Pills instead of surgery?

It is not every day you find something as beautiful as research that can change your perception of the world. The image is CC from photophilde.
It is not common to find something as research that can change your perception of the world – it’s a beauty. The image is CC from photophilde.

I recently stumbled upon one of the most interesting articles in a while. Albert et al. questioned the long-standing theory behind low back pain by doing a double-blind randomized clinical controlled trial. They randomized patients to antibiotics or placebo for 100 days and found an impressive effect on pain and other outcomes in the treatment group.

While acute low back pain generally subsides within a couple of weeks, chronic low back pain is often difficult to treat. We have traditionally treated these patients with pain killers and physiotherapy. In those where we suspect disorders such as disc degenerative disorder we try to perform heroic surgery where fusion between vertebral bodies, disc arthroplasties (se Berg et al’s study) and more has been tried. The SweSpine register has shown that many improve after surgery and remain that way after surgery although randomized trials such as Brox et al’s fail to show much benefit with surgery.

Albert et al. had noticed that bacterially “contaminated” cultures from the discs are more common among patients with low back pain issues. This combined with that MRI-changes that may indicate infections (Modic-type I) are 6-times as common in this population, made them pose the question: what if a low virulent bacteria was causing this disease? Armed with this hypothesis they decided to do a RCT-trial with antibiotic treatment as the active treatment group.

The cohort

The cohort was very broadly defined with MRI-identified previous disc herniations between 6-24 months, chronic low back pain and presence of Modic type I changes in a recent MRI scan. It is interesting that they did not exclude previous surgery, and the only slightly strange criteria was the previous disc herniation (see my random thoughts below).

The results

The results were overwhelming to say the least:

  • Both the disease specific score and the back pain was sliced in half for the treatment group while the controls remained the same
  • Leg pain was reduced to one third while the controls remained the same
  • One third reported not to have low back pain at all compared to unchanged in the treatment group
  • Three out of four had no longer constant pain while the controls dropped by less than one out of ten

To summarize: it seems that all outcomes that matter were changed in favor for the treatment group – they did not have to cherry-pick the best outcomes.

Random thoughts

A few random thoughts have struck me as I read the article:

  • Why was this not published in NEJM/Lancet or some other high-ranking journal? This has major potential to change our view of spine pathology while at the same time being of general interest.
  • They collected C-reactive protein (CRP) but I was not able to find this in the tables or the text. The blood tests reported were mostly uninteresting, CRP and erythrocyte sedimentation rates (SR) would be of interest and more relevant than most of the reported tests.
  • Why did they focus on patients with previous disc herniations? There is a high false-positive rate for these findings – Boden et al showed lumbar disc herniations in 1/3 of patients in healthy subjects.
  • How soon can we get some kind of confirmation study?

H. B. Albert, J. S. Sorensen, B. S. Christensen, and C. Manniche, “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,” Eur Spine J, vol. 22, no. 4, pp. 697–707, Apr. 2013.

S. Berg, T. Tullberg, B. Branth, C. Olerud, and H. Tropp, “Total disc replacement compared to lumbar fusion: a randomised controlled trial with 2-year follow-up,” European Spine Journal, 2009.

J. I. Brox, O. Reikerås, Ø. Nygaard, R. Sørensen, A. Indahl, I. Holm, A. Keller, T. Ingebrigtsen, O. Grundnes, J. E. Lange, and A. Friis, “Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: A prospective randomized controlled study,” Pain, vol. 122, no. 1–2, pp. 145–155, May 2006.

S. Boden, D. Davis, T. Dina, N. Patronas, and S. Wiesel, “Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation,” J Bone Joint Surg Am, vol. 72, no. 3, pp. 403–408, Mar. 1990.

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