Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Nov 15;2(4):100292.
doi: 10.1016/j.inpm.2023.100292. eCollection 2023 Dec.

Efficacy of stepped care treatment for chronic discogenic low back pain patients with Modic I and II changes

Heidi Mylenbusch  1 , Michiel Schepers  1 , Elmar Kleinjan  1 , Marije Pol  1 , Henk Tempelman  1 , Hanneke Klopper-Kes  1
Affiliations

Efficacy of stepped care treatment for chronic discogenic low back pain patients with Modic I and II changes

Heidi Mylenbusch et al. Interv Pain Med. .

Abstract

Objective: This study investigated whether patients with Modic changes (MC) of types I, I/II, and II would respond to an anti-inflammatory-based, stepped care treatment with three treatment steps: first, oral administration of NSAIDs, 2 × 200 mg celecoxib daily for two weeks; second, an intradiscal steroid injection (ID) with dexamethasone and cefazolin; and third, oral treatment with antibiotics (AB), 3 × 1 g amoxicillin daily for 100 days.

Design: This was an observational clinical study based on analyses of categorical data of patient-reported outcome measurements.

Subjects: Subjects were consecutive patients with chronic low back pain (CLBP), diagnosed by assessment of anamnestic signs of inflammation; a pain score ≥6 on the Numeric Pain Rating Scale (NPRS); a mechanical assessment; MC I, I/II, or II based on MRI; and lack of response to conservative treatment.

Methods: From January 1, 2015, to December 31, 2021, 833 eligible patients were selected for the stepped care treatment. A total of 332 patients completed requested follow-up questionnaires at baseline and 12 months (optional at 3 and 6 months). Primary outcomes were pain (at least 50 % pain relief) and/or a minimum of 40 % improvement in functionality as measured by the Roland Morris Disability Questionnaire (RMDQ) or the Oswestry Disability Questionnaire (ODI). Secondary outcome measures were use of pain medication and return to work.

Results: At 1 year of follow-up, 179 (53.6 %) of 332 patients reported improvement according to the responder criteria. Of the 138 patients that had received only NSAIDs, 88 (63.8 %) had improved. In addition, 50 (56.8 %) of the 183 patients that had received ID had improved, and 41 (38.7 %) of the 106 patients treated with AB had improved. None of the patients reported complications. 12.0 % of patients using AB stopped preterm due to undesirable side effects.

Conclusion: Treatment with a stepped care model for inflammatory pain produced clinically relevant, positive reported outcomes on pain and/or function. Our stepped care model appears to be a useful, safe, and cost-saving treatment option that is easily reproducible. Further studies, including randomized controlled trials and analyses of subgroups, may help to develop a more patient-tailored approach and further avoidance of less-effective treatments and costs.

Keywords: Antibiotics; Intradiscal steroid injection; Modic changes; NSAIDs; Stepped care model.

PubMed Disclaimer

Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Fig. 1
Fig. 1
Treatment pathways and responder numbers.
Fig. 2
Fig. 2
Dropout rates and losses to follow-up.
Fig. 3
Fig. 3
Average development of average back pain during 1 year of follow-up.
Fig. 4
Fig. 4
Average development of worst back pain during 1 year of follow-up.
Fig. 5
Fig. 5
Average development of disability during 1 year of follow-up.
See this image and copyright information in PMC

Similar articles

See all similar articles

References

    1. Modic M.T., Masaryk T.J., Ross J.S., Carter J.R. Imaging of degenerative disk disease. Radiology. 1988;168(1):177–186. - PubMed
    1. Mitra D., Cassar-Pullicino V.N., McCall I.W. Longitudinal study of vertebral type-1 end-plate changes on MR of the lumbar spine. Eur Radiol. 2004;14(9):1574–1581. - PubMed
    1. Braithwaite I., White J., Saifuddin A., Renton P., Taylor B.A. Vertebral endplate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography. Eur Spine J. 1998;7(5):363–368. - PMC - PubMed
    1. O'Neill C. Modic changes and intradiscal steroids. Spine J. 2011;11(2):109–110. - PubMed
    1. Modic M.T., Steinberg P.M., Ross J.S., Masaryk T.J., Carter J.R. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology. 1988;166(1 Pt 1):193–199. - PubMed

LinkOut - more resources