Low back/Modic help

Mar 27, 24 9:13

Post #1 of 18 (1206 views)

I’ve been reading through the forum on low back/disc/herniations and have gleaned a lot of useful info. I haven’t seen much about Modic changes so am hoping some experts can weigh in.

I’m F, 40, former D1 runner. Also swam competitively years ago. Now just run and dabble in sprint tris occasionally.
My low back blew up a year and a half ago during an incredibly traumatic time in which I lost both parents. One day I could hardly walk or get out of bed without excruciating low back pain. No acute injury and no imaging or diagnosis at the time (I’m in Europe with socialized medecine). Gradually, most of the pain went away with running but still had achiness lifting my toddler and cleaning.

Three months ago the same pain returned and I got an MRI (image attached):
Normal position. No lysis, nor listhesis. At level L5-S1disc dehydration, central anulus tear and protrusion, without radicular compression.
Here also an intraspongous herniation with Modic 1 changes. No canal stenosis.
Sacroiliac otherwise no abnormalities demonstrated.

I have constant stiffness achiness and sometimes sharp pain across my low back, but mostly on the right side around the iliac crest and SI joint. I tried lots of core work (McGill, McKenzie press ups) and saw a few fysios who thought it was an SI problem. Did several prolotherapy sessions. Everything seemed to just make things tighter and more inflamed and stiff. I’m can’t run at all and elliptical and swimming aggravate it too. I can barely do daily household tasks most days. I walk a ton and that usually is ok. Pain is always with movement and not with sitting or lying down. In the morning I feel better. No radiating pain or nerve involvement.

After a lot of medical runaround I found a holistic private spine/pain clinic. Have been examined by a neurologist and MDT fysio. They think MRI is not terrible and that there is no hernia. Maybe a minor bulge. They are focusing on the tear and Modic inflammation as possible source of pain. They’ve done research on Modic and have a stepped protocol involving epidural, NSAID’s, possibly antibiotics. I’m scheduled for an epidural next week and will also get evaluated by an MSK doctor who works with elite athletes. Right now I’m in too much pain to do fysio other than very light Pilates work.

Being physically incapacitated on top of the emotional turmoil of the past year has been devastating. Many people have suggested that the pain is at least partly related to trauma/stress. I’m in so much pain and it seems to go up and down fairly randomly. I’m at my wits end and am hoping I might gain more insight by posting my story and imaging. Many thanks in advance.

Last edited by: Gazellerunner: Mar 27, 24 9:37

Re: Low back/Modic pain? [Gazellerunner] [ In reply to ]

Mar 27, 24 9:38

Post #2 of 18 (1186 views)

Hello, I am a neuroradiologist and spinal interventionalist. It sounds like you are experiencing a debilitating level of discomfort. I always tell patients that their symptoms often do not correlate with their findings on MRI. Imaging can sometimes be useful at guiding treatments/interventions, but it does not supercede a high quality physical exam. You definitely want to see a physician who specializes in pain and/or sports medicine. As far as your MRI goes, I agree with the report. A Schmorl's node with accompanying type 1 modic changes can sometimes incite "axial-type" low back pain. This manifests as localized pain, rather than radicular pain which travels to your hip, groin, or lower extremities. That tiny disc protrusion with an annular fissure is likely not responsible for your symptoms given its small size and lack of neural impingement. Finally, I would add that stress and psychological trauma can manifest as somatic symptoms. I had extremely traumatic personal event several years ago that manifested as irritable bowel syndrome, ulcers, severe nausea, and fatigue. After seeing a therapist for around a year, taking an antidepressant as well as letting time pass to help me process things, my symptoms are now completely gone. I am not saying that what you are experiencing is somatic/psychological, but it is something to consider. I hope that helps.

Re: Low back/Modic pain? [Thebigturtle] [ In reply to ]

Mar 27, 24 9:48

Post #3 of 18 (1174 views)

Thank you so much Thebigturtle for your swift reply and expertise. On top of the trauma, the lack of medical guidance here and not being taken seriously after over a year of pain also led to a lot of anxiety and catastrophizing about the MRI. In your experience, is the inflamed Schmorls node very unusual and can they heal/become asymptomatic with time? From what I’ve read online they’re usually caused by an accident or fall, so I’m not sure how it occurred.

Thanks also for sharing your experience with psychological trauma/pain. The pattern and flare ups do seem to indicate some role and I’m seeing a therapist and trying to work on that as well.

Last edited by: Gazellerunner: Mar 27, 24 9:52

Re: Low back/Modic pain? [Gazellerunner] [ In reply to ]

Mar 27, 24 10:18

Post #4 of 18 (1152 views)

Schmorl's nodes are very common. They are usually not caused by real trauma, but are rather considered by most to be a "degenerative process", meaning that they occur due to "wear and tear". Virtually everyone over the age of 60 has a Schmorls node present at least one level within their spine. Schmorl's nodes with associated edema or inflammation are also quite common. Some radiologists, including myself, believe that every Schmorl's node has an "acute" phase with inflammation before healing over time. Many of these are asymptomatic (IE we see them on patients getting an MRI for something completely different) and it is very possible that the Schmorl's node on your MRI was/is not the cause of your symptoms.

Traumatic Schmorl's nodes are a completely different entity with a similar imaging appearance, but are most usually also associated with an endplate or compression deformity, which your MRI does not demonstrate.

Last edited by: Thebigturtle: Mar 27, 24 10:21

Re: Low back/Modic pain? [Thebigturtle] [ In reply to ]

Mar 27, 24 10:25

Post #5 of 18 (1146 views)

Thank you once again for your reply. So, is Modic change 1 also commonly seen in an acute Schmorls node? The images of Modic changes online look quite different (more of a sandwich than a semicircle) than mine.

Finally (sorry for so many questions) is the L5 disc severely degenerated? The neurologist I saw didn’t think so and said height still looks good and some compression at age 40 in an athlete is not uncommon. I just worry because it’s so dark in comparison.

Re: Low back/Modic pain? [Gazellerunner] [ In reply to ]

Mar 27, 24 10:36

Post #6 of 18 (1135 views)

You ask great questions! Terminology in radiology is extremely confusing, because different radiologists and clinicians will call the same entity 100 different names.
To simplify things a little bit at the cost of being completely precise, Type 1 modic change=edema=inflammation=acute.
Theses changes can be seen along endplates (sandwich), or a Schmorl's node (semicircle).

The L5-S1 disc is dehydrated without significant height loss. This is considered "mild".
Some of the MRI's I interpret on older/obese/chronically ill patients have advanced disc degeneration at every lumbar level.

Re: Low back/Modic pain? [Thebigturtle] [ In reply to ]

Mar 27, 24 10:47

Post #7 of 18 (1132 views)

Thank you once again! Your comments have provided much peace of mind about the MRI. I live in the Netherlands and speak Dutch fluently, but it’s not my mother tongue so trying to correlate the radiology reports and doctors comments with English medical terminology, with which Im more familiar, is sometimes tricky.

Re: Low back/Modic help [Gazellerunner] [ In reply to ]

Mar 27, 24 15:44

Post #8 of 18 (1063 views)

You have had some great advice already.
If I can add a few things as well.
(I work as an anaesthesiologist and work alongside an interventional pain specialist for some of my work, and I have also suffered with 4 L5/S1 disc prolapses this last 2 years).
Finding the pain generator is important (and you may have more than one).
With this pathology and minimal disc protrusion we would commonly do an actual disc block, where we inject the disc itself to provide pain relief. We do these under sedation and image intensifier guidance, it is normally often clear when we inject into the disc whether it is the source of the pain given the pain response we see under sedation. I am not sure how commonly these are done where you are based. Epidurals are useful when you have some compression but with yours I am not sure you will get as much relief as hoped.
The MRI might not have captured your sacroiliac joints, personally, I have found it can be difficult to differentiate sacro iliac joint pain from facet joint pain and in our service we will often take a step wise diagnostic approach (if the scans are not conclusive) and block one lot of joints and assess the results and if no relief block the other, then we can target more longer term options for relief.
I am fortunate to work in Australia where, when you have private health cover, these sorts of things can be accessed rapidly and generally with very small out of pocket expenses.
I hope this settles down for you soon....
PS: have they optimised your medication management to ensure you have a good analgesic regimen to help?

Re: Low back/Modic help [Amnesia] [ In reply to ]

Mar 27, 24 17:21

Post #9 of 18 (1056 views)

Thank you Amnesia! In regards to your questions:

I’m in the Netherlands and pain management here generally consists of being sent home with paracetamol regardless of your suffering. I begged for something while giving birth and received zero intervention. Despite having serious pain with daily activities right now I have nothing but over the counter meds that don’t help much.

The clinic is semiprivate and I pay most out pocket. They do ‘test’ injections to check individual discs, I believe. My next appointment is with a sports MSK doc so he may order something else but the likely first step is some kind of epidural to bring down the inflammation. He can also prescribe meds like celebrex and steroids.

The MRI was of lower lumbar plus SI joints specifically. That and the X-Ray showed no SI abnormalities. Prolotherapy for the SI region also did nothing, and maybe made things worse. During the MDT exam at the clinic they mentioned that the main painful area on palpation was quite a bit higher than SIJ.

Re: Low back/Modic help [Gazellerunner] [ In reply to ]

Mar 28, 24 18:27

Post #10 of 18 (953 views)

Sorry for the slow reply, been a hectic 24 hours at this end.
That sounds like a really tough set of circumstances you are faced with. I feel somewhat fortunate to live and work in Australia where the access to so many high level, specialist investigations and treatment is reasonably quick. Sorry to hear what you were faced with in childbirth, I specialise in caring for pregnant women so it always hits home when women are not able to access what we take for granted over here.
Please update us as you can. I always like to think of these situations as needing a very holistic approach, tackling the problem from a variety of angles. (Sometimes there are situations where you clearly need surgery rather than anything else but this certainly does not sound like the case with you). So this includes the physiotherapy, optimisation of your pain relief medications etc.
Good luck with getting some relief, I hope it comes sooner rather than later for you.

Re: Low back/Modic help [Amnesia] [ In reply to ]

Apr 5, 24 4:21

Post #11 of 18 (681 views)

Thanks again to the previous posters for your expertise. Here is an update after seeing the MSK doctor:

He thought my pain level is far beyond what imaging shows. He could tell from how I moved/breathed that it was excruciating. Previously, as a D1 runner, I raced and trained through broken bones, etc and also gave birth without any pain relief, so it doesn’t make sense that I’m this debilitated.

A thorough physical evaluation was impossible because I was in so much pain. It was hard for him to distinguish true biomechanical issues from muscle spasm/guarding from pain. For what it’s worth, the pinpoint pain I have is higher than the SI joints and pretty focused at the upper sacrum/right side of L5.

He’s still not sure what the source is but gave me an epidural at the L5 disc level to hopefully calm things down. In two weeks he’ll determine if another injection or meds are warranted. I don’t get in to see the physio/biomechanical expert until 5 weeks out since he was booked. If the pain subsides, he can do a more thorough evaluation then.

So, still frustrated that there’s not a definitive answer, but at least they’re trying things and focusing on pain control now. Where I am, this is the best I can do. I’ve thought about sending images to specialists in the US but everyone seems to agree the MRI doesn’t indicate anything operative and that it’s more of a pain management/physio issue.

Last edited by: Gazellerunner: Apr 5, 24 4:25

Re: Low back/Modic help [Gazellerunner] [ In reply to ]

Apr 5, 24 4:41

Post #12 of 18 (671 views)

Thanks for the update and sorry to hear how sore you are.
I wouldn’t be worried about sending scans for further opinions at the moment You may need more scans, focused on other areas or as a different modality, eg a bone scan to look for any hot spots etc.
It’s really difficult, I am sorry you have to go through this. A bit like you, I have ran and worked on nasty fractures etc so when I complain of pain it generally means something significant is going on.
Please keep us/me updated if you are comfortable doing so.
Fingers crossed for you.

Re: Low back/Modic help [Amnesia] [ In reply to ]

Apr 5, 24 6:32

Post #13 of 18 (653 views)

BTW, could you show me some sagittal images from your MRI to the right of midline. Particularly a sequence labeled STIR or T2FS. I want to take a closer look at your pars interarticularis. Radiologists miss subtle pars defects all the time on MRI and xrays. They are actually most easily seen on CT. I also want to see if you have transitional anatomy (congenital), resulting in a L5-S1 pseudoarticulation. This can result in an entity called Bertolotti syndrome. Finally, as was mentioned by amnesia, you may want to get in MRI of the sacrum and SI joints. This could pick up a subtle stress fracture or SI joint inflammation. SI joints extend higher up than most people think...

Re: Low back/Modic help [Amnesia] [ In reply to ]

Apr 5, 24 7:02

Post #14 of 18 (641 views)

Indeed, it's worrying that it's so painful and yet there seems to be no conlusive origin for the pain.Thank you for the kind words :-) I will be sure to keep you posted.

Re: Low back/Modic help [Amnesia] [ In reply to ]

Apr 7, 24 23:51

Post #15 of 18 (466 views)

Update: it’s been 3 days since the ESI. I felt a little relief in the first day or two but now am in a lot of pain again. It’s a constant deep ache, sometimes sharp, like my sacrum is broken. I don’t know how else to describe it.

I’m worried that since the pain has worsened since my x-ray/MRI from 3 months ago they might not show everything. But it’s impossible to get new imaging here. And I don’t know what they should be looking for at this point? I’m really worried something is seriously wrong with me.

Re: Low back/Modic help [Gazellerunner] [ In reply to ]

Apr 8, 24 0:25

Post #16 of 18 (465 views)

I am sorry that things are feeling slightly worse rather than better.
A few things to keep in mind, we do normally say to patients that it can take up to two weeks to see a benefit from the steroid injections, they are not something that will cause immediate relief and you can also get a brief flare at times from the procedure. You may get a little bit of immediate relief from the injections depending on whether some local anaesthetic was included with the steroid. We often use a long acting local with ours, in small doses so you don't get weakness etc but that may explain why you have had some initial relief followed by some more pain.
I can't give you much advice in terms of how best to get this sorted in the health system that you live within, but I am sure there must be ways to have this escalated and sorted rather than suffering like you are.

Re: Low back/Modic help [Amnesia] [ In reply to ]

Apr 17, 24 12:39

Post #17 of 18 (261 views)

Here is an update for those still reading:

The transforaminal epidural did nothing and I was in even worse pain at two weeks. Since my next appointment is not until Monday I called the doctor's office begging for some kind of pain relief and now have a two week trial of Celebrex. It's better than ibuprofen but I still have substantial pain.

Today I had a telehealth consult with a spine specialist in the US who came highly recommended since there is no real diagnosis or plan here and I'm getting desperate. He took over an hour to review everything with me and believes the pain is directly related to the L5-S1 disc, which is dehydrated and probably acquired the annular tear when this all began 18 months ago. He said it definitely sounds like discogenic pain. He is writing a letter to my provider here to recommend an interlaminar epidural for pain relief (which he believes should work better than the transforaminal, if it works) and a discography to prove that the L5 is the pain source. Thereafter he said my options are basically regenerative medicine (PRP, stem cells) or disc replacement. He was not optimistic about the annular tear healing on its own after so long and trying fysio, rest, etc.

I'm terrified at the prospect of being in pain perpetually and also at the prospect of surgery on my back. There is also no prospect of any further help where I am located so for either regenerative medicine or surgery I would have to go abroad.

Re: Low back/Modic help [Gazellerunner] [ In reply to ]

Apr 17, 24 15:29

Post #18 of 18 (228 views)

Thank you for updating.
Unfortunately don’t expect great things with the celebrex. It’s an anti inflammatory the same as ibuprofen (just a little more specific, but the evidence shows ibuprofen is actually better!).
Do you mind me asking which spinal surgeon you were able to get a consult with and whether that was horrifically expensive?
I see a lot of them advertise online for consults etc, normally surgery is their way of making good money so I was quite interested in how they bill for this. Feel free to PM me instead.

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