Antibiotic Spinal Therapy: Can We Just Cut It Out?
There has been much controversy since the inception of antibiotic spinal therapy; some warranted, much based on questionable motives unrelated to the concerns regarding documented evidence and patient suffering as well as consequences to society in terms of lost productivity and quality of life.
Well noted is the recent change of the name to Cutibacterium from Propionibacterium acnes. Now pronounced as cut-ee-bacterium, presumably derived from the cutaneous nature involved with the skin condition acnes, it’s note as an opportunistic pathogen does not make it cute, however, many surgeons would like to cut it out, especially when it comes to back pain and/or leg pain (sciatica).
A 2019 study in the European Spine Journal highlights some problems in the understanding of clinically relevant Modic I changes and back/leg pain, as well as virtue/alarm signaling.
In this article, the authors performing surgery, state, “Cutibacterium acnes (Propionibacterium acnes) has been found in painful degenerated discs, why it has been suggested treating patients with LDH/LBP with antibiotics.” Is this a question? Is the “why” supposed to be “where”? In either case, they are clearly questioning using antibiotics for LDH/Low Back Pain.
The authors continue, “As multidrug-resistant bacteria are a worldwide concern, new indications for using antibiotics should be based on solid scientific evidence.” I agree, however, this is not new and it is based on well established scientific evidence dating over a decade, however; the authors/surgeons seem to ignore much of the specific scientific evidence, choosing to generalize based on the least scientifically sound evidence and focus on scare tactics. Cut it out!
No reasonably treating doctor is suggesting treating disc herniation and or low back pain using antibiotic spinal therapy. This is common sense and would seemingly eliminate the “where” explained above. This is simply absurd! They ignore the specific indications established for a trial of antibiotics using the protocol indicated only in a specific subset of patients exhibiting Modic Type I changes; a self-limiting, non-contagious condition.
The authors indicate Modic changes and not specifically Modic Type I, as there are very different subjective and objective findings that are well established. Similarly, I cannot imaging where surgery is indicated for every instance of low back pain and/or sciatica, however, I can easily make a statement that we should just cut it out where we find it. Works for me – if I’m a surgeon.
How about some reasonable alternatives and some specific indications, presuming there are specific indications for surgical treatment to minimize failed back surgery, possible complications, and side effects. The more specific we get, the less we are concerned about multidrug-resistant bacteria and the worldwide concern; as if the protocol established for successful implementation of antibiotics for functionally disabling Modic I changes would be the main culprit. This is a concern if we are treating all instances of “Modic changes” and any related disc herniation and/or low back pain, however, to suggest this is irresponsible and self serving regardless of the discipline.
Since the ground breaking work of Dr. Albert over a decade ago, many in the medical community have suggested this will lead to treating all back pain with antibiotics. However, surgeons have addressed this with surgery and others address it with alternative, more expensive biologics with significantly more ominous side effects. All in the name of preventing antibiotic abuse and the worldwide concern about multidrug-resistant bacteria? Really?
Even with scientific proof that antibiotics can successfully manage Modic tye I changes in select patients, the hysteria just increases. However, the specific history and objective findings for clinically relevant Modic I changes related to subclinical bacterial infection have been outlined and do not represent anyone with Modic changes and back pain. Are antibiotics used before, during, or after surgery? Maybe we should cut that out?
Biopsies seeking to prove P. acne in sampled discs range from 0 to 55%. Obtaining sterile biopsies from the vertebra and disc and analysis is technically and methodologically challenging. This has led to different conclusions being drawn from the literature. With such contradictory data based on current methods, these conclusions should not be the basis for determining treatment.
The FISH (fluorescence in situ hybridization) method provides the basis for more solid conclusions than previous investigations using PCR techniques and culturing methods. This can detect a protective biofilm inside the disc caused by some strains of the Propionibacterium acne. This biofilm induces an inflammatory reaction with resulting tissue
Biofilm is a slimy, thin, layer which binds the bacteria together. It also functions as a chemical communication system and provides protection against the outside environment like attacks from the immune system. So, attention clinically must be focused on a more fundamental discussion of relevant functional effects that Modic changes has on the patient instead of broad statements based on questionable methodological issues.
The scientific evidence indicating the effectiveness of antibiotic spinal therapy for Modic change and back pain is compelling, however; despite general lack of answers calling for replication, it is clearly not an isolated isolated phenomenon. Antibiotics should be considered as a treatment option a special subgroup of patients with persistent back pain and confirmed Modic I changes, considering it can be a chronic disabling condition that can occur in the most productive time of life. Rightly have Manniche and O’Neill noted the evidence for antibiotic spinal therapy and future indications based on scientific literature and clinical experience.
Antibiotic Spinal Therapy: Diagnosing & Treating Chronic, Treatment Resistant Back Pain Where Low-Virulent Bacterial Infection Is Suspect
- Patient presents with well localized and persistent back pain
- Exacerbation with exercise therapy
- Awakens during the night with pain
- Reports stiffness for more than 30 minutes in the morning
- Disc herniation or breach within the previous 2 – 3 years, with subsequent improvement of any sciatica, but back pain remains or increases
- Conservative treatments explored without improvement
- Average pain intensity greater than 4/10 with functional disability
- MRI: Modic change Type I or I/II mixed within the relevant painful location
Antibiotic Spinal Therapy: Considerations
- This is not a standardized treatment protocol in the medical community, yet
- Treatment should be followed closely by the responsible doctor.
- Patient education is crucial for best results and compliance
- Treatment offered after careful consideration of the individual Modic change case
- Patient’s pain is persistent with significant functional affect
- Relevant conservative therapies explored without sufficient effect: Consider antibiotics (general practitioner or rheumatologist
- Minimum single dose application: Amoxicillin/Clavulanic acid 500 mg × 3/day for 100 days.
- Note common side effects and/or complications: fatigue, diarrhea, fungal infections, allergic reaction, liver-enzymes, etc.
- Effects of antibiotics likely to manifest after 2 – 4 months. Slow improvements for following 12 months are often noted.
Questions For Future Management Of Modic Changes
- Can we develop reliable methods of differential diagnostics of low-virulent infectious changes in comparison to strictly mechano-immunological?
- Can we determine prevalence for an infectious pathway as a clinically important condition?
- Are infectious pathway Modic changes preventable?
- Can we identify patients for whom anti-microbial treatment is more efficacious as opposed to anti-inflammatory treatment? Which management protocol(s) are associated with the least complications and are most effective and for the patient as well as environment?
Regarding a 2019 article where it was stated “We aimed to replicate the findings in the former randomised trial”, it should be noted the study deviated from the former trial. The authors present criticisms of the trial by other authors, but fail to acknowledge responses by the previous study author directly addressing the criticisms.
This clearly sets the tone and bias of the study.
The aimed replication included 750mg of amoxicillin for 90 days, including both Modic I and II participants; whereas the original trial was amoxicillin–clavulanate (500 mg/125 mg) tablets three times a day, at 8 h intervals, for 100 days, including a double dose group that proved better efficacy.
The authors of this study indicate, “…we chose to include patients with type 2 Modic changes because differentiating between type 1 and type 2 Modic changes is of uncertain relevance…”, a rather suspicious statement given the well established differences, also not included in the original study.
The authors additionally state, “About 40-50% of patients with non-specific low back pain have Modic changes, and antibiotic treatment in subgroups of this large patient population could increase antibiotic resistance.” Another example of generalizing and alarmist statements, as nobody is suggesting treating All Modic changes and back pain with antibiotics! Did they?
Perhaps the almost thirty listed authors of the new study do not understand or want to broaden the term “replication” for intended effects.
A Study Update
Following up on their previous study , the authors of a 2020 publication  sought to retrospectively find clinical effect modifiers of antibiotic treatment in patients with chronic low back pain and Modic changes. The previous study included both type I and II. They found a slight effect for younger age, however, it should be noted the authors indicate:
“However, these explorative results should be interpreted with great caution, and require confirmation in future studies. Further, our predefined subgroups should be interpreted as surrogate subgroups, meaning that there is no claim of a causal mechanism involved.”
“However, this theory has not been confirmed and it is uncertain how our results for treatment modifiers would have been in patients without a previous disc herniation.”
“Our results indicating age as an effect modifier may represent a type I error due to multiple testing. The present findings should therefore not influence clinical practice.”
The Cognitive Dissonance Continues
A Swedish article is titled, “Antibiotics should not be used to treat patients with back/leg pain”. The authors cherry pick 3 studies to make this conclusion, ignoring relevant information and the plethora of relevant studies on Modic changes to make this claim. The authors state, “Antibiotic resistance is one of the biggest threats to public health today and in the future”.
I do agree that antibiotics should not be used to treat back or back related leg pain, however, who is suggesting this as a blanket statement? If it was to treat anyone with back pain and/or related leg pain, even Modic changes in general, antibiotic use should not be considered. That is not the question. The preponderance of literature does suggest that treating Modic Type I changes that include back and/or rarely related leg pain, with specific objective and subjective findings in history and examinations, a self limiting, non-contagious condition, is absolutely warranted. Antibiotic resistance is a completely different situation and certainly not related to responsible use in specific cases that can save a lifetime of pain, suffering and disability.
A recent study  indicates self-reported understanding of 14 terms including terms like annular fissure, disc degeneration, disc extrusion, disc protrusion, facet joint degeneration, high intensity zone, and Modic changes among others is poor. From 774 responses 35% reported understanding the term ‘disc degeneration’, while only 10.5% reported understanding the term ‘Modic changes’.
The authors conclude, “Common and usually non-serious terms in lumbar spine imaging reports are poorly understood by the general population and may contribute to the burden of LBP [Low Back Pain].” There are many terms with serious implications that are not very common that were used. They seem to lump all noted findings into single groups to generalize in efforts to justify decreased use of imaging…. or paying for imaging.
The authors also indicate that for all terms used, up to 71% considered they indicated a serious back problem, that pain might persist and they would be fearful of movement – up to 57%. It seems logical to be fearful of terms relating to pain conditions that you do not understand. Were they explained regarding severity and details for each individual? Since when are we treating names on imaging findings and not people?
Moving The Window of Discourse
A recent study proposal for trial  is titled, “Is antibiotic treatment effective in the management of chronic low back pain with disc herniation?” The answer is obviously, no! Nobody is stating it is, why even ask or spend money to find out? So they can say they have scientific proof it does not and push a preconceived narrative?
The authors of the proposed study state, “There has been immense interest and debate regarding the effectiveness of antibiotic treatment for chronic low back pain.” No there is not. What would be the evidence for that? The secondary investigation is, “… investigate whether the presence of Modic changes predicts response to antibiotic therapy.”
There is evidence that a specific subset of individuals with Modic type I (there are 3 types, including combined or mixed types) with a specific set of objective and subjective findings that can respond to antibiotics, regardless of current disc herniation. In other words, there is evidence of a specific phenotype of chronic back pain patients that can respond to antibiotics.
But now they have broaden it to focus on chronic low back pain with disc herniation and, secondarily, seemingly incidental findings of Modic changes. They do not state all 170 recruited patients with chronic lower back pain and disc herniation will have Modic I changes with specific subjective and objective findings.
It is a means to an end, to move the window of discourse. To state that antibiotics do not help chronic low back pain and disc herniation with or without Modic changes. This is not antibiotic spinal therapy proven efficacious in 2013. Nobody is saying antibiotics should be used to treat chronic back pain with or without disc herniation or with or without any type of Modic change. Why not get more specific instead of more general. The answer is obvious. Cut it out!
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