Abstract
Introduction
Erosive intervertebral osteochondritis is the destructive form of intervertebral osteochondrosis with inflammatory degeneration of the intervertebral disk. In Modic type I classification, there is an inflammation in vertebral plates and bone marrow, with MRI hypersignal in T2, STIR and T1 with Gadolinium sequences, and hyposignal in T1-weighted MRI; there is no change in the intensity of disk signal.
The main difference of erosive intervertebral osteochondritis with Modic I changes is that there is a hypersignal in the disk itself in T2, STIR, and T1 with Gadolinium sequences, in addition to the characteristic changes of Modic I.
The erosive intervertebral osteochondritis is rarely mentioned in the spine literature, and sometimes it is controversial because of its similarity with MRI imagenology of infectious disease. But there are clinical characteristics, imagenology, and blood test that help to analyze and make differential diagnosis with infectious diskitis. Modic has only one mention to the hyperintensity of disk with Gadolinium, probably due to fibrovascular granulation.
Our aim is to analyze the clinical and radiological presentation of patients with lumbar and cervical erosive intervertebral osteochondritis, and to describe their treatment and outcomes.
Materials and Methods
A retrospective analysis of patients with lumbar and cervical erosive intervertebral osteochondritis. There were 28 patients, 14 female and 14 male.
Average age was 44 years (range: 29 to 57). Mean follow-up was 27 months (range: 12 months to 8 years). A total of 23 cases affected lumbar spine and 5 cases affected cervical spine. The study consisted in static and dynamic X-ray of lumbar and cervical spine, CT scan, MRI enhanced with Gadolinium, diskitis serologic tests (sedimentation rate, white cell counting, CRP, procalcitonin), and psychological evaluation. No needle biopsy was performed in lumbar cases. In two cervical cases treated with fusion, the disk was send to biopsy and culture.
All patients had only axial pain, with lumbar and cervical muscle contracture, rigidity, and limited mobility. No one had neurologic symptoms. The most characteristic clinical finding was severe pain in the back during sneeze and percussion.
Treatment was conservative in 13 of the 23 lumbar cases. Surgical treatment was performed in 10 lumbar cases (8 female, 2 male): 4 open posterolateral pedicle screw fusion with autologous bone graft, 3 MISS posterolateral pedicle screw fusion witht bone substitute, and 3 percutaneous pedicle screws fixation and fusion with bone substitutes (Mozaic). The conservative treatment was based on restriction of activity and NSAID. Physiotherapy was needed for several weeks, especially in female patients. There was 10/14 (71.4%) female patients with associated fibromyalgia that were treated with psychotherapy and anxiolytic and antidepressant medication when needed.
In cervical cases, three were treated conservatively and in two cases (both female) anterior cervical diskectomy and fusion with cage and plate fixation were performed.
Results
No patient had symptoms or signs of infectious disease. Blood tests were normal in all cases.
The time of response to conservative treatment in both regions was slow and varied from 4 to 12 months.
Patients who underwent lumbar surgery showed a rapid relief of back pain with the immediate disappearance of pain with Valsalva maneuver. The standing position was at 24 hours in percutaneous group, 24 to 48 hours in MISS group, and 24 to 72 hours in open surgery group. All 10 patients instrumented in lumbar spine got fusion in a usual period. All cases returned to normal activities. Two out of eight female patients fused, had persistent fibromyalgia, with intermittent symptoms.
The biopsy of two cervical disks showed advanced degenerative changes with new formation of blood vessels and stromal fibrosis; no signs of infection. Both cultures were negative.
X-rays were of no value in diagnosis and evolution.
In the instrumented patients, there was a regression of the Modic I inflammatory signs in postoperative period, between 3 and 8 months. The disappearance of hyperintensity MRI signs in disk was evident between 6 to 10 months.
Conclusion
Erosive intervertebral osteochondritis is a form of disk and intervertebral degeneration that has to be suspected as a source of discogenic pain. This entity has its own clinical presentation and typical imagenology, if we try to find it. The T1 gadolinium-enhanced weighted MRI could be the image study that can define the final diagnosis with hypersignal in the disk and erosion in vertebral plates. It is always necessary to rule out infectious diskitis based on clinical signs imagenology and blood tests as white cell counting, sedimentation rate, CRP, and procalcitonin.
Conservative treatment is slow, but can cure half of the patients. Surgery is successful in refractory back and cervical pain, with quick recovery of pain, mobility, and function.
Further study is necessary to know anatomopathology of these changes.
Yes
None declared
Modic M et al. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology 1988;166:193–199
Grane P. Septic and aseptic postoperative discitis in the lumbar spine: evaluation by MR imaging. Acta Radiology 1998;39(2):108–115