Modic Changes Are Associated With Increased Pain Intensity, Greater Disability, and Reduced Quality of Life in Low Back Pain: A Cross-Sectional Study.

Abstract

Background: Low back pain (LBP) is a common health problem and a major contributor to disability. Modic changes, or vertebral marrow changes visible on MRI, are frequently observed in individuals with LBP. However, there is inconsistent evidence assessing the relationship between Modic changes and LBP, pain-related disability, and quality of life.

Questions/purposes: (1) Are Modic change parameters, including their type, number, and extent, positively associated with the characteristics of LBP, particularly when classified into intermittent LBP and chronic LBP? (2) Are Modic change parameters associated with participant-reported longer duration and higher intensity of LBP? (3) Are Modic change parameters associated with worsened pain-related disability and poorer quality of life?

Methods: This study was a Phase III, single-center, cross-sectional analysis drawing its data from the ongoing Berlin Back Study (research unit FOR5177). A total of 1218 participants who met the inclusion and exclusion criteria were recruited between January 2022 and January 2024. Of these, 18% (217 of 1218) were excluded because of the lack of results from orthopaedic clinical examination and MRI evaluation. After clinical examination and completion of questionnaires, another 24% (289 of 1218) were excluded because of pain in other locations or pain experienced in the past, leaving 58% (712 of 1218) of participants in our study. The individuals included in this study had a mean age of 42 ± 11 years, with 57% women and 43% men. Data on demographic characteristics, LBP features, pain-related disability, and quality of life were collected using structured questionnaires and clinical evaluations. Three independent evaluators, blinded to the participants' demographic information and health status, assessed the Modic change parameters, referring to signal alterations in the vertebrae's endplate. The relationship between Modic change parameters and individual health status was assessed using multiple regression analysis after adjustment for age, gender, BMI, smoking and alcohol consumption, disc herniation, facet joint degeneration, and spinal instability.

Results: Among the common Modic change parameters, when Type I Modic changes were observed, we found higher odds of chronic LBP (OR 7.3 [95% confidence interval (CI) 3.1 to 17.0]; p < 0.001) and intermittent LBP (OR 4.9 [95% CI 1.7 to 14.0]; p = 0.003) after adjusting for potential confounders. However, when greater depth and area of Modic changes were observed, we found higher odds of chronic LBP (OR 3.1 [95% CI 1.3 to 7.3]; p = 0.01 and OR 1.3 [95% CI 1.0 to 1.7]; p = 0.03, respectively) but not of intermittent LBP (OR 1.2 [95% CI 0.4 to 4.1]; p = 0.72 and OR 1.0 [95% CI 0.7 to 1.3]; p = 0.86, respectively). In the chronic LBP subgroup, we found that Type I Modic changes were associated with slightly higher maximum pain intensity (β 1.1 [95% CI 0.4 to 1.7]; p = 0.001), and multiple Modic changes were associated with modestly longer duration of chronic LBP (β 5.1 [95% CI 1.2 to 9.0]; p = 0.01). Increased Modic change depth and area were associated with slightly higher pain intensity in the chronic LBP group but not in the intermittent LBP group. In addition, Type II and single Modic changes were associated with slightly worsened pain-related disability (β 1.1 [95% CI 0.1 to 2.0]; p = 0.03 and β 1.5 [95% CI 0.6 to 2.4]; p = 0.001, respectively). The presence of Modic changes was also associated with slightly poorer quality of life, particularly in terms of physical health.

Conclusion: Modic changes were found to be associated with higher odds of LBP, greater pain intensity, worsened pain-related disability, and reduced quality of life. The Type I and larger Modic changes were associated with slightly higher intensity of chronic LBP and slightly reduced physical function. Our study associated Modic changes with these findings, but it was not designed to demonstrate a causal relationship. Future studies will need to explore the causal relationship between Modic changes and health conditions, as well as whether targeting Modic changes could offer a potential approach to alleviating LBP.

Level of evidence: Level III, prognostic study.