The paper by  Hanne B. Albert et al “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“ throws up a fascinating possibility. That some back pain and sciatica is  caused by a pathogen and as such, can be treated by antibiotics .

The pathogen that could be causing this is Propionibacterium acnes.

If you think you recognise the “acne” bit. You’d be correct. The stuff that ruins your teenage years and gives you acne!
As Dr long in his article  “The Murky world of Mordic Changes” . says “there will always be a proportion of our patients who simply don’t respond to our care…….Could there be something far more ‘pathological’ that might perpetuate lower back pain”
To understand this issue you need to  vaguely understand “mordic changes”. These are changes in the bones marrow of the vertebral body either side of a damaged disc. In stage 1 changes these areas have increased levels of pro inflammatory cytokines and increased levels of innervation

“Propionibacterium acnes bacteria secrete propionic acid, which has the capacity to dissolve fatty bone marrow and bone. We hypothesize that diffusion of propionic acid from the disc into the vertebrae causes the Modic changes. Similarly, as increased TNF-alpha and the growth of PGP-5 unmyelinated nerve fibres have been reported in Type 1 Modic changes, with the inherent slowness of these pathological processes perhaps explaining the delayed onset of improvement observed in this study”.(Albert et al)

Needless to say, shooting up clients with lots of antibiotics has drawbacks!

“High-dose long-term antibiotics should not be prescribed without due consideration. Clearly in a condition as chronic lower back pain there is a potential community as well as individual hazard if used indiscriminately. However, as many patients, as in this trial, are on sick leave, at risk of losing their jobs and have a high analgesic intake, we suggest that antibiotics, when applied along the lines of this MAST protocol may be appropriate in this subgroup, i.e. chronic lower back pain with Modic Type 1 changes. We do not support the proposition that all patients with lumbar pain should have a trial course of antibiotics. The criteria in this study were very clear: chronic lower back for more than 6 months, Modic Type 1 changes in the adjacent vertebrae following a previous disc herniation. As we do with other drugs, we rely on our fellow colleagues to use clear evidence-based criteria and to avoid excessive antibiotic use.”

However antibiotic issues to one side, this treatment is mired in controversy .  Lars Bråten authored a report totally failing to find any beneficial effect.

“Efficacy of antibiotic treatment in patients with chronic low back pain and Modic changes (the AIM study): double blind, randomised, placebo controlled, multicentre trial” (click here for report ) tested patients with chronic low back pain and Modic changes at the level of a previous disc herniation. For three months they were treated  with amoxicillin. It  did not provide a clinically important benefit. These  results do not support the use of antibiotic treatment for chronic low back pain and Modic changes

I note though that that Albert experiment (Pro) used amoxicillin–clavulanate and the Braten report (Anti) used Amoxicillin. Im not clever enough to state whether this would have made any difference.
So, keep an eye on that research!
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