Clinical and Radiological Outcomes of Cervical Disc Arthroplasty in Patients with Modic Change

Abstract

Objective: Modic change (MC) is defined as abnormalities observed in the intervertebral disc subchondral and adjacent vertebral endplate subchondral bone changes. Most studies on MC were reported in the lumbar spine and associated with lower back pain. However, MC has been rarely reported in the cervical spine, let alone in those who underwent cervical disc replacement (CDR). This study aimed to focus on MC in the cervical spine and reveal clinical and radiological parameters, especially heterotopic ossification (HO), for patients who underwent CDR. Furthermore, we illustrated the association between MC and HO.

Methods: We retrospectively reviewed patients who underwent CDA from January 2008 to December 2019. The Japanese Orthopaedic Association (JOA), Neck Disability Index (NDI), and Visual Analog Scale (VAS) scores were used to evaluate the clinical outcomes. Radiological evaluations were used to conclude the cervical alignment (CL) and range of motion (ROM) of C2-7, functional spinal unit angle (FSUA), shell angle (SA), FSU height, and HO. Univariate and multivariate logistic regressions were performed to identify the risk factors for HO. The Kaplan–Meier (K-M) method was used to analyze potential risk factors, and multivariate Cox regression was used to identify independent risk factors.

Results: A total of 139 patients were evaluated, with a mean follow-up time of 46.53 ± 26.60 months. Forty-nine patients were assigned to the MC group and 90 to the non-MC group. The incidence of MC was 35.3%, with type 2 being the most common. Clinical outcomes (JOA, NDI, VAS) showed no significant difference between the two groups. The differences in C2-7 ROM between the two groups were not significant, while the differences in SA ROM and FSUA ROM were significantly higher in the non-MC than in the MC group (p < 0.05). Besides, FSU height in MC group was significantly lower than that in non-MC group. Parameters concerning CL, including C2-7, FSUA, SA, were not significantly different between the two groups. The incidence of HO and high-grade HO, respectively, in the MC group was 83.7% and 30.6%, while that in the non-MC group was 53.3% and 2.2%, and such differences were significant (p < 0.05). Multivariate logistic regression analyses and Cox regression showed that MC and involved level were significantly associated with HO occurrence (p < 0.05). No implant migration and secondary surgery were observed.

Conclusion: MC mainly affected the incidence of HO. Preoperative MC was significantly associated with HO formation after CDR and should be identified as a potential risk factor for HO. Rigorous criteria for MC should be taken into consideration when selecting appropriate candidates for CDR.

Keywords

Cervical Disc Arthroplasty / Cervical Disc Replacement / Cervical Spine / Heterogenic Ossification / Modic Change

References

[1] Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the global burden of disease study 2010. Lancet. 2012; 380: 2163–2196.

[2] de Roos A, Kressel H, Spritzer C, et al. MR imaging of marrow changes adjacent to end plates in degenerative lumbar disk disease. AJR Am J Roentgenol. 1987; 149: 531–534.

[3] Modic MT, Steinberg PM, Ross JS, Masaryk TJ, Carter JR. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology. 1988; 166(1 Pt 1): 193–199.

[4] Modic MT, Masaryk TJ, Ross JS, Carter JR. Imaging of degenerative disk disease. Radiology. 1988; 168: 177–186.

[5] Tropiano P, Huang RC, Girardi FP, Cammisa FP, Marnay T. Lumbar total disc replacement. Seven to eleven-year follow-up. J Bone Joint Surg Am. 2005; 87: 490–496.

[6] Blondel B, Tropiano P, Gaudart J, Huang RC, Marnay T. Clinical results of lumbar total disc arthroplasty in accordance with modic signs, with a 2-year-minimum follow-up. Spine. 2011; 36: 2309–2315.

[7] Liu T, Tian S, Zhang J, He M, Deng L, Ding W, et al. Comparison of cervical sagittal parameters among patients with neck pain and patients with cervical spondylotic radiculopathy and cervical spondyloticmyelopathy. Orthop Surg. 2024; 16: 329–336.

[8] Nouri A, Murray JC, Fehlings MG. Degenerative cervical myelopathy: a spectrum of degenerative spondylopathies. In: M Kaiser, R Haid, C Chaffer, M Fehlings, editors. Degenerative Cervical Myelopathy and Radiculopathy. Cham, Switzerland: Springer; 2019. p. 37–51.

[9] Peterson CK, Humphreys BK, Pringle TC. Prevalence of modic degenerative marrow changes in the cervical spine. J Manipulative Physiol Ther. 2007; 30: 5–10.

[10] Albert HB, Manniche C. Modic changes following lumbar disc herniation. Eur Spine J. 2007; 16: 977–982.

[11] Nguyen C, Poiraudeau S, Rannou F. From Modic 1 vertebral-endplate subchondral bone signal changes detected by MRI to the concept of active discopathy. Ann Rheum Dis. 2015; 74(8): 1488–1494.

[12] Vital JM, Gille O, Pointillart V, Pedram M, Bacon P, Razanabola F, et al. Course of Modic 1 six months after lumbar posterior osteosynthesis. Spine (Phila Pa 1976). 2003; 28: 715–720. discussion 21.

[13] Auerbach JD, Jones KJ, Fras CI, Chin KR, et al. The prevalence of indications and contraindications to cervical total disc replacement. Spine J. 2008; 8(5): 711–716.

[14] Zhou F, Li S, Zhao Y, Sun Y, et al. Quantitative analysis ofthe correlation betweenpreoperative cervical degeneration and postoperative heterotopic ossification after cervical disc replacement: minimum 10-year follow-up data. J Neurosurg Spine. 2020; 33: 674–679.

[15] Wu HL, Ding WY, Shen Y, CaoL Z, et al. Prevalence of vertebral endplate modic changesin degenerative lumbar scoliosis and its associated factors analysis. Spine. 2012; 37(23): 1958–1964.

[16] Wang H, Wang X, Liu H, Hong Y, et al. Risk factors for high-grade heterotopic ossification after total disc replacement: a single-center experience of 394 cases. Neurosurgery. 2021; 89(5): 852–861.

[17] Deng Y, Li G, Liu H, Hong Y, Meng Y. Mid-to long-term rates of symptomatic adjacent-level disease requiring surgery after cervical total disc replacement compared with anterior cervical discectomy and fusion: a meta-analysis of prospective randomized clinical trials. J Orthop Surg Res. 2020; 15(1): 468.

[18] Kjaer P, Leboeuf-Yde C, Korsholm L, Sorensen JS, Bendix T. Magnetic resonance imaging and low back pain in adults: a diagnostic imaging study of 40-year-old men and women. Spine (Phila Pa 1976). 2005; 30: 1173–1180.

[19] Lang P, Chafetz N, Genant HK, et al. Lumbar spinal fusion. Assessment of functional stability with magnetic resonance imaging. Spine (Phila Pa 1976). 1990; 15: 581–588.

[20] Chataigner H, Onimus M, Polette A. Surgery for degenerative lumbar disc disease.Should the black disc be grafted? Rev Chir Orthop Reparatrice Appar Mot. 1998; 84(7): 583–589.

[21] Li J, Zhang D, Ding W, Shen Y, et al. Comparison of clinical outcomes after anterior cervical discectomy and fusion versus cervical total disk replacement in patients with modic-2 changes on MRI. Clin Spine Surg. 2017; 30(8): E1088–E1092.

[22] Baker JD, Sayari AJ, Harada GK, Samartzis D, et al. The modic endplate complex phenotype in cervical spine patients: association with symptoms and outcomes. J Orthop Res. 2022; 40(2): 449–459.

[23] Huang K, Hong Y, Liu H, Duan Y, Wang B, Chen H, et al. Is the bone fusion affected by Modic-2 changes in single-level anterior cervical discectomy and fusion. Medicine (Baltimore). 2020; 99(1): e18597.

[24] Xu L, Chu B, Feng Y, Zou YF, et al. Modic changes in lumbar spine: prevalence and distribution patterns of end plate oedema and end plate sclerosis. Br J Radiol. 2016; 89(1060): 20150650.

[25] Jarvik JG, Hollingworth W, Heagerty PJ, Haynor DR, Boyko EJ, Deyo RA. Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors. Spine (Phila Pa 1976). 2005; 30: 1541–1548.

[26] Mitra D, Cassar-Pullicino VN, McCall IW. Longitudinal study of vertebral type-1 end-plate changes on MR of the lumbar spine. EurRadiol. 2004; 14: 1574–1581.

[27] Kaapa E, Luoma K, Pitkaniemi J, et al. Correlation of size and type of Modic types 1 and 2 lesions with clinical symptoms: a descriptive study in a subgroup of patients with chronic low back pain on the basis of a university hospital patient sample. Spine (Phila Pa 1976). 2012; 37: 134–139.

[28] Hayashi T, Daubs MD, Suzuki A, Phan K, Shiba K, Wang JC. Effect of Modic changes on spinal canal stenosis and segmental motion in cervical spine. Eur Spine J. 2014; 23: 1737–1742.

[29] Baker JD, Harada GK, Tao Y, Samartzis D, et al. The impact of Modic changes on preoperative symptoms and clinical outcomes in anterior cervical discectomy and fusion patients. Neurospine. 2020; 17(1): 190–203.

[30] Mann E, Peterson CK, Hodler J. Degenerative marrow (modic)changes on cervical spine magnetic resonance imaging scans: prevalence, inter-and intra-examiner reliability and link to disc herniation. Spine. 2011; 36: 1081–1085.

[31] Matsumoto M, Okada E, Ichihara D, Chiba K, Toyama Y, Fujiwara H, et al. Modic changes in the cervical spine: prospective 10-year follow-up study in asymptomatic subjects. J Bone Joint Surg Br. 2012; 94: 678–683.

[32] Crock HV. Internal disc disruption. A challenge to disc prolapse fifty years on. Spine (Phila Pa 1976). 1986; 11: 650–653.

[33] Siepe CJ, Mayer HM, Wiechert K, Korge A. Clinical results of total lumbar discreplacement with ProDisc II: three-year results for different indications. Spine. 2006; PhilaPa 1976(31): 1923–1932.

[34] Albert HB, Sorensen JS, Christensen BS, Manniche C. Antibiotic treatment in patients withchronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized clinical controlled trial of effcacy. Eur Spine J. 2013; 22: 697–707.

[35] Gronblad M, Virri J, Tolonen J, et al. A controlled immunohistochemical study of inflammatory cells in disc herniation tissue. Spine (Phila Pa 1976). 1994;19: 2744–2751.

[36] Weishaupt D, Zanetti M, Hodler J, Boos N. MR imaging of the lumbar spine: prevalence of intervertebral disk extrusion and sequestration, nerve root compression, end plate abnormalities, and osteoarthritis of the facet joints in asymptomatic volunteers. Radiology. 1998; 209: 661–666.

[37] Karppinen J, Daavittila I, Solovieva S, Kuisma M, Taimela S, Natri A, et al. Genetic factors are associated with Modic changes in endplates of lumbar vertebral bodies. Spine (Phila Pa 1976). 2008; 33: 1236–1241.

[38] Karppinen J, Solovieva S, Luoma K, Raininko R, Leino-Arjas P, Riihimäki H. Modic changes and interleukin 1 gene locus polymorphisms in occupational cohort of middle-aged men. Eur Spine J. 2009; 18: 1963–1970.

[39] Kang X, Qian M, Qin T, Liu M, Xu H, Xu B. Increased expression of inflammatory cytokines and discogenic neck pain. Orthop Surg. 2024; 16(1): 227–233.

RIGHTS & PERMISSIONS

2024 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.