Vertebral Endplate Changes / Modic Changes: An Audit Study Using Antibiotics in 147 Chronic Low Back Pain Patients
Authors: Manniche Claus , Morsø Lars , Kiertzner Lene 
Published: April 2016

Introduction

Vertebral endplate changes/Modic changes (MC) are the MRI-image of inflammatory vertebral endplate damage.1 In patients with chronic back pain, the prevalence of (MC) is 40%.2 MC are most often related to general disc degeneration or herniation.3 However, in a subgroup of patients, disc infection may be involved.4,5 In one high quality RCT more than 50% of patients with persistent pain and prolapsed discs showed clinically significant improvement after treatment with a broad spectrum antibiotic at 6 Month Follow Up (6MFU).6

Material and Methods

A cohort study was established to evaluate the effect of treatment with Amoxicillin/ Clavulanic Acid for 3 months. 70 patients were treated with 1 1/2 g per day for one month followed by 3 g per day for 2 months (HighDose). Another 77 patients were treated with 2 g per day for 3 months (LowDose). The clinical profile of the included patients: referred to a secondary care outpatient Spine Centre with persistent low back pain and lumbar MC Type 1 and no effect of other non-surgical treatment forms. Main outcome measures at 6MFU: Patient's global assessment (Global), change in spinal pain intensity on a 0–10 numerical rating scale (DeltaPain) and Number of Days with Pain (DaysPain) over a 14 day period. Responders were compared with non-responders.

Results

147 patients (95 females) were included. The outcome analysis compares the treatment effect of the responders to the non-responders. Overall, 78/147; 53.01% of the patients stated a positive responder treatment effect after 6 months. DeltaPain in ‘the responder group’ at 6 months follow up was -29.96%[SD 36.2%] and in ‘the non-responder group’ 2.16% [SD 43.3%]. DaysPain decrease in ‘the responder group’ at 6MFU were 22.17% [SD 60.3], and in ‘the non-responder group’ an increase of 28.07%[SD 153.6]. Substantial side effects were noted in 17/70(24%) patients in HighDose and 12/77(16%) in LowDose patients. Minor side effects: 17/70(24%) of patients in HighDose and 14/77(18%) patients in LowDose. No difference in responderrate were seen between HighDose/ LowDose; 52.9%/53.3%.

Conclusion

The antibiotic treatment regime in this group of low back pain patients represented positive outcome results for 53% of the patients. At 6MFU clinically relevant improvements regar- ding pain intensity were obtained and numbers of days with pain was reduced by 22%. A higher number of side effects was seen using HighDose antibiotics compared with LowDose, but there was no difference in treatment efficacy. References Modic MT, Steinberg PM, Ross JS, Masaryk TJ, Carter JR. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology 1988;166(1 Pt 1):193–199 Kjaer P, Korsholm L, Bendix T, Sorensen JS, Leboeuf-Yde C. Modic changes and their associations with clinical findings. Eur Spine J 2006;15(9):1312–1319 Albert HB, Kjaer P, Jensen TS, Sorensen JS, Bendix T, Manniche C. Modic changes, possible causes and relation to low back pain. Med Hypotheses 2008;70(2):361–368 Hongli W, Jianyuan J. Re.: Axial gout is frequently associated with the presence of current tophi, although not with spinal symptoms. Spine 2015;40(8):587 Zhou Z, Chen Z, Zheng Y, et al. Relationship between annular tear and presence of Propionibacterium acnes in lumbar intervertebral disc. Eur Spine J 2015;24(11):2496–2502 Albert HB, Lambert P, Rollason J, et al. Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae? Eur Spine J 2013;22(4):690–696