{"id":4902,"date":"2013-05-08T01:57:19","date_gmt":"2013-05-08T00:57:19","guid":{"rendered":"https:\/\/blogs.bmj.com\/bjsm\/?p=4902"},"modified":"2013-05-08T01:57:19","modified_gmt":"2013-05-08T00:57:19","slug":"peterbrukner-discusses-todays-major-headline-successful-antibiotic-treatment-in-a-subset-of-people-with-chronic-low-back-pain","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bjsm\/2013\/05\/08\/peterbrukner-discusses-todays-major-headline-successful-antibiotic-treatment-in-a-subset-of-people-with-chronic-low-back-pain\/","title":{"rendered":"@PeterBrukner discusses today’s major headline: Successful antibiotic treatment in a subset of people with chronic low back pain"},"content":{"rendered":"

\"PBIt is not often that something I read in the medical research literature gives me goosebumps and an incredible urge to tell everyone I know about it (thank god for Twitter!). I had that feeling today when, after an article in this morning’s Guardian newspaper<\/a>, I read two recent papers published by a Danish group of researchers led by Hanne Albert in the European Spine Journal (links below)<\/i>.<\/p>\n

Infection and low back pain!?<\/span><\/p>\n

The\u00a0papers\u00a0relate to the possibility of an infective cause in a sub-group of patients with chronic low back pain. This sub-group is those patients with Modic changes. Modic changes (MC) are bone oedema in the adjoining vertebra to one in which there is a disc herniation. MC are present\u00a0in 46% of patents with chronic low back pain\u00a0compared to 6% in the general population. MC can only be reliably detected using MR imaging. A number of previous studies have demonstrated the presence of bacteria especially Propionbacterium acnes<\/i> (P. acnes<\/i>) in disc\u00a0nucleus\u00a0tissue evacuated at surgery from patients with lumbar disc herniation.<\/p>\n

The first paper\u00a0Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae? <\/i><\/a>reports on 61 patients who had nuclear disc material removed\u00a0while\u00a0undergoing surgery for chronic low back pain. Microbiological cultures were positive in 28 (46%) patients, of which 26\/28 were anaerobic cultures, 2 (3%) aerobic and 4 (7%) mixed. In the discs with a nucleus with anaerobic bacteria present, 80% developed MC in the\u00a0vertebrae adjacent\u00a0to the\u00a0previous disc\u00a0herniation, compared to none in the\u00a0aerobic\u00a0group and 44% with negative cultures. They concluded\u00a0that\u00a0the occurrence of MCs in the\u00a0vertebrae adjacent to a previously herniated disc may be due to oedema surrounding an infected disc.<\/p>\n

How do intervetebral discs become\u00a0infected?<\/span><\/p>\n

Organisms such as P. acnes<\/i> are commonly found in\u00a0hair\u00a0follicles\u00a0in the\u00a0skin and\u00a0in the\u00a0oral\u00a0cavity. They frequently\u00a0invade\u00a0the circulatory system during tooth brushing where they do not present an immediate risk because the blood stream is an aerobic<\/span> environment. When an intervertebral disc is herniated, nuclear material extrudes into the spinal canal. Within a short time, neocapillarisation begins in and around the extruded nucleus material, inflammation occurs and brings with it macrophages. So far so good – no debate about any of that.<\/p>\n

The innovation of the authors is their proposal that avascular and thus anaerobic disc<\/span> provides an ideal environment for these anaerobic bacteria to flourish. In this setting, anaerobic bacteria that are normally inconsequential (low virulent) may enter the disc and give rise to a slowly developing infection.<\/p>\n

Local inflammation in the adjacent bone (MC Type 1) may be a secondary effect due to cytokine production or microbial metabolites (e.g. propionic acid) entering the vertebrae through normal disc nutrition. P. acnes<\/em> is known from the skin to trigger an adjacent inflammatory response. P. acnes<\/em> cannot multiply in the highly vascular aerobic bone and are therefore not present where the MC occur.<\/p>\n

All good in theory but what about an RCT?<\/span><\/p>\n

The second paper is entitled\u00a0Antibiotic treatment in patients with chronic low back pain\u00a0<\/i>and vertebral bone edema (Modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy.\u00a0<\/i> <\/a> this paper reports the efficacy of antibiotic\u00a0treatment\u00a0in this group of patients with MC lesions and chronic low back pain. This double blind RCT study examined 162 patients with chronic low back pain (> 6 months duration) occurring\u00a0after a previous disc\u00a0herniation AND who had MC changes in the\u00a0vertebrae\u00a0adjacent\u00a0to the previous herniation. Subjects were\u00a0randomised to either 100 days of\u00a0antibiotic\u00a0treatment (Bioclavid) of two different\u00a0dosages\u00a0or placebo. Outcomes were evaluated at baseline, end of treatment and at 1 year follow up.<\/p>\n

Primary outcomes were the well accepted disease-specific disability Roland Morris Questionnaire as well as the report of lumbar pain. The\u00a0antibiotic\u00a0group made highly statistically\u00a0significant improvements on all outcome measures; the\u00a0improvement\u00a0continued from 100 days\u00a0follow\u00a0up\u00a0until\u00a01 year follow up. For\u00a0example, on the disease specific disability, the antibiotic group was 15 at baseline, 11 at 100 days and 5.7 at 1 year\u00a0compared\u00a0to placebo (15, 14, 14). The report of lumbar pain decreased much more in the antibiotic group who started at a score of 6.7 and improved to scores of\u00a0 5.0 (100 days) and 3.7 (1 year). The placebo group mean report of lumbar pain stayed constant at 6.3 from baseline through 100 days and 1 year (lower is better, of course).<\/p>\n

Biologically plausible time course<\/span><\/p>\n

Patients also reported that pain relief and improvement in disability commenced gradually, for\u00a0most patients 6-8 weeks after the start of the\u00a0antibiotic\u00a0tablets and for some at the end of the treatment period. Improvements reportedly continued long after the end of the treatment period, at least for another 6 months, and some patients reported\u00a0continuing\u00a0improvement at 1-year follow up. The\u00a0improvement seen in the antibiotic group at 1 year follow up was approximately twice that observed at\u00a0the end\u00a0of the 100 day treatment period, suggesting that a biological healing process that starts only when and after the bacteria have\u00a0been\u00a0killed.<\/p>\n

Half the\u00a0treatment\u00a0group took one Bioclavid (amoxycillin-clavulanate 500mg\/125mg)\u00a0tablet\u00a0three times a day while the other\u00a0half took two tablets. The authors state that the\u00a0long\u00a0duration of antibiotic\u00a0treatment\u00a0is commonly prescribed for post-operative\u00a0discitis. There was a trend towards an improvement\u00a0with\u00a0double dose, but did not reach significance.<\/p>\n

What\u00a0should\u00a0we\u00a0make of\u00a0these\u00a0papers?<\/span><\/p>\n

This\u00a0treatment\u00a0is\u00a0certainly\u00a0an\u00a0exciting\u00a0possibility for one of\u00a0the most\u00a0difficult management challenges in medicine.\u00a0 At this stage all the authors are saying is that in a particular sub-group of patients with chronic (>6 months) low\u00a0back pain, those with Modic changes on MRI scan after lumbar disc herniation\u00a0may respond\u00a0well to long term antibiotic treatment. We are\u00a0reluctant\u00a0to prescribe long term antibiotics for reasons of potential\u00a0development\u00a0of\u00a0resistance\u00a0but there seems to be a\u00a0rationale\u00a0for long term use in this situation. Further studies need to assess the\u00a0efficacy\u00a0of shorter terms of treatment. Because this is the BJSM blog, we can point out to readers that the group’s pilot study <\/a>was not accepted by a number of famous journals but saw the light of day via BJSM’s ‘peer-review fair review’ process. That paper came out in 2008.<\/p>\n

I\u00a0would\u00a0think\u00a0on the basis\u00a0of this\u00a0research it is reasonable to prescribe the recommended antibiotic program to those who strictly meet the clinical and MR imaging criteria. Especially if the only\u00a0alternative\u00a0seems\u00a0to be surgery\u00a0which\u00a0has limited\u00a0efficacy in these patients and is\u00a0obviously\u00a0vast\u00a0more expensive than a\u00a0course (albeit prolonged) of antibiotic therapy. Remember if you have this infection surgery will not be treating the cause.<\/p>\n

It took the Nobel\u00a0prize\u00a0winning\u00a0research\u00a0 on Heliobacter and its relationship to stomach ulcers of West Australians Barry Marshall and Robin Warren<\/a> to alert the skeptical medical community of the potential\u00a0of\u00a0infective causes of common conditions. Many investigators are currently seeking infective\u00a0causes for\u00a0a wide\u00a0variety\u00a0of\u00a0common and uncommon medical disorders. This research will encourage such investigation. Undoubtedly we will\u00a0find more\u00a0causal\u00a0infective\u00a0relationships.\u00a0Further work needs to be done to answer a range\u00a0of\u00a0questions (which antibiotic, what dose, how \u00a0long etc), but\u00a0these\u00a0two\u00a0papers\u00a0are an exciting step forward in the management\u00a0of a very difficult condition. If I were a\u00a0sufferer\u00a0of chronic low\u00a0back\u00a0pain I\u00a0would\u00a0be\u00a0feeling a\u00a0little\u00a0more optimistic after the publication of this research.<\/p>\n

Dr Peter Brukner (@PeterBrukner<\/a>)<\/b>,\u00a0<\/i><\/b>MBBS, FACSP,\u00a0<\/b>Sports Physician,\u00a0<\/b>Melbourne, Australia,\u00a0<\/b>is an experienced team physician and writing in his capacity at BJSM Senior Associate Editor and regular blogger.<\/i><\/p>\n

\"ModicBJSMCover\"<\/a>
Cover of December 2008 BJSM issue that included this group’s pilot study. We congratulate the Albert group of researchers for their persistent pursuit of better outcomes for patients – well done! For their 2008 BJSM paper see this link\u00a0 http:\/\/bjsm.bmj.com\/content\/42\/12\/969.full<\/figcaption><\/figure>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

It is not often that something I read in the medical research literature gives me goosebumps and an incredible urge to tell everyone I know about it (thank god for Twitter!). I had that feeling today when, after an article in this morning’s Guardian newspaper, I read two recent papers published by a Danish group […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[188,187,1898],"tags":[2963,2968,2970,8280,2969],"class_list":["post-4902","post","type-post","status-publish","format-standard","hentry","category-guest-posts","category-hot-topic","category-low-back-pain","tag-peterbrukner","tag-modic","tag-p-acnes","tag-peter-brukner","tag-the-guardian"],"yoast_head":"\n@PeterBrukner discusses today's major headline: Successful antibiotic treatment in a subset of people with chronic low back pain - BJSM blog - social media's leading SEM voice<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bjsm\/2013\/05\/08\/peterbrukner-discusses-todays-major-headline-successful-antibiotic-treatment-in-a-subset-of-people-with-chronic-low-back-pain\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"@PeterBrukner discusses today's major headline: Successful antibiotic treatment in a subset of people with chronic low back pain - BJSM blog - social media's leading SEM voice\" \/>\n<meta property=\"og:description\" content=\"It is not often that something I read in the medical research literature gives me goosebumps and an incredible urge to tell everyone I know about it (thank god for Twitter!). 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