Elsevier

The Spine Journal

Volume 12, Issue 5, May 2012, Pages 411-416
The Spine Journal

Technical Report
Modic changes: prevalence, distribution patterns, and association with age in white men

https://doi.org/10.1016/j.spinee.2012.03.026Get rights and content

Abstract

Background context

Suspected as a cause of back pain, Modic changes (MCs) have received increasing attention in spine research and care. Yet, epidemiologic knowledge of MCs based on the general population, which may provide an important clinical reference, is limited.

Purpose

To investigate the prevalence and distribution patterns of MCs in the lumbosacral spine and their associations with age in a large population-based sample of men.

Study design

An epidemiologic investigation of lumbar magnetic resonance images (MRIs).

Patient sample

This study was based on the Twin Spine Study database, comprising a sample of male twins shown to be largely representative of the base Finnish population. Lumbar spine MRIs (1.5 Tesla Magnetom; Siemens AG, Erlangen, Germany) of 561 subjects (mean age, 49.8 years; range, 35–70 years) were included in the present study.

Methods

For each spine, all 11 end plates (L1–S1) in the lumbar region were evaluated using both T1- and T2-weighted images to identify MCs, which were classified into Type 1, 2, 3, and mixed types. Furthermore, the number and location of MCs were recorded, as well as the anteroposterior (AP) and transverse sizes, to explore the prevalence and distribution pattern of MCs in the lumbar region and associations with age.

Results

Modic changes were identified in 55.6% (312) of individuals and 13.5% (830) of end plates studied. Among these MCs, 64.2% (533) were Type 2, 16.0% (133) were Type 1, 18.1% (150) were Mixed Type 1/2, and the remaining 1.6% (13) were noted as Type 3 or Mixed Type 2/3. Modic changes were more common in the lower (74.5%) than in the upper lumbar region (25.5%), and 77.9% (642) of MCs presented in pairs at opposing end plates of a disc. Moreover, the specific type of MCs on opposing end plates was usually concordant. The presence of MCs in the lumbar region was associated with age (odds ratio=1.05–1.08 for each additional year of age, depending on type of MCs, p<.001). In addition, greater age was associated with a greater number of end plates affected and MCs of larger size (p<.001).

Conclusions

Modic changes are common MRI findings in the lumbar spines of middle-aged white men, with Type 2 MCs predominating. Mainly present in the lower lumbar region, MCs tend to affect both end plates adjacent to a disc simultaneously, and they commonly involve the entire AP diameter of the vertebral end plate. The presence and size of MCs are clearly related to age, suggesting that aging or associated factors may play an essential role in the pathogenesis of MCs.

Introduction

Modic changes (MCs) are signal variations of the vertebral end plate and the adjacent subchondral vertebral marrow seen on magnetic resonance images (MRIs) [1], [2]. According to the patterns of signal changes on T1- and T2-weighted images, traditionally MCs have been classified into three types [1], [3]. Type 1 MCs show decreased signal intensity on T1-weighted images and increased signal intensity on T2-weighted images. Type 2 MCs demonstrate increased signal intensity on both T1- and T2-weighted images, whereas Type 3 MCs reflect decreased signal intensity on both T1- and T2-weighted images. The presence of different types of MCs together within an end plate was later regarded as mixed MCs, such as Mixed Type 1/2 and Mixed Type 2/3 [4], [5], [6].

Despite over 20 years of study, much about MCs remains either controversial or unknown. Assumed to be degenerative features of the vertebral end plate and marrow, MCs have long been suspected as a cause of low back pain [2], although this remains controversial [4], [7], [8], [9], [10]. Because of limited cases of biopsy, the pathologic nature of MCs largely remains unclear [2], [11]. Even the prevalence of MCs and the predominant type are uncertain. For example, the prevalence rates reported in the scientific literature widely range from 0.5% [12] to 62% [13]. Among the factors underlying the inconsistencies are variations in age and race of the subjects, back pain status [7], [14], and occupation [9]. To date, there are only two reports on MCs in the general population, which come from the same cohort [8], [15]. The role age may play in the pathogenesis of MCs, and the distribution pattern of MCs, has not yet been explored in the general population.

A systematic study of MCs in the lumbosacral region in the general population would provide fundamental epidemiologic insights of MCs and an important reference for clinical observations. The purpose of the present study was to investigate the prevalence and distribution pattern of MCs and their associations with age using a large population-based sample. Evidence suggests that MCs are closely related to disc [16], [17]. Thus, we refer to end plates containing MCs relative to the intervertebral disc and differentiate them as cranial and caudal to the adjacent disc.

Section snippets

Subjects

This study used the lumbar MRI of the Twin Spine Study cohort [18], which consists of 300 pairs of male monozygotic and dizygotic twin pairs (N=600). Subjects were recruited from the population-based Finnish Twin Cohort, containing virtually all Finnish sex-matched twin pairs born before 1958 and alive in 1975, which has been shown to be representative of the general Finnish population [19]. Initially, monozygotic twins were recruited and compared with the larger twin cohort on a variety of

Prevalence of MCs

Of the 561 lumbar spines assessed, 55.6% (312 individuals; mean age, 51.4 years) had some sort of MCs present, and the remaining 44.4% (249 individuals; mean age, 47.7 years) had no MCs present. Observed in 29.2% (164) of subjects, Type 2 MCs were most common in our sample. Type 1 MCs were noted in only 6.4% (36) of subjects, whereas Type 1 and 2 MCs presented together (either at the same end plate or separate end plates of a spine) in another 18.0% (101) of lumbar spines. Type 3 MCs were

Discussion

Modic changes were found to be common MRI findings in the lumbar spines of a general population sample of middle-aged white men, with Type 2 MCs predominating. Mainly present in the lower lumbar region, MCs tended to affect both end plates adjacent to a disc simultaneously, and it commonly involved the entire AP diameter of the vertebral body. The presence and size of MCs were clearly related to age, suggesting that aging or associated factors may play an essential role in the pathogenesis of

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    Author disclosures: YW: Nothing to disclose. TV: Nothing to disclose. MCB: Nothing to disclose.

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