1/Do you feel there’s a back-log of findings in a spine MRI report?
Everyone talks about discs & facets, but not everyone talks about the endplates
Do you?
Do you need to talk about degenerative changes (Modic changes) of the endplates?
Here’s thread w/all you need to know!
2/Over 30 years ago, Modic et al. found there were 3 types of degenerative endplate changes:
(1) T2 bright changes (indicating edema, Modic 1)
(2) T1 bright changes (indicating fat, Modic 2)
(3) T1 & T2 dark changes (indicating sclerosis, Modic 3)
But what do they mean?
3/Let’s start w/Modic 1.
These are bright on T2, indicating edema
On pathology, it’s what you’d expect w/edema: inflammation, vascular granulation tissue, & high cellular turnover
Vascular granulation tissue means these can enhance on post contrast images—mimicking discitis!
4/Modic 2 changes seem to be when the pendulum swings the other direction.
These are bright on T1, indicating fat.
They show fatty conversion of the marrow & low cellular turnover.
I think of them as the middle-aged dad bod of degenerative change—lots of fat & slow to change!
5/Modic 3 changes seem to be the endgame.
These are dark on T1 & T2, indicating sclerosis—which is what you see on pathology: dense fibrous tissue & sclerosis.
It’s like the endplates get fossilized—once you turn into rock, you are never going back.
6/I remember these bc the forces at work in the endplates are like the famous astrology signs—almost.
Instead of earth, wind, & fire—it’s earth (sclerosis), fat, & fire (inflammation)
7/Although, it can also be earth, WIND, & fire
Just remember: when we eat a big fatty meal, we tend give off some, well, gas or WIND.
So why is inflammation type 1, fat type 2, and sclerosis type 3?
8/Modic watched patients longitudinally & found inflammation turned to fat but never the other way around.
So he hypothesized these are the stepwise chronological changes of the endplates in response to stress & degeneration
They mirror the same way we respond to stress & conflict
9/Endplates are like two neighbors w/a wall (disc) separating them.
When the wall is too thin, you get conflict! This is what happens when disc degenerates!
Your first response is anger & yelling at them to keep it down!
Just like the endplates, you first get inflamed
10/When anger & inflammation don’t resolve it, you give up, get depressed & start stress eating.
Same w/the endplates! You will transition to from inflammation to low turnover & fat!
11/Finally, you try to resolve the conflict by reinforcing the barrier between you by adding some rock
Same w/the endplates. They start to increase the bony sclerosis between them.
12/But why are degenerative endplate changes important?
Most important reason is that Modic 1 changes are associated w/pain.
It makes sense, as inflammation tends to be painful, as opposed to fatty atrophy.
This pain can sometimes be treated w/basivertebral nerve ablation
13/So what causes these Modic 1 inflammatory changes?
Sadly, after >30 years, we still don’t really know.
Theories include microtrauma, low grade infection, or an autoimmune response.
Basically, you can remember the things that get YOU inflamed
14/First is microtrauma
Just like little annoyances from a coworker eventually get you inflamed, same happens w/endplates
Microtraumas constantly happens. So there’s a frustrated healing response—bc there’s no break for endplates to fully heal, so you get inflammation
15/Next is low grade infection
Low grade bacteria have been cultured from Modic 1 changes.
It’s just like how you are more like to get super annoyed when you are already feeling sick!
However, this theory is not widely accepted & many dismiss it.
16/Finally is autoimmune.
Nucleus pulposis is notochord. It’s shielded from the immune system early in development—meaning the immune system never recognizes it as its own
It’s like having a brother that is separated from you at birth, so you never get to know him
17/When the disc fissures & exposes it, it gets attacked as foreign by the immune system
It’s the same way you would get inflamed if you met your long lost brother. You wouldn’t know him & you would freak out!
18/So now you know the types of degenerative endplate changes, why their important, & the theories as to why they happen.
Now you can use this when you go BACK to work on reading spine MRIs!
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