Oral Presentation 51st International Society for the Study of the Lumbar Spine Annual Meeting 2025

Association between MRI findings and inflammatory symptoms in non-specific chronic low back pain (115309)

Katharina Ziegeler 1 , Lianne Gensler 1 , Thomas Link 1 , Nicholas Harris 1 , Colin A Roach 1 , Aaron Scheffler 1 , Aaron Fields 1 , Noah Bonnheim 1 , Abel Torres-Espin 2 , Jeffrey Lotz 1 , Trisha Hue 1 , Mark Wallace 3 , Fadel Zeiden 3 , Joel Castellanos 3 , Scott Fishman 4 , Patricia Zheng 1 , Conor ONeill 1
  1. University of California, San Francisco, San Francisco, CALIFORNIA, United States
  2. University of Waterloo, Waterloo, Ontario, Canada
  3. University of California, San Diego, San Diego, California
  4. University of California Davis, Davis, California

INTRODUCTION

Chronic low back pain (CLBP) associated with axial spondyloarthritis (axSpA), an autoimmune condition that leads to spinal inflammation, has characteristic symptoms, such as morning stiffness, improved pain with exercise, worsened pain with rest, and night-time pain. While they are a hallmark of axSpA, inflammatory symptoms are also common in subjects with non-specific CLBP (nsCLBP). Inflammatory imaging findings, such as bone marrow edema and endplate erosion2, are also common in nsCLBP.  Given this, pain in many nsCLBP patients may be due to an inflammatory response to degeneration.  If so, these patients may constitute a degenerative nsCLBP inflammatory phenotype, much like the inflammatory phenotype recognized in osteoarthritis1. The objective of this study was to determine associations between inflammatory symptoms and MRI findings in subjects with nsCLBP.

METHODS

comeBACK is a longitudinal cohort of deeply phenotyped adults with nsCLBP, conducted as part of the NIH-funded Back Pain Consortium Research Program (BACPAC).  Lumbar spine MRI scans were obtained on 3 Tesla scanners and included sagittal fat-saturated T2- and T1-weighted spin-echo sequences as well as axial T1- and T2-weighted spin-echo sequences. A musculoskeletal radiologist interpreted all scans, using a comprehensive scoring system3 that includes assessment of Modic changes and erosive osteochondrosis per endplate, and spinal stenosis per segment. Inflammatory symptoms (morning stiffness > 30 minutes, improved pain with exercise, worsened pain with rest, and night-time pain) were scored as Yes/No using a validated questionnaire. An ordinal regression was performed using the number of inflammatory symptoms (0-4) as the outcome and MRI features as predictors, adjusting for age, biological sex, depression, NSAID use, opioid use, smoking, Charleson Comorbidity Index and BMI.

RESULTS

239 participants had complete data and were included in the analysis. The results are summarized in Table 1. Endplate erosions and Modic 1 changes at any level were significantly associated with greater risk of further inflammatory symptoms.  For every additional spinal level affected, the odds of a higher level of  inflammatory symptoms increased by 25% (Odds ratio 1.252) for endplate erosions and 36% (Odds ratio 1.364) for Modic 1 changes. Conversely, no association was found for Modic 2 changes or spinal canal stenosis.  

DISCUSSION

The key finding from this study is that inflammatory MRI features, namely Modic 1 changes and endplate erosions, are associated with inflammatory symptoms in nsCLBP. These data suggest that there may be a nsCLBP inflammatory phenotype, defined by a combination of symptoms and MRI findings. Patients with an inflammatory phenotype may benefit preferentially from pharmacologic and procedural interventions that are directed specifically towards inflammation.    The association between erosive endplate changes and pain is novel, and may reflect disc-vertebra crosstalk, which has been demonstrated in surgical tissue and animal models4. A limitation is that only endplate and vertebral body changes were studied. Future work should include measurements of other potential inflammatory pathology, such as facet synovitis, as well as enthesitis at the insertion sites of the interspinous ligaments and annulus fibrosus.

Supported by the National Institute Of Arthritis And Musculoskeletal And Skin Diseases of NIH; Award Number U19AR076737. 67324c12bb1a9-ISSLS+IBP+abstract+table.jpg

  1. Van Spil WE, et al. Osteoarthritis phenotypes and novel therapeutic targets. Biochem Pharmacol. 2019. PMID: 30831073.
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  3. Sollmann N, et al. Magnetic Resonance Imaging of the Lumbar Spine: Recommendations for Acquisition and Image Evaluation from the BACPAC Spine Imaging Working Group. Pain Med. 2023. PMID: 36069660.
  4. Dudli S, et al. Intervertebral disc/bone marrow cross-talk with Modic changes. Eur Spine J. 2017. PMID: 28138783