MAINSTREAM MEDIA HAS BEEN PUBLISHING
the results of several exciting and controversial studies on the use of antibiotics for treating lowback pain. Other studies point to the presence of bacteria (propionibacterium acnes) in the disc and surrounding tissues in many patients with lowback pain. These studies show that as many as 40 percent of those with low-back pain may have a low-grade infection of the disc and end plates, causing the pain.
The findings of bacteria in tissues and the response to antibiotic therapy appear to be strongly associated with Modic 1 changes. Modic 1 changes, which are visualized on MRI, have long been considered an inflammatory response to mechanical injury and are six times more prevalent in people with chronic low-back pain than in the general population. [For more on Modic changes, see “Bone Morphology and Modic Changes,” January/February 2015 ACA News, Page 22
If these preliminary studies are found to be accurate and substantiated by additional randomized controlled studies, it will be highly disruptive to the current models of care for low-back pain. In fact, it will be astonishing. I would venture to say that if these studies are correct, then the authors should be in the running for the Nobel Prize in medicine, like Barry Marshall and Robin Warren, who received the Nobel Prize in 2005 for discovering that the bacteria helicobacter pylori was responsible for peptic ulcers. While I would love to see a cure for 40 percent of those with refractory low-back pain, I am skeptical. However, I look forward to the results of further research.
While I am unconvinced, I am not willing to totally refute the conclusions of these studies. You may recall it was not too long ago that helicobacter pylorus was discovered to be the culprit in causing gastric ulcers. Those who adamantly and publicly ridiculed the early research on helicobacter pylori were left looking a little foolish.
Talking to Patients
My response to patients who inquire about a bacterial source of their pain is something like this: “These are certainly some exciting studies, and like many studies that sound promising in the newsstand, they may not bear the scrutiny of further research. I will be following the progress of further research on this matter and will inform my patients of any new or novel treatment for their pain.” I allow room for these studies to be substantiated or disproven, and I encourage my patients to continue this discussion with their medical doctors.
Further Research Needed
Here are a couple of other possible explanations for the findings in these studies:
• Many antibiotics have an anti-inflammatory effect, and we may be seeing the results of this anti-inflammatory effect. I am more skeptical about the bacteria causing back pain than I am about antibiotics relieving back pain.
• The tissue samples that contained the bacteria could have been contaminated in handling. It should be noted that propionibacterium acnes is a common contaminant in pathology samples.
What is not clear is whether the bacteria arrive in the low back first and are the source of the Modic changes or if a back injury occurs resulting in bony edema and then this region of slowmoving blood allows bacteria from the blood to establish a foothold and grow.
It would be interesting to see how many of the patients who had tissue samples removed had previous epidural steroid injections (i.e., a treatment that is both immunosuppressive and a possible route of infection) or other immunosuppressive therapy.
Some “early adopters” in medicine are not waiting for further research. They have created clinics and certification in Modic Antibiotic Spinal Therapy (MAST). MAST treatments currently utilize a 100-day course of antibiotic treatment. This prolonged course of antibiotic treatment caused several of the research subjects to drop out of the study because of side effects (e.g., diarrhea and gut pain).
These studies on the use of antibiotics to treat back pain are certainly sensational and have the potential to change the way we treat low-back pain. They have the appearance of being well-documented, well-written science, and while these concepts are far from being scientifically confirmed, they also cannot be ignored. This research is compelling science, but it is not conclusive.
1. Aebi M. Is low back pain after disc herniation with Modic Type 1 changes a low-grade infection? Eur Spine J.
2013 Apr; 22(4):689. Epub 2013 Mar 08.
2. Albert HB, Sorensen JS, Christensen BS, Manniche C. Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy. Eur Spine J.
2013 Apr; 22(4):697-707. Epub 2013 Feb 13.
3. Albert HB, Lambert P, Rollason J, Sorensen JS, Worthington T, Pedersen MB, Nørgaard HS, Vernallis A, Busch F, Manniche C, Elliott T. Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae? Eur Spine J.
2013 Apr; 22(4):690-6. Epub 2013 Feb 10.
4. Urquhart DM, Zheng Y, Cheng AC, Rosenfeld JV, Chan P, Liew S, Hussain S, Cicuttini FM. Could low grade bacterial infection contribute to low back pain? A systematic review. BMC Med.
2015 Jan 22;13(1):13.www.ncbi.nlm.nih.gov/pubmed/25609421
Dr. Morgan divides his clinical time between a hospital based chiropractic clinic and executive health clinics in Washington, D.C. He is adjunct faculty for a medical school and several chiropractic colleges. He is on the Board of Trustees for Palmer College of Chiropractic. His speaking calendar can be viewed athttp://bethesdaspineinstitute.com
. He can be reached through his website, www.drmorgan.info