Bacteria: back pain, leg pain and Modic sign—a surgical multicentre comparative study

Abstract

Purpose To compare bacterial findings in pain-generating degenerated discs in adults operated on for lumbar disc herniation (LDH), and mostly also suffering from low back pain (LBP), with findings in adolescent patients with non-degenerated non-pain-generating discs operated on for scoliosis, and to evaluate associations with Modic signs on magnetic resonance imaging (MRI). Cutibacterium acnes (Propionibacterium acnes) has been found in painful degenerated discs, why it has been suggested treating patients with LDH/LBP with antibiotics. As multidrug-resistant bacteria are a worldwide concern, new indications for using antibiotics should be based on solid scientific evidence. Methods Between 2015 and 2017, 40 adults with LDH/LBP (median age 43, IQR 33–49) and 20 control patients with scoliosis (median age 17, IQR 15–20) underwent surgery at seven Swedish hospitals. Samples were cultured from skin, surgical wound, discs and vertebrae. Genetic relatedness of C. acnes isolates was investigated using single-nucleotide polymorphism analysis. DNA samples collected from discs/vertebrae were analysed using 16S rRNA-based PCR sequencing. MRI findings were assessed for Modic changes. Results No bacterial growth was found in 6/40 (15%) LDH patients, compared with 3/20 (15%) scoliosis patients. Most positive samples in both groups were isolated from the skin and then from subcutis or deep within the wound. Of the four disc and vertebral samples from each of the 60 patients, 235/240 (98%) were DNA negative by bacterial PCR. A single species, C. acnes, was found exclusively in the disc/vertebra from one patient in each group. In the LDH group, 29/40 (72%) patients had at least one sample with growth of C. acnes, compared to 14/20 (70%) in the scoliosis group. Bacterial findings and Modic changes were not associated. Conclusions Cutibacterium acnes found in discs and vertebrae during surgery for disc herniation in adults with degenerated discs may be caused by contamination, as findings in this group were similar to findings in a control group of young patients with scoliosis and non-degenerated discs. Furthermore, such findings were almost always combined with bacterial findings on the skin and/or in the wound. There was no association between preoperative Modic changes and bacterial findings. Antibiotic treatment of lumbar disc herniation with sciatica and/or low back pain, without signs of clinical discitis/spondylitis, should be seriously questioned. Graphic abstract These slides can be retrieved under Electronic Supplementary Material.

Antibiotics should not be used for back/leg pain

“…That is what the Swedish study (Fritzell et al. 2019 ) produced evidence of. Manniche claims that the presence of “aggregates and biofilm” and “local inflammatory response” disproves the evidence.…”

“…acnes is a commensal of the skin flora with the potential to contaminate sampling procedures. That is what the Swedish study (Fritzell et al 2019) produced evidence of. Manniche claims that the presence of "aggregates and biofilm" and "local inflammatory response" disproves the evidence.…”

“…2. Fritzell et al (2019) also refer to their own biopsy article in which they found no evidence of bacteria in the disc material from several patients and in which they conclude that if bacteria were found in an individual patient that this would be due to a contamination process due to the biopsy itself. Many studies (20+) have disproven the contamination hypothesis during the years (Capoor et al 2019, Manniche and O'Neill 2019.…”

Chronic Low Back pain, Modic Changes and low-grade Virulent Infection: Efficacy of Antibiotic Treatment

“…This knowledge should inspire researchers to carry out further studies as regards both diagnostics and treatment. Researchers in this field who previously have expressed skepticism regarding an infectious pathway may consider re-evaluating their positions; the evidence is now beyond reasonable dispute [ 27 , 28 ].…”

Modic changes in the lumbar spine: histology, risk factors, clinical presentation and treatment

“…Infectious theory of the MСs1 development is the most frequently debated [19,28,29]. Most studies feature strong evidence as to the MСs being a form of chronic inflammatory process, associated with a gram-positive anaerobic Propionibacterium acnes (P. Acnes / Cutibacterium acnes / C. acnes) bacterium [30,31] present as a relatively pathogenic flora on the skin, in the mouth cavity, intestinal tract and external auditory meatus [32].…”