Type 1 Modic changes can genuinely cause back pain. But fusion is irreversible, and there is a good deal to try first.
Have you been struggling with ongoing lower back pain and found Modic changes reported on your MRI?
I have explained elsewhere what Modic changes are. Here I want to set out my treatment protocol, and in particular what I try before considering fusion surgery.
What Type 1 Modic changes are
They appear as bright areas within the bone adjacent to a worn disc, and they usually indicate inflammation within that bone.
We believe they are caused by damage to the end plates, the surfaces of the two bones either side of the disc, possibly from microfractures occurring there.
It is quite possible this is the source of your back pain. But we do see these changes occasionally in people who have no back pain at all. That is why a good history, thorough examination, and then further tests are needed before I can say it is responsible.
Confirming it
A SPECT CT scan is a special type of CT using a radioactive tracer.
If the end plates are inflamed and their cells highly active, they take up that substance and it glows in the same zone where we see the signal change on the MRI. Two tests pointing to the same place gives us far more confidence.
Why I don’t go straight to surgery
Fusing that segment can yield good results.
But it means undergoing an operation, which carries risk. It means immobilising that segment. And it is irreversible.
So there are measures worth taking first that may prevent you needing it at all.
Step one: targeted physiotherapy
The discs act as shock absorbers. When a disc is worn, particularly at the very lowest segment of the spine which takes the brunt of day-to-day forces, the pressure between the two end plates is believed to be distributed unevenly. That produces micro-movement, and with it the microfractures.
The logic of physiotherapy here is therefore quite specific. Building a brace of muscle around that segment gives it additional stability and support, which helps prevent that ongoing damage to the end plates.
Step two: basivertebral nerve ablation
If you are not making progress, or if the physiotherapy exercises themselves trigger pain and make the programme impossible to complete, there is another option.
The surfaces of these bones are sensitised by the basivertebral nerve. It is these nerve endings that transmit pain signals to the brain.
Basivertebral nerve ablation involves passing a special needle into the affected bone either side of the disc and ablating that nerve ending. Importantly, this is not a major nerve trunk with any functional role. It exists purely to sensitise the bone, so we are simply removing that sensitivity.
“Aren’t you just hiding the problem?”
You would be right to ask, and in a sense, yes.
But the purpose is to give you a window of pain relief long enough to do the physiotherapy that strengthens and supports the segment. Theoretically, with time, less damage is done to the end plates and the inflammatory change reduces.
There is some evidence that a reduction in Type 1 Modic changes correlates with clinical improvement. But my job is to treat you rather than the test result. The questions that matter are whether your pain has reduced and whether you are functioning better day to day.
A caveat worth stating
If you have already done a great deal of physiotherapy, or you are a fit and active person with a genuinely strong core, it would be somewhat foolish of me to tell you simply to work on your core strength.
Where all of the above has been tried and failed, then we consider fusion.
The key takeaway
Following this process, a good many of the patients I see never reach the point of needing lumbar fusion.
I want to be clear that this is not intended to scare you away from surgery. I carry out a great deal of lumbar fusion myself. But the best results come from patients being assessed thoroughly with all options explored.
And there is a further benefit to working through this sequence. If the conservative measures fail and you do end up needing surgery, studies show that post-operative back pain is generally better in patients who have gone through a period of conditioning and physiotherapy beforehand. We call this prehabilitation.
So the time spent is rarely wasted, whichever way it goes.
