Intradiscal Steroid Injection Provides Short-Term Relief From Low Back Pain
Patients with Modic type 1 findings have evidence of disc inflammation on MRI, manifesting as vertebral endplate subchondral bone edema.
A single glucocorticoid intradiscal injection (GC IDI) provided relief from low back pain (LBP) at 1, but not 12, months in patients with active discopathy, as indicated by a study recently published in the Annals of Internal Medicine.1
Some patients with chronic LBP exhibit intervertebral disc changes on magnetic resonance imaging (MRI), which are categorized according to the Modic classification system, and indicate the presence of degenerative disc disease. Patients with Modic type 1 findings have evidence of disc inflammation on MRI, manifesting as vertebral endplate subchondral bone edema, and account for 46% of the chronic LBP population.1,2 The Modic 1 classification can be further divided into phenotypes such as low-grade systemic inflammation and inflammatory-like chronic LBP.3,4
Patients with chronic LBP and Modic 1 lesions have poorer outcomes than patients in the other 2 Modic groups.5 However, identifying patients who may benefit from targeted therapy for LBP can be difficult. GC IDI may improve discogenic LBP, but data are limited and conflicting in the absence of clinical trials evaluating GC IDI in large numbers of patients with LBP with Modic 1 findings on MRI.
Researchers, led by François Rannou, MD and Christelle Nguyen, MD, PhD, from Hôpitaux Universitaires Paris Centre-Groupe Hospitalier Cochin in France, investigated the efficacy of a single GC IDI at 1 month in patients with chronic LBP due to ongoing intervertebral disc inflammation who have not responded to first-line therapy.
A total of 135 patients with Modic 1 findings on MRI were randomly assigned 1:1 to receive a single IDI of 25 mg prednisolone acetate during discography, or discography alone. The primary end point was acceptable pain level, defined as a score ≤40 on a 100-point pain scale (0 = no pain, 100 = maximum pain).
At 1 month, more patients treated with GC ICI reported acceptable pain levels than patients in the control group (55.4% vs 33.3%; P =.009). At 12 months, however, pain scores were similar in both groups.
Patients in the GC ICI arm reported fewer limitations in activity due to LBP at 1 month and lower depression scores at 12 months compared with controls. No differences in MRI findings in the treatment groups were observed at 12 months.
Only 1 patient in the control group and no patients in the GC ICI group experienced adverse events that were considered to be related to the study intervention. There were no cases of infectious spondylodiscitis or intervertebral disc calcifications.
Summary and Clinical Applicability
Intervertebral disc inflammation on MRI is a common finding in patients with chronic LBP. The current study indicates that a single GC IDI of prednisolone improved pain scores at 1 month, but not at 12 months in patients with LBP and active disc inflammation on MRI.
Dr Rannou told Clinical Pain Advisor that GC IDI for LBP-related discopathy requires further exploration. He and his colleagues showed that GC IDI can produce short-term relief from LBP, but whether longer-term relief can be achieved is unclear. “Do we need to use another product or to propose iterative intradiscal injection as we currently do in sciatica by herniated disc?” he asked.
Study results may not be generalizable since participants were enrolled from tertiary care centers.
- Nguyen C, Boutron I, Baron G, et al. Intradiscal glucocorticoid injection for patients with chronic low back pain associated with active discopathy: a randomized trial. [published online March 21, 2017] Ann Intern Med. doi:10.7326/M16-1700
- Modic MT, Steinberg PM, Ross JS, Masaryk TJ, Carter JR. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology. 1988;166(1 Pt 1):193-199.
- Rannou F, Ouanes W, Boutron I, et al. High-sensitivity C-reactive protein in chronic low back pain with vertebral end-plate Modic signal changes. Arthritis Rheum. 2007;57(7):1311-1315.
- Bailly F, Maigne JY, Genevay S, et al. Inflammatory pain pattern and pain with lumbar extension associated with Modic 1 changes on MRI: a prospective case-control study of 120 patients. Eur Spine J. 2014;23(3):493-497. doi:10.1007/s00586-013-3036-6
- Jensen RK, Leboeuf-Yde C, Wedderkopp N, Sorensen JS, Jensen TS, Manniche C. Is the development of Modic changes associated with clinical symptoms? A 14-month cohort study with MRI. Eur Spine J. 2012;21(11):2271-2279. doi:10.1007/s00586-012-2309-9