Modic changes of the cervical spine in patients with whiplash injury: A prospective 11-year follow-up study

doi:10.1016/j.injury.2012.12.001

Injury

Volume 44, Issue 6, June 2013, Pages 819-824

https://doi.org/10.1016/j.injury.2012.12.001 Get rights and content

Abstract

Introduction

There are few studies on Modic changes of the cervical spine in patients suffering from whiplash. This study compared Modic changes seen in whiplash patients 10 years after the injury with those observed in asymptomatic volunteers.

Methods

This is a follow-up study of 133 patients who suffered whiplash injuries in 1994–1996 and underwent MRI with a superconductive imager (63 men, 70 women, mean age 49.6 ± 15.3 years, mean follow-up 11.4 years). In addition, 223 healthy volunteers who underwent MRI during the same period were included as controls (123 men, 100 women, mean age 50.5 ± 15.0 years, mean follow-up 11.6 years). All participants underwent follow-up MRI. We examined all participants for Modic changes, and investigated relationships between Modic changes and clinical symptoms or potentially related factors.

Results

Modic changes were observed in 4 patients (3%) and at 7 intervertebral levels in the initial study, and in 17 patients (12.8%) and at 30 intervertebral levels at the follow-up. Modic Type 2 changes were the most prevalent in the whiplash patients in both the initial and follow-up studies. There was no significant difference in the percentage of whiplash patients versus control subjects with positive Modic changes, either at the initial study or at follow-up. Modic changes were not related to clinical symptoms present at follow-up, but were associated with preexisting disc degeneration. There was no association between Modic changes and the details of the car accident that caused the injury.

Conclusions

While Modic changes became more common in whiplash patients in the 10-year period after the accident, they occurred with a similar frequency in control subjects. We did not find any association between Modic changes and the nature of the car accident in which the whiplash occurred. Modic changes found in whiplash patients may be a result of the physiological ageing process rather than pathological findings relating to the whiplash injury.

Introduction

Whiplash injuries, which are most frequently caused by motor vehicle collisions, have become a serious socio-economic and medical problem throughout the world.1, 2, 3, 4 Patients with whiplash injury experience pain in the neck, head, and shoulder, numbness in the upper extremities, and various other symptoms that may be long-lasting and obstinate. The pain suffered by whiplash patients is believed to come partly from the degeneration of intervertebral discs exposed to forced flexion and extension as the neck reacts to collision forces.5, 6 Jónsson et al.⁵ reported a high incidence of discoligamentous injuries in whiplash-type neck distortions, based on MRI and surgical findings.

Modic changes are degenerative changes of the vertebral bone marrow adjacent to the endplates. These changes are classified according to the following signal intensity patterns on T1 and T2 sagittal MRI: Type 1, low T1 and high T2; Type 2, high T1 and T2; and Type 3, low T1 and T2.7, 8 Modic Type 1 changes in the lumbar spine have been associated with low back pain,9, 10, 11, 12, 13, 14, 15 and Toyone et al. found an association between Modic Type 1 changes and segmental instability of the lumbar spine.¹⁵ Several longitudinal studies have observed alterations in the types of Modic changes during follow-up.16, 17

Although Modic changes have been extensively investigated in the lumbar spine, only a few studies have reported on changes in the cervical spine.18, 19, 20 We recently reported a longitudinal follow-up study of Modic changes in the cervical spine of 497 originally asymptomatic subjects.²⁰ Modic changes were observed in 4.5% of the subjects at the initial investigation and in 13.9% at a follow-up period of 11.6 years, with Type 2 Modic changes being the most frequent at follow-up. To date, there has not been a study of Modic changes in the cervical spine in whiplash patients.

We hypothesised that Modic changes are more likely to develop in patients with cervical whiplash injuries caused by vehicle collision forces than in healthy individuals. The objective of this study, therefore, was to elucidate the development of Modic changes of the cervical spine in whiplash patients during a follow-up period of 10 or more years.

Section snippets

Materials and methods

Prior approval for this study was obtained from the institutional review board of each participating institution. All study participants gave informed, written consent. This study was conducted as a follow-up to our previously reported MRI studies20, 21, 22, 23, 24, 25 of 506 patients who suffered acute whiplash injury between 1993 and 1996 and were seen in hospitals and underwent MRI within 2 weeks after the injury, and of a control group of 497 asymptomatic volunteers. In this follow-up

Modic changes in whiplash patients

In the initial study, Modic changes were observed in four patients (3%) and at 7 intervertebral levels. At the follow-up study, Modic changes were observed in 17 patients (12.8%) and at 30 intervertebral levels. C5–6 and C6–7 were the levels most frequently involved (Table 1). Type 2 Modic changes were the most prevalent type, in both the initial and follow-up studies (Fig. 1).

All of the Modic changes observed at the follow-up were newly developed; the Modic Type 1 changes observed at two

Discussion

Several studies have reported on the long-term prognosis of whiplash injury.23, 24, 26, 27 Gargan and Bannister followed 43 whiplash patients for a mean interval of 10.8 years and found that only 12% recovered completely.²⁶ Clinical symptoms at follow-up may be sequelae of the accident, but may also be attributable to structural deterioration of the cervical spine during the follow-up period. Our previous study of whiplash patients and healthy volunteers showed that while neck pain, shoulder

Conflict of interest

Morio Matsumoto has consultant fee from Kyoei Fire & Marine Insurance and has received a grant for this work and honorarium from the General Insurance Association of Japan.

The other authors have no conflict of interest.

Acknowledgments

This study was supported by a grant from the General Insurance Association of Japan. We cordially thank Mr. Toshio Watanabe of the Department of Central Radiotechnology, Keio University Hospital, for his assistance.

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Cited by (21)

Does Overall Cervical Spine Pathology Relate to the Clinical Heterogeneity of Chronic Whiplash?
2020, American Journal of Emergency Medicine
Citation Excerpt :
Albeit preliminary, this study may reveal a potentially important piece of new knowledge in this field. While it is acknowledged that previous cross-sectional and prospective imaging work has failed to consistently reveal pathological findings that are strongly related to whiplash symptoms and outcomes [21,36-41], this work is a primary example where the number of degenerative pathological findings were considered and appear to be in parallel with known clinical risk factors. We acknowledge the prognostic value of radiological observations in patients with acute and chronic whiplash remains highly controversial, particularly considering evidence to suggest some pathoanatomical findings from traditional imaging applications of the cervical region are common in asymptomatic participants ranging from 20 to 70 years of age [16].
There remains limited evidence for the clinical importance of most imaging findings in whiplash. However, it is possible the type and number of findings on Computed Tomography (CT) may contribute to prognostic recovery models. The purpose is to interpret cervical spine pathologies in the context of known factors influencing recovery.
This is a secondary analysis from a database of 97 acutely injured participants enrolled in a prospective inception cohort study. Thirty-eight participants underwent standard of care cervical spine CT in the emergency medicine department. All 38 participants were assessed at <1-week, 2-weeks, and 3-months post-injury and classified using percentage scores on the Neck Disability Index (recovered/mild (NDI of 0–28%) or moderate/severe (NDI ≥ 30%)). Between-group comparison of categorical variables (gender (male/female), presence of at least one CT finding (yes/no), and presence of ≥3 pathologies on CT (yes/no)) was conducted using 2-tailed Fisher's exact test.
Participants from both groups demonstrated at least one observable pathology. The group with persistent moderate/severe symptoms presented with significantly more pathology at baseline than those who later reported recovery or milder symptoms at 3-months post injury (p = 0.02).
This preliminary study, which needs replication in a larger cohort, provides foundation that the number of degenerative pathologies seen on initial post MVC CT may be associated with the subsequent clinical course of whiplash.
A systematic review of the association between fault or blame-related attributions and procedures after transport injury and health and work-related outcomes
2020, Accident Analysis and Prevention
Attributions of fault are often associated with worse injury outcomes; however, the consistency and magnitude of these impacts is not known. This review examined the prognostic role of fault on health, mental health, pain and work outcomes after transport injury. A systematic search of five electronic databases (Medline, Embase, CINAHL, PsycINFO, Cochrane Library) yielded 16,324 records published between 2000 and January 2018. Eligibility criteria were: adult transport injury survivors; prospective design; multivariable analysis; fault-related factor analysed; pain, mental health, general health or work-related outcome. Citations (n = 10,558, excluding duplicates) and full text articles (n = 555) were screened manually (Reviewer 1), and using concurrent machine learning and text mining (Reviewer 2; using Abstrackr, WordStat and QDA miner). Data from 55 papers that met all inclusion criteria were extracted, papers were evaluated for risk of bias using the QUIPS tool, and overall level of evidence was assessed using the GRADE tool. There were six main fault-related factors classified as: fault or responsibility, fault-based compensation, lawyer involvement or litigation, blame or guilt, road user or position in vehicle, and impact direction. Overall there were inconsistent associations between fault and transport injury outcomes, and 60% of papers had high risk of bias. There was moderate evidence that fault-based compensation claims were associated with poorer health-related outcomes, and that lawyer involvement was associated with poorer work outcomes beyond 12 months post-injury. However, the evidence of negative associations between fault-based compensation claims and work-related outcomes was limited. Lawyer involvement and fault-based compensation claims were associated with adverse mental health outcomes six months post-injury, but not beyond 12 months. The most consistent associations between fault and negative outcomes were not for fault attributions, per se, but were related to fault-related procedures (e.g., lawyer engagement, fault-based compensation claims).
Modic changes in the cervical spine: Prospective 20-year follow-up study in asymptomatic subjects
2019, Journal of Orthopaedic Science
Citation Excerpt :
Only three studies have evaluated changes in Modic type in the cervical spine over time [11,15,16]. Two prospective 10-year follow-up studies, one focusing on asymptomatic subjects and the other focusing on patients with whiplash injury, reported that a change from normal to Modic type 2 was the most frequent pattern [11,15]. However, a retrospective study of subjects with neck pain and an average interval of 2.4 years between MR imaging studies reported that type 1 Modic changes was the most frequent [16].
Few studies have characterized the development of Modic changes in the cervical spine over time. We evaluated Modic changes of the cervical spine that developed over a 20-year period in a healthy cohort, and sought to clarify the relationship between Modic changes and the development of clinical symptoms.
For this multicenter prospective cohort study, we recruited 193 subjects from an original cohort of asymptomatic volunteers who underwent MRI of the cervical spine between 1993 and 1996. Each cervical level from C2/3 to C7/T1 (total n = 1158 intervertebral levels) was assessed on current MRIs as normal or showing type 1, 2, or 3 Modic change, and we asked about symptoms related to the cervical spine. Relationships between the presence of Modic changes and patient characteristics, pre-existing disc degenerations or clinical symptoms were evaluated by logistic regression analysis.
After 20-year follow-up, Modic changes affected 31 subjects (16.1%) at 47 intervertebral disc levels. Of these 47 intervertebral disc levels, type 2, found at 30 levels (63.8%), was the most frequent, followed by type 1 at 15 levels (31.9%) and type 3 at two levels (4.3%). The most frequent changes were observed at the C5/6 segment with type 2 Modic changes. The presence of Modic changes correlated with pre-existing posterior disc protrusion (odds ratio 3.31, 95% confidence interval 1.21–9.05) and neck pain (odds ratio 2.71, 95% confidence interval 1.08–6.80).
In the cervical spine over a 20-year period, type 2 Modic changes were most frequent at the C5/6 segment. The Modic changes were associated with pre-existing disc degeneration and neck pain but not with age, BMI, smoking, shoulder stiffness, arm pain or numbness.
ACR Appropriateness Criteria <sup>®</sup> Suspected Spine Trauma
2019, Journal of the American College of Radiology
Citation Excerpt :
These studies have primarily focused on signal changes within the craniocervical (alar and transverse) ligaments, atrophy of the paraspinal muscles, and progression of cervical degenerative changes as indicators of WAD. Associations between MRI findings and WAD are weak at best [86,87], and most studies have found no difference in MRI findings between WAD patients and non-WAD patients [85,92,94-97,103] and no correlation between MRI findings and WAD symptoms or progression [88,89]. There is no role for MRA in the assessment of patients with persistent pain on follow-up visit with cervical collar in place.
Injuries to the cervical and thoracolumbar spine are commonly encountered in trauma patients presenting for treatment. Cervical spine injuries occur in 3% to 4% and thoracolumbar fractures in 4% to 7% of blunt trauma patients presenting to the emergency department. Clear, validated criteria exist for screening the cervical spine in blunt trauma. Screening criteria for cervical vascular injury and thoracolumbar spine injury have less validation and widespread acceptance compared with cervical spine screening. No validated criteria exist for screening of neurologic injuries in the setting of spine trauma. CT is preferred to radiographs for initial assessment of spine trauma. CT angiography and MR angiography are both acceptable in assessment for cervical vascular injury. MRI is preferred to CT myelography for assessing neurologic injury in the setting of spine trauma. MRI is usually appropriate when there is concern for ligament injury or in screening obtunded patients for cervical spine instability.
The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Advancing imaging technologies for patients with spinal pain: with a focus on whiplash injury
2018, Spine Journal
Radiological observations of soft-tissue changes that may relate to clinical symptoms in patients with traumatic and non-traumatic spinal disorders are highly controversial. Studies are often of poor quality and findings are inconsistent. A plethora of evidence suggests some pathoanatomical findings from traditional imaging applications are common in asymptomatic participants across the life span, which further questions the diagnostic, prognostic, and theranostic value of traditional imaging. Although we do not dispute the limited evidence for the clinical importance of most imaging findings, we contend that the disparate findings across studies may in part be due to limitations in the approaches used in assessment and analysis of imaging findings.
This clinical commentary aimed to (1) briefly detail available imaging guidelines, (2) detail research-based evidence around the clinical use of findings from advanced, but available, imaging applications (eg, fat and water magnetic resonance imaging and magnetization transfer imaging), and (3) introduce how evolving imaging technologies may improve our mechanistic understanding of pain and disability, leading to improved treatments and outcomes.
A non-systematic review of the literature is carried out.
A narrative summary (including studies from the authors' own work in whiplash injuries) of the available literature is provided.
An emerging body of evidence suggests that the combination of existing imaging sequences or the use of developing imaging technologies in tandem with a good clinical assessment of modifiable risk factors may provide important diagnostic information toward the exploration and development of more informed and effective treatment options for some patients with traumatic neck pain.
Advancing imaging technologies may help to explain the seemingly disconnected spectrum of biopsychosocial signs and symptoms of traumatic neck pain.
Do findings identified on magnetic resonance imaging predict future neck pain? A systematic review
2018, Spine Journal
Citation Excerpt :
Laimi et al. [32] included 60 school children (12-years-olds) and investigated the associations between disc degeneration and disc bulging with neck pain intensity and headache intensity 5 years later. Matsumoto et al. [37] investigated 356 participants from a previous study recruited from 15 institutes with acute whiplash injury. They reported on the association between Modic changes (type 1, type 2, and all types) with the presence of neck pain or headaches 11 years later.
Magnetic resonance imaging (MRI) has the potential to identify pathology contributing to neck pain. However, the importance of findings on MRI remains unclear.
We aimed to investigate whether findings on cervical spine MRI predict future neck pain.
A systematic review was carried out.
People with or without neck pain comprised the study sample.
Clinically important neck pain outcomes such as pain and disability.
The review protocol was registered on PROSPERO [CRD42016049228]. MEDLINE, CINAHL, and EMBASE databases were searched. Prospective cohort studies investigating the association between baseline MRI findings and clinical outcome were included. Cohorts with serious underlying diseases as the cause of their neck pain were excluded. Associations between MRI findings and neck pain outcomes were extracted from the included studies.
A total of 12 studies met all inclusion criteria. Eight studies presented data on participants with current neck pain, two studies included a mixed sample, and two studies included a sample of participants with no current neck pain. Because of the heterogeneity between the studies in terms of MRI findings, populations, and clinical outcomes investigated, it was not possible to pool the results. No consistent associations between MRI findings and future outcomes were identified. Single studies of populations with neck pain reported significant associations for neck muscle fatty infiltrate (risk ratio [RR]: 21.00, 95% confidence interval [CI]: 2.97–148.31) with persistent neck disability; disc protrusion (mean difference ranged from −1.83 to −2.88 on a 10-point pain scale), and disc degeneration (RR: 0.59; 95% CI: 0.36–0.98) with neck pain. In a population without pain, the development of foraminal stenosis over a 10-year period was associated with development of neck pain (RR: 2.99; 95% CI: 1.23–7.23).
The limited number, heterogeneity, and small sample size of the included studies do not permit definitive conclusions on the association between MRI findings of the cervical spine with future neck pain.

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Modic changes of the cervical spine in patients with whiplash injury: A prospective 11-year follow-up study

Abstract

Introduction

Methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Modic changes in whiplash patients

Discussion

Conflict of interest

Acknowledgments

Pain

Spine J

J Manipulative Physiol Ther

Injury

J Orthop Sci

Scientific monograph of the Quebec Task Force on whiplash-associated disorders: redefining “whiplash” and its management

Spine

Whiplash-type neck distortion in restrained car drivers: frequency, causes and long-term results

Eur Spine J

Chronic whiplash and whiplash-associated disorders: an evidence-based approach

J Am Acad Orthop Surg

Findings and outcome in whiplash-type neck distortions

Spine

Disc pathology after whiplash injury. A prospective magnetic resonance imaging and clinical investigation

Spine

Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging

Radiology

Imaging of degenerative disk disease

Radiology

Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography

Eur Spine J