Modic changes,

background and treatment

Hanne B. Albert, PT, MPH,

Ph.D.
 Modic changes
1. Why are Modic changes interesting ?

2. Possible pathogenesis

3. Laser treatment of Modic changes ?

Patho-anatomical diagnosis

Non disc related pain

disc related pain

??
 Guideline recomendations
• Studies are needed to determine how and by whom interventions are
best delivered to specific target groups.

• More research is required to develop tools to improve the

classification and identification of specific clinical sub-groups
of CLBP patients. Good quality RCTs are then needed to
determine the effectiveness of specific interventions aimed at
these specific risk/target groups.
•Modic changes
what is it ?
 Modic Type 1 changes

• Fibrovascular

tissue

• ”fluid”

T2 T1
 Modic Type 2 changes

• Yellow fat

T2 T1
 Modic type 3 changes

• Rarely
observed

• Sclerotic
bone
 Why are Modic changes interesting ?
• Strongly related to low back pain.
Kjær et al 2005, Bratiewaite et al 1998, Toyone et al 1994, Weishaupt et al 2001

• The disease is very frequent

• The pain is disabling and long lasting

• Difficult to treat

• Possible a ”new disease”, a specific sub

group of low back pain.

• Can only be observed on MRI not x-ray

 Are Modic changes painfull ?
* For years radiologist said ” Modic changes
are a natural part of disc generation and
are not painful”

• Never supported by data from studies

• Similar bone changes in knee, hip etc are

recognised as painful (bone oedema)
Modic changes and Low back pain

In the normal population:

• Is (almost) not observed in children
• In 40 years old adults 23% Modic changes

• Strong correlation between Modic changes

and low back pain in 40 year olds.
Kjær et al 2005
 Literature
Association between Modic changes
and lumbar pain
* 10 of 13 studies have a positive
correlation
• Not one with a negative correlation
• Not possible with a meta-analysis

* Ref: Jensen, Eur. Spine J., 2008

 Discography and Modic

Study %

ID OR (95% CI) Weight

Ito 18.20 (1.03, 321.87) 5.76

Braithwaite 9.13 (2.06, 40.56) 11.64

Kokkonen 1.15 (0.52, 2.55) 15.91

Weishaupt 19.93 (5.50, 72.31) 12.86

Lim 0.46 (0.12, 1.77) 12.47

O'Neill 8.69 (3.03, 24.96) 14.33

Thompson 2.56 (1.99, 3.28) 18.35

Lei 27.86 (3.55, 218.37) 8.68

Overall (I-squared = 80.2%, p = 0.000) 4.50 (1.96, 10.32) 100.00

NOTE: Weights are from random effects analysis

.00311 1 322
How frequent are Modic changes,
58 studies
13 studier på ikke kliniske populationer
45 studier på kliniske populationer
 Latest study

• Retrospective study of all MRI’s at the

Back Centre a total of 4,233 chronic low
back patients.

• Albert et al. European Spine 2011

 40

35

30

25
Prevalence (%)

20

15

10
Modic change type 1 and/or 2
Modic change type 1
5 Modic change type 2

85 +
10-15

16-20

21-25

26-30

31-35

36-40

41-45

46-50

51-55

56-60

61-65

66-70

71-75

76-80

81-85
Age bracket (years)
Modic changes are long lasting
• Few longitudinal studies

• Starts Type 1 , 3-5 years

• Next Type 2 , 5-7 years
• Normal bone, but can turn to
Type 1 again
 Exercise study
• 46 patients with Modic changes
• 48 patients without Modic changes

• 1 year follow-up

• Patients with Modic changes have:

• Frequent and worse pain than non Modic pt.

• No positive effect of exercise, the majority
experienced worsening.
 ikke-discus relaterede smerter

discus relaterede

?? smerter

20 %

Modic forandringer
Modic changes after lumbar
disc herniation
• Patients with sub acute lumbar disc
herniations

• Baseline n=181

• After 2 month treatment n=172

• 14 months follow-up n=166

 Overall prevalence
• At baseline 46 (26%) had Modic changes

• At 1 year follow-up 81 (49%) had Modic

changes
 The prevalence of Modic Changes at baseline and at 14 months
follow-up
The frequency in percentage of people with m odic

45
40

35

30
Modic type 1
changes

25
Modic type 2
20
Modic type 3
15

10
5

0
At acute herniation, baseline (n = 14 months after baseline (n= 166)
180)
 Modic changes and low back pain
100%
90%
80%
Patients in percent

70%
60%
Pain free
50%
Pain
40%
30%
20%
10%
0%
Modic changes n=81 No changes n=85
 Lumbar pain and Modic changes

• The difference is significant (p<.0001)

• This increases the risk of lumbar pain with an

OR of 6.1 (2.9 – 13.1).
 Which lesions result in Modic changes
Disc contour at Distribution Modic changes at
baseline (%) follow-up (%)
Normal disc 15 (8) 0 (0)
Bulge 30 (18) 15 (47)
Focal protrusions 62 (37) 35 (56)
Broad-based 13 (8) 4 (31)
protrusions
Extrusions 39 (24) 22 (56)
Sequestrations 8 (5) 5 (63)
 Surgery
• In 1 year follow-up period, 12 people had
surgery, mainly for new herniations

• 9 of the 12 with surgery developed Modic

changes (75%)
• 72 of the 154 non-surgery patients
developed Modic changes (47%)

• OR 3.5
• (p<.055)
 Conclusion

• The prevalence of Modic changes

increases dramatically after a lumbar disc
herniation
• Modic changes (especially Type 1) have a
close relation to low back pain

• If no disc lesion, Modic will not develop

 Modic og lændesmerter

Prolaps

Modic

Fraktur Degeneration
 Phatogenese for Modic
forandringer
•Mekanisk årsag

•Infektiøs årsag
• Albert et al, Medical Hypotheses, 2008
Stirling Bacteriae N= 36 Off all infected n = 19
2001

Propione acnes 45 % 84 %

Negativ cocci 5% 11 %

Coryne propinquum 3% 5%

Positive cultures 53 % 100 %

• Stirling’s study was questioned about possible
problems with hygiene, the opposition
suggested that the cultures were a result of skin
contaminations.

• Stirling responded with a new study he operated

207 patients with lumbar disc herniation

• Stirling operated 27 patients with trauma, tumour

and scoliosis, and evacuated their nucleus
material.
• Not one single patient of these had a positive
culture
Stirling N= 207 Off all N = 27,
2002 herniations infected Trauma,
n = 76 tumour,
Herniations scoliosis

Propione acnes 28 % 75 % 0%

Negativ cocci 5% 15 % 0%

Other 2% 5% 0%
organisms

Mixed 2% 5% 0%

Positive cultures 37 % 100 % 0%

 Why antibiotic treatment ????
• Around the herniated nucleus material
new capillaries occur Doita M et al. 1996, Hirabayashi S et al. 1990,
Lindblom K et al 1950, Ito T et al. 1996

• Inflammation occurs in and around the

herniated nucleus material. Macrophages
in great numbers are in the area, they
carry low virulent anaerobic bacteria. Gronblad M
et al. 1994, Ito T et al. 2001
 Why antibiotic treatment ?

• After brushing teeth, bacteria are

in the bloodstream for a mean of
10 minutes Bhanji S et al. 2002, Farrar MD et al 2004, Fiehn
NE et al. 1995, Roberts GJ et al. 1997

• The bacteria in the mouth are low

virulent anaerobic bacteria
 Hypothesis
• Do these bacteria invade the anaerobic
disc and cause a low virulent infection ??
Albert et al. Med Hypotheses (2008)

• Is the Modic type 1 the edema surrounding

an infection ???
Albert et al. Med Hypotheses (2008)
• 61 patients operated on a private
hospital in Denmark for a lumbar
disc herniation.
• Uptake area all of Denmark

• Culture
Albert N= 61 Of all infected
Herniated disc n =33
Anaerobic

Propione acnes 37 % 74 %

Gram positive 5% 9%
cocci
Aerobic

Gram positive 6% 11 %
cocci

Gram negative rod 1.5 % 3%

Gram negative 1.5 % 3%

diplo cocci

Positive cultures 51 % 100 %

 Nye Modic Ingen nye I
forandringer efter en Modicforandring alt
lumbal discus prolaps er

Positive anaerobe 20 5 25
kulturer

Positive aerobe 0 2 2
kulturer

Negative kulturer 15 19 34
Confirmation of the theory of infection

• Fisher's exact test p< 0.0038

 Choice of drug
• 3 independent microbiologist in different
countries were sent Stirlings study.

• ”Which antibiotic would you suggest to

treat patients with infection of these
bacteria”

• Unison = Amoxicilin
Antibiotic treatment of patients
with low back pain and Modic
changes following disc
herniation

A pilot cohort study

 Inclusion criteria
• Previous lumbar disc herniation
• Pain in the area L1-L5
• Modic changes observed on MRI

included in an RCT with two active

conservative treatments
 Suffers from Starts After 3 months
24-year old severe LBP antibiotics antibiotics,
hotel maid feels healthy.
has a herniated Is tested for Approved Starts appren-
disc her ability to pension ticeship as a
work flower decorator

100
90
Værdi i procent af maximum

80
70
60 Bensmerter
50 Rygsmerter
Funktionsproblemer
40
30
20
10
0
0 2 mdr. 5 mdr. 8 mdr 14 22 25
mdr. mdr. mdr
Variable Base-line End of Follow- Significant
treatment up difference

Roland 8 4 5 p<.001
Morris 4.5 – 13.5 0.5 - 9 1 - 10
Questionnaire
Days with 100 35 20 p<.001
Low Back 25 - 100 7 - 35 10 - 84
Pain
Low Back 9 5 5 p<.001
Pain 6 - 15 1.5 – 9.5 2.5 - 12
 Devellopment in RMQ

20

15
RMQ 0-23

10

Follow-up after
One year Start End of 3 months 10,8 months
control for antibiotic antibiotic
herniated disc treatment
 Conclusion
• For patients with a previous herniated
disc, current low back pain and Modic type
1 changes, long term antibiotic treatment
might relieve their back pain and improve
function.
Antibiotic treatment of patients with low back pain
and Modic changes after a lumbar disc herniation –
double blind controlled clinical trial

Modic forandring
What about the patients that did
not get well on antibioticks ?

• What about the patients that

have Modic changes on a
mechanical background ?
Two problems in Modic changes

1. Micro fractures

2. Inflammation
Laser is light, light that stimulates some of
the biological healings processes

Laser promotes bone healing

Laser reduces the inflamatoric
reaction
Taget is 7-15 cm inside the body,
needed a especielly strong laser.

Power Medic did build a prototype with

the effect of 7000 mW
 • Pilot study
• 25 patients were invited
• Constant pain 6.2 years, from 22
years – 4 years
• All had a minimum of one
previous disc herniation
• All had previous antibiotic
treatment
 Early drop-outs

• 6 never started, due to long transportation,

severe psykosocial problems

• 2 had new lumbar disc herniations before

start

• 1 had nausia and diarrea as a side effect

• 2 had no effect after 3 treatments stoped

 Partisipants in pilot study
• 14 participants ( 43 % women)
• 71 % received disability pension or
workers litigation
• 29 % at work
• Mean age 49 years
 Functional capasity; Roland Morris
Pre- Start End 2 years
treatment treatment treatment follow-up
Mean 13.8 13.9 7 9.8
Roland Morris
 Low back pain
Pre- Start End 2 years
treatment treatment treatment follow-up
Low back pain
0-30
17.0 17.8 6.9 12.8
 Number of analgetic units
Start treatment End treatment

Analgetic 30.1 13.5

 MRI data

Not yet available

 Conclution
• In a group of patients who are severely
chronic and treatment resistant.
• After laser treatment the pain decreased,
function increased and there was a
reduction in analgesic intake.
• The reduction was larger at end of
treatment than 2 year post treatment.
Thank you for your attention