192- Breaking Down Modic Changes

Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langman.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langme. Today we are talking all about modic changes in the vertebral bodies and the end plates. This is a topic that confused me forever. But I'm gonna break it down in a way that makes it simple, that makes it easy to remember the differences and also we'll talk a little bit on the patient conversation side of things. So it's gonna be a good episode. Before we get started, I'll say a few words about Roc tape. Rocktape is proud to be a sponsor of the Evidence Based Chirof and as such, you can imagine that I am going to be out at Rock Stock. It is happening September 13th and 14th in Huntington Beach, California. One of my favorite places to go and hang out and I hope to see you there. If you have not picked up your tickets yet, time has not run out, but it's running short. Head over to rocktape.com rockstock pick up your tickets. The event this year is going to be awesome. I took a look at some of the educational classes or seminar aspect of it. Check that out for sure at the website I just listed. Also, come and hang out. I'm going to be filming, having a good time. There's just a bunch of cool people out there. So hopefully I will see you out at Rock Stock. It is happening again in Huntington Beach September 13th and 14th and this is the movement summit of the year. So you definitely want to check that out and hopefully I will see you out there. But as I said at the top, we are talking all about modic and endplate changes. Today I want to break down sort of what they are, the end plate, the disc. How do these things interact? Where does pain fit in into the equation? And what can you expect when somebody has these changes? Whether you see them on an X ray yourself or whether it's dictated on the mri, however they come across. I want you to be prepared to have those conversations and also to feel more comfortable than I did in the past, quite frankly, regarding them. So this all my kind of change point, I guess you could say was a couple years back at the multidisciplinary surgical group that I was working in, I did a presentation at our annual physician conference. So it was all of our orthopedic surgeons, all of our neurosurgeons, some of our chiros, and our executive leadership team. I actually did a presentation on modic changes because I didn't feel great about my knowledge base. So I said, let me present on it. That's gonna force me to dive deep. It's gonna force me to take a good look at what's going on and also simplify it down in a way that makes sense and I could get through in roughly a 10 to 20 minute presentation. So that's what I'm gonna break down. I'm using that sort of as the foundation of what we'll talk about today. And with that, let's dive right in. So when I talk about modic changes, what are they? That's the first question, right? So I want you to think about them as pathological changes to the body and endplate of the vertebra. Pretty straightforward. Anytime you see motic changes, pathological changes. So they are not normal and usual and customary. They are pathological changes to the body and endplate of the vertebrae. So there is a Strong correlation between Modic1 changes and pain in the lower back. I want to say that again. There's a Strong correlation between Modic1 changes and pain in the lower back. There's multiple different types of motic changes. Modic1, modic2, modic3. But modic1 changes do have a high correlation with pain. Important to keep in mind. So with Modic1 changes, what we find in the literature is 75% of people report constant pain, and 75% also suffer pain at night. They're constantly turning over. They can't sleep. So if somebody has strong, unrelenting axial. Right. Local lower lumbar spine pain or local spine pain, you definitely want to have your antennas up, so to speak, that they might have some Modic1 changes. That's a very, very high correl with 75% of people with Modic1 changes having constant pain. So that is something to keep in mind, especially when you get back an mri, let's say. And there's no potential disc herniation. There's no encroachment on the nerves, and the person just has this constant pain. There's no annular tear on the disc. Well, what's going on? It very well could be modic changes. So let's talk a little bit about the disc, because, you know, the end plate is where the vertebral body and the disc kind of synergize and meet. Right? So one of the biggest things That I think came to mind for me investigating this was the fact that the disc is not a shock absorber. We almost always define it as that for simplicity's sake, but it's not. The disc, by definition displaces hydrostatic forces. So axial compression deforms the nucleus and it stresses and concurrently stiffens the annular fibers that evenly distribute the load. Let me say that one more time. When there's direct axial compression, that compression, that pressure, that load, that stress deforms the nucleus, which stresses and concurrently stiffens the annular fibers. So, right, Things are pushing out to the annular fibers. Those then stiffen and then evenly distribute the load concentrically around the rings. Important to keep in mind. And end plates adhere to the disc and protect them from the destructive vascular tissues of the vertebral body. So the end plates adhere to the disc, there's sort of that interface, right. But they also protect the disc from the vascular tissues of the vertebral body. So we'll talk about that more in a moment. Now, let's break down the end plate itself. When you really look, if you look at the end plate under a microscope, so to speak, you'd see vascular loops that extend from the vertebral body into the end plate. So loops of vascularity, vascular loops, just like you think of a shoelace or something like that. Vascular loops extending from the vertebral body and end plate. The end plate itself is semipermeable and allows nutrient transfer to the disc, which is a great good thing. When this process is altered by age or injury, that's when the disc begins to degenerate. So those loops are there, they're vascular. The end plate itself is semi permeable. It's allowing great stuff in. But as we age, as the degenerative process and as the, the injuries mount up now we start to see the bad side of that, so to speak. So that's where we start to see some of the challenges and disc degenerative changes as we age. Let's talk about the vertebral body. Let's break down that the vertebral body, as you probably well know, is extremely porous and it's filled with a vascular network of vessels and marrow. And it is malleable. It is what actually acts as the shock absorber. Compression creates retroflow of venous blood, which dampens the compressive load. So I wanna say that again. When there's axial compression, the disc itself, right, they're displacing hydrostatic forces. The annular fibers are stiffening up. But the vertebral body itself, when that compression happens, that's happening in the disc. But there's a retroflow of venous blood, which dampens that compressive load in the vertebral body. And because it's so porous, because it's malleable, the. Now, obviously, if there's such a tremendous amount of load that could cause a potential fracture, compression fracture would make sense, right? Especially the vertebral body's compromised, or there's a crazy amount of load, but in normal circumstance, there'll be a retroflow of venous blood that dampens the load. Everybody moves on with their day. And that's sort of how the process works. And modic changes come into play. Because when we look at modic changes, there are ultimately kind of four types of. There's type zero, which really means there is no motic change. That's normal bone, a healthy endplate, no visible marrow changes. Everything looks cool. It's probably not even noted because it's not really a finding. But when we look at type one, there's a lot of inflammation. In a type one modic change, there's bony edema. This is why there is such a high correlative. 75% of those people have constant pain. When we look at type 2, here's where we start to see yellow fat infiltration. So this starts to show up a little bit differently, specifically on MRI in terms of the look, the appearance of it, literally. And then type three, we see bony sclerosis, we see degradation of the bone, and we see permanent and non reversible changes. Now, incidentally, as you go from Modic 1 to Modic 2, the pain level or the amount of people, the correlation of pain and decreases dramatically. So over time, if you're suffering with modic one changes, people have that constant pain. But the light at the end of the tunnel is ultimately, as they continue to age, as that process continues to go on, their pain will naturally subside as they go into modic two changes. So what are those end plate changes and how does this really break down? Let's talk about a few key points. Number one is that when there's end plate changes, there's typically micro fractures in the end plate that allow the passage of material from the vertebral body marrow to the subchondral endplate. So it's actually these micro fractures that allow the vascularity. Now we see the semipermeable endplate becomes more permeable. All of that, you know, the vascularity starts to become a challenge, not a good thing. And we start to see that infiltration into the end plate. That infiltration results in an inflammatory response and then subsequent changes. So that is where the pain, the inflammation, that's where everything picks up. There's micro fractures. Those micro fractures allow those nasty little chemical substances, irritants to get in there. That creates an inflammatory response. And from there, now you're off to the races as far as pain and as far as challenge is concerned. So all of those things are very important to keep in mind. Now, subsequently, when we look at it on an mri, let's round up this episode by talking a little bit about what they look like on an MRI. A modic type 1 change on an MRI, if you're looking at your T2 weighted images, right, that's what we standardly look at, our T2 weighted images, a Modic1 change is going to look hyper intense, Modic1 change, T2 weighted image, hyper intense. If we look at a modic type 2 change, type 2 change, less pain, less inflammation, we are going to see that it's only mildly hyper intense or ISO intense, meaning it's sort of neutral. So a type 1 high level of intensity, a type 2 modic change, lower level or neutral level of intensity. So keep that in mind as you kind of look at things on your images or certainly if you're reading reports. Again, if you're seeing motic changes and people have type one and they have, they have axial back pain, that would be a good reason. But also, hopefully this gave you a better idea on how that process works. Those micro fractures create challenge over time. Consistent axial compression, aging injury, et cetera, causes the vascularity into the subchondral endplate, stimulates inflammatory response, causes pain. And now people are rolling downhill, so to speak, in terms of challenges. So keep all of that in mind. If you have any questions about this whatsoever, feel free to shoot me an email. Jeffevidencebasedchiropractor. And I hope you have a great week in practice and I will talk to you soon.

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