up MRI:Follow-up MRI: 46/64 patients (72%) had Modic changes at 46/64 patients (72%) had Modic changes at

follow-up.follow-up. This corresponded to 30.5% of motion This corresponded to 30.5% of motion

segments.segments.


Results Continued

Baseline:Baseline: 19 segments with MC 119 segments with MC 1 37 segments with MC 237 segments with MC 2

Follow-up:Follow-up: 21 segments with MC 121 segments with MC 1 57 segments with MC 257 segments with MC 2

‘‘New’ Modic changes in 22 segments (MC 1 in New’ Modic changes in 22 segments (MC 1 in 14 segments and MC 2 in 8 segments)14 segments and MC 2 in 8 segments)


Results Continued Change of Modic 1 to Modic 2 occurred in 12 Change of Modic 1 to Modic 2 occurred in 12

segments (4.7%).segments (4.7%).

No cases of Modic 2 changing to Modic 1 or a No cases of Modic 2 changing to Modic 1 or a disappearing Modic change.disappearing Modic change.

Average time between MRI exams for ‘new’ MC 1 Average time between MRI exams for ‘new’ MC 1 was 2.4 years.was 2.4 years.

‘‘New’ MC 2 average time was 5.0 yearsNew’ MC 2 average time was 5.0 years MC 1 changing to MC 2 average time was 3.1 MC 1 changing to MC 2 average time was 3.1

years.years.


Conclusions:

Modic changes in the cervical spine are Modic changes in the cervical spine are dynamic in nature, like in the lumbar dynamic in nature, like in the lumbar spine.spine.

Their relevance to patient symptoms and Their relevance to patient symptoms and prognosis is currently unknown. prognosis is currently unknown.


Symptomatic, MRI Confirmed Lumbar Disc Herniation Patients: A Comparative

Effectiveness Observational Study of Two Age and Gender Matched

Cohorts Treated with either Spinal Manipulative Therapy or Imaging-

Guided Lumbar Nerve Root Injections

Cynthia Peterson, DC, DACBR, M.Med.Ed Cynthia Peterson, DC, DACBR, M.Med.Ed Serafin Leemann, DCSerafin Leemann, DC

Marco Lechmann, B.MedMarco Lechmann, B.MedChristian W.A. Pfirrmann, MD, MBAChristian W.A. Pfirrmann, MD, MBA

Jürg Hodler, MD, MBAJürg Hodler, MD, MBAB. Kim Humphreys, BSc, DC, PhDB. Kim Humphreys, BSc, DC, PhD

Departments of Radiology and Chiropractic, Orthopaedic University Hospital Balgrist, Zürich, Switzerland

Christian Pfirrmann, MD, MBA Jürg Hodler, MD, MBAMarco Lechmann B.Med.

Serafin Leemann, DC, Cynthia Peterson DC, DACBR, M.Med.Ed, Kim Humphreys, DC, PhD

Background

Lumbar nerve root injections are an Lumbar nerve root injections are an accepted treatment for patients with accepted treatment for patients with radiculopathy from LDH.radiculopathy from LDH.

More supporting literature.More supporting literature. SMT remains more controversial.SMT remains more controversial. Less supporting literature.Less supporting literature.

Methods

• Comparative effectiveness outcomes study. Comparative effectiveness outcomes study. (Tinetti ME, Studenski SA, N Engl J Med 2011, 364:2478-2481.)(Tinetti ME, Studenski SA, N Engl J Med 2011, 364:2478-2481.)

• Two age, gender and diagnosis matched Two age, gender and diagnosis matched cohorts (+/- 2 years).cohorts (+/- 2 years).

• 51 patients who received an imaging-guided 51 patients who received an imaging-guided lumbar nerve root injection at the level of the lumbar nerve root injection at the level of the radiculopathy.radiculopathy.

• 51 patients who received lumbar SMT at the 51 patients who received lumbar SMT at the site of disc herniation.site of disc herniation.

Methods cont.

Patients clinical sx (dermatome, myotome, Patients clinical sx (dermatome, myotome, reflex) had to correspond to the level of reflex) had to correspond to the level of disc herniation noted on MRI scans.disc herniation noted on MRI scans.

Exclusion criteria for SMT patients Exclusion criteria for SMT patients (tumors, (tumors,

infections, SSAs, acute fxs, Paget’s disease, severe OP, previous infections, SSAs, acute fxs, Paget’s disease, severe OP, previous spinal surgery, S/S of cauda equina, body mass index >30, spinal surgery, S/S of cauda equina, body mass index >30, spondylolisthesis, neurogenic claudication, pregnancy).spondylolisthesis, neurogenic claudication, pregnancy).

Exclusion criteria for NRI patients Exclusion criteria for NRI patients (pregnancy, (pregnancy,

anticoagulation therapy, overlying skin infections).anticoagulation therapy, overlying skin infections).

Methods cont• Pain evaluated immediately prior to both Pain evaluated immediately prior to both

treatments using the NRS (0 – 10).treatments using the NRS (0 – 10).• 1 month after the first SMT treatment and NRI, 1 month after the first SMT treatment and NRI,

follow-up data was collected by telephone follow-up data was collected by telephone interviews.interviews.

• NRS and Patient’s Global Impression of Change NRS and Patient’s Global Impression of Change (PGIC) data (7 point scale) were collected at 1 (PGIC) data (7 point scale) were collected at 1 month.month.

• Only ‘Much better’ and ‘Better’ were considered Only ‘Much better’ and ‘Better’ were considered clinically relevant ‘Improvement’.clinically relevant ‘Improvement’.

• ‘‘Slighty Worse’, ‘Worse’ and ‘Much Worse’ were Slighty Worse’, ‘Worse’ and ‘Much Worse’ were all counted at ‘Worse’.all counted at ‘Worse’.

Methods: Statistical Analysis

The % of patients ‘Improved’ and ‘Worse’ The % of patients ‘Improved’ and ‘Worse’ with each treatment was calculated.with each treatment was calculated.

Pre-TX and 1 Month mean NRS scores Pre-TX and 1 Month mean NRS scores were compared within each group using were compared within each group using the paired Student’s t-test.the paired Student’s t-test.

Mean NRS and NRS change scores for the Mean NRS and NRS change scores for the NRI and SMT groups were compared at NRI and SMT groups were compared at baseline and 1 month using the unpaired baseline and 1 month using the unpaired t-test.t-test.

The NRI and SMT groups were also The NRI and SMT groups were also compared for ‘improvement’ using the Chi compared for ‘improvement’ using the Chi Squared test.Squared test.

Odds Ratios and 95% C.I.s were calculatedOdds Ratios and 95% C.I.s were calculated

Cost Comparison

Mean treatment costs between the two Mean treatment costs between the two groups were compared (excluding the MRI groups were compared (excluding the MRI costs). costs).

Results Mean patient age was 47.56 (SD = 10.62)Mean patient age was 47.56 (SD = 10.62) 62.7% were male62.7% were male The L5 and S1 nerve root levels were the most The L5 and S1 nerve root levels were the most

commonly involved.commonly involved. 76.5% of the SMT patients reported clinically relevant 76.5% of the SMT patients reported clinically relevant

improvement (OR 1.40, 95% CI = 0.85-2.30).improvement (OR 1.40, 95% CI = 0.85-2.30). 62.7% of NRI patients reported clinically relevant 62.7% of NRI patients reported clinically relevant

improvement (OR = 0.75, 95% CI = 0.51-1.09). (p improvement (OR = 0.75, 95% CI = 0.51-1.09). (p =0.15 )=0.15 )

5.9% of the NRI patients (3) were ‘worse’ compared to 5.9% of the NRI patients (3) were ‘worse’ compared to 2.0% (1) of SMT patients. All cases were ‘slightly 2.0% (1) of SMT patients. All cases were ‘slightly worse’.worse’.

Results cont

Both treatment groups had significant Both treatment groups had significant decreases in their NRS scores at 1 month decreases in their NRS scores at 1 month (p = 0.0001).(p = 0.0001).

The NRI group had significantly higher The NRI group had significantly higher baseline NRS scores (7.36 (1.77) vs. 6.34 baseline NRS scores (7.36 (1.77) vs. 6.34 (2.55) (p = 0.02). (2.55) (p = 0.02).

No significant differences between the No significant differences between the groups for the 1 month NRS, 1 month NRS groups for the 1 month NRS, 1 month NRS change score or the PGIC score at 1 monthchange score or the PGIC score at 1 month

No serious Adverse events in either group.No serious Adverse events in either group.

NRI (Mean and SD) SMT (Mean and SD)

Pre NRS score 7.36 (1.77) 6.34 (2.55) (P = 0.02)

1 month NRS score 3.40 (2.81) 2.52 (1.87)

1 month PGIC 2.25 (1.38) 1.94 (1.04)

NRS Change score 3.89 (2.836) 3.79 (2.80)

SMT group Chronicity Results

29 Acute and 15 chronic SMT patients29 Acute and 15 chronic SMT patients 22/29 acute pts (75%) ‚improved‘22/29 acute pts (75%) ‚improved‘ 8/15 chronic (53%) ‚improved‘8/15 chronic (53%) ‚improved‘

Cost Comparison

Average cost in the SMT group was CHF Average cost in the SMT group was CHF 533.77 (SD = 177.67, range = 176.00 – 533.77 (SD = 177.67, range = 176.00 – 1056.00). (Average number of Txs was 1056.00). (Average number of Txs was 11.20, SD 3.61. Range = 5-20.)11.20, SD 3.61. Range = 5-20.)

NRI treatment costs were CHF 697.00 NRI treatment costs were CHF 697.00 (fixed costs include one ‘simple’ pre-(fixed costs include one ‘simple’ pre-injection physician consultation plus the injection physician consultation plus the injection procedure).injection procedure).

Limitations

Not an RCT: Therefore outcomes cannot be Not an RCT: Therefore outcomes cannot be directly attributed to the treatments.directly attributed to the treatments.

Limited demographic information on NRI Limited demographic information on NRI patients for more specific matching (i.e. patients for more specific matching (i.e. chronicity). It appeared that perhaps a higher chronicity). It appeared that perhaps a higher % of the SMT patients may have been acute.% of the SMT patients may have been acute.

Relative small sample sizes. Power calculation Relative small sample sizes. Power calculation indicates that at least 50 per group are indicates that at least 50 per group are needed and we barely met that target.needed and we barely met that target.

Conclusions

• Most patients suffering from MRI Most patients suffering from MRI confirmed lumbar disc herniations treated confirmed lumbar disc herniations treated with SMT or NRIs report significant with SMT or NRIs report significant improvement in pain and functioning 1 improvement in pain and functioning 1 month after start of treatment.month after start of treatment.

• The outcomes are better than the reported The outcomes are better than the reported natural history of this condition.natural history of this condition.

• SMT was slightly less expensive when only SMT was slightly less expensive when only evaluating the direct costs of treatment.evaluating the direct costs of treatment.

Gender Differences in Pain Levels Before and After Treatment: A Prospective

Outcomes Study on 3,900 Swiss Patients with MSK Complaints

Cynthia Peterson DC, DACBR, M.Med.Ed. Cynthia Peterson DC, DACBR, M.Med.Ed. B. Kim Humphreys BSC, DC, PhD B. Kim Humphreys BSC, DC, PhD

Jürg Hodler MD, MBA Jürg Hodler MD, MBA Christian W.A. Pfirrmann MD, MBA Christian W.A. Pfirrmann MD, MBA

Department s of Radiology and Chiropractic, Department s of Radiology and Chiropractic, Orthopaedic University Hospital Balgrist, Orthopaedic University Hospital Balgrist,

Zürich, SwitzerlandZürich, Switzerland

BACKGROUND

Higher prevalence of pain in women suffering Higher prevalence of pain in women suffering from headaches, neck and back pain as well as from headaches, neck and back pain as well as knee pain.knee pain.

Women are more likely to experience chronic Women are more likely to experience chronic pain.pain.

Women are more likely to receive treatment.Women are more likely to receive treatment. Women are more likely to report higher pain Women are more likely to report higher pain

intensity scores.intensity scores. Pain may be underdiagnosed and under treated Pain may be underdiagnosed and under treated

in women??in women?? But…But… Pain intensity studies only measure pain levels at Pain intensity studies only measure pain levels at

one point in time. one point in time. Is there a gender difference in response to Is there a gender difference in response to

various MSK treatments?various MSK treatments?

METHODS

Prospective outcomes study using several Prospective outcomes study using several cohorts from large databases in 2 cohorts from large databases in 2 departments at the Orthopaedic University departments at the Orthopaedic University Hospital Balgrist.Hospital Balgrist.

1 month outcomes available.1 month outcomes available. Imaging-guided MSK therapeutic injections Imaging-guided MSK therapeutic injections

(sites with at least 100 patients).(sites with at least 100 patients). Chiropractic patients treated for neck pain, Chiropractic patients treated for neck pain,

low back pain or MRI confirmed lumbar low back pain or MRI confirmed lumbar disc herniation patients (at least 100 disc herniation patients (at least 100 patients in each database).patients in each database).

METHODS: Imaging-guided Therapeutic MSK Injections

Inclusion CriteriaInclusion Criteria Age 18 and overAge 18 and over Pain strongly suspected to arise from specific Pain strongly suspected to arise from specific

joint, nerve root or spinal canal targeted for joint, nerve root or spinal canal targeted for injection.injection.

Exclusion CriteriaExclusion Criteria Overlying skin infectionsOverlying skin infections PregnancyPregnancy Anticoagulants (spine injections only)Anticoagulants (spine injections only)

METHODS: Chiropractic Patient Selection

Inclusion CriteriaInclusion Criteria Age 18 and overAge 18 and over No chiropractic or manual therapy in the No chiropractic or manual therapy in the

previous 3 months.previous 3 months.

Exclusion CriteriaExclusion Criteria tumours, infections, SSPA, acute fractures, tumours, infections, SSPA, acute fractures,

Paget‘s disease, severe osteoporosis.Paget‘s disease, severe osteoporosis.

OUTCOME MEASURES:

NRS at baseline and 1 month after the NRS at baseline and 1 month after the injection procedure or 1st chiropractic injection procedure or 1st chiropractic treatment.treatment.

Patient‘s Global Impression of Change Patient‘s Global Impression of Change (PGIC) 7 point scale at 1 month.(PGIC) 7 point scale at 1 month.

Postal questionnaire data collection for Postal questionnaire data collection for Radiology patientsRadiology patients

Telephone interview data collection for Telephone interview data collection for Chiropractic patients.Chiropractic patients.

STATISTICAL ANALYSIS

Means + SD for NRS data at baseline and Means + SD for NRS data at baseline and 1 month for each injection site and 1 month for each injection site and chiropractic treatment site.chiropractic treatment site.

Unpaired t-test for differences between Unpaired t-test for differences between the genders for baseline NRS, 1 month the genders for baseline NRS, 1 month NRS and NRS change scores for each MSK NRS and NRS change scores for each MSK region.region.

1 month PGIC scores for each gender were 1 month PGIC scores for each gender were compared using the MW-U test.compared using the MW-U test.

RESULTS 3,900 total patients3,900 total patients 1,954 from Imaging-guided injections 1,954 from Imaging-guided injections

database.database. Higher female prevalence for Epidural (61%), Higher female prevalence for Epidural (61%),

Lumbar Facet injections (55%), GH (52%), Knee Lumbar Facet injections (55%), GH (52%), Knee (57%), Hip (58%).(57%), Hip (58%).

Male predominance for Cervical Nerve Root Male predominance for Cervical Nerve Root (55%), Lumbar Nerve Root (52%) injections, and (55%), Lumbar Nerve Root (52%) injections, and Subacromial (56%).Subacromial (56%).

1,946 from Chiropractic database.1,946 from Chiropractic database. 62% of neck pain patients were female.62% of neck pain patients were female. 79% of lumbar disc herniation patients were male.79% of lumbar disc herniation patients were male.

Gender Differences for Imaging-guided Spine

Injections Cervical Indirect NRBs,Cervical Facet Cervical Indirect NRBs,Cervical Facet

Injections, Lumbar Facet injections, Injections, Lumbar Facet injections, Lumbar NRBs, Epidural injections.Lumbar NRBs, Epidural injections.

No differences in baseline NRS scores.No differences in baseline NRS scores. No differences in 1 month NRS or NRS No differences in 1 month NRS or NRS

change scores.change scores. No difference in mean PGIC scores No difference in mean PGIC scores

Gender Differences for Imaging-Guided Extremity

Injections Glenohumeral, Subacromial, Knee, HipGlenohumeral, Subacromial, Knee, Hip 3 of the 4 injection sites showed 3 of the 4 injection sites showed

significantly higher baseline NRS scores significantly higher baseline NRS scores for women.for women.

However……..However…….. At 1 month there were no significant At 1 month there were no significant

gender differences in NRS or PGIC scores gender differences in NRS or PGIC scores between the genders for any of these between the genders for any of these sites.sites.

PROCEDURE DATA TIME POINT

MALES Mean (SD) FEMALES Mean (SD) P-VALUE

Gleno-Humeral Injections (n = 224)

Baseline NRS 5.79 (2.11) n = 107 6.51 (2.22) n = 117 0.01*

1 Month NRS 2.72 (2.29) 3.00 (2.62) 0.40

PGIC @ 1 Month

2.65 (1.40 2.36 (1.51) 0.14

Subacromial Injections (n = 165)

Baseline NRS 5.88 (2.08) n = 93 6.74 (1.75) n = 72 0.004*

1 Month NRS 2.49 (2.19) 2.59 (2.32) 0.80

PGIC @ 1 Month

2.45 (1.49) 2.20 (1.38) 0.30

Knee Injections (n = 309)

Baseline NRS 6.10 (2.58) n = 134 6.76 (2.08) n = 175 0.014*

1 Month NRS 4.56 (2.88) 4.68 (2.95) 0.73

PGIC @ 1 Month

3.43 (1.58) 3.38 (1.69) 0.65

Hip Injections (n = 135)

Baseline NRS 5.78 (2.49) n = 57 6.47 (1.92) n = 78 0.07

1 Month NRS 4.11 (2.75) 4.51 (2.79) 0.42

PGIC @ 1 Month

3.37 (1.63) 3.58 (1.61) 0.45

Gender Differences for Chiropractic Treatment

Patients LBP Patients:LBP Patients:

No gender difference in baseline NRS scores.No gender difference in baseline NRS scores. Highly significant difference in 1 month NRS and Highly significant difference in 1 month NRS and

NRS Change scores between the genders. Males NRS Change scores between the genders. Males responded better.responded better.

Males also have a significantly lower PGIC score at Males also have a significantly lower PGIC score at 1 month (p = 0.0001).1 month (p = 0.0001).

Neck Pain Patients:Neck Pain Patients: No gender differences in any of the outcome measures No gender differences in any of the outcome measures

at any time point.at any time point. MRI Confirmed Lumbar DH Patients:MRI Confirmed Lumbar DH Patients:

No gender differences in any of the outcome measures No gender differences in any of the outcome measures at any time point.at any time point.

PROCEDURE DATA TIME POINT

MALES Mean (SD)

FEMALES Mean (SD)

P-VALUE

Low Back Pain Chiropractic Pts (n = 1065)

Baseline NRS 5.68 (2.12) n = 538 5.91 (2.27) n = 527 0.09

1 Month NRS 2.29 (2.03) 3.03 (2.33) 0.0001*

1 Month NRS Change score

3.38 (2.62) 2.82 (2.83) 0.002*

PGIC @ 1 Month

1.87 (1.19) 2.13 (1.27) 0.0001*

Lumbar Disc Herniation Chiropractic Pts (n = 139)

Baseline NRS LBPBaseline NRS Leg

5.84 (2.78) n = 1105.35 (3.18)

6.06 (3.27) n = 295.50 (3.22)

0.710.82

1 Month NRS LBP1 Month NRS Leg

2.27 (1.95)2.31 (2.26)

2.71 (2.23)2.17 (2.29)

0.330.78

1 Month NRS LBP Change score1 Month NRS Leg Change score

3.39 (2.88) 2.97 (2.71)

3.42 (3.49) 3.62 (3.08)

0.96 0.30

PGIC @ 1 Month

1.92 (1.00) 1.60 (1.00) 0.10

Neck Pain Chiropractic Pts (n = 742)

Baseline NRS 5.56 (2.10) n = 279 5.87 (2.36) n = 463 0.08

1 Month NRS 2.54 (2.15) 2.83 (2.28) 0.18

1 Month NRS Change score

2.98 (2.52) 2.99 (3.01) 0.96

PGIC @ 1 Month

1.93 (1.16) 1.92 (1.18) 0.86

CONCLUSIONS

Measuring pain intensity at one point in time does Measuring pain intensity at one point in time does not give a complete clinical picture of gender not give a complete clinical picture of gender differences.differences.

Females had higher levels of pain at the GH, Females had higher levels of pain at the GH, Subacromial and Knee anatomical regions prior to Subacromial and Knee anatomical regions prior to treatment but had larger NRS change scores after treatment but had larger NRS change scores after treatment compared to males. treatment compared to males.

The only area in these databases where males had The only area in these databases where males had better 1 month outcomes was LBP treated by better 1 month outcomes was LBP treated by chiropractors. chiropractors.

Although the majority of neck pain patients in the Although the majority of neck pain patients in the chiropractic database were women, their 1 month chiropractic database were women, their 1 month outcomes were no different compared to the men. outcomes were no different compared to the men.

Why do women with neck pain respond as well as Why do women with neck pain respond as well as men to chiropractic treatment but women with LBP men to chiropractic treatment but women with LBP do not?do not?

Departments of Radiology and Chiropractic, Orthopaedic University Hospital Balgrist. Zürich SwitzerlandDepartments of Radiology and Chiropractic, Orthopaedic University Hospital Balgrist. Zürich Switzerland 6161

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