Degenerative Spinal Disease

  • Johan Van GoethemEmail author
  • Marguerite Faure
  • Michael T. Modic


Back pain is one of the most common disorders worldwide. A global burden of disease study from 2010 [1] ranks it sixth between HIV and malaria in terms of its impact on disability-adjusted life years. Degenerative disease of the spine is considered the most common etiologic cause. Mechanical, traumatic, nutritional, and genetic factors all play a role in the cascade of disk degeneration. The presence of degenerative change is by no means an indicator of symptoms, and there is a very high prevalence in asymptomatic individuals. The etiology of pain as the symptom of degenerative disease is complex and appears to be a combination of mechanical deformation and the presence of inflammatory mediators. The role of imaging is to provide accurate morphologic information and influence therapeutic decision making. A necessary component, which connects these two purposes, is accurate natural history data. This is critical because the justification of an intervention, whether diagnostic or therapeutic, requires the intervention to have a more favorable outcome than the untreated natural history of the disease process. In order to fully understand the value of imaging findings on therapeutic thinking, the following five considerations are critical: first, the reliability and reproducibility of imaging findings; second, the prevalence of findings in asymptomatic and symptomatic populations; third, the natural history and behavior over time; fourth, the prognostic value of the findings; and fifth, the treatability of the condition.


Degenerative disk disease Degenerative facet disease Back pain Disk herniation Modic changes Radicular pain Foraminal stenosis Hyperintensity zone SPECT MRI CT 


  1. 1.
    Murray CJL, Vos T, Lozano R et al (2012) Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380:2197–2223CrossRefPubMedGoogle Scholar
  2. 2.
    Fardon DF et al (2014) Lumbar disc nomenclature: version 2.0: Recommendations of the combined task forces of the North American Spine Society, The American Society of Spine Radiology and the American Society of Neuroradiology. Spine J 14(11):2525–2545CrossRefPubMedGoogle Scholar
  3. 3.
    Lurie Jon D MD, MS (2008) Reliability of Magnetic Resonance Imaging Readings for Lumbar Disc Herniation in the Spine Patient Outcomes Research Trial (SPORT). Spine 33:991–998CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Carrino JA, Lurie JD, Tosteson AN, Tosteson TD, Carragee EJ, Kaiser J, Grove MR, Blood E, Pearson LH, Weinstein JN, Herzog R (2009) Lumbar spine: reliability of MR imaging findings. Radiology 250(1):161–170CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Wiesel SW, Tsourmas N, Feffer HL, Citrin CM, Patronas N (1984) A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients. Spine 9:549–551CrossRefPubMedGoogle Scholar
  6. 6.
    Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW (1990) Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. J Bone Joint Surg Am 72:403–408PubMedGoogle Scholar
  7. 7.
    Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS (1994) Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med 331:69–73CrossRefPubMedGoogle Scholar
  8. 8.
    Borenstein DG, O’Mara JW Jr, Boden SD et al (2001) The value of magnetic resonance imaging of the lumbar spine to predict low back pain in asymptomatic subjects: a 7-year follow-up study. J Bone Joint Surg Am 83-A:1306–1311PubMedGoogle Scholar
  9. 9.
    Saal JA, Saal JS, Herzog RJ (1990) The natural history of lumbar intervertebral disc extrusions treated nonoperatively. Spine 15:683–686CrossRefPubMedGoogle Scholar
  10. 10.
    Modic MT, Ross JS, Obuchowski NA, Browning KH, Cianflocco AJ, Mazanec DJ (1995) Contrast-enhanced MR imaging in acute lumbar radiculopathy: a pilot study of the natural history. Radiology 195:429–435CrossRefPubMedGoogle Scholar
  11. 11.
    Modic MT, Obuchowski NA, Ross JS et al (2005) Acute low back pain and radiculopathy. Radiology 237:597–604CrossRefPubMedGoogle Scholar
  12. 12.
    Chou R, Fu R, Carrino JA, Deyo RA (2009) Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet 373(9662):463–472CrossRefPubMedGoogle Scholar
  13. 13.
    Verrilli D, Welch HG (1996) The impact of diagnostic testing on therapeutic interventions. JAMA 275(15):1189–1191CrossRefPubMedGoogle Scholar
  14. 14.
    ECRI. Treatment of degenerative lumbar spinal stenosis. I. Evidence report. Agency for Healthcare Research and Quality publication no. 01-E048 #32. Plymouth Meeting, Pa: ECRI, 2001Google Scholar
  15. 15.
    Benoist M (2002) The natural history of lumbar degenerative spinal stenosis. Joint Bone Spine 69(5):450–457CrossRefPubMedGoogle Scholar
  16. 16.
    Takahashi K, Aoki Y, Ohtori S (2008) Resolving discogenic pain. Eur Spine J 17(Suppl 4):428–31CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Troyanovich SJ, Harrison DD, Harrison DE (1999) Low back pain and the lumbar intervertebral disk: clinical considerations for the doctor of chiropractic. J Manipulative Physiol Ther 22(2):96–104CrossRefPubMedGoogle Scholar
  18. 18.
    Coppes MH, Marani E, Thomeer RT, Oudega M, Groen GJ (1990) Innervation of annulus fibrosus in low back pain. Lancet 336:189–190CrossRefPubMedGoogle Scholar
  19. 19.
    Freemont AJ, Peacock TE, Goupille P, Hoyland JA, O’Brien J, Jayson MIV (1997) Nerve ingrowth into diseased intervertebral disc in chronic back pain. Lancet 350:178–181CrossRefPubMedGoogle Scholar
  20. 20.
    O’Neill C, Kurgansky M, Kaiser J, Lau W (2008) Accuracy of MRI for diagnosis of discogenic pain. Pain Physician 11(3):311–326PubMedGoogle Scholar
  21. 21.
    Peng B, Hou S, Wu W, Zhang C, Yang Y (2006) The pathogenesis and clinical significance of a high-intensity zone (HIZ) of lumbar intervertebral disc on MR imaging in the patient with discogenic low back pain. Eur Spine J 15(5):583–587CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Aprill C, Bogduk N (1992) High-intensity zone: a diagnostic sign of painful lumbar disc on magnetic resonance imaging. Br J Radiol 65:361–369CrossRefPubMedGoogle Scholar
  23. 23.
    DeRoss A, Kressel H, Spritzer C et al (1987) MR imaging of marrow changes adjacent to end plates in degenerative lumbar disc disease. AJR Am J Roentgenol 149:531–534CrossRefGoogle Scholar
  24. 24.
    Modic MT, Steinbert PM, Ross JS et al (1988) Degenerative disc disease; assessment of changes in vertebral body marrow with MR imaging. Radiology 166:193–199CrossRefPubMedGoogle Scholar
  25. 25.
    Rahme R, Moussa R (2008) The modic vertebral endplate and marrow changes: pathologic significance and relation to low back pain and segmental instability of the lumbar spine. AJNR 29:838–842CrossRefPubMedGoogle Scholar
  26. 26.
    Ross JS, Obuchowski N, Zepp R (1998) The postoperative lumbar spine: evaluation of epidural scar over a 1-year period. AJNR Am J Neuroradiol 19:183–186PubMedGoogle Scholar
  27. 27.
    Masaryk TJ, Boumphrey F, Modic MT, Tamborrello C, Ross JS, Brown MD (1986) Effects of chemonucleolysis demonstrated by MR imaging. J Comput Assist Tomogr 10:917–923CrossRefPubMedGoogle Scholar
  28. 28.
    Modic MT, Masary TJ, Ross JS et al (1988) Imaging of degenerative disk disease. Radiology 168:177–186CrossRefPubMedGoogle Scholar
  29. 29.
    Ulmer JL, Elster AD, Mathews VP, Allen AM (1995) Lumbar spondylolysis: reactive marrow changes seen in adjacent pedicles on MR images. AJR Am J Roentgenol 164:429–433CrossRefPubMedGoogle Scholar
  30. 30.
    Morrison JL, Kaplan PA, Dussault RG, Anderson MW (2000) Pedicle marrow signal intensity changes in the lumbar spine: a manifestation of facet degenerative joint disease. Skelet Radiol 29:703–707, 2002;69:450–457CrossRefGoogle Scholar
  31. 31.
    Toyone T, Takahashi K, Kitahara H et al (1994) Vertebral bone marrow changes in degenerative lumbar disc disease: an MRI study of 74 patients with low back pain. J Bone Joint Surg (Br) 76:757–764Google Scholar
  32. 32.
    Mitra D, Cassar-Pullicino VN, McCall IW (2004) Longitudinal study of vertebral type-1 end-plate changes on MR of the lumbar spine. Eur Radiol 14:1574–1581CrossRefPubMedGoogle Scholar
  33. 33.
    Kuisma M et al (2006) A three-year follow up of lumbar spine endplate (Modic) changes. Spine 31(15):1714–1718CrossRefPubMedGoogle Scholar
  34. 34.
    Albert HB, Manniche C (2007) Modic changes following lumbar disc herniation. Eur Spine J 16:977–982CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Modic MT (2007) Modic type I and type 2 changes. J Neurosurg Spine 6:150–151CrossRefPubMedGoogle Scholar
  36. 36.
    Karchevsky M, Schweitzer ME, Carrino JA et al (2005) Reactive endplate marrow changes: a systematic morphologic and epidemiologic evaluation. Skelet Radiol 34:125–129CrossRefGoogle Scholar
  37. 37.
    Boos N, Weissbach S, Rohrbach H et al (2002) Classification of age-related changes in lumbar intervertebral discs: 2002 Volvo Award in basic science. Spine 27:2631–2644CrossRefPubMedGoogle Scholar
  38. 38.
    Chataigner H, Onimus M, Polette A (1998) Surgery for degenerative lumbar disc disease: should the black disc be grafted (in French)? Rev Chir Orthop Reparatrice Appar Mot 84:583–589PubMedGoogle Scholar
  39. 39.
    Albert H et al (2008) Modic changes, possible causes and relation to low back pain. Med Hypotheses 70:361–368CrossRefPubMedGoogle Scholar
  40. 40.
    Albert H et al (2013) Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized controlled trial of efficacy. Eur Spine J 22:697–707CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Fujiwara A, Tamai K, Yamato M, An HS, Yoshida H, Saotome K et al (1999) The relationship between facet joint osteoarthritis and disc degeneration of the lumbar spine: an MRI study. Eur Spine J 8:396–401CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Gellhorn AC, Katz JN, Suri P (2013) Osteoarthritis of the spine: the facet joints. Rheumatology 9(4):216–224PubMedPubMedCentralGoogle Scholar
  43. 43.
    Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley JH, Laslett M, Bogduk N (2007) Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 16:1539–1550CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Schwarzer AC, Wang SC, O’Driscoll D, Harrington T, Bogduk N, Laurent R (1995) The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain. Spine 20:907–912CrossRefPubMedGoogle Scholar
  45. 45.
    Makki D, Khazim R, Zaidan AA, Ravi K, Toma T (2010) Single photon emission computerized tomography (SPECT) scan-positive facet joints and other spinal structures in a hospital-wide population with spinal pain. Spine J 10:58–62CrossRefPubMedGoogle Scholar
  46. 46.
    Pathria M, Sartoris DJ, Resnick D (1987) Osteoarthritis of the facet joints: accuracy of oblique radiographic assessment. Radiology 164:227–230CrossRefPubMedGoogle Scholar
  47. 47.
    Meyerding HW (1932) Spondylolisthesis. Surg Gynecol Obstet 54:371–377Google Scholar
  48. 48.
    Weishaupt D, Zanetti M, Boos N, Hodler J (1999) MR imaging and CT in osteoarthritis of the lumbar facet joints. Skeletal Radiol 28(4):215–219CrossRefPubMedGoogle Scholar
  49. 49.
    Carrino JA et al (2008) Lumbar spine: reliability of MR imaging findings. Radiology 250:161–170CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Resnick D, Niwayama G (1995) Degenerative diseases of the spine. In: Resnick D (ed) Diagnosis of bone and joint disorders. Saunders, Philadelphia, pp 1396–1462Google Scholar
  51. 51.
    Gorbach C, Schmid MR, Elfering A, Hodler J, Boos N (2006) Therapeutic efficacy of facet joint blocks. AJR Am J Roentgenol 186:1228–1233CrossRefPubMedGoogle Scholar
  52. 52.
    Rihn JA, Lee JY, Khan M, Ulibarri JA, Tannoury C, Donaldson WF et al (2007) Does lumbar facet fluid detected on magnetic resonance imaging correlate with radiographic instability in patients with degenerative lumbar disease? Spine (Phila Pa 1976) 32:1555–1560CrossRefGoogle Scholar
  53. 53.
    Czervionke LF, Fenton S (2008) Fat-saturated MR imaging in the detection of inflammatory facet arthropathy (facet synovitis) in the lumbar spine. Pain Medicin 9:400–406CrossRefGoogle Scholar
  54. 54.
    Kim KY, Wang MY (2006) Magnetic resonance image-based morphological predictors of single photon emission computed tomography-positive facet arthropathy in patients with axial back pain. Neurosurgery 59:147–156CrossRefPubMedGoogle Scholar
  55. 55.
    Pneumaticos SG, Chatziioannou SN, Hipp JA, Moore WH, Esses SI (2006) Low back pain: Prediction of short-term outcome of facet joint injection with bone scintigraphy. Radiology 238:693–698CrossRefPubMedGoogle Scholar
  56. 56.
    Lehman VT, Murphy RC, Kaufmann TJ, Diehn FE, Murthy NS, Wald JT et al (2014) Frequency of discordance between facet joint activity on technetium Tc99m methylene diphosphonate SPECT/CT and selection for percutaneous treatment at a large multispecialty institution. AJNR Am J Neuroradiol 35:609–614CrossRefPubMedGoogle Scholar
  57. 57.
    Matar HE, Navalkissoor S, Berovic M, Shetty R, Garlick N, Casey AT et al (2013) Is hybrid imaging (SPECT/CT) a useful adjunct in the management of suspected facet joints arthropathy? Int Orthop 37:865–870CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Gregory DS, Seto CK, Wortley GC, Shugart CM (2008) Acute lumbar disk pain: navigating evaluation and treatment choices. Am Fam Physician 78(7):835–842PubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • Johan Van Goethem
    • 1
    • 2
    Email author
  • Marguerite Faure
    • 2
  • Michael T. Modic
    • 3
  1. 1.Department of RadiologyAZ NikolaasSint-NiklaasBelgium
  2. 2.Department of RadiologyUniversity Hospital AntwerpEdegemBelgium
  3. 3.Neurological InstituteCleveland ClinicClevelandUSA

Personalised recommendations