Chronic Back Pain Is a Painful Vertebral Body Problem

One study demonstrates that chronic back pain is associated not so much with plain disc degeneration but with disc degeneration combined with end plate or vertebral body schmorl nodes. Another study found that people with back pain and modic type I  bony  changes benefit from vertebroplasty (hot cement pumped in) of their painful vertebral bodies.

Spine J. 2015 Apr 1;15(4):622-8. doi: 10.1016/j.spinee.2014.11.012
The association of combination of disc degeneration, end plate signal change, and Schmorl node with low back pain in a large population study: the Wakayama Spine Study.
Teraguchi M(1), Yoshimura N(2), Hashizume H(3), Muraki S(4), Yamada H(1), Oka H(2), Minamide A(1), Nakagawa H(1), Ishimoto Y(1), Nagata K(1), Kagotani R(1), Tanaka S(5), Kawaguchi H(6), Nakamura K(7), Akune T(2), Yoshida M(1).
http://www.ncbi.nlm.nih.gov/pubmed/25433277

•  975 men and women – large study
• “Schmorl node was characterized by a localized defect at the rostral, caudal,or both endplates, with a well-defined herniation pit in the vertebral body with or without a surrounding sclerotic rim (low signal on T2-weighted image”

Results:

• End plate changes rarely occurred by self
• End plate changes, seen with disc degeneration, at L3/4/5/S1 levels, significantly increase chronic back pain

Masala, Salvatore, et al.
Treatment of painful Modic type I changes by vertebral augmentation with bioactive resorbable bone cement.
Neuroradiology 56.8 (2014): 637-645.
http://link.springer.com/article/10.1007/s00234-014-1372-9

•  218 cases with chronic back pain and Modic type 1 changes (“end plate changes in the acute phase”)

exclusions:

•  focal disc herniations -protruded or extruded
• acquired or congenital spinal canal stenosis

“Disc bulgings and broad base disc herniations at the involved or nearby levels were not excluded because of their almost constant presence”

• Used “Resorbable ceramic bone substitute consisting of 60 % synthetic calcium sulfate and 40 % hydroxyapatite, mixed with the radiocontrast agent Cerament”

Results:

• 79% pain dropped from  VAS pain scores 6.5/10 to 3/10 within  1 month and stayed at 3 over 1 year; disability scores cut in half by 1 month
• 19% dropped more gradually over 6 months but were  3/10 by 1 year
• 1% did not improve
• 1% died of unrelated issues

This study was recently discussed:

Radiologe. 2015 Apr;55(4):281-4. doi: 10.1007/s00117-015-2844-6.
[Does treatment of patients with chronic back pain and proven Modic type 1 alterations using vertebroplasty make sense?].
[Article in German]
Weber MA(1).
http://www.ncbi.nlm.nih.gov/pubmed/25773114

•  Big concern I could derive from translation, was lack of control group.

Comments – results are mouth watering but limited to those with type 1 modic changes (accompanying disc issues universal). It does appear that chronic low back pain more likely to originate from these bony structures. More than one level may need doing at one sitting.

And they were able to reduce disability by 50% without pumping cement into their brains! I always felt that the pain was the #1 cause of disability.

Injecting cement into vertebral bodies can have serious complications and has lead one doctor to have serious lawsuits. Doubt if we will see it here anything soon.

http://webcache.googleusercontent.com/search?q=cache:KWAtUGzBjmMJ:www.abqjournal.com/556087/news/doctor-involved-in-bone-cement-cases-seeks-second-chance.html+&cd=3&hl=en&ct=clnk&gl=ca

However, IV pamidronate could be used to deal with bony issues and I have written about this before:

Chronic Back Pain May Be a Pamidronate Infusion Treatable Disease – And Why Did It take 10 Years to Replicate That? 
http://painmuse.org/?p=3002

Any comments?