Introduction: Modic changes of the lumbar spine have been abundantly reported in the adult population and are highly associated with low back pain(1). It has been a long-held belief that Modic changes occur in older age, following the progression of disc degeneration. However, little is known regarding the development of Modic changes in the pediatric population. As such, the following study addressed the occurrence of Modic changes in younger patients, and reported on their epidemiology, risk factors and clinical relevance. In addition, the study aimed to raise awareness of the “juvenile” variant of Modic changes.

Methods: 207 consecutive patients that sought medical consultation for low back pain at a single center from 2009 to 2018 that had no history of deformities, neoplasms, trauma, or infections were included in this ambispective study. Sagittal T1- and T2-weighted 1.5T MRIs of L1-S1 were assessed for Modic changes as well as other spinal degenerative phenotypes (e.g. disc degeneration, herniated disc, high intensity zones (HIZs), endplate abnormalities, osteophytes). The presence of Modic types 1, 2, 3, and mixed types were assessed. Measurements were performed independently by two raters, whereby good to excellent reliability was noted. Subject demographics were assessed. Clinical characteristics collected included duration of symptoms in months, total office visits, types of conservative management utilized (physical therapy, NSAIDs, opioids, injections), and if later underwent spine surgery. Univariate and multivariate analyses were performed. Significance for all analyses was set at a p<0.05.

Results: The mean age was 16.5 years old (46.9% males), 14% had MCs and they occurred throughout the spine. Subject baseline demographics were similar between MCs and non-MCs patients (p>0.05). Modic type 2 (50%) was the most common type (type 1:27.1%; type 3:18.8%; mixed:4.7%). Multivariate analyses noted that endplate damage (OR: 11.36), disc degeneration (OR: 5.81), disc space narrowing (OR: 5.77), Schmorl’s nodes (OR: 4.30) and spondylolisthesis (OR: 3.55) to be significantly associated with MCs (p<0.05). No significant differences in conservative management were noted between Modic and non-MCs patients (p>0.05). Among surgery patients (n=44), 21% also had MCs (p=0.134). Symptom-duration was significantly greater in MC patients (p=0.049).

Discussion: To our knowledge, this is the first study to address Modic changes, multiple subtypes and their clinical relevance in a pediatric population with low back pain. “Juvenile” Modic changes can occur in pediatric patients who experience low back pain with a prevalence rate of 14% and were noted at every lumbar disc space level. Modic type 2 is the most common sub-type, followed by types 1 and 3. Determinants of Juvenile Modic changes consisted of specific disc and endplate phenotypes. Juvenile MCs have prolonged symptoms and related to specific structural spine phenotypes. Modic changes were also found to be commonly noted in surgery patients. Additional studies are needed to further validate our findings in the young population. Our study further warrants a refined classification of Modic changes for the juvenile variant, and its implications in the lifespan.