MODIC antibiotic therapy (MAST). Antibiotics for Back pain

There have been sporadic reports in the literature over many years that certain cases of back pain characterised by a particular MRI appearance of the vertebrae called Modic change (after the clinician who described them) are associated with the presence of low grade infection in the adjacent intervertebral disc.  In May of this year, Dr Hanne Albert of the University of Southern Denmark published a landmark trial of the use of high dose antibiotic (Augmentin/Co-Amoxiclav: a standard Penicillin based antibiotic) in a group of patients with back pain, with really excellent results (Eur Spine J. Online 13 Feb 2013, paper available on request). 

These were highly selected patients with a documented prior history of disc herniation (slipped disc with or without surgery) and Modic type 1 on MRI (there are 3 classifications – types 1-3) with a history of chronic and often very severe back pain for at least 6 months. Average pain was 6.7/10 and 52% had had daily pain in back and/or leg for over 2 years. Substantial reductions were seen in the treated group, but not in those treated with placebo (sugar pills).  At 1 year average disability scores fell from 15 – 7, back pain from 6.7/10-3.7/10, leg pain from 5.3-1.7, number of hours with pain in a month from 488 – 64 and days off work from 51 pa -18. No changes were seen in the placebo group. Overall just over 70% of cases may be expected to respond.

The hypothesis is that in these cases bacteria from skin or mouth get in ths blod when we wash or brush our teeth and can enter the disc when it is going through a pahse of  increased blood supply during healing after the injury. Since there is no blood supply to the disc in health or after healing, there are no immune cells to chew up the bugs and they can live quite happily causing low grade infection or discitis.

The treatment comprises double the usual maximum short-term dose (Co-amoxiclav 625, 2 tabs 3-times/day) sustained for 100 days. Usual side effects are diarrhoea to start, occasional are skin rashes or other minor and there is a rare risk of antibiotic related colitis which could be a very severe illness.

Before this can be accepted as a generally  applied treatment, these result will have to be repeated in other places and in larger numbers, so at this point the medical community is cautiously welcoming the possibility.

My patient is a 51 year old man who had surgery for slipped disc 13 years ago. He did well initially then gradually experienced worsening episodes of back pain and spasm provoked by simple activities (lifting etc), eventually entering the phase of significant, continuous pain.  Daily pain was rated 5-6/10 with frequent worsening, pain disturbed sleep, intruded and restricted daily activities etc. MRI showed typical Modic type 1 change.

After 100 days MAST treatment, he is pleased to report he has almost no back pain of any sort.

This is an impressive result in what would otherwise be a difficult to treat case.  How this response in selected groups of patients will play out in the more general case is not known but meantime the patients of this type, there appears to be a new treatment available.

Figure 1

Modic

Modic type 1 changes at the L5/S1 vertebral end-plates (Bright pattern around the L5/S1 the disc on left, going dark in the second imaging sequence on the right)