Ekşi et al. (2022)

Aging Paradigm in patients with Low Back Pain

Spinal degenerative processes such as intervertebral disc degeneration and Modic changes increase with age in subjects with low back pain

This data was not compared against individuals without low back pain

No correction was made for confounding factors, yet this information may be used to help educate your patient

Introduction

Just as all bodily tissues age, the spine also does. Degeneration of the spine is commonly seen in older adults and these degenerative findings often worry patients. They may think that this makes their spine weak and vulnerable, or they attribute their ongoing complaints to their “worn out” spine and they subsequently adopt a passive coping mechanism. This study sought to map the natural history of degenerative processes in the spine of patients with low back pain. This information would be particularly interesting to educate people with low back pain.

 

Methods

The authors conducted a retrospective cross-sectional study of patients between the ages of 10 and 100 years. The degenerative findings that were studied were intervertebral disc degeneration of the spine and Modic changes as these are frequently associated with low back pain.

Patients who visited outpatient clinics with complaints of chronic low back pain for over 3 months were included. Important to note is that in these individuals, no pain relief was obtained with paracetamol, nonsteroidal anti-inflammatory drugs, or back exercises.

The MRI scans were evaluated for Modic changes and degenerative intervertebral discs. The latter was evaluated using the Pfirrmann grading system where grades 1 to 3 represent mild to moderate disc degeneration of the spine and grades 4 and 5 were rated as severe disc degeneration.

degeneration of the spine
From: Eksi et al., Clin Neurol Neurosurg (2022)

 

Results

In total, 2434 patients were included between 10 and 98 years. They had a lumbar spine MRI which was evaluated for degenerative intervertebral discs and Modic changes. The ages of the included participants were normally distributed around the mean age of 47.2 +/- 17.2 years. Men and women were almost evenly included, but women were significantly older than men.

When looking at the data of these 2434 subjects, half of them had a level of severe intervertebral disc degeneration of the spine and it appeared that women were more likely to have it. Modic changes were less frequent: at any lumbar level in 26.3% of patients. The most common type was Modic type 2. The frequency of intervertebral disc degeneration and Modic changes increased from the second to tenth decade. The authors were able to establish 2 important time points:

  • The frequency of severe intervertebral disc degeneration most pronouncedly increased from the 7th decade to the 8th decade of life,
  • The frequency of Modic changes pronouncedly increased from the 9th decade to the 10th decade of life
Degeneration of the spine
From: Eksi et al. Clin Neurol Neurosurg (2022)

 

Further, it was found that these degenerative changes had certain gear-up periods. None of women below 19 years had intervertebral disc degeneration. This increased to nearly 25% between the ages of 19-40y, nearly 50% between 40-51y, more than 75% between 51-69y and nearly 95% in those above 69y.

In men below 19y only 1% had intervertebral disc degeneration, nearly 20% between 23-33y, 42% between 33-51 years, 68% between 51-76 years and 98.6% in those over 76 years of age.

Degeneration of the spine
From: Eksi et al., Clin Neurol Neurosurg (2022)

 

Modic changes were present in 7% of women below 38 years of age, in 22% between 38-61 years, and in 46% of those over 61 years of age. In men below 41 years of age 9.5% had Modic changes, 25% between 41-58 years, and 42.6% in those above 58 years of age.

As you can see, aging in people with low back pain goes hand in hand with increasing spinal degenerative processes.

 

Questions and thoughts

It would have been interesting to examine a sample of a population having no low back pain complaints. As we know, findings found on MRI do not always reflect pathological findings. This study adds to the literature that these intervertebral disc degeneration and Modic changes increase throughout the older a patient with low back pain gets. However, it wasn’t measured whether or not this increased their pain. So can we really confidently say that these changes are causing their low back pain based on these results? Or do these findings come because they experience low back pain? This study did not include a healthy control group, which isn’t rare because MRI findings are not widely available in asymptomatic people. However, if these data could have been compared against asymptomatic people, this could have opened up new information. Maybe these age-related degenerative changes are seen as often in asymptomatic people. Maybe they aren’t.

In 2015, Brinjikji et al. from their meta-analysis found evidence that disc degeneration and Modic 1 changes, (among others) are more prevalent in adults 50 years of age or younger with back pain compared with asymptomatic individuals. However, they stated, “While these findings do not prove that disc- and endplate-related imaging and spondylolysis are pain generators, they do suggest that evidence of these findings could be explored as candidates for biomarkers of low back pain.”

 

Talk nerdy to me

Inter- and intra-rater reliability was examined between and in 5 different examiners from a random sample of 10 subjects. Intra-rater reliabilities for intervertebral disc degeneration and Modic changes were 0.658 and 0.563, respectively. Inter-rater reliabilities for intervertebral disc degeneration and Modic changes were 0.767 and 0.638, respectively. It seems thus that the level of agreement in these observations was moderate, but weak for repeated intra-rater Modic changes. The raters were blinded to the clinical data of the patients, which was good as this way they were unbiased when evaluating the MRI scans.

One limitation of this study lies in the fact that based on this retrospective cross-sectional analysis, it was not possible to correct for confounders such as bone mineral density, vitamin D deficiency, smoking, occupational status, body mass index, comorbidities, or hormonal influences.

 

Take home messages

The frequency of severe intervertebral disc degeneration most pronouncedly increased from the 7th decade to the 8th decade of life. The frequency of Modic changes pronouncedly increased from the 9th decade to the 10th decade of life. No correction for confounders such as bone mineral density, vitamin D deficiency, smoking, occupational status, body mass index, comorbidities or hormonal influences was made.

 

Reference

Ekşi MŞ, Orhun Ö, Yaşar AH, Dursun AT, Berikol G, Börekci A, Özcan-Ekşi EE. At what speed does spinal degeneration gear up?: Aging Paradigm in Patients with Low Back Pain. Clin Neurol Neurosurg. 2022 Apr;215:107187. doi: 10.1016/j.clineuro.2022.107187. Epub 2022 Feb 25. PMID: 35245774.

 

Additional reference

Brinjikji W, Diehn FE, Jarvik JG, Carr CM, Kallmes DF, Murad MH, Luetmer PH. 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 Am J Neuroradiol. 2015 Dec;36(12):2394-9. doi: 10.3174/ajnr.A4498. Epub 2015 Sep 10. PMID: 26359154; PMCID: PMC7964277.

ATTENTION THERAPISTS WHO ARE REGULARLY TREATING PATIENTS WITH PERSISTENT PAIN

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