preview only...modic changes: what are they? vertebral endplate signal changes seen on mri three...
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19/09/2013
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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
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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
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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)
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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
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MRI ”crash course”
What can you see on MRI? PREVIEW ONLY
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MRI ”crash course”
What can you see on MRI?
MRI ”crash course”
What can you see on MRI? PREVIEW ONLY
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Normal disc
Vertebra
CSF
Herniation
Degen. disc
T1-weighted T2-weighted
Spinal cord / nerve roots
Short EBP intro
Odds ratio (OR)
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Odds ratio (OR)
Odds ratio (OR)
Odds ratio (OR)
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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
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Modic changes: What are they?
Modic type 1
• Histology
• Fibro-vascular tissue
• Fissured endplates
• MRI
• Low T1-signal
• High T2-signal
* Modic MT, 1988
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Modic changes: What are they?
Modic type 2
• Histology
• Fatty bone marrow
• Fissured endplates
• MRI
• High T1-signal
• High T2-signal
* Modic MT, 1988
Modic changes: What are they?
Modic type 3
• Histology
• Sclerosis
• MRI
• Low T1-signal
• Low T2-signal
* Modic MT, 1988
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Modic changes: Why are they?
Autoimmune
Biomechanical
Infection
1 Albert HB et al, 2008
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Modic changes: Why are they?
Autoimmune
Biomechanical
Infection
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Biomechanical theory
Biomechanical theory
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Biomechanical theory
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
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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
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Prevalence of Modic changes
Clinical >> non-clinical
Jensen TS et al, 2008
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Prevalence
Increases with age
Jensen TS et al, 2008
Prevalence
Modic changes are common in adult patients with LBP
Albert H et al, 2008
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Association with LBP
Vertebral endeplate and pain
• Nociceptors in the endplate1,2
Association with LBP + Number of individuals * Number of levels
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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)
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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
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Natural course (patient)
Baseline (n=74)
Modic Type I
77% (n=74)
23% (n=22)
1 year (n=74)
74% (n=55)
26% (n=19)
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Natural course (patient)
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
Natural course (patient)
Baseline (n=74)
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Case 1
40 year-old woman with LBP
Two MRI scans four years apart
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Case 1
Age 40
T1 T2
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Case 1
Age 40
Age 44
T1 T2 T1 T2
Case 2
50 year old woman
Initial presentation
• Disc herniation and sciatica
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Case 2
T1 T2
Baseline
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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
• Good effect at 3 and 12 months
1 Cao P et al, 2011 2 Jensen RK et al, 2012 3 Albert HB et al, 2013
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Treatment
Only three RCTs
• Intradiscal steroid1
• Good effect at 3 and 6 months
• Exercise vs. Rest2
• No effect at 10 weeks and 12 months
• Antibiotics3
• Good effect at 3 and 12 months
1 Cao P et al, 2011 2 Jensen RK et al, 2012 3 Albert HB et al, 2013
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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
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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
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Are Modic changes clinically relevant?
Clinical value
Diagnosis
Treatment
Prognosis
Are Modic changes clinically relevant?
X
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Live Q & A With Tue Secher Jensen
19/09/2013
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Coming up October 15
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Live Q & A With Tue Secher Jensen
19/09/2013
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Thank you
From Tue Secher Jensen &
World Health Webinars Australia http://worldhealthwebinars.com.au