Case report: positive pitfalls of PSMA PET/CT: diagnostic challenges in degenerative bone lesions including MODIC type 1.

Prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) is an imaging technique that has demonstrated high sensitivity and specificity in detecting prostate cancer and its metastasis, especially in the bones. This case describes a 60-year-old man who presented for increased prostate-specific antigen (PSA) level and underwent [68Ga]gallium-PSMA-11 PET/CT imaging for better disease assessment. 68Ga-PSMA-11 PET/CT revealed numerous radiotracer-positive lesions in both prostate lobes with associated sclerotic lesions on L4 and L5, but only L5 showed increased radiotracer avidity raising the possibility of metastasis. Magnetic Resonance Imaging (MRI) raises the possibility of aggressive MODIC type 1 lesion vs. infectious/inflammatory process. A biopsy of the radiotracer avid area was performed and showed no evidence of metastasis. The final diagnosis was aggressive MODIC type 1, in keeping with the false positive result of 68Ga-PSMA-11 PET/CT. This example demonstrates the possible limitations of 68Ga-PSMA-11 PET/CT, particularly in detecting bone metastases, and emphasizes the need for cautious interpretation and additional study to improve its diagnostic accuracy. Understanding and resolving these limitations is critical for increasing the accuracy of PSMA PET/CT in prostate cancer management.

Intradiscal administration of autologous platelet-rich plasma in patients with Modic type 1 associated low back pain: A prospective pilot study.

Background: Various treatments for chronic low back pain (LBP) have been reported; among them, platelet-rich plasma (PRP) as a regenerative medicine has attracted much attention. Although Modic type 1 change (MC1) is associated with LBP, no treatment has been established so far. In addition, no studies have administered PRP to intervertebral discs (IVDs) in patients with LBP, targeting MC1 only. Thus, the purpose of this study was to determine the safety and efficacy of PRP administration to the IVDs in patients with MC1 experiencing LBP. Methods: PRP was injected intradiscally to 10 patients with MC1 experiencing LBP. Patients were followed prospectively for up to 24 weeks after primary administration. Physical condition, laboratory data, and lumbar x-ray images were evaluated for safety assessment. Furthermore, to evaluate the effectiveness of PRP, patient-reported outcomes were considered. In addition, changes in MC1 were assessed using magnetic resonance imaging (MRI). Results: There were no adverse events in the laboratory data or lumbar X-ray images after administration. The mean visual analog scale, which was 70.0 ± 13.3 before the treatment, significantly decreased 1 week after PRP administration and was 39.0 ± 28.8 at the last observation. Oswestry disability index and Roland Morris disability questionnaire scores promptly improved after treatment, and both improved significantly 24 weeks after PRP administration. Follow-up MRI 24 weeks after treatment showed a significant decrease in the mean high-signal intensity of fat-suppressed T2-weighted imaging from 10.1 to 7.90 mm2 compared with that before PRP administration. Conclusions: The safety and efficacy of PRP administration to the IVDs of patients with MC1 experiencing LBP were identified. Post-treatment MRI suggested improvement in inflammation, speculating that PRP suppressed inflammation and consequently relieved the patient's symptoms. Despite the small number of patients, this treatment is promising for patients with MC1 experiencing LBP. The study protocol has been reviewed and approved by the Certified Committee for Regenerative Medicine and the Japanese Ministry of Health, Labor and Welfare (Japan Registry of Clinical Trials [jRCT] No. jRCTb042210159).

Autologous Platelet-Rich Plasma Administration on the Intervertebral Disc in Low Back Pain Patients with Modic Type 1 Change: Report of Two Cases.

Background and Objectives: Modic type 1 is known to be associated with lower back pain (LBP), but at present, a treatment has not been fully established. Meanwhile, platelet-rich plasma (PRP) has been used for tissue regeneration and repair in the clinical setting. There is no clinical PRP injection trial for the intervertebral disc of LBP patients with Modic type 1. Thus, this study aimed to verify PRP injection safety and efficacy in LBP patients with Modic type 1. As a preliminary experiment, two LBP cases with Modic type 1 are presented. Materials and Methods: PRP was administered intradiscally to two LBP patients with Modic type 1. PRP was obtained from the patients' anticoagulated blood. Primary endpoints were physical condition, laboratory data, and X-ray for safety evaluation. Secondary endpoints were pain scores using the visual analog scale (VAS), the Oswestry Disability Index (ODI), and the Roland-Morris Disability Questionnaire (RDQ) to evaluate PRP efficacy. The observation period was 24 weeks after the PRP injection. In addition, changes in Modic type 1 using MRI were evaluated. Results: This study assessed two LBP patients with Modic type 1. There were no adverse events in physical condition, laboratory data, or lumbar X-rays after injection. Follow-up MRI showed a decrease of high signal intensity on T2WI compared to before PRP administration. The pain scores tended to improve after the injection. Conclusions: PRP injection into the intervertebral disc of LBP patients with Modic type 1 might be safe and effective. This analysis will be continued as a prospective study to establish the efficacy.

Vertebral Bone Marrow and Endplate Assessment on MR Imaging for the Differentiation of Modic Type 1 Endplate Changes and Infectious Spondylodiscitis.

On magnetic resonance (MR) imaging, Modic type 1 (MT1) endplate changes and infectious spondylodiscitis share similar findings. Therefore, this study investigated vertebral bone marrow and endplate changes to enable their differentiation. The lumbar spine MR examinations of 91 adult patients were retrospectively included: 39 with MT1; 19 with early spondylodiscitis without abscess; and 33 with advanced spondylodiscitis with abscess. The assessment included percentage of bone marrow edema on sagittal short tau inversion recovery images, and the signal ratio of edema to unaffected bone and endplate contour (normal; irregular, yet intact; blurred; destructive) on sagittal unenhanced T1-weighted images. Differences were tested for statistical significance by Chi-square test and mixed model analysis of variance. The MR diagnostic accuracy in differentiating MT1 and spondylodiscitis was assessed by cross-tabulation and receiver-operating characteristic analysis. The endplate contours, edema extents, and T1-signal ratios of MT1 (extent, 31.96%; ratio, 0.83) were significantly different (p < 0.001) from early spondylodiscitis (56.42%; 0.60), and advanced spondylodiscitis (91.84%; 0.61). The highest diagnostic accuracy (sensitivity, 94.87%; specificity, 94.23%; accuracy, 94.51%) in identifying MT1 was provided by an irregular, yet intact endplate contour. This may be a useful MR feature for the differentiation between MT1 and spondylodiscitis, particularly in its early stage.

Short-term pain evolution in chronic low back pain with Modic type 1 changes treated by a lumbar rigid brace: A retrospective study.

BACKGROUND: Blocking the lumbar or lumbosacral spine with a custom-made rigid lumbar brace, based on the mechanical origin of active discopathy, is a therapeutic option for low back pain, but no study has yet defined its applicability in low back pain. OBJECTIVE: To assess the pain evolution of individuals with non-specific chronic low back pain associated with Modic type 1 changes treated with custom-made rigid lumbar brace. METHODS: This was a retrospective observational study conducted in the Physical Medicine and Rehabilitation unit at Clermont-Ferrand University Hospital, France, between January 2014 and December 2016. Inclusion criteria were adults with non-specific chronic low back pain associated with Modic type 1 changes on the lumbar or lumbosacral spine confirmed by MRI. Patients had 4 consultations with the physician (baseline, 5 weeks, 3 months, and 5 months). The brace was progressively withdrawn at 3 months. The main outcome was pain improvement of at least 30% at 3 months (visual pain scale). The secondary outcome was an improvement of at least 50%. We also studied the association between pain improvement at the 2 thresholds (30 and 50%) and clinical data, level of Modic type 1 changes, and pain recurrence after withdrawal of the brace. RESULTS: Among the 174 patients who wore the brace, 62 were included in the study; 49/62 (79%) showed improvement of at least 30% at 3 months. Two months after brace withdrawal, pain recurred for 30/46 patients (16 missing data). No sociodemographic, clinical or radiographic criteria were associated with pain evolution. CONCLUSION: In the present study, a rigid lumbar brace worn for 3 months was associated with a 30% reduction in pain for 79% of patients with chronic low back pain and active discopathy. However, the retrospective open and uncontrolled design of our study limits our interpretation about a specific treatment effect. A prospective randomized controlled trial is needed to clarify the effect of a rigid lumbar brace in this condition.

Modic Type 1 Vertebral Endplate Changes: Injury, Inflammation, or Infection?

OBJECTIVE: In the 29 years since the initial description of Modic type 1 vertebral endplate changes there has been ongoing debate regarding their cause. Studies have attributed Modic type 1 vertebral endplate changes to traumatic injury to the vertebral endplate, localized action of proinflammatory mediators, and more recently low-grade bacterial infection. Can we reconcile these conflicting data about the underlying cause of Modic type 1 vertebral endplate changes? Are we now in a position to conclude whether Modic type 1 vertebral endplate changes are secondary to injury, inflammation, or infection? CONCLUSION: We argue that the processes are not disparate but are in fact closely linked, each potentially instigating a chain of events leading to the MRI findings of Modic type 1 vertebral endplate change. A method of delineating which process is predominantly at play in an individual patient is required so that tailored treatment options can be offered with huge potential benefit to individuals and society alike.

Reliability of diffusion weighted MR imaging in differentiating degenerative and infectious end plate changes.

BACKGROUND: The aim of the study was to investigate the value of diffusion weighted MR imaging in the diagnosis of Modic type 1 change, which may be confused with the acute infectious spondylodiscitis on conventional MR imaging. PATIENTS AND METHODS: Twenty-seven patients with erosive intervertebral osteochondrosis, Modic type 1 and 18 patients with spondylodiscitis were included in this retrospective study. All images were acquired using on 1.5 Tesla MR units. Lumbar spinal MR imaging of 45 patients were retrieved from a digital database of a radiology record system and evaluated by one experienced radiologist. Patients with Modic type 1 change had CT slices obtained from the diseased disc space and the affected vertebrae. RESULTS: Bone marrow adjacent to the vertebral end plate in both Modic type 1 change and acute spondylodiscitis were hypointense on T1-weighted images. On T2-weighted images corresponding levels of vertebral end-plates showed hyperintense signal intensity in both group. All the patients with spondylodiscitis and Modic type 1 change were hyperintense and hypointense on diffusion-weighted MR images, respectively. CONCLUSIONS: Our findings suggest that diffusion weighted MR imaging is an useful method in differentiating Modic type 1 changes from acute spondylodiscitis, both of which may mimic each other, either on clinical or conventional MRI findings.