Vertebral endplate signal changes (Modic change): a systematic literature review of prevalence and association with non-specific low back pain

The prevalence of “vertebral endplate signal changes” (VESC) and its association with low back pain (LBP) varies greatly between studies. This wide range in reported prevalence rates and associations with LBP could be explained by differences in the definitions of VESC, LBP, or study sample. The objectives of this systematic critical review were to investigate the current literature in relation to the prevalence of VESC (including Modic changes) and the association with non-specific low back pain (LBP). The MEDLINE, EMBASE, and SveMED databases were searched for the period 1984 to November 2007. Included were the articles that reported the prevalence of VESC in non-LBP, general, working, and clinical populations. Included were also articles that investigated the association between VESC and LBP. Articles on specific LBP conditions were excluded. A checklist including items related to the research questions and overall quality of the articles was used for data collection and quality assessment. The reported prevalence rates were studied in relation to mean age, gender, study sample, year of publication, country of study, and quality score. To estimate the association between VESC and LBP, 2 × 2 tables were created to calculate the exact odds ratio (OR) with 95% confidence intervals. Eighty-two study samples from 77 original articles were identified and included in the analysis. The median of the reported prevalence rates for any type of VESC was 43% in patients with non-specific LBP and/or sciatica and 6% in non-clinical populations. The prevalence was positively associated with age and was negatively associated with the overall quality of the studies. A positive association between VESC and non-specific LBP was found in seven of ten studies from the general, working, and clinical populations with ORs from 2.0 to 19.9. This systematic review shows that VESC is a common MRI-finding in patients with non-specific LBP and is associated with pain. However, it should be noted that VESC may be present in individuals without LBP.

[1]  J. Ott,et al.  An allele of COL9A2 associated with intervertebral disc disease. , 1999, Science.

[2]  R. Deyo,et al.  Lumbar spinal fusion. A cohort study of complications, reoperations, and resource use in the Medicare population. , 1993, Spine.

[3]  J. Carrino,et al.  Prospective evaluation of contrast-enhanced MR imaging after uncomplicated lumbar discography , 2007, Skeletal Radiology.

[4]  R. Fraser,et al.  ISSLS Prize Winner: The Innervation of the Intervertebral Disc: A Quantitative Analysis , 2003, Spine.

[5]  B. Vernon‐roberts,et al.  Remodeling of Vertebral Bone After Outer Anular Injury in Sheep , 1996, Spine.

[6]  M. Reiser,et al.  Degenerative disk vascularization on MRI: correlation with clinical and histopathologic findings , 1996, Skeletal Radiology.

[7]  J. Carrino,et al.  MR imaging findings in spinal infections: rules or myths? , 2003, Radiology.

[8]  J. Lurie,et al.  Retrolisthesis and lumbar disc herniation: a preoperative assessment of patient function. , 2007, The spine journal : official journal of the North American Spine Society.

[9]  A. Cotten,et al.  Evaluation of destructive spondyloarthropathies in hemodialysis by computerized tomographic scan and magnetic resonance imaging. , 1996, The Journal of rheumatology.

[10]  H. Moriya,et al.  Vertebral bone-marrow changes in degenerative lumbar disc disease. An MRI study of 74 patients with low back pain. , 1994, The Journal of bone and joint surgery. British volume.

[11]  C. Vestergaard,et al.  A retrospective study of six cases of severe recalcitrant atopic dermatitis treated with long-term extracorporeal photopheresis. , 2010, Acta dermato-venereologica.

[12]  D. M. van der Heijde,et al.  Inflammation in ankylosing spondylitis: a systematic description of the extent and frequency of acute spinal changes using magnetic resonance imaging , 2004, Annals of the rheumatic diseases.

[13]  M. Onimus,et al.  [Surgery for degenerative lumbar disc disease. Should the black disc be grafted?]. , 1998, Revue de chirurgie orthopedique et reparatrice de l'appareil moteur.

[14]  M. Modic,et al.  MR imaging of vertebral osteomyelitis revisited. , 1996, AJR. American journal of roentgenology.

[15]  S. Goldsmith,et al.  SPECT and Lumbar MRI in Back Pain with Emphasis on Changes in End Plates in Association with Disc Degeneration , 1998, Journal of neuroimaging : official journal of the American Society of Neuroimaging.

[16]  P. Chiewvit,et al.  Diagnostic accuracy of MR imaging in tuberculous spondylitis. , 2007, Journal of the Medical Association of Thailand = Chotmaihet thangphaet.

[17]  Y. van der Graaf,et al.  Pain response in the first trimester after percutaneous vertebroplasty in patients with osteoporotic vertebral compression fractures with or without bone marrow edema. , 2006, AJNR. American journal of neuroradiology.

[18]  O. Tervonen,et al.  Radiologic phenotypes in lumbar MR imaging for a gene defect in the COL9A3 gene of type IX collagen. , 2003, Radiology.

[19]  R. Fraser,et al.  Magnetic Resonance Imaging Assessment of Disc Degeneration 10 Years After Anterior Lumbar Interbody Fusion , 1995, Spine.

[20]  Massoud Pedram,et al.  Course of Modic 1 Six Months After Lumbar Posterior Osteosynthesis , 2003, Spine.

[21]  A. Roos,et al.  MR imaging of marrow changes adjacent to end plates in degenerative lumbar disk disease. , 1987, AJR. American journal of roentgenology.

[22]  M. Modic,et al.  The postoperative lumbar spine: enhanced MR evaluation of the intervertebral disk. , 1996, AJNR. American journal of neuroradiology.

[23]  H. Ursin,et al.  Chapter 4 European guidelines for the management of chronic nonspecific low back pain , 2006, European Spine Journal.

[24]  K. Fujikawa,et al.  Lumbar disc herniation associated with separation of the posterior ring apophysis: analysis of five surgical cases and review of the literature , 2003, Acta Neurochirurgica.

[25]  T. Malinin,et al.  Changes in Vertebral Bodies Adjacent to Acutely Narrowed Intervertebral Discs: Observations in Baboons , 2007, Spine.

[26]  I. McCall,et al.  Marginal erosive discovertebral ”Romanus” lesions in ankylosing spondylitis demonstrated by contrast enhanced Gd-DTPA magnetic resonance imaging , 2000, Skeletal Radiology.

[27]  O. Tervonen,et al.  Post-traumatic findings of the spine after earlier vertebral fracture in young patients: clinical and MRI study. , 2000, Spine.

[28]  M. Hellström,et al.  Back pain and degenerative abnormalities in the spine of young elite divers: a 5-year follow-up magnetic resonance imaging study. , 2006, Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA.

[29]  Potchen Ej.  Magnetic resonance imaging of the lumbar spine. , 1994, The New England journal of medicine.

[30]  Feasibility of a RARE-based sequence for quantitative diffusion-weighted MRI of the spine , 2007, European Radiology.

[31]  B. Ghelman,et al.  Association between findings of provocative discography and vertebral endplate signal changes as seen on MRI. , 2000, Journal of spinal disorders.

[32]  J. Laredo,et al.  SAPHO syndrome: MR appearance of vertebral involvement. , 2007, Radiology.

[33]  H. Baba,et al.  Salvage operation for persistent low back pain and sciatica induced by percutaneous laser disc decompression performed at outside institution: correlation of magnetic resonance imaging and intraoperative and pathological findings. , 2006, Photomedicine and laser surgery.

[34]  E. Tsiridis,et al.  High-Intensity Zone, Intradiscal Electrothermal Therapy, and Magnetic Resonance Imaging , 2003, Journal of spinal disorders & techniques.

[35]  J. Laredo,et al.  [Differential diagnosis of infective spondylodiscitis and erosive degenerative disk disease]. , 2000, Journal de radiologie.

[36]  O. Cvitanic,et al.  Subchondral marrow changes after laser diskectomy in the lumbar spine: MR imaging findings and clinical correlation. , 2000, AJR. American journal of roentgenology.

[37]  B. K. Humphreys,et al.  Inter- and intraexaminer reliability in identifying and classifying degenerative marrow (Modic) changes on lumbar spine magnetic resonance scans. , 2007, Journal of manipulative and physiological therapeutics.

[38]  E. Carragee,et al.  Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. , 2005, The spine journal : official journal of the North American Spine Society.

[39]  P Kjaer,et al.  Modic changes, possible causes and relation to low back pain. , 2008, Medical hypotheses.

[40]  L E Gibbons,et al.  Observer Variability in the Assessment of Disc Degeneration on Magnetic Resonance Images of the Lumbar and Thoracic Spine , 1995, Spine.

[41]  R. Montgomery,et al.  Evaluation of Cryopreserved Bone and Synthetic Biomaterials in Promoting Spinal Fusion , 1991, Spine.

[42]  P. Emery,et al.  Efficacy of etanercept in the treatment of the entheseal pathology in resistant spondylarthropathy: a clinical and magnetic resonance imaging study. , 2001, Arthritis and rheumatism.

[43]  M. Madkour,et al.  Brucellar and tuberculous spondylitis: comparative imaging features. , 1989, Radiology.

[44]  H. An,et al.  Anatomic Considerations for Plate‐Screw Fixation of the Cervical Spine , 1991, Spine.

[45]  E. Hurwitz,et al.  Are first-time episodes of serious LBP associated with new MRI findings? , 2006, The spine journal : official journal of the North American Spine Society.

[46]  M. Schweitzer,et al.  Edematous Schmorl’s nodes on thoracolumbar MR imaging: characteristic patterns and changes over time , 2006, Skeletal Radiology.

[47]  M. Zanetti,et al.  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. , 1998, Radiology.

[48]  M. Jayson,et al.  Nerve ingrowth into diseased intervertebral disc in chronic back pain , 1997, The Lancet.

[49]  D. Wendling,et al.  Les spondylodiscites aseptiques de la spondylarthrite ankylosante : étude rétrospective de 14 cas , 2005 .

[50]  M. Schweitzer,et al.  Can imaging findings help differentiate spinal neuropathic arthropathy from disk space infection? Initial experience. , 2000, Radiology.

[51]  H. Pihlajamäki,et al.  Long-term Vertebral Changes Attributable to Postoperative Lumbar Discitis: A Retrospective Study of Six Cases , 2005, Clinical orthopaedics and related research.

[52]  M. Bollow,et al.  Magnetic resonance imaging of the axial skeleton in rheumatoid disease. , 2004, Best practice & research. Clinical rheumatology.

[53]  Raija Korpelainen,et al.  Modic Changes in Endplates of Lumbar Vertebral Bodies: Prevalence and Association With Low Back and Sciatic Pain Among Middle-Aged Male Workers , 2007, Spine.

[54]  A. Nachemson,et al.  THE PREVALENCE OF DISC AGING AND BACK PAIN AFTER FUSION EXTENDING INTO THE LOWER LUMBAR SPINE , 2001 .

[55]  Achim Elfering,et al.  Young Investigator Award 2001 Winner: Risk Factors for Lumbar Disc Degeneration: A 5-Year Prospective MRI Study in Asymptomatic Individuals , 2002, Spine.

[56]  I. McCall,et al.  Longitudinal study of vertebral type-1 end-plate changes on MR of the lumbar spine , 2004, European Radiology.

[57]  R. Willburger,et al.  Verteilungsmuster von (Modic-)Signalveränderungen an den vertebralen Endplatten voroperierter Patienten und ihr Bezug zu Rezidivvorfällen , 2006 .

[58]  M. Jergas,et al.  Lumbar disk herniation: correlation of histologic findings with marrow signal intensity changes in vertebral endplates at MR imaging. , 2004, Radiology.

[59]  C. Leboeuf‐Yde,et al.  Modic changes and their associations with clinical findings , 2006, European Spine Journal.

[60]  G. Schmid,et al.  [(Modic) signal alterations of vertebral endplates and their correlation to a minimally invasive treatment of lumbar disc herniation using epidural injections]. , 2006, RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin.

[61]  M. Revel,et al.  Relation of inflammatory modic changes to intradiscal steroid injection outcome in chronic low back pain , 2007, European Spine Journal.

[62]  Sun-Won Park,et al.  Single shot fast spin echo diffusion-weighted MR imaging of the spine; Is it useful in differentiating malignant metastatic tumor infiltration from benign fracture edema? , 2004, Clinical imaging.

[63]  T. Murakami,et al.  Percutaneous vertebroplasty: relationship between vertebral body bone marrow edema pattern on MR images and initial clinical response. , 2006, Radiology.

[64]  I. Shuaib,et al.  Correlation of Clinical Presentation, Radiography, and Magnetic Resonance Imaging for Low Back Pain — a Preliminary Survey , 2003 .

[65]  G. V. von Schulthess,et al.  FDG positron emission tomography for differentiation of degenerative and infectious endplate abnormalities in the lumbar spine detected on MR imaging. , 2002, AJR. American journal of roentgenology.

[66]  J. Assheuer,et al.  New aspects of lumbar disc disease. MR imaging and histological findings. , 1990, Archives of orthopaedic and trauma surgery.

[67]  Per Kjaer,et al.  Magnetic Resonance Imaging and Low Back Pain in Adults: A Diagnostic Imaging Study of 40-Year-Old Men and Women , 2005, Spine.

[68]  O. Tervonen,et al.  Magnetic Resonance Imaging Findings in Relation to the COL9A2 Tryptophan Allele Among Patients With Sciatica , 2002, Spine.

[69]  R. Willburger,et al.  [Distribution of MRI signal alterations of the cartilage endplate in pre-operated patients with special focus on recurrent lumbar disc herniation]. , 2006, RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin.

[70]  K. Fujikawa,et al.  Vertebral arch reconstruction based on 90 degree rotational laminoplasty after removal of spinal cord and cauda equina tumours , 2003, Acta Neurochirurgica.

[71]  I. Karacan,et al.  Lumbar Disc Herniation in Ankylosing Spondylitis: A Dual Role of Discovertebral Enthesopathy , 2006 .

[72]  John A. Carrino,et al.  Reactive endplate marrow changes: a systematic morphologic and epidemiologic evaluation , 2005, Skeletal Radiology.

[73]  Samuli Ripatti,et al.  Determinants of the Progression in Lumbar Degeneration: A 5-Year Follow-up Study of Adult Male Monozygotic Twins , 2006, Spine.

[74]  L. Martí-Bonmatí,et al.  Magnetic resonance myelography evaluation of the lumbar spine end plates and intervertebral disks , 2005, Acta radiologica.

[75]  M. Modic,et al.  Imaging of degenerative disk disease. , 1988, Radiology.

[76]  P. Renton,et al.  Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography , 1998, European Spine Journal.

[77]  H. Stein,et al.  Correlation of histopathological findings and magnetic resonance imaging in the spine of patients with ankylosing spondylitis , 2006, Arthritis research & therapy.

[78]  John C. Davis,et al.  Magnetic resonance imaging examinations of the spine in patients with ankylosing spondylitis before and after therapy with the tumor necrosis factor α receptor fusion protein etanercept , 2005 .

[79]  J. Stack,et al.  The role of discography in lumbar disc disease: a comparative study of magnetic resonance imaging and discography. , 1990, Clinical radiology.

[80]  Y. Ahn,et al.  Recurrence after Successful Percutaneous Endoscopic Lumbar Discectomy , 2007, Minimally invasive neurosurgery : MIN.

[81]  W. Frobin,et al.  Height of lumbar discs measured from radiographs compared with degeneration and height classified from MR images , 2001, European Radiology.

[82]  J. Laredo,et al.  End plate marrow changes in the asymptomatic lumbosacral spine: frequency, distribution and correlation with age and degenerative changes , 2004, Skeletal Radiology.

[83]  Carsten Perka,et al.  The Surgical Treatment of the Lumbar Disc Prolapse: Nucleotomy With Additional Transpedicular Dynamic Stabilization Versus Nucleotomy Alone , 2005, Spine.

[84]  M. Zanetti,et al.  MR abnormalities of the intervertebral disks and adjacent bone marrow as predictors of segmental instability of the lumbar spine , 1998, Acta radiologica.

[85]  J. Polak,et al.  Sensory and sympathetic innervation of the vertebral endplate in patients with degenerative disc disease. , 1997, The Journal of bone and joint surgery. British volume.

[86]  F. Fazekas,et al.  Pyogenic infectious spondylitis: clinical, laboratory and MRI features. , 1997, European neurology.

[87]  P. Heagerty,et al.  Three-Year Incidence of Low Back Pain in an Initially Asymptomatic Cohort: Clinical and Imaging Risk Factors , 2005, Spine.

[88]  A. Siddiqui,et al.  Role of magnetic resonance imaging in lumbar spondylosis. , 2005, Journal of the College of Physicians and Surgeons--Pakistan : JCPSP.

[89]  B. Worthington,et al.  The changes in the intervertebral disc after chemonucleolysis demonstrated by magnetic resonance imaging. , 1986, The Journal of bone and joint surgery. British volume.

[90]  D. Haynor,et al.  Similarities in degenerative findings on magnetic resonance images of the lumbar spines of identical twins. , 1995, The Journal of bone and joint surgery. American volume.

[91]  S. Rajasekaran,et al.  ISSLS Prize Winner: A Study of Diffusion in Human Lumbar Discs: A Serial Magnetic Resonance Imaging Study Documenting the Influence of the Endplate on Diffusion in Normal and Degenerate Discs , 2004, Spine.

[92]  J. Ott,et al.  Identification of a novel common genetic risk factor for lumbar disk disease. , 2001, JAMA.

[93]  W. Jee,et al.  Discogenic lumbar pain: association with MR imaging and CT discography. , 2005, European journal of radiology.

[94]  M. Reiser,et al.  Differentialdiagnose der erosiven Osteochondrose und bakteriellen Spondylitis in der Magnetresonanztomographie (MRT) , 1998 .

[95]  S. Froelich,et al.  Predictive value of MRI vertebral end-plate signal changes (Modic) on outcome of surgically treated degenerative disc disease. Results of a cohort study including 60 patients. , 2006, Neuro-Chirurgie.

[96]  J. Hodler,et al.  Magnetic Resonance Imaging of the Lumbar Spine: Findings in Female Subjects From Administrative and Nursing Professions , 2006, Spine.

[97]  W. Maksymowych,et al.  Validation of the spondyloarthritis research consortium of Canada magnetic resonance imaging spinal inflammation index: is it necessary to score the entire spine? , 2007, Arthritis and rheumatism.

[98]  F. Murtagh,et al.  Relationship of Schmorl's nodes to vertebral body endplate fractures and acute endplate disk extrusions. , 2000, AJNR. American journal of neuroradiology.

[99]  I. Boutron,et al.  High-sensitivity C-reactive protein in chronic low back pain with vertebral end-plate Modic signal changes. , 2007, Arthritis and rheumatism.

[100]  S. Ohtori,et al.  Tumor Necrosis Factor-Immunoreactive Cells and PGP 9.5-Immunoreactive Nerve Fibers in Vertebral Endplates of Patients With Discogenic Low Back Pain and Modic Type 1 or Type 2 Changes on MRI , 2006, Spine.

[101]  D. Wendling,et al.  Aseptic discitis in patients with ankylosing spondylitis: a retrospective study of 14 cases. , 2005, Joint, bone, spine : revue du rhumatisme.

[102]  H. An,et al.  Differentiation Between Spinal Tumors and Infections with Magnetic Resonance Imaging , 1991, Spine.

[103]  J. Niinimäki,et al.  The Treatment of Disc Herniation-Induced Sciatica With Infliximab: One-Year Follow-up Results of FIRST II, a Randomized Controlled Trial , 2006, Spine.

[104]  J. Bramble,et al.  Interobserver reliability in the interpretation of diagnostic lumbar MRI and nuclear imaging. , 2006, The spine journal : official journal of the North American Spine Society.

[105]  J. Le Huec,et al.  Video-assisted ALIF With Cage and Anterior Plate Fixation for L5-S1 Spondylolisthesis , 2006, Journal of spinal disorders & techniques.

[106]  O. Tervonen,et al.  Endplate Degeneration Observed on Magnetic Resonance Imaging of the Lumbar Spine: Correlation with Pain Provocation and Disc Changes Observed on Computed Tomography Diskography , 2002, Spine.

[107]  P. Parizel,et al.  The value of MRI in the diagnosis of postoperative spondylodiscitis , 2000, Neuroradiology.

[108]  P. Sham,et al.  Phenotypic and population differences in the association between CILP and lumbar disc disease , 2007, Journal of Medical Genetics.

[109]  J. Hodler,et al.  Do MRI findings correlate with mobility tests? An explorative analysis of the test validity with regard to structure , 2007, European Spine Journal.

[110]  P. Parizel,et al.  Review Article: MRI of the postoperative lumbar spine , 2002, Neuroradiology.

[111]  V. Jevtič.  Magnetic resonance imaging appearances of different discovertebral lesions , 2001, European Radiology.

[112]  M. Reiser,et al.  MR imaging of enhancing intraosseous disk herniation (Schmorl's nodes). , 1997, AJR. American journal of roentgenology.

[113]  C. Leboeuf‐Yde,et al.  An Epidemiologic Study of MRI and Low Back Pain in 13-Year-Old Children , 2005, Spine.

[114]  T. Tsunoda,et al.  Association study of COL9A2 with lumbar disc disease in the Japanese population , 2006, Journal of Human Genetics.

[115]  G. Buttermann.  The effect of spinal steroid injections for degenerative disc disease. , 2004, The spine journal : official journal of the North American Spine Society.

[116]  W. Yuh,et al.  MR imaging of spinal cord and vertebral body infarction. , 1992, AJNR. American journal of neuroradiology.

[117]  C. Pfirrmann,et al.  Painful Lumbar Disk Derangement: Relevance of Endplate Abnormalities at MR Imaging. , 2001, Radiology.

[118]  D. Sartoris,et al.  Focal fat deposition in axial bone marrow: MR characteristics. , 1987, Radiology.

[119]  J. Brotchi,et al.  Gadolinium enhancement of vertebral endplates following lumbar disc surgery , 1993, Neuroradiology.

[120]  P. Renton,et al.  Effects on the vertebral end-plate of uncomplicated lumbar discography: an MRI study , 1998, European Spine Journal.

[121]  M. Reiser,et al.  [Differential diagnosis of erosive osteochondrosis and bacterial spondylitis: magnetic resonance tomography (MRT)]. , 1998, RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin.

[122]  O. Tervonen,et al.  Chronic Chlamydia pneumoniae Infection Increases the Risk of Occlusion of Lumbar Segmental Arteries of Patients with Sciatica: A 3-Year Follow-up Study , 2003, Spine.

[123]  M. Ito,et al.  Predictive Signs of Discogenic Lumbar Pain on Magnetic Resonance Imaging With Discography Correlation , 1998, Spine.

[124]  M. DeLano,et al.  Lumbar spine MRI in the elite-level female gymnast with low back pain , 2006, Skeletal Radiology.

[125]  D. M. van der Heijde,et al.  Magnetic resonance imaging examinations of the spine in patients with ankylosing spondylitis, before and after successful therapy with infliximab: evaluation of a new scoring system. , 2003, Arthritis and rheumatism.

[126]  C. Hamanishi,et al.  Schmorl's nodes on magnetic resonance imaging. Their incidence and clinical relevance. , 1994, Spine.

[127]  G. Buttermann,et al.  Pain and disability correlated with disc degeneration via magnetic resonance imaging in scoliosis patients , 2008, European Spine Journal.

[128]  J. Braun,et al.  Outcome of patients with active ankylosing spondylitis after two years of therapy with etanercept: clinical and magnetic resonance imaging data. , 2005, Arthritis and rheumatism.

[129]  P. Lukas,et al.  [Clinical value of MR tomography of spondylodiscitis in ankylosing spondylitis]. , 1990, Zeitschrift fur Rheumatologie.

[130]  C. Manniche,et al.  Modic changes following lumbar disc herniation , 2007, European Spine Journal.

[131]  R. Steiner,et al.  Demonstration of vertebral body end plate veins by magnetic resonance imaging. , 1989, The British journal of radiology.

[132]  M. Béhé,et al.  18F-FDG hybrid PET in patients with suspected spondylitis , 2002, European Journal of Nuclear Medicine and Molecular Imaging.

[133]  V. Jevtič,et al.  Demonstration of evolution of hemispherical spondysclerosis by contrast enhanced Gd-DTPA magnetic resonance imaging , 2004 .

[134]  T. Tullberg,et al.  Septic and aseptic post-operative discitis in the lumbar spine — evaluation by MR imaging , 1998, Acta radiologica.

[135]  Anastasios A. Tsiatis,et al.  Median Unbiased Estimation for Binary Data , 1989 .

[136]  A. Mannion,et al.  Are “Structural Abnormalities” on Magnetic Resonance Imaging a Contraindication to the Successful Conservative Treatment of Chronic Nonspecific Low Back Pain? , 2006, Spine.

[137]  C. Manelfe,et al.  Magnetic resonance imaging and axial involvement in spondylarthropathies. Delineation of the spinal entheses. , 1997, Revue du rhumatisme.

[138]  K. Heithoff,et al.  Vertebral body MRI related to lumbar fusion results , 2005, European Spine Journal.

[139]  M. Grevitt,et al.  The Modic Classification: Inter- and Intraobserver Error in Clinical Practice , 2005, Spine.

[140]  T J Masaryk,et al.  Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. , 1988, Radiology.

[141]  A. Gillams,et al.  MR appearances of the temporal evolution and resolution of infectious spondylitis. , 1996, AJR. American journal of roentgenology.

[142]  Jeffrey C Lotz,et al.  ISSLS Prize Winner: Repeated Disc Injury Causes Persistent Inflammation , 2007, Spine.

[143]  R. Jubb,et al.  Signal changes in the intervertebral discs on MRI of the thoracolumbar spine in ankylosing spondylitis. , 1995, Clinical radiology.

[144]  A. Natri,et al.  Genetic Factors Are Associated With Modic Changes in Endplates of Lumbar Vertebral Bodies , 2008, Spine.

[145]  P. Huddleston,et al.  Follow-up MR imaging in patients with pyogenic spine infections: lack of correlation with clinical features. , 2007, AJNR. American journal of neuroradiology.

[146]  J. Assheuer,et al.  Long-term changes in the magnetic resonance image after chemonucleolysis , 2005, European Spine Journal.

[147]  A. Nachemson,et al.  The prevalence of disc aging and back pain after fusion extending into the lower lumbar Spine: A matched MR study twenty-five years after surgery for adolescent idiopathic scoliosis , 2001, Acta radiologica.

[148]  J. Niinimäki,et al.  A Three-Year Follow-up of Lumbar Spine Endplate (Modic) Changes , 2006, Spine.

[149]  N. Bogduk,et al.  Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain , 2007, European Spine Journal.

[150]  J. Hentz,et al.  Vertebral Endplate Fractures: An Indicator of the Abnormal Forces Generated in the Spine After Vertebroplasty , 2006, Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research.

[151]  M. Battié,et al.  Lumbar Disc Degeneration: Epidemiology and Genetic Influences , 2004, Spine.

[152]  O. Tervonen,et al.  Lumbar disc degeneration. Correlation between CT and CT/discography. , 1990, Acta radiologica.

[153]  J. Braun,et al.  Magnetic resonance imaging examinations of the spine in patients with ankylosing spondylitis before and after therapy with the tumor necrosis factor alpha receptor fusion protein etanercept , 2005, Arthritis and rheumatism.

[154]  T. Theodoridis,et al.  (Modic -)Signalveranderungen vertebraler Endplatten und ihr Bezug zu einer minimalinvasiven Injektionstherapie lumbaler Bandscheibenvorfalle , 2006 .

[155]  K. Lyons,et al.  Magnetic resonance imaging of acute intraosseous disc herniation. , 1998, Clinical radiology.

[156]  P. Sham,et al.  The TRP2 Allele of COL9A2 is an Age-Dependent Risk Factor for the Development and Severity of Intervertebral Disc Degeneration , 2005, Spine.

[157]  P. Kjaer,et al.  Intra- and interobserver reproducibility of vertebral endplate signal (Modic) changes in the lumbar spine: the nordic modic consensus group classification , 2007, Acta radiologica.

[158]  H. Genant,et al.  Lumbar spinal fusion. Assessment of functional stability with magnetic resonance imaging. , 1990, Spine.