ne marche que dans certains cas
Antibiotic treatment in patients with low-back pain
associated with Modic changes Type 1 (bone
oedema): a pilot study
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) 36day
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
Infection is one hypothetical cause of Modic
changes Type 1.6 Both Van Goethem et al7 and
Modic et al8 showed that vertebral endplate signal
changes resembling Modic changes Type 1 were a
sensitive indicator for spondylodiscitis or disc space
infection. Caragee9 observed that about one-third
of patients with pyogenic vertebral osteomyelitis
were infected with low-virulent bacteria. When
antibiotics were given, the majority recovered and
became pain- and symptom-free. Similarly, in
nuclear tissue removed under sterile conditions
during surgery for lumbar herniated discs, 53% of
patients were found to be infected with lowvirulent
anaerobic organisms (Propionibacterium
acnes and Corynebacterium propinquum) in contrast
to no patients who were operated on for other
spinal disorders.10 Stirling et al,10 11 therefore,
hypothesised that patients with sciatica sustain a
breach in the mechanical integrity of the spinal
disc, possibly from minor trauma, which allows
access by low-virulent microorganisms.10
The aim of this pilot study was to test antibiotic
treatment in a group of patients with Modic
changes Type 1 and LBP following herniation of a
lumbar disc.
