BackgroundEstimating the contribution of endplate oedema known as Modic changes to lower back pain (LBP) has been the subject of multiple observational studies and reviews, some of which conclude that the evidence for an association of Modic change with LBP is uncertain while others demonstrate a clear link. The clinical trials demonstrating the benefit of basivertebral nerve ablation, a therapeutic intervention, in a tightly defined homogenous patient group with chronic LBP and Modic changes type 1 or type 2, provides further evidence for the contribution of Modic changes to LBP and shows that in these subjects, nerve ablation substantially reduces pain and disability. These interventional studies provide direct evidence that Modic changes can be associated with lower back pain and disability. This review set out to explore why the literature to date has been conflicting.MethodsA narrative, forensic, non-systematic literature review of selected articles to investigate why the published literature investigating the association between Modic imaging changes and chronic low back pain is inconsistent.ResultsThis review found that previous systematic reviews and meta-analyses included both heterogeneous study designs and diverse patient syndromes resulting in an inconsistent association between Modic changes and nonspecific chronic lower back pain. Re-analysis of literature data focussing on more homogenous patient populations provides clearer evidence that Modic changes are associated with nonspecific chronic lower back pain and that type 1 Modic changes are more painful than type 2.ConclusionsStudies using tightly defined homogenous patient groups may provide the best test for association between MRI-findings and pain and disability. Clinical benefit of basivertebral nerve ablation observed in randomised controlled trials further supports the association between type 1 and type 2 Modic changes with pain and disability.