What?
A 66 year old lady presented with an 8 week history of severe sciatica that had come on quite suddenly, without obvious injury. The poor lady had been having private physio twice a week for 8 weeks, and unfortunately felt no better at all. She wanted to have a private MRI scan, so I referred her for one, expecting her to have some sort of disc lesion. As the results came back, I was quite puzzled to find they said “Reactive Modic type 1 changes at end plates of L2 and L3”. In my haste I had forgotten that private MRI’s when done in isolation are not attached to orthopaedic services, so results are received in "Radiologist Language" rather than "Orthopaedic Language".
So what?
I honestly had no idea of how to interpret what "reactive Modic type 1 changes" meant. I had heard of Modic changes before but had assumed that they defined progressive radiological changes seen in OA. Or was that Kirkaldy-Willis? Obviously this was a gap in my knowledge that would be quite likely to present problems again in future if I did not attempt to address it. And better sooner rather than later, or I would have no idea what to recommend for this poor patient.
Now what?
I found an excellent paper that addressed my predicament rather well. Unfortunately, Modic Type 1 (low T1 signal, high T2 signal) changes aren’t directly diagnostic, but could likely be one (or several!) of 3 things. They could represent: degenerative change; end plate fracture; or discitis.
Given that this poor lady had a rather rapid onset of pain (OA less likely), that wasn’t getting any better with physio (again, OA less likely), but thankfully wasn’t worsening (discitis less likely) and she wasn’t systemically unwell, that left end plate fractures to be the most likely candidate.
She had a previous history of known osteopenia, so was managed with a repeat DEXA to inform any appropriate pharmacological management, an orthopaedic referral to assess any serial changes, and analgesia cover whilst she was waiting.
As a case study, this made me realise that MRI scans really are quite useless without relevant interpretation, and at this stage of my career I may not be the best placed clinician to do that! In future I will likely refer to an orthopod with a view to them requesting and interpreting any MRI findings. However, should the situation arise again, I feel a little bit more capable at interpreting the relevance of Modic changes in the context of the patient’s history.