Vertebral Endplate Changes: Insights Into Its Natural Course and Clinical Implications in Low Back Pain

Abstract

This study presents the literature review on vertebral endplate (EP) changes, which are frequently observed in patients with chronic low back pain (LBP). The disc, EP, and bone marrow region of the spine form a single anatomical and functional interdependent unit; isolated degeneration of any one structure is rare. The cartilaginous EP supported by a bony EP is responsible for anatomical integrity and controls diffusion, the only source of nutrition to the disc. A break in the EP establishes disc-bone marrow contact leading to possible severe autoimmune inflammation and also neovascularization and destruction of the disc. Conversely, degeneration, herniation, or infection of the disc will end in the destruction of both EPs as well as involve the subchondral bone. It is then logical that this region must be considered together as a whole. To consider any one of them in isolation can lead to the error of overlooking changes in the other structures of the disc EP bone marrow complex. Modic changes are discussed extensively in the literature from various angles of being a separate clinical phenotype, having a controversial etiology with the possibility of subclinical infection and treatment with antibiotics, having poor outcomes, and having higher complication rates after surgery. This review article highlights our understanding of vertebral EP changes and progression from Modic classification to disc EP bone marrow complex classification with more clearer depiction of its natural course and clinical implication in LBP.