Antibiotic treatment in patients with low-back pain associated with Modic changes Type 1 (bone oedema): a pilot study

Abstract

Objective: The aim of this study was to assess the clinical effect of antibiotic treatment in a cohort of patients with low-back pain (LBP) and Modic changes Type 1 (bone oedema) following a lumbar herniated disc. Design: This was a prospective uncontrolled trial of 32 LBP patients who had Modic changes and were treated with Amoxicillin-clavulanate (500 mg/125 mg) 3 6 day for 90 days. All patients had previously participated in a randomised controlled trial (RCT) that investigated active conservative treatment for a lumbar herniated disc (n = 166). All patients in that RCT who had Modic changes and LBP at 14 months follow-up (n = 37) were invited to participate in this subsequent antibiotic trial but five did not meet the inclusion criteria. Results: 29 patients completed the treatment, as three patients dropped out due to severe diarrhoea. At the end of treatment and at long-term follow-up (mean 10.8 months) there was both clinically important and statistically significant (p(0.001) improvement in all outcome measures: LBP intensity, number of days with pain, disease-specific and patient-specific function, and global perceived effect. Conclusions: In this uncontrolled trial, the clinical effect of antibiotic treatment was large in a group of patients with Modic changes suffering from persistent LBP following a disc herniation. These results provide tentative support for a hypothesis that bacterial infection may play a role in LBP with Modic changes and indicate the need for randomised controlled trials to test this hypothesis.Modic changes (bone oedema) in vertebrae are an imaging finding recently identified as a prevalent pathoanatomical finding that is commonly associated with low-back pain (LBP).1 2 Modic changes are only visible on magnetic resonance images (MRI) 3 and three subtypes have been identified (Types 1 to 3). From histological studies of material harvested during surgery, Modic changes Type 1 involve disruption and fissuring of the endplate with regions of degeneration, regeneration, reactive bone formation, endplate oedema and vascular granulation tissue.3 4 Type 1 are seen on T2-weighted MRI as areas of increased signal intensity and on T1-weighted MRI as low signal intensity extending from the vertebral endplates.There is an association between Modic changes and LBP.1 2 A recent systematic review of Modic changes and LBP identified 77 study samples from the general, working, and clinical populations. The median prevalence rate for any type of Modic change was 46% in patients with non-specific LBP and 6% in non-clinical populations. A positive association between Modic changes and nonspecific LBP was found in 70% of studies with odds ratios ranging from 2.0 to 19.9. 5

Correlação entre as classificações de Pfirrmann e Modic na degeneração do disco intervertebral lombar

“…Alterações do tipo Modic são largamente relacionadas, por diversos autores, como fonte de dor lombar 4,7,8,11,15 , principalmente no tipo 1, como apontado por Albert e Manniche 6 . Porém, da mesma maneira que alterações degenerativas discais permanecem com etiologia desconhecida, as mudanças de sinal dos corpos vertebrais são indicadas por diversas causas, como: a) alterações de arquitetura interna dos discos que liberam mediadores quí-micos ou que facilitariam microfraturas do platô vertebral 27 ; b) hérnia discal 27 ; c) causas infecciosas 28 ; d) nódulos de Schmorl 5 ; e) causas tumorais 26 . No presente estudo, a grande maioria dos pacientes não apresentava alterações tipo Modic (88,3%), além de não ser encontrado nenhum Modic tipo 3, situação considerada rara 5,15,26 .…”

Propionibacterium acnes: infection beyond the skin

“…These associate Modic type 1 changes, (indicating fissuring and edema of the endplates) with low back pain. Antibiotic treatment with amoxicillin-clavulanate has been shown to improve low back pain, suggesting that infection may play a role in low back pain with Modic changes [74].…”

Treatment of bone marrow lesions (bone marrow edema)

“…35 This notion is further supported by the fact that antibiotic therapy has been shown to be effective in reducing back pain in these patients. 36 Metabolic/endocrine lesions Tissue Deposition of uric acid or hydroxyapatite crystals in the gout or connective tissue disorders are associated with BML. 37,38 Latrogenic lesions Damage to the bone marrow by surgery or radiotherapy also causes BML.…”