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timedw

Registered: 19/11/12
Posts: 21
Reply with quote  #1 
I have a 39 year old male patient with a long history of intermittent back pain. Normally settles in a week or two without treatment and can happen 2-3 times per year. Presented to me 5 weeks ago now with pain that had lasted for about 6 weeks and not resolving. X-rays showed loss of disc height at L4-5 and he didn't respond well to manual adjustments so moved to blocking and trigger point work. MRI ordered at the end of last week because of limited improvement. Shows a type 1 modic change at L4 end-plate, no annular tears and only a small bulge with no herniation. All other discs normal according to the report faxed to me tonight, haven't seen the image.

I am not sure what to offer him now in terms of treatment. I am aware of the antibiotic treatment, but was that only for a herniation with modic changes. Obviously he is inflammed and he has previously been resistant to taking anything, but I did convince him to try anti-inflams at the end of last week. Aside from that is the best I can offer him to say rest and wait it out for another 3-6 months? Is there a more effective treatment that people have tried, referred to or know of?

Thanks

Tim
mdlong

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Registered: 10/12/10
Posts: 475
Reply with quote  #2 
Hi Tim,

What are his examination findings? Antalgia? Intrathecal pressure? Slump/SLR? Pain on arising from chair? Superficial tenderness in lumbar spine? Pain distribution? Power/tone/sensation in lower limbs? etc
timedw

Registered: 19/11/12
Posts: 21
Reply with quote  #3 
Hi Matthew,

He reports the pain as deep, worse when sitting and rising. I can elicit superficial tenderness at the L4 and L5 spinous and facet joints as well as at the errector spinae muscles on both sides. Standing he has no antalgia but when bending forward he has a lean of to the left. Bending forward causes some discomfort, but he complains more of tightness into the hamstrings bilaterally. SLR is normal, slumps causes some mild discomfort into the lower back, but legs are lifted to 90 degrees. Valsalvas is negative. No loss muscle strength or change in sensation. We had some improvement to last week and then he went backwards with a slight increase in activity. Even before the MRI I was treating him as if he had a disc injury based on findings and history.

Tim
mdlong

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Registered: 10/12/10
Posts: 475
Reply with quote  #4 
Hi Tim,

This patient has three prime diagnoses still in play. These include:

1. Symptomatic Type I Modic changes - supported by: MRI

2. Annular tear - supported by: Age of patient, epidemiology, pain character, pain behaviour (worse on sitting and rising from chair), duration of symptoms, possible thecal tension sign during slump test. Not supported by: presence of superficial tenderness, no signs of increased intrathecal pressure. The lack of clear annular tear on MRI has yet to be confirmed - we need to see the images. The mere fact that there is a bulge and there are signs of thecal tension suggest an occult tear. The lack of antalgia is also not uncommon, particularly if there is a central tear.

3. Facet joints - supported by: presence of superficial tenderness, no antalgia, no signs of increased intrathecal pressure, equivocal slump test. Not supported by: Age of patient, epidemiology, pain increased by sitting and rising from chair, we have no STIR images to look for synovitis.

Issues such as hamstring tightness are not diagnostic as they'll accompany any lumbar source of pain.

At this stage the balance of probability still lies on the side of a symptomatic disc, most likely a central annular tear. This may not be visualised well on the MRI (depending upon techniques used, age/ T-strength of machine, radiologist interpreting), but it may still be present. While symptomatic Modic changes are still a possibility, the other diagnoses should be excluded first.

We really need to see the images....

Regards,

Matthew
timedw

Registered: 19/11/12
Posts: 21
Reply with quote  #5 
The patient brought his MRI in today and I have taken a photo, hopefully the links work. The modic changes is very evident. He has been resting all week and seems to be settling down with minimal intervention. Talked to him about taking it easy and trying anti-inflams and will phone him later in the week and then see him again in a week or two. 

https://dl.dropboxusercontent.com/u/75392763/IMAG0769.jpg
https://dl.dropboxusercontent.com/u/75392763/IMAG0770.jpg
mdlong

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Registered: 10/12/10
Posts: 475
Reply with quote  #6 
Hi Tim,

The images you posted are very interesting, but they do not demonstrate Modic Type I changes. Rather, they show Schmorl's nodes with associated marrow oedema. The extrusion of disc material through a fractured endplate can be painful and the nucleus pulposus will induce an inflammatory reaction, seen as a high signal intensity halo around the invagination on T2 sequences. You will also see the vertebral body marrow surrounding the Schmorl's node as low signal intensity on Tl-weighted images (1,2).  Although Schmorl's nodes are typically asymptomatic, they do represent an uncommon form of non-radiating back pain. Your MRI images show this via the tell-tale halo effect.

According to Takahashi (2),

"In this study, MRI of patients with symptomatic Schmorl's nodes has demonstrated inflammation and oedema in the cancellous bone of the vertebral body, localized to the area around the Schmorl's node. In contrast, these changes were not seen in cases with asymptomatic Schmorl's nodes. We presume that symptomatic Schmorl's nodes represent a fresh intraosseous fracture in the vertebral body. Inflammatory change in the vertebral body marrow induced by intraosseous fracture and some biological reaction to the intraspongious disc materials might cause pain. Intraosseous fracture in the vertebral body leads to an inflammatory reaction during the healing stage, and this is likely to cause pain by stress on the affected vertebra. After the fracture has healed and the inflammation subsided, the Schmorl's node would be asymptomatic in analogy with an old vertebral compression fracture. In the early cases of this study, since we could not differentiate symptomatic Schmorl's node from spondylitis, surgical treatment was performed. However, it is clear that the natural course of a symptomatic Schmorl's node leads to resolution, as based on the results of conservatively treated cases and the existence of many asymptomatic Schmorl's nodes, which might be the remains of symptomatic Schmorl's nodes. Symptomatic Schmorl's nodes should be treated similarly to vertebral compression fracture, and conservative treatment should be the first choice. If conservative treatment has failed, surgery with anterior interbody fusion might be indicated."

References:
1. Wagner, A. L., Murtagh, F. R., Arrington, J. A., & Stallworth, D. (2000). Relationship of Schmorl’s Nodes to Vertebral Body Endplate Fractures and Acute Endplate Disk Extrusions. Am J Neuroradiol, 21, 276–281.
2. Takahashi, K., Miyazaki, T., Ohnari, H., Takino, T., & Tomita, K. (1995). Schmorl's nodes and low-back pain. Analysis of magnetic resonance imaging findings in symptomatic and asymptomatic individuals. European spine journal, 4(1), 56–59.
timedw

Registered: 19/11/12
Posts: 21
Reply with quote  #7 
Thanks Matthew. I read the mri report long before I saw the images and that is where the diagnosis of modic 1 changes was made. It looked a lot like the images I checked out before the patient came in and would not have been able to make the distinction. Now that you have pointed out the difference I can see it. From a recovery stand point how long should this type of injury take to heal? He's been suffering with this for close to 3 months now. 

Tim
mdlong

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Registered: 10/12/10
Posts: 475
Reply with quote  #8 
Yes it is very interesting to see the differing interpretation given by radiologists when reading MRI's. In truth, there are many radiologists who do not specialise in musculoskeletal imaging, yet they are often called upon to deliver a report. In such circumstances the descriptions given often are incomplete or just plain wrong. I have noted many such examples of inaccurate reporting, which I have confirmed with musculoskeletal specialist radiologists after I queried the original report. 

In regards to healing time, generally 3 months is quoted. Passive treatments don't seem to offer much, and gentle exercises (such as walking) are typically of value. Adjustments are contraindicated in the area and will usually aggravate the symptoms. In the end, like all fractures, it takes time.
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