Conditions and treatments
Vertebrogenic back pain
Your scan looks normal. Your pain is real.
There is a cause of chronic lower back pain that is easily overlooked.
If you have had persistent lower back pain for months or years, you may well have been told that your MRI shows some wear and tear, that the changes are normal for your age, and that nothing on the scan clearly explains your symptoms.
All of that can be entirely true and still leave a diagnosis unmade.
Most people over forty do have several abnormalities on a spinal MRI, and the majority of those findings cause no symptoms at all. That is a genuine and important fact. But it means the useful question is not whether your scan has changes on it — it is which of those changes, if any, is the one producing your pain. Answering that takes time and a deliberate look.
There is one answer in particular that I find is often not considered.
Not all back pain comes from the disc, the facet joints or the muscles. In a proportion of patients it comes from the bone itself — from the vertebral end plates, the thin layers of bone immediately above and below each disc.
This is called vertebrogenic pain. It is visible on a standard MRI, it can be confirmed, and it is treatable.
What is happening
When a disc becomes worn, it stops distributing load evenly across the end plates above and below it. Pressure that was once spread across the whole surface concentrates in patches.
Bone responds to abnormal load the way any tissue does. Sustained uneven pressure is thought to produce microscopic injury within the end plate, and the body responds with inflammation.
That inflammation is visible on MRI as a Modic type 1 change, sitting in the bone immediately adjacent to the worn disc.
The end plates have their own nerve supply — the basivertebral nerve, which runs into the centre of the vertebral body. When the end plate is inflamed, this nerve carries the pain.
The resulting pain has a recognisable character. It tends to be deep and central rather than to one side, mechanical and clearly related to load, worse on sitting and on bending forward, and often eased by lying flat.
It also tends to respond poorly to treatments aimed at the disc or the facet joints — because those are not where the problem is.
How I confirm it
A Modic change on a scan is not by itself a diagnosis. These changes occur in people with no back pain at all.
Three things need to agree: your symptoms, your imaging, and — where there is any doubt — a SPECT-CT scan, which shows metabolic activity within the bone and demonstrates whether the level in question is genuinely active rather than an incidental finding.
Only when all three point to the same level do I treat.
If they do not, I will tell you. Not every patient with back pain has this condition, and not every patient with Modic changes has vertebrogenic pain.
How it is treated?
Treatment is tailored to the individual, but it draws on three elements.
1
Restoring the support around the segment.
2
Creating a window where it is needed.
Some patients cannot tolerate meaningful rehabilitation because of pain. Where that is the case, basivertebral nerve ablation — a minimally invasive day-case procedure that interrupts the nerve carrying pain from the inflamed end plate — creates a period of substantially reduced pain in which effective rehabilitation becomes possible. It does not repair the disc or reverse the end plate changes. It opens the window. Not every patient needs it.
3
Assessing the bone where appropriate.
Where rehabilitation is likely to run over months and needs directing, I offer personalised clinical direction — a service in which I liaise directly with your physiotherapist, review your imaging with them, and stay actively involved as the programme progresses.
Does this sound like you?
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