- Research article
- Open Access
- Open Peer Review
Characteristics and natural course of vertebral endplate signal (Modic) changes in the Danish general population
- Tue S Jensen1, 2Email author,
- Tom Bendix†2,
- Joan S Sorensen†1,
- Claus Manniche†1,
- Lars Korsholm†3 and
- Per Kjaer1
© Jensen et al; licensee BioMed Central Ltd. 2009
- Received: 29 December 2008
- Accepted: 03 July 2009
- Published: 03 July 2009
Vertebral endplate signal changes (VESC) are more common among patients with low back pain (LBP) and/or sciatica than in people who are not seeking care for back pain. The distribution and characteristics of VESC have been described in people from clinical and non-clinical populations. However, while the clinical course of VESC has been studied in patients, the natural course in the general population has not been reported. The objectives of this prospective observational study were to describe: 1) the distribution and characteristics of VESC in the lumbar spine, 2) its association with disc degeneration, and 3) its natural course from 40 to 44 years of age.
Three-hundred-and-forty-four individuals (161 men and 183 women) sampled from the Danish general population had MRI at the age of 40 and again at the age of 44. The following MRI findings were evaluated using standardised evaluation protocols: type, location, and size of VESC, disc signal, and disc height. Characteristics and distribution of VESC were analysed by frequency tables. The association between VESC and disc degeneration was analysed by logistic regression analysis. The change in type and size of VESC was analysed by cross-tabulations of variables obtained at age 40 and 44 and tested using McNemar's test of symmetry.
Two-thirds (67%) of VESC found in this study were located in the lower part of the spine (L4-S1). VESC located at disc levels L1-L3 were generally small and located only in the anterior part of the vertebra, whereas those located at disc levels L4-S1 were more likely to extend further into the vertebra and along the endplate. Moreover, the more the VESC extended into the vertebra, the more likely it was that the adjacent disc was degenerated. The prevalence of endplate levels with VESC increased significantly from 6% to 9% from age 40 to 44. Again, VESC that was only observed in the endplate was more likely to come and go over the four-year period compared with those which extended further into the vertebra, where it generally persisted.
The prevalence of VESC increased significantly over the four-year period. Furthermore, the results from this study indicate that the distribution of VESC, its association with disc degeneration and its natural course, is dependent on the size of the signal changes.
- Disc Degeneration
- Disc Height
- Evaluation Protocol
- Disc Level
- Magnetic Resonance Image Evaluation
Vertebral endplate signal changes (VESC) have been proposed to be a cause of low back pain (LBP)[1, 2]. In a recent systematic literature review, the prevalence of VESC was found to increase with age and to be lower in non-clinical populations (i.e. non-LBP, general, and working populations) than in clinical populations (people with LBP and/or sciatica), with median prevalence rates of 6% and 43% respectively. Moreover, a statistically significant positive association between VESC and LBP was found in 7 out of 10 articles that reported sufficient data to calculate odds ratios.
In a descriptive study of VESC, Modic et al investigated 474 patients referred for lumbar Magnetic Resonance Imaging (MRI). They described two types of signal changes: type 1 seen as hypointensity on T1-weighted images and hyperintensity on T2, and type 2 seen as hyperintensity on T1 and T2-weighted images. Further histological examination of type 1 changes in three patients, showed fissured endplates and vascular granulation tissue adjacent to the endplates. In three patients with type 2 changes, histology also identified disruption of the endplates as well as fatty degeneration of the adjacent bone marrow. Later, type 3 was described as hypointensity on T1 and T2-weighted images representing sclerosis as seen on radiographs.
The distribution and characteristics of VESC in the lumbar spine have been described in patients with non-specific LBP and/or sciatica [4, 6–9], in the working population[10, 11], and in people without LBP. In people who have no LBP, VESC has been described to be focal and located in the anterior third of the superior endplates of the mid lumbar vertebrae. In contrast, in people seeking care for LBP and/or sciatica, VESC has been described to be distributed equally between the superior and inferior endplates, to have a larger extent, and to be more prevalent in the lower lumbar spine than in the upper lumbar spine[8, 9]. Several studies have reported that VESC is often seen adjacent to degenerated or herniated discs[4, 6, 8–10, 13–15]. In fact, the term 'Modic changes' is described as the combination of VESC and disc degeneration. However, in a study of 59 individuals without LBP, there was no correlation between focal type 1 changes and disc degeneration.
The natural course of VESC has been investigated in longitudinal studies of patients with LBP and/or sciatica[4, 6, 9, 16] and in people with no LBP. From these studies, VESC seems to be stable in 48% to 86% of people and to convert from one type to another in 14% to 52% over periods of 14 to 72 months. In three of the five studies, new VESC appeared over time in 6% to 34% of levels/individuals without VESC at baseline[6, 9, 17]. In one study of 166 patients with sciatica, the signal changes disappeared in 16% of 38 patients who had VESC at baseline.
To our knowledge, the distribution and characteristics of VESC have not been described in the general population. The aims of this study were to describe the distribution and characteristics of VESC in the lumbar spine, its association with disc degeneration, and its natural course from the age of 40 to 44.
In this prospective observational study, people sampled from the Danish general population were MRI-scanned at the age of 40 years (in 2000/2001) and 44 years (in 2004/2005). Details of this cohort have been described previously. Permission for the study was granted by the local ethics committee (ref. no. 20000042) and for the database by the Danish Data Protection Agency (ref. no. 2000-53-0037). Informed consent was signed by all participants after they were informed about the study.
MRI was performed with a 0.2 T MRI-system (Magnetom Open Viva; Siemens AG, Erlangen, Germany). A body spine surface coil was used with the participants lying in the supine position. The following sequences were used:
A localizer sequence of five images, 40/10/40 degrees (TR/TE/flip angle) consisting of two coronal and three sagittal images in orthogonal planes
Sagittal T1-weighted spin echo, 621/26 (TR/TE), 144 × 256 matrix, 300 mm. field of view, 11 slices of 4 mm. thickness, 2 acquisitions, 6 min. 1 sec. scan time
Sagittal T2-weighted turbo spin echo 4609/134 (TR/effective TE), 210 × 256 matrix, 300 mm. field of view, 11 slices of 4 mm. thickness, 2 acquisitions, 8 min. 42 sec. scan time
Axial T2-weighted turbo spin echo 6415/134 (TR/effective TE), 180 × 256 matrix, 250 mm field of view, 15 slices of 5 mm. thickness, 2 acquisitions, 7 min. 49 sec. scan time. Slices were placed in the plane of the five lower discs.
The MRI evaluation was performed by an experienced radiologist (JSS), the first author (TSJ) and a second chiropractor (Chiro2) using standardized evaluation protocols[19, 20]. JSS evaluated disc signal and disc height for all image sets. TSJ and Chiro2 evaluated the VESC findings idependently, so that TSJ evaluated 58 of the 688 image sets and Chiro2 evaluated the remaining 630 cases.
The inter observer reproducibility of disc height and disc signal between JSS and a second radiologist, has previously been reported to be 0.59 and 0.66, respectively. The training of TSJ and the reproducibility of the evaluation of VESC findings has been previously reported. In this study, MRIs of 50 individuals were evaluated independently by JSS and TSJ. The Kappa value for inter observer reproducibility of the evaluation of VESC per endplate between JSS and TSJ was 0.80.
Chiro2 is a chiropractic radiologist who has been trained in radiology in a three year full-time residency program (DACBR) and in three Fellowships in musculoskeletal radiology and neuroradiology. The training of Chiro2 in this study was carried out by TSJ under supervision of the radiologist. After introduction to the evaluation protocol, 18 cases from the study cohort were read in a joint session in order to reach consensus. After consensus was reached, 38 image sets from the study cohort were evaluated independently by TSJ and Chiro2. The Kappa value for inter-observer reproducibility between the two readers for the 38 cases was 0.51, which was lower than the limit of 0.6 that was predefined as acceptable. Communication on the reasons for disagreement was undertaken and a new round of consensus readings of 8 cases was performed. Nine weeks after the first reproducibility study, the same 38 cases and 12 new cases were evaluated independently by the two chiropractors. The results from the chiropractors evaluations were compared to the radiologists original readings. The Kappa value for inter-observer reproducibility between the two chiropractors and the radiologist was 0.81 which was above the cut-point of 0.6 for having acceptable agreement.
Variables of interest
For the purpose of the present study, the type, location, and size of VESC were evaluated for each lumbar endplate (L1 – S1). The type of VESC was graded for each lumbar endplate (L1-S1) as either type 1, type 2, or type 3 as described by Modic et al. If more than one type was present within the same endplate, that endplate was graded as a mixed type.
Validity of variables
The MRI evaluation protocols used in the present study have been shown to have substantial to almost perfect reproducibility in relation to the evaluation of disc signal, disc height, and VESC with Kappa values for intra- and inter-observer reproducibility ranging from 0.77 to 1.0 and 0.72 to 0.91 respectively[19, 20].
An analysis was performed on people who participated in the study at both the age of 40 and 44 (responders) and those who only participated in the original study at age 40 (non-responders). The proportions of the following baseline variables were analysed at age 40: gender, presence of VESC, disc contour, disc degeneration, spondylolisthesis, LBP, heavy smoking, heavy physical workload, Body Mass Index, highest educational level, employment status, and the Back Beliefs Questionnaire score. The only significant difference between non-responders (n = 68) and those who participated in the follow-up study was their employment status. Nineteen percent of the non-responders were unemployed as compared with only seven percent among those who participated in the follow-up study.
Descriptive data were obtained for the VESC variables at both ages. The characteristics and distribution of VESC were analysed by frequency tables and cross-tabulations. Difference in prevalence of VESC at the two points of time was tested with McNemar's test of symmetry. The association between VESC and disc degeneration was analysed using logistic regression analysis. The change in type and size of VESC was analysed by cross-tabulations of the same variable obtained at age 40 and 44.
Three hundred and forty four people aged 44 years (161 men and 183 women), of the original cohort of 412 individuals aged 40 (83%), had an MRI at both time points and were therefore included in this study.
Characteristics at baseline
Persons with VESC
Type of VESC
Size of VESC
Only one type
Only one size
Persons with VESC
Two or more*
Two or more*
The distribution of the type, size, and location of VESC at age 40 in relation to vertebral levels is shown in Additional file 1. There was no difference in the prevalence rates in relation to gender or the involvement of the upper and lower endplates (data not shown). Type 1 was the most prevalent VESC, accounting for 214 (90%) of the 237 signal changes. The majority of the signal changes, 159 (67%) of 237, were observed in the lower lumbar spine, at the L4-5 and L5-S1 disc levels. At the upper lumbar levels (L1-2, L2-3, and L3-4), the majority of the signal changes were observed only in the endplate and were located in the anterior part of the vertebra, whereas in the lower part of the lumbar spine, VESC was more likely to also extend further into the vertebra and to involve more than just the anterior part of the endplate.
Change of VESC over four years
As mentioned above, the number of vertebral levels with VESC increased over the four-year period (see Additional files 1 and 2). Of the 3547 endplates that did not display VESC at age 40 years, six percent (195) had developed VESC at age 44. Sixty-five percent of the 237 endplates with VESC at age 40 persisted over the four-year period and the remaining 35% signal changes disappeared.
New and disappeared VESC
Type of VESC
Size of VESC
New VESC (n = 195)
Disappeared (n = 84)
To our knowledge, this is the first study that has investigated the natural course of VESC in the general population. The results from this study show that: 1) the prevalence of VESC increases from the age of 40 to the age of 44 and 2) the distribution over vertebral levels, presence of disc degeneration and the natural course of VESC is dependent on the size of the signal changes.
As stated in the introduction, other studies suggest that there is a difference in the size and distribution of VESC in patients with LBP compared with people without LBP[8, 9, 12]. In the current study, the association between size or location of VESC and the presence of pain was not investigated. However, VESC that was only observed in the endplate were equally distributed among the lumbar levels and often located in the anterior part of the endplate, whereas those extending beyond the endplate were found primarily at levels L4-L5 and L5-S1 and extended further along the endplate. Whether the size and location of VESC were associated with the LBP status of these people will be analysed and reported separately.
The positive association between the size of VESC and the presence of disc degeneration raises the question as to whether or not VESC is a response to advanced and/or accelerated disc degeneration. In support of this theory, two prospective studies of patients with sciatica treated non-surgically and surgically, have reported a large increase of type 1 changes over periods of 14 and 24 months respectively[6, 7]. Further evidence in favour of this theory are results from studies on baboons and rats, which report that disc injury induces change in the adjacent vertebrae with subsequent bone marrow depletion, degeneration and regeneration of the bone [25–27].
Regarding the natural course of VESC, the results from this study show that the signal changes that were only observed in the endplate were those that tended to be transient, whereas those that extended beyond the endplate were more likely to persist over a four-year period. The most straightforward explanation for this is that the smaller the lesion, the easier it is for the body to heal itself. A related explanation could be that people in whom the VESC progress over time 1) are more prone to injury, 2) have a greater inflammatory response to injury, 3) have poorer regenerative abilities, and/or 4) have one or more of the lifestyle factors associated with VESC (i.e. smoking, hard work, and BMI).
There are factors in the present study that could have influenced the reported prevalence of VESC and need to be addressed. The evaluation protocol used in this study described all VESC regardless of size, whereas the protocol from the previous study excluded the smallest VESC . This might explain why the prevalence of VESC in people of 40 years of age reported in the present study was higher (39%) than previously reported (23%) for the same cohort. Furthermore, the evaluation protocol used in the present study included four variables to evaluate the size of VESC (i.e. volume, maximum height, endplate area, and anteroposterior diameter). However, in daily clinical practice it would be impractical to use all four measures. Therefore, on the basis of personal communication with clinicians and researchers with various MRI experience, 'maximum height' was selected as the variable that was easiest to evaluate and was used as 'size' in the analysis. Furthermore, we did perform a sensitivity analysis using the three other variables and this did not change the results.
In relation to the high prevalence of type 1 changes, all MRI scans in the cohort study were performed on a low-field MRI unit (0.2 T). It is known that the contrast between different types of tissues are visualised differently at low-field scanners and high-field scanners. Therefore, it is possible that there are differences in the way that the different types of VESC are visualised on the two types of scanners. Results from a study of 20 patients with LBP and VESC, conducted at the Back Research Centre subsequent to data collection for the cohort study, showed that there are differences in the way that VESC is displayed on high- and low-field scanners. When comparing high- and low-field MRIs from the same patients, the prevalence of VESC was 10% higher on high-field scanners as compared with low-field scanners. More importantly, the proportion of type 1 changes seen on low-field systems was three times greater than when evaluating the same patients on a high-field system. These results might explain why more than 90% of the signal changes at baseline were type 1 changes or mixed type 1 and 2 as compared with studies performed with high-field MRI systems, where the prevalence of VESC type 1 ranged between 3 and 50%[4, 8–10, 13, 30–38].
The major strength of this study is that the study sample was population-based, representative of the Danish general population, and that all individuals were of the same age. Furthermore, the protocols used in the study for the evaluation of VESC and disc degeneration have been shown to have excellent reproducibility when compared with previous studies using high-field systems [8, 9, 12, 23, 39–41].
The results from this study indicate that the distribution of VESC, its association with disc degeneration and its natural course are dependent on VESC size.
Supported by grants from the Danish Foundation of Chiropractic Research and Postgraduate Education (Tue Secher Jensen).
- Albert HB, Kjaer P, Jensen TS, Sorensen JS, Bendix T, Manniche C: Modic changes, possible causes and relation to low back pain. Med Hypotheses. 2008, 70: 361-368. 10.1016/j.mehy.2007.05.014.View ArticlePubMedGoogle Scholar
- Kjaer P, Korsholm L, Bendix T, Sorensen JS, Leboeuf-Yde C: Modic changes and their associations with clinical findings. Eur Spine J. 2006, 15: 1312-1319. 10.1007/s00586-006-0185-x.View ArticlePubMedPubMed CentralGoogle Scholar
- Jensen TS, Karppinen J, Sorensen JS, Niinimaki J, Leboeuf-Yde C: Vertebral endplate signal changes (Modic change): a systematic literature review of prevalence and association with non-specific low back pain. Eur Spine J. 2008, 17: 1407-1422. 10.1007/s00586-008-0770-2.View ArticlePubMedPubMed CentralGoogle Scholar
- 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: 193-199.View ArticlePubMedGoogle Scholar
- Modic MT, Masaryk TJ, Ross JS, Carter JR: Imaging of degenerative disk disease. Radiology. 1988, 168: 177-186.View ArticlePubMedGoogle Scholar
- Albert HB, Manniche C: Modic changes following lumbar disc herniation. Eur Spine J. 2007, 16: 977-982. 10.1007/s00586-007-0336-8.View ArticlePubMedPubMed CentralGoogle Scholar
- Barth M, Diepers M, Weiss C, Thome C: Two-year outcome after lumbar microdiscectomy versus microscopic sequestrectomy: part 2: radiographic evaluation and correlation with clinical outcome. Spine. 2008, 33: 273-279. 10.1097/BRS.0b013e31816201a6.View ArticlePubMedGoogle Scholar
- Karchevsky M, Schweitzer ME, Carrino JA, Zoga A, Montgomery D, Parker L: Reactive endplate marrow changes: a systematic morphologic and epidemiologic evaluation. Skeletal Radiol. 2005, 34: 125-129. 10.1007/s00256-004-0886-3.View ArticlePubMedGoogle Scholar
- Kuisma M, Karppinen J, Niinimaki J, Kurunlahti M, Haapea M, Vanharanta H: A three-year follow-up of lumbar spine endplate (Modic) changes. Spine. 2006, 31: 1714-1718. 10.1097/01.brs.0000224167.18483.14.View ArticlePubMedGoogle Scholar
- Kuisma M, Karppinen J, Niinimaki J, Ojala R, Haapea M, Heliovaara M: Modic changes in endplates of lumbar vertebral bodies: prevalence and association with low back and sciatic pain among middle-aged male workers. Spine. 2007, 32: 1116-1122. 10.1097/01.brs.0000261561.12944.ff.View ArticlePubMedGoogle Scholar
- Schenk P, Laubli T, Hodler J, Klipstein A: Magnetic resonance imaging of the lumbar spine: findings in female subjects from administrative and nursing professions. Spine. 2006, 31: 2701-2706. 10.1097/01.brs.0000244570.36954.17.View ArticlePubMedGoogle Scholar
- Chung CB, Berg Vande BC, Tavernier T, Cotten A, Laredo JD, Vallee C: End plate marrow changes in the asymptomatic lumbosacral spine: frequency, distribution and correlation with age and degenerative changes. Skeletal Radiol. 2004, 33: 399-404. 10.1007/s00256-004-0780-z.View ArticlePubMedGoogle Scholar
- de Roos A, Kressel H, Spritzer C, Dalinka M: MR imaging of marrow changes adjacent to end plates in degenerative lumbar disk disease. AJR Am J Roentgenol. 1987, 149: 531-534.View ArticlePubMedGoogle Scholar
- Kokkonen SM, Kurunlahti M, Tervonen O, Ilkko E, Vanharanta H: Endplate degeneration observed on magnetic resonance imaging of the lumbar spine: correlation with pain provocation and disc changes observed on computed tomography diskography. Spine. 2002, 27: 2274-2278. 10.1097/00007632-200210150-00017.View ArticlePubMedGoogle Scholar
- Schmid G, Witteler A, Willburger R, Kuhnen C, Jergas M, Koester O: Lumbar disk herniation: correlation of histologic findings with marrow signal intensity changes in vertebral endplates at MR imaging. Radiology. 2004, 231: 352-358. 10.1148/radiol.2312021708.View ArticlePubMedGoogle Scholar
- Mitra D, Cassar-Pullicino VN, McCall IW: Longitudinal study of vertebral type-1 end-plate changes on MR of the lumbar spine. Eur Radiol. 2004, 14: 1574-1581. 10.1007/s00330-004-2314-4.View ArticlePubMedGoogle Scholar
- Elfering A, Semmer N, Birkhofer D, Zanetti M, Hodler J, Boos N: Risk factors for lumbar disc degeneration: a 5-year prospective MRI study in asymptomatic individuals. Spine. 2002, 27: 125-134. 10.1097/00007632-200201150-00002.View ArticlePubMedGoogle Scholar
- 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. 2005, 30: 1173-1180. 10.1097/01.brs.0000162396.97739.76.View ArticlePubMedGoogle Scholar
- Jensen TS, Sorensen JS, Kjaer P: Intra- and interobserver reproducibility of vertebral endplate signal (modic) changes in the lumbar spine: the Nordic Modic Consensus Group classification. Acta Radiol. 2007, 48: 748-754. 10.1080/02841850701422112.View ArticlePubMedGoogle Scholar
- Solgaard SJ, Kjaer P, Jensen ST, Andersen P: Low-field magnetic resonance imaging of the lumbar spine: reliability of qualitative evaluation of disc and muscle parameters. Acta Radiol. 2006, 47: 947-953. 10.1080/02841850600965062.View ArticleGoogle Scholar
- Eyre D, Nemya P, Buckwalter , Caterson N, Heinegard D, Oegema T: Intervertebral Disk: Basic Science perspectives. New Perspectives on Low Back Pain. Edited by: Frymoyer JW, Gordon SL. 1989, American Academy of Orthopaedic Surgeons, 147-207.Google Scholar
- 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.View ArticlePubMedGoogle Scholar
- Raininko R, Manninen H, Battie MC, Gibbons LE, Gill K, Fisher LD: Observer variability in the assessment of disc degeneration on magnetic resonance images of the lumbar and thoracic spine. Spine. 1995, 20: 1029-1035. 10.1097/00007632-199505000-00009.View ArticlePubMedGoogle Scholar
- Roberts N, Gratin C, Whitehouse GH: MRI analysis of lumbar intervertebral disc height in young and older populations. J Magn Reson Imaging. 1997, 7: 880-886. 10.1002/jmri.1880070517.View ArticlePubMedGoogle Scholar
- Malinin T, Brown MD: Changes in vertebral bodies adjacent to acutely narrowed intervertebral discs: observations in baboons. Spine. 2007, 32: E603-E607. 10.1097/BRS.0b013e31815574e7.View ArticlePubMedGoogle Scholar
- Ulrich JA, Liebenberg EC, Thuillier DU, Lotz JC: ISSLS prize winner: repeated disc injury causes persistent inflammation. Spine. 2007, 32: 2812-2819. 10.1097/BRS.0b013e31815b9850.View ArticlePubMedGoogle Scholar
- Moore RJ, Vernon-Roberts B, Osti OL, Fraser RD: Remodeling of vertebral bone after outer anular injury in sheep. Spine. 1996, 21: 936-940. 10.1097/00007632-199604150-00006.View ArticlePubMedGoogle Scholar
- Kuisma M, Karppinen J, Haapea M, Niinimaki J, Ojala R, Heliovaara M: Are the determinants of vertebral endplate changes and severe disc degeneration in the lumbar spine the same? A magnetic resonance imaging study in middle-aged male workers. BMC Musculoskeletal Disorders. 2008, 9: 51-10.1186/1471-2474-9-51.View ArticlePubMedPubMed CentralGoogle Scholar
- Henriksson GAC, Bolstad JE: Lumbar Modic changes – a comparison between findings in low-and high-field MRI scannings. 2008, Master Thesis, Faculty of Health Sciences – University of Southern Denmark, MasterGoogle Scholar
- Stabler A, Weiss M, Scheidler J, Krodel A, Seiderer M, Reiser M: Degenerative disk vascularization on MRI: correlation with clinical and histopathologic findings. Skeletal Radiol. 1996, 25: 119-126. 10.1007/s002560050047.View ArticlePubMedGoogle Scholar
- Molla E, Marti-Bonmati L, Arana E, Martinez-Bisbal MC, Costa S: Magnetic resonance myelography evaluation of the lumbar spine end plates and intervertebral disks. Acta Radiol. 2005, 46: 83-88. 10.1080/02841850510016036.View ArticlePubMedGoogle Scholar
- Bram J, Zanetti M, Min K, Hodler J: MR abnormalities of the intervertebral disks and adjacent bone marrow as predictors of segmental instability of the lumbar spine. Acta Radiol. 1998, 39: 18-23.View ArticlePubMedGoogle Scholar
- Weishaupt D, Zanetti M, Hodler J, Min K, Fuchs B, Pfirrmann CW: Painful Lumbar Disk Derangement: Relevance of Endplate Abnormalities at MR Imaging. Radiology. 2001, 218: 420-427.View ArticlePubMedGoogle Scholar
- Lim CH, Jee WH, Son BC, Kim DH, Ha KY, Park CK: Discogenic lumbar pain: association with MR imaging and CT discography. Eur J Radiol. 2005, 54: 431-437. 10.1016/j.ejrad.2004.05.014.View ArticlePubMedGoogle Scholar
- Becker GT, Willburger RE, Liphofer J, Koester O, Schmid G: [Distribution of MRI signal alterations of the cartilage endplate in pre-operated patients with special focus on recurrent lumbar disc herniation]. Rofo. 2006, 178: 46-54.View ArticlePubMedGoogle Scholar
- Kleinstuck F, Dvorak J, Mannion AF: Are "structural abnormalities" on magnetic resonance imaging a contraindication to the successful conservative treatment of chronic nonspecific low back pain?. Spine. 2006, 31: 2250-2257. 10.1097/01.brs.0000232802.95773.89.View ArticlePubMedGoogle Scholar
- Peterson CK, Gatterman B, Carter JC, Humphreys BK, Weibel A: Inter- and intraexaminer reliability in identifying and classifying degenerative marrow (Modic) changes on lumbar spine magnetic resonance scans. J Manipulative Physiol Ther. 2007, 30: 85-90. 10.1016/j.jmpt.2006.12.001.View ArticlePubMedGoogle Scholar
- Luoma K, Vehmas T, Gronblad M, Kerttula L, Kaapa E: MRI follow-up of subchondral signal abnormalities in a selected group of chronic low back pain patients. Eur Spine J. 2008, 17: 1300-1308. 10.1007/s00586-008-0716-8.View ArticlePubMedPubMed CentralGoogle Scholar
- Jones A, Clarke A, Freeman BJ, Lam KS, Grevitt MP: The Modic classification: inter- and intraobserver error in clinical practice. Spine. 2005, 30: 1867-1869. 10.1097/01.brs.0000173898.47585.7d.View ArticlePubMedGoogle Scholar
- Mulconrey DS, Knight RQ, Bramble JD, Paknikar S, Harty PA: Interobserver reliability in the interpretation of diagnostic lumbar MRI and nuclear imaging. Spine J. 2006, 6: 177-184. 10.1016/j.spinee.2005.08.011.View ArticlePubMedGoogle Scholar
- Pfirrmann CW, Resnick D: Schmorl nodes of the thoracic and lumbar spine: radiographic-pathologic study of prevalence, characterization, and correlation with degenerative changes of 1,650 spinal levels in 100 cadavers. Radiology. 2001, 219: 368-374.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/10/81/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.