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Are high-intensity zones and Modic changes mutually exclusive in symptomatic lumbar degenerative discs?

Clinical article

Laurence A. G. Marshman, Andrew V. Metcalfe, Manoj Krishna, and Tai Friesem

Object

Modic changes (MCs) and high-intensity zones (HIZs) potentially serve as variably sensitive markers for discogenic chronic low-back pain (CLBP). No study has hitherto assessed the phenomenon of MC-HIZ coexistence at a single level, and the goal in this study was to assess the nature and frequency of this phenomenon.

Methods

One hundred twenty consecutive patients with discogenic CLBP in whom lumbar MR imaging studies had demonstrated an HIZ, an MC, or both were included.

Results

This cohort (120 consecutive patients with 193 degenerative discs) had discogenic CLBP in at least 1 lumbar level associated with either an HIZ (77 discs), an MC (67 discs), or both (16 patients); there were 55 coexistent non-HIZ/non-MC degenerative discs. Painful MC-HIZ coexistence at 1 level occurred in 6 patients (5 of whom were female). If HIZs and MCs were random, independent entities, then MC-HIZ coexistence at 1 level would have been expected in 67 × 77/193 (that is, 27) discs. The observed frequency was therefore significantly lower (χ2 = 41, p < 0.001). There were no significant demographic differences between groups. The HIZ disc height (8 ± 0.2 mm) was significantly greater than the MC (6.6 ± 0.2 mm) or MC-HIZ (6.7 ± 0.2 mm) disc heights (p < 0.001).

Conclusions

In patients with discogenic CLBP associated with HIZ or MC lesions, MC-HIZ coexistence at 1 level was significantly rarer than expected even by chance; thus, despite both being manifestations of a seemingly common degenerative process, HIZ and MC more closely represent “either/or” phenomena. Because HIZ disc height was significantly greater, HIZs may develop earlier in the disc degenerative ontogeny. If any degenerative disc may only display an HIZ first, yet may ultimately display an MC instead, then HIZs must invariably regress as MCs supervene (or even vice versa). The MC-HIZ coexistence would therefore represent either a rare stable state (possibly more common in females) or a transitory state, as one lesion gradually replaces the other. Longitudinal studies would confirm or refute these hypotheses, although significantly larger sample sizes would be required.

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Reverse transformation of Modic Type 2 changes to Modic Type 1 changes during sustained chronic low-back pain severity

Report of two cases and review of the literature

Laurence A. G. Marshman, Matthew Trewhella, Tai Friesem, Chandra K. Bhatia, and Manoj Krishna

✓Modic Type 2 (MT2) neuroimaging changes are considered stable or invariant over time and relatively quiescent, whereas Modic Type 1 (MT1) changes are considered unstable and more symptomatic. The authors report two cases in which MT2 changes were symptomatic and evidently unstable, and in which chronic low-back pain severity remained unaltered despite a MT2–MT1 reverse transformation. Two women (41 and 48 years old) both presented with chronic low-back pain. Magnetic resonance (MR) images demonstrated degenerating discs at L5–S1 associated with well-established MT2 changes in adjacent vertebrae. Repeated MR imaging in these two patients after 11 months and 7 years, respectively, revealed reverse transformation of the MT2 changes into more florid MT1 changes, despite unaltered chronic low-back pain severity. Following anterior discectomy and disc arthroplasty, immediate abolition of chronic low-back pain was achieved in both patients and sustained at 3-year follow up. Modic Type 2 changes are therefore neither as stable nor as quiescent as originally believed. Each type can change, with equal symptom-generating capacity. More representative imaging–pathological correlates are required to determine the precise nature of MT changes.