Last week, a very interesting study from Denmark was published, which suggested that chronic back pain may be improved or cured with an antibiotic regimen. The Orthopaedic world was abuzz with the news and many began dreaming of the immense changes that could be seen in the way chronic back pain is treated. Why so much excitement over a potential cure for chronic back pain? Perhaps some statistics are in order to help quantify why this news could be so significant…There are approximately 116 million U.S. residents (40% of the population) who suffer from some form of chronic pain, which costs the nation as much as $635 billion annually in lost productivity and health care expenses, according to an Institute of Medicine report. Large numbers of these patients will seek medical care through physical therapists, chiropractors or physicians and may even undergo surgery seeking pain relief. Obviously, the expense of such treatment is staggering, but more importantly, a large number of these patients will still have back pain after all of the medical treatments and the money spent. A significant number of these patients will also be unable to work or will not be able to return to a previous level of employment because of their back pain.
The diagnosis itself is not a difficult one to make, as “back pain” can be caused by multiple triggers. However, determining the actual cause of the back pain can be quite problematic. Simple back pain, related to muscle strain or overexertion, is generally self-limited and will improve over several weeks. Those that do not get better will be placed in the “chronic” category after experiencing back pain for a period longer than 6 months. The potential causes of the chronic back pain can range from fractures to arthritis to more complex nerve-related issues. There may be simple and effective long-term treatments for most of these patients, including arthritis medications and exercise programs, but when the pain persists despite appropriate treatments, these patients may undergo more invasive testing and procedures. Injections around the spinal discs or the small facet joints of the spine may help to decrease the arthritic grinding pain associated with degenerated cartilage in the spine. These injections have varied effectiveness and can last for several weeks or several years. Instability in the spine, associated with the bones or discs placing pressure on the nerves, will cause shooting pain into the leg, termed sciatica. These patients may proceed with a surgical intervention for the slipping of the bones and discs.
However, this new study adds a new dimension to the discussion of chronic back pain. As part of the study, the Danish research team did tissue cultures on all of the spinal disc material that was removed surgically at their hospital. The results of those tissue cultures showed that a large portion of these patients had an anaerobic bacteria grow from this material, even though the material was considered sterile at the time of surgery. This was an unexpected result. As noted in the study, the researchers then decided to treat those patients with back pain (for more than 6 months) and specific inflammatory signs (indicated on their MRI) with Amoxicillin/Clavulonate for 100 days and compare them to a group with the same signs and symptom, but who were treated with a placebo (a pill which contains no medication). They were surprised to find the patients treated with antibiotics did better than those that received the placebo. This seemed to prove the theory that a significant number of patients with back pain and inflammatory changes on their MRI will improve with an antibiotic regimen.
It is a very interesting theory and one that bears a need for further investigation. So far, this is the only study that has ever demonstrated an improvement in back pain with an antibiotic. This may add another element to the diagnostic scheme needed to find the cause of a patient’s back pain. It also may add another treatment for some specific back pains. However, there are real concerns about overuse of antibiotics, especially when used for 100 days. Patients that are on antibiotics too frequently may develop antibiotic- resistant strains of bacteria in their bodies. This can make treatment of minor infections, where an antibiotic is definitely needed, more difficult or lead to the growth of a much nastier bacteria.
Physicians are trained to look for evidence that a treatment consistently works and works well before applying it to our patient practice. While this study offers great promise, the results of this study need to be duplicated to ensure that the antibiotic protocol works time-after-time. Hopefully, the amount of antibiotic needed can also be decreased, in order to lessen the risk of super-bacterial infections.
Dr. Jeffrey R. Carlson is a Harvard Orthopaedic/Neurosurgical Spine Fellow and is Chief-of-Surgery at Bon Secours Mary Immaculate Hospital in Newport News, VA. He is the Managing Partner of Orthopaedic and Spine Center in Newport News, VA. For more information or for an appointment, contact OSC at 757-596-1900.