Management of Significant Endplate Changes
The management of significant endplate changes should focus on a combination of conservative measures, targeted injections, and surgical intervention when indicated, with treatment decisions based on the severity of symptoms, degree of functional limitation, and presence of associated pathology.
Diagnostic Evaluation
- MRI with and without contrast is the diagnostic modality of choice for evaluating endplate changes, with a sensitivity of 96% and specificity of 94% 1
- The MRI protocol should include T1, T2 with fat suppression or STIR sequences, followed by T1 sequences with contrast in the axial and sagittal planes 1
- Modic endplate changes on MRI, indicative of vertebral inflammation, can be observed in patients with chronic low back pain 2
Conservative Management
- Initial management should include:
- Pain control with appropriate analgesics
- Physical therapy focusing on core strengthening and spine stabilization
- Activity modification to avoid aggravating positions and movements 2
- Patients with inflammatory Modic endplate changes may benefit more from epidural steroid injections than those without inflammatory changes 2
Interventional Management
- Epidural steroid injections (ESIs) may provide short-term relief (less than 2 weeks) for chronic back pain associated with endplate changes 2
- For patients with Modic endplate changes, ESIs have shown more frequent relief of low-back pain compared to patients without these changes 2
- Lumbar facet joint injections may be considered for facet-mediated pain that can coexist with endplate changes, though pain patterns from facet joints can be variable and overlapping 2
Surgical Management
- Surgical decompression is indicated in the presence of neurological deficits and documented spinal cord compression 1
- Before considering surgery, blood cultures and image-guided biopsy should be performed if infection is suspected as a cause of endplate changes 1
- When planning surgery, CT scans can be useful for pre-surgical planning, especially if instrumentation is being considered 1
Monitoring and Follow-up
- Regular monitoring of inflammatory markers (CRP and ESR) is recommended to assess treatment response, particularly if infection is suspected 1
- Follow-up MRI is useful to evaluate treatment response, though imaging findings may take longer to normalize than clinical improvement 1
- Approximately 10% of cases may have non-contiguous multilevel endplate changes, which should be considered in the diagnostic workup and treatment planning 1
Special Considerations
- In cases of diagnostic uncertainty, PET-CT with FDG may be useful, especially if MRI is inconclusive or contraindicated 1
- The American College of Radiology recommends against delaying treatment while waiting for imaging studies if neurological deficits are present 1
- CT has low sensitivity (6%) for identifying epidural abscess and should not replace MRI in initial evaluation of suspected infectious endplate changes 1