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Modic Antibiotic Spine Therapy
Research has shown that there is a subgroup of people with back pain that relates to a low grade of infection in damaged discs.
These bacteria can produce a substance called propionic acid which can then damage the adjacent bone and produces characteristic appearances on MRI scans called Modic changes.
The pain arises because of the effect of propionic acid on the bone which then is reported to cause microfractures which are painful. The researchers suggest that Modic-related low back pain could account for perhaps 20-40% of all chronic low back pain.
What is Modic Antibiotic Spine Therapy?
Modic Antibiotic Spine Therapy (MAST) is an experimental treatment for chronic low back pain. It is based on the theory that some cases of severe back pain are caused by a low-grade bacterial infection in the spinal discs—often Cutibacterium acnes—following a previous disc injury.
Who is suitable for this treatment?
An MRI scan is essential for making this diagnosis to find the appearances described by Dr Michael Modic. He described 3 different types, graded 1 – 3, which have different appearances on MRI and it is the Type 1 changes that are most closely related to severe back pain. Type 2 changes may also be associated but the relationship is less strong.
Not all people with back pain require an MRI scan. However, if you do have a scan and it shows Modic Type 1 changes, and your symptoms and examination findings are compatible, then MAST treatment is a possible treatment option.
You will need a 100-day course of a specific antibiotic, taking it three times a day, in order to eradicate the bacteria and so should not be undertaken lightly.
It is very important that the treatment is sustained for as long as prescribed for it takes this time for the antibiotics to penetrate into the disc in sufficient quantity to kill these low-grade bacteria.
The antibiotic of choice is one of the penicillin group called Co-Amoxiclav. For those allergic to Penicillin there is an alternative antibiotic, Doxycycline, which can be used.
As with all medication, MAST therapy carries some risks.
There is the risk of an allergic response to the antibiotic and you should not take it if you have a known allergy. There may also be risks related to the action of the antibiotic on the normal flora of bacteria in the gut (resulting in diarrhoea) and mouth or perineal (resulting in thrush).
If you develop severe diarrhoea you should stop taking the MAST therapy and see your doctor. Rarely, the bowel can be taken over by a bacterium called Clostridium difficile which produces severe diarrhoea. Doxycycline should not be taken during pregnancy or breast feeding.
Avoid exposure to sunlight or tanning beds if taking Doxycycline which can cause your skin to burn more easily or develop rashes. Wear protective clothing and use sunscreen (SPF 30 or higher) when you are outdoors. Report any adverse effects to your doctor.
It will take 6-8 weeks for the antibiotics to kill the bacteria and the symptoms will slowly improve over this time. You must continue with the antibiotics for the full 100 days.
The symptoms can continue to improve for over a year after starting treatment.
Physical activity is restricted during the treatment phase and can then progressively increase as long as symptoms of back pain do not worsen.
The need to refrain from significant physical activity relates to the micro-fractures. The bone has to heal before you can exercise again.
After the 100 days, you can begin to very gradually increase the amount of exercise you do. Add a little more activity each week and see if it can be tolerated before adding any more.
If the discomfort increases then reduce to the previous level. This is known as “pacing” and is individual, and probably the hardest aspect, but one of the most important.
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