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Many patients with chronic low back pain have physiologic changes to their vertebrae that are the result of stress as the degenerative disc disease progresses. Many of you will see the term Modic Type 1 or degenerative endplate sclerosis on your MRI report. But what does this mean and what can you do about it?
Low back pain has been very difficult to treat because the cause is often multifactorial. It is very easy to identify the cause when there is a fracture or instability. It is often the result of a herniated disc or from spinal stenosis. However, many patients with back pain do not have these conditions but rather are diagnosed with degenerative disc disease. I cannot tell you how many patients come to me and tell me they have degenerative disc disease and that it is the cause of their pain and ask me to fix it.
Doctors from all disciplines treated this disease with physical rehabilitation, injections and ultimately surgery all with varying degrees of success. In the late 90's and into the early 2000's there was a phenomenon called the "cage rage" when spinal fusions using threaded cages inserted between the vertebrae to fuse them using a laparoscopic approach, It was very easy surgery to perform and it paid very well and even non-spine surgeons would fuse patients with degenerative or "black discs". Unfortunately many patients did not receive any benefit from this surgery and it fell out of favor.
This raises a question. If we had presumed our patient's back pain was arising from the disc, and we removed the disc and fused the spine, why didn't the pain go away? Is it possible that the cause of the pain was originating not from the disc but from the bone itself?
In the late 80's, a radiologist named - you guessed it - Modic identified signal characteristic within the vertebrae adjacent to the degenerative disc. He noted that most of the patients who were receiving MRI's for low back pain who had degenerative disc disease, also had signal changes within the adjacent vertebral bodies. More specifically this area is called the endplate, and bone's response to stress is called sclerosis. Degenerative endplate sclerosis is a mouthful and Modic described grades of sclerosis and since it is easier to say and he wrote about it, we now and rightly so, describe these changes as Modic type 1 and Modic type 2.
So you may wonder how do these changes in the bone cause back pain. You will just have to read my next post to find out.