Should DWMRI Be Routinely Recommended For Modic 1 Changes?

We already know that Dr. Albert has indicated those with osteophytes and scoliosis do not respond well to the antibiotic protocol. She recommends against antibiotics in these cases. So, we can rule out DWMRI in these instances.

Hi mastdoc,

You are raising very important questions.

We know that a negative biopsy to the disk does not rule out for sure the existance of p.acnes. The culture of p.acnes is difficult to obtain as the bacteria is anaerobic. One well known imunologist is Lisbon agreed to develop a vaccine for p.acnes and it was not easy as he told me. Only one laboratory in Madrid managed to get the culture and the vaccine. We also know as well that this p. acnes infection is of low virulence, not showing in blood analysis and maybe in the dw-mri, as well.

I agree that further invetigations need to be done.

Just a short story from a patient who undertook the 100 day Amoxiclav trial earlier in 2014, I will forever be indebted to the spinal consultant who agreed the trial but not the GPs who refuted vigorously that the severe Modic 1 changes on MRI could be related to p.acnes as my blood tests were 'normal'. In reality the Lymphocytes were at the lowest possible end of the scale and the Globulins at the highest end of the 'normal' range. For what it is worth Frizell, Bergstrom and Olsen detected bacteral DNA in p[ainful degenerate discs in patients without signs of clinical infection. Pre treatment biopsy was not considered necessary, whether this was a financial consideration or a health risk I do not know. I read that Lipid S could have been tested as a marker for anaerobic bacteria but this was not done.

What I can say is the result has been miraculous. For seven years I suffered day in/day out severe pain which has now dissipated. For what it is worth I had lost 75% of height of two lumbar vertebrae and have osteoporosis in both  vertebrae with osteopaenia in the rest of the spine.. I also have some L5/S1 arthropathy. I would not exclude people like myself from an antibiotic course. I have been saved from a lumbosacral fusion..........

Spondylodiscitis, an infection of the spine that includes spondylitis (inflammation of the vertebrae) and discitis (inflammation of the vertebral disk space).

Gram-positive organisms cause most spine infections in both adults and children, with 40% to 90% caused by Staphylococcus aureus. Gram-negative organisms (Escherichia coli, Pseudomonas, and Proteus), which can also cause spondylodiscitis, typically occur after genitourinary infections or procedures. IV drug abusers are prone to Pseudomonas infections. Anaerobic infections may be seen in patients with diabetes or after penetrating trauma - should this include disc herniation? Salmonella species can cause spondylodiscitis, especially in patients with sickle cell disease from an intestinal source.

Spondylodiscitis is an important differential diagnosis of lower back, flank, groin, and buttock pain. It’s important to be aware of this diagnosis, especially in patients who have risk factors such as IV drug abuse, diabetes, and morbid obesity. Although previous spinal surgery is a risk factor, spondylodiscitis should be considered in patients with persistent back pain even if they haven’t had spinal surgery. It can be present even when there is no tenderness over the spinous process or any fever.

Mycobacterium tuberculosis is the most common nonpyogenic infecting agent that also can cause spondylodiscitis. Infection caused by tuberculosis has had a recent resurgence with resistant strains, especially in patients with human immunodeficiency virus. Although less than 10% of patients with TB have skeletal involvement, 50% of the skeletal involvement occurs in the spine.

In patients with discitis, the patient’s WCC will be normal, but the ESR is almost always elevated. Checking inflammatory markers is a reasonable next step if a patient’s pain does not resolve after at least 4 weeks. If levels of inflammatory markers such as CRP and ESR are elevated and symptoms continue, MRI can confirm or rule out the presence of spondylodiscitis. Treatments include orthotic support, antibiotics, and surgical intervention when complications arise.

Untreated spondylodiscitis can also send distant infective emboli and cause endocarditis or mycotic abdominal aneurysm. Historically, mortality in patients with vertebral osteomyelitis has been as high as 25%. The combination of earlier diagnosis, antibiotics, and surgical debridement and stabilization has decreased mortality to less than 15%.

I don't think anyone is dying from Modic changes, but there is some fierce competition for medical dollars nonetheless. So, are Modic changes greater than gade 1 (endplate only) considered spondylodiscitis? Osteomyelitis? Grade 1 - discitis?

Maybe DWMRI is differentiating between aggressive and passive spondylodiscitis?

Dear mastdoc, many interesting points which I hope the medical fraternity need to be acutely aware of when presented with chronic back pain sufferers in their consulting rooms.

I thought I would share the following:

 I strongly believe my case was related to teeth brushing and gum disease.. Not long after I fractured my spine and sustained several prolapsed discs I became aware that I had a case of gingivitis that would not be quelled despite very regular trips to the dental hygienist , twice daily brushing with a sonic toothbrush and a cupboard full of antibacterial mouthwashes!. I was even sent to a specialist but all to no avail, I was repeatedly told I could not be brushing my teeth well enough. Maybe coincidence but ten months after finishing the amoxiclav course I have no gingivitis and no spinal pain? 

Dear mastdoc, 

See KB Patel et al study on DWMRI which I am assuming is being propelled at high speed to back up the antibiotic treatment protocol. I feel sorry for my spinal consultant who was in at the beginning of these studies and then supported the RCT run by  Dr Albert & Co. The beaurocratic hoops through which everything must pass endless scrutiny are very frustrating. 

I have every confidence this will become mainstream treatment in the near future if the MRI can prove bacterial infection versus metastases or other... As antibiotics for helicobacter etc have become.

What I know will take much much longer is plasma replacement prtein therapy in to degenerate discs to aid proliferation.  Currently American study on young medical personnel under 30 only in USA. Unfortunately not my profile!

Regards the dental side of things. I have a disinterested dentist so I have taken my own path on this.

I have not changed my dental regime at all since coming off the antibiotics six months ago but I have very good teeth and gums now. But another coincidence occured that dreq me to my own conclusion: I have never had  acne but at the beginning of 2014 when I was diagnosed with a fractured vertebral endplate and severe  Modic 1 changes at several levels in the lumbar spine, I had a breakout of acne! .  

Will also try the Q10 toothpaste, see there are versions without carcinogen lauryl sulphate content! 

Work as a consultant physiotherapist specialising in  spinal problems. Disturbingly I am being returned MRI films for patients in which obvious  modic changes are still not being reported by some radiologists.  Not sure why? Is it lack of training ? These radiographic findings have been known about since the turn of the millenium. This lack of reporting is relevant to my own situation in which the changes were blindingly obvious in 2006 and very similar in 2014. The bony destruction in all those years led to serious distal lumbar segmental instability. Despite dedicated adherence to core and global muscle strengthening I could not stabilise the joints sufficiently . Again I stumbled along my own path looking for solutions and elected to try  prolotherapy sclerosant injections into the spinal ligaments which worked extremely well.