Modic Changes in Patients Who Have Undergone Anterior Cervical Discectomy and Fusion: The Correlation With Fusion Success and Subsidence

Abstract

Objective: There is a lack of research on modic change (MC) in the cervical spine, especially regarding its impact on patients following anterior cervical discectomy and fusion (ACDF). Some researchers strongly believe that MC may affect the prognosis after anterior cervical surgery. Thus, this study aimed to assess MC in patients who underwent ACDF, investigating its incidence, risk factors, and correlation with fusion success and subsidence rate.

Methods: We retrospectively reviewed 154 patients who underwent single-level ACDF from January 2010 to December 2020, with a minimum follow-up of 12 months. Preoperative and postoperative clinical and radiological parameters were recorded at pre-operation, 1 week, 3 months after operation, and the last follow-up. The primary outcomes were the fusion rate and cage subsidence. Radiological measurements, including overall (Cobb C) and segmental cervical angle (Cobb S), anterior disc height (ADH), and posterior disc height (PDH) were also recorded. The independent t-test or Mann-Whiteny U test was used to compare continuous data, and categorical variables were assessed using the Pearson's chi-square test of Fisher's exact test. Logistic regression analysis was also adopted to distinguish corresponding factors related with the progress of MC.

Results: Of the 154 patients, the incidence of MC was 44.2% (68/154). The group with MC showed a larger proportion of males and osteoporosis. The fusion rate of those with MC was 88.2% (60/68) while that in the non-MC group was 97.7% (84/86, p = 0.02). The MC group presented a subsidence rate of 27.9%, which was substantially higher than in the non-MC group (9.3%, p < 0.01). NDI and VAS neck was significantly higher in the MC group than in the non-MC group (p = 0.014; p = 0.039). Sex and osteoporosis were distinguished as independent factors related to MC by regression analysis (p = 0.006; p = 0.026).

Conclusion: Preoperative MC could adversely hinder the fusion process and may increase the incidence of subsidence, affecting clinical outcomes of those underwent ACDF. Patients with MC, especially type 1 MC, are more easily suffered from neck pain than those without MC. Male sex and osteoporosis were risk factors for MC. In order to achieve a better bony fusion and avoid cage subsidence in those with MC, we encourage patients to prolong their immobilization duration with a cervical collar and precisely manage osteoporosis during the peri-operative period.

Keywords

anterior cervical discectomy and fusion (ACDF) / fusion / modic change (MC) / neck pain / subsidence

References

[1] M. T. Modic, P. M. Steinberg, J. S. Ross, et al., “Degenerative Disk Disease: Assessment of Changes in Vertebral Body Marrow With MR Imaging,” Radiology 166, no. 1 Pt 1 (1988): 193-199, https://doi.org/10.1148/radiology.166.1.3336678.

[2] C. Nguyen, S. Poiraudeau, and F. Rannou, “From Modic 1 Vertebral-Endplate Subchondral Bone Signal Changes Detected by MRI to the Concept of ‘Active Discopathy’,” Annals of the Rheumatic Diseases 74, no. 8 (2015): 1488-1494, https://doi.org/10.1136/annrheumdis-2015-207317.

[3] M. Kuisma, J. Karppinen, J. Niinimaki, et al., “Modic Changes in Endplates of Lumbar Vertebral Bodies: Prevalence and Association With Low Back and Sciatic Pain Among Middle-Aged Male Workers,” Spine (Phila Pa 1976) 32 (2007): 1116-1122, https://doi.org/10.1097/01.brs.0000261561.12944.ff.

[4] M. J. Hutton, J. H. Bayer, and J. M. Powell, “Modic Vertebral Body Changes: The Natural History as Assessed by Consecutive Magnetic Resonance Imaging,” Spine (Phila Pa 1976) 36 (2011): 2304-2307, https://doi.org/10.1097/BRS.0b013e31821604b6.

[5] T. S. Jensen, J. Karppinen, J. S. Sorensen, et al., “Vertebral Endplate Signal Changes (Modic Change): A Systematic Literature Review of Prevalence and Association With Non-Specific Low Back Pain,” European Spine Journal 17, no. 11 (2008): 1407-1422, https://doi.org/10.1007/s00586-008-0770-2.

[6] Y. H. Zhang, C. Q. Zhao, L. S. Jiang, et al., “Modic Changes: A Systematic Review of the Literature,” European Spine Journal 17, no. 10 (2008): 1289-1299, https://doi.org/10.1007/s00586-008-0758-y.

[7] J. B. Bai, K. L. Yu, Y. N. Sun, et al., “Prevalence of and Risk Factors for Modic Change in Patients With Symptomatic Cervical Spondylosis: An Observational Study,” Journal of Pain Research 11 (2018): 355-360, https://doi.org/10.2147/JPR.S151795.

[8] T. Hayashi, M. D. Daubs, A. Suzuki, K. Phan, K. Shiba, and J. C. Wang, “Effect of Modic Changes on Spinal Canal Stenosis and Segmental Motion in Cervical Spine,” European Spine Journal 23 (2014): 1737-1742, https://doi.org/10.1007/s00586-014-3406-8.

[9] E. Mann, C. K. Peterson, and J. Hodler, “Degenerative Marrow (Modic) Changes on Cervical Spine Magnetic Resonance Imaging Scans Prevalence, Inter- and Intra-Examiner Reliability and Link to Disc Herniation,” Spine (Phila Pa 1976) 36 (2011): 1081-1085, https://doi.org/10.1097/BRS.0b013e3181ef6a1e.

[10] J. Li, Y. Q. Li, J. C. Wei, et al., “A Study on the Cervical Spondylotic Myelopathy Treated by Anterior Cervical Diskectomy and Fusion in Accordance With Modic Changes With a 2-Year Minimum Follow-Up,” Journal of Orthopaedic Surgery and Research 10 (2015): 6, https://doi.org/10.1186/s13018-014-0146-8.

[11] J. D. Baker, G. K. Harada, Y. Tao, et al., “The Impact of Modic Changes on Preoperative Symptoms and Clinical Outcomes in Anterior Cervical Discectomy and Fusion Patients,” Neurosurgery 17, no. 1 (2020): 190-203, https://doi.org/10.14245/ns.2040062.031.

[12] K. Huang, Y. Hong, H. Liu, et al., “Is the Bone Fusion Affected by Modic-2 Changes in Single-Level Anterior Cervical Discectomy and Fusion?,” Medicine 99, no. 1 (2020): e18597, https://doi.org/10.1097/MD.0000000000018597.

[13] G. W. Smith and R. A. Robinson, “The Treatment of Certain Cervical-Spine Disorders by Anterior Removal of the Intervertebral Disc and Interbody Fusion,” Journal of Bone and Joint Surgery. American Volume 40 (1958): 607-624.

[14] R. B. Cloward, “The Anterior Approach for Removal of Ruptured Cervical Discs,” Journal of Neurosurgery 15 (1958): 602-617.

[15] M. Matsumoto, E. Okada, D. Ichihara, et al., “Anterior Cervical Decompression and Fusion Accelerates Adjacent Segment Degeneration: Comparison With Asymptomatic Volunteers in a Ten-Year Magnetic Resonance Imaging Follow-Up Study,” Spine (Phila Pa 1976) 35 (2010): 36-43, https://doi.org/10.1097/BRS.0b013e3181b8a80d.

[16] J. Li, T. Lei, and Y. Shen, “The Impact of Modic-2 Changes on the Clinical Outcomes of Single-Level Anterior Cervical Discectomy and Fusion,” European Spine Journal 24 (2015): 2936-2940, https://doi.org/10.1007/s00586-015-4161-1.

[17] X. Yang, R. Donk, M. P. Arts, and C. L. A. Vleggeert-Lankamp, “Are Modic Vertebral End-Plate Signal Changes Associated With Degeneration or Clinical Outcomes in the Cervical Spine?,” World Neurosurgery 129 (2019): e881-e889, https://doi.org/10.1016/j.wneu.2019.06.067.

[18] Y. F. Deng, Y. Meng, H. Liu, et al., “Space Between the Titanium Plate of Zero-Profile Cage and Endplate of the Vertebral Body Might Affect the Fusion Process in Anterior Cervical Discectomy and Fusion,” Chinese Medical Journal 133, no. 21 (2020): 2641-2643, https://doi.org/10.1097/CM9.0000000000001129.

[19] C. K. Peterson, B. K. Humphreys, and T. C. Pringle, “Prevalence of Modic Degenerative Marrow Changes in the Cervical Spine,” Journal of Manipulative and Physiological Therapeutics 30 (2007): 5-10, https://doi.org/10.1016/j.jmpt.2006.11.013.

[20] J. Burke, R. Watson, D. McCormack, et al., “Endplate Changes Are Associated With Increased Disc Inflammatory Mediator Production,” Journal of Bone and Joint Surgery (British Volume) 85-B, no. S2 (2003): 164.

[21] M. Torkki, M.-L. Majuri, H. Wolff, et al., “Osteoclast Activators Are Elevated in Intervertebral Disks With Modic Changes Among Patients Operated for Herniated Nucleus Pulposus,” European Spine Journal 25, no. 1 (2016): 207-216, https://doi.org/10.1007/s00586-015-3897-y.

[22] E. Perilli, I. H. Parkinson, L.-H. Truong, et al., “Modic (Endplate) Changes in the Lumbar Spine: Bone Microarchitecture and Remodeling,” European Spine Journal 24 (2014): 1926-1934, https://doi.org/10.1007/s00586-014-3455-z.

[23] A. J. Teichtahl, D. M. Urquhart, Y. Wang, et al., “Modic Changes in the Lumbar Spine and Their Association With Body Composition, Fat Distribution and Intervertebral Disc Height—A 3.0 T-MRI Study,” BMC Musculoskeletal Disorders 17 (2016): 92, https://doi.org/10.1186/s12891-016-0934-x.

[24] H. Li, L. Y. Yu, X. L. Gao, et al., “Novel Modic Grading Scoring System and Its Clinical Validation: A Preliminary Investigation,” European Spine Journal 33, no. 1 (2024): 84-92, https://doi.org/10.1007/s00586-023-08003-w.

[25] N. E. McGregor, M. Murat, J. Elango, et al., “IL-6 Exhibits Both Cis- and Trans-Signaling in Osteocytes and Osteoblasts, but Only Trans-Signaling Promotes Bone Formation and Osteoclastogenesis,” Journal of Biological Chemistry 294, no. 19 (2019): 7850-7863, https://doi.org/10.1074/jbc.RA119.008074.

[26] W. Feng, P. Yang, H. R. Liu, et al., “IL-6 Promotes Low Concentration of RANKL-Induced Osteoclastic Differentiation by Mouse BMMs Through Trans-Signaling Pathway,” Journal of Molecular Histology 53, no. 3 (2022): 599-610, https://doi.org/10.1007/s10735-022-10077-7.

[27] D. S. Amarasekara, H. Yun, S. Kim, et al., “Regulation of Osteoclast Differentiation by Cytokine Networks,” Immune Network 18, no. 1 (2018): e8, https://doi.org/10.4110/in.2018.18.e8.

[28] A. Marahleh, H. Kitaura, F. Ohori, et al., “TNF-α Directly Enhances Osteocyte RANKL Expression and Promotes Osteoclast Formation,” Frontiers in Immunology 10 (2019): 2925, https://doi.org/10.3389/fimmu.2019.02925.

[29] Y. Xiao, C. Zhu, P. Xiu, et al., “Postoperative Sclerotic Modic Changes After Transforaminal Lumbar Interbody Fusion: The Prevalence, Risk Factors, and Impact on Fusion,” Spine (Phila Pa 1976) 49, no. 10 (2024): E135-E141, https://doi.org/10.1097/BRS.0000000000004890.

[30] S. Dudli, A. J. Fields, D. Samartzis, et al., “Pathobiology of Modic Changes,” European Spine Journal 25, no. 11 (2016): 3723-3734, https://doi.org/10.1007/s00586-016-4459-7.

[31] J. Zhou, L. Li, T. Li, and Y. Xue, “Preoperative Modic Changes Are Related to Axial Symptoms After Anterior Cervical Discectomy and Fusion,” Journal of Pain Research 11 (2018): 2617-2623, https://doi.org/10.2147/JPR.S172953.

[32] J. H. Määttä, S. Wadge, A. MacGregor, J. Karppinen, and F. M. K. Williams, “ISSLS Prize Winner: Vertebral Endplate (Modic) Change Is an Independent Risk Factor for Episodes of Severe and Disabling Low Back Pain,” Spine 40 (2015): 1187-1193, https://doi.org/10.1097/brs.0000000000000937.

[33] K. Luoma, T. Vehmas, L. Kerttula, M. Grönblad, and E. Rinne, “Chronic Low Back Pain in Relation to Modic Changes, Bony Endplate Lesions, and Disc Degeneration in a Prospective MRI Study,” European Spine Journal 25 (2016): 2873-2881, https://doi.org/10.1007/s00586-016-4715-x.

[34] W. Brinjikji, F. E. Diehn, J. G. Jarvik, et al., “MRI Findings of Disc Degeneration Are More Prevalent in Adults With Low Back Pain Than in Asymptomatic Controls: A Systematic Review and Meta-Analysis,” AJNR. American Journal of Neuroradiology 36 (2015): 2394-2399, https://doi.org/10.3174/ajnr.A4498.

[35] M. J. Lambrechts, P. Brush, T. Z. Issa, et al., “Evaluating the Impact of Modic Changes on Operative Treatment in the Cervical and Lumbar Spine: A Systematic Review and Meta-Analysis,” International Journal of Environmental Research and Public Health 19 (2022): 10158, https://doi.org/10.3390/ijerph191610158.

[36] M. Karchevsky, M. E. Schweitzer, J. A. Carrino, A. Zoga, D. Montgomery, and L. Parker, “Reactive Endplate Marrow Changes: A Systematic Morphologic and Epidemiologic Evaluation,” Skeletal Radiology 34 (2005): 125-129, https://doi.org/10.1007/s00256-004-0886-3.

[37] T. S. Jensen, P. Kjaer, L. Korsholm, et al., “Predictors of New Vertebral Endplate Signal (Modic) Changes in the General Population,” European Spine Journal 19, no. 1 (2010): 129-135, https://doi.org/10.1007/s00586-009-1184-5.

[38] K. Yiu, H. Ahn, G. K.-H. Shea, et al., “The Effect of Long-Term Alendronic Acid Treatment on Modic Changes in the Lumbar Spine: A Gender and Age-Matched Study,” Journal of Orthopaedic Surgery and Research 19, no. 1 (2024): 291, https://doi.org/10.1186/s13018-024-04780-2.

[39] G. Cai, L. L. Laslett, D. Aitken, et al., “Effect of Zoledronic Acid and Denosumab in Patients With Low Back Pain and Modic Change: A Proof-Of-Principle Trial,” Journal of Bone and Mineral Research 33, no. 5 (2018): 773-782.

[40] G. K. Shea, C. Zhang, W. S. Suen, et al., “Oral Zoledronic Acid Bisphosphonate for the Treatment of Chronic Low Back Pain With Associated Modic Changes: A Pilot Randomized Controlled Trial,” Journal of Orthopaedic Research 40, no. 12 (2022): 2924-2936.

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