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Jia Y, Chen H, Huang S, Huo Z, Xu B. Causal effects of skin microbiota on intervertebral disk degeneration, low back pain and sciatica: a two-sample Mendelian randomization study. J Orthop Surg Res 2024; 19:476. [PMID: 39138503 PMCID: PMC11321032 DOI: 10.1186/s13018-024-04980-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 08/06/2024] [Indexed: 08/15/2024] Open
Abstract
OBJECTIVE The purpose of this study is to use two-sample Mendelian randomization (MR) to investigate the causal relationship between skin microbiota, especially Propionibacterium acnes, and intervertebral disc degeneration (IVDD), low back pain (LBP) and sciatica. METHODS We conducted a two-sample MR using the aggregated data from the whole genome-wide association studies (GWAS). 150 skin microbiota were derived from the GWAS catalog and IVDD, LBP and sciatica were obtained from the IEU Open GWAS project. Inverse-variance weighted (IVW) was the primary research method, with MR-Egger and Weighted median as supplementary methods. Perform sensitivity analysis and reverse MR analysis on all MR results and use multivariate MR to adjust for confounding factors. RESULTS MR revealed five skin microbiota associated with IVDD, four associated with LBP, and two with sciatica. Specifically, P.acnes in sebaceous skin environments were associated with reduced risk of IVDD; IVDD was found to increase the abundance of P.acnes in moist skin. Furthermore, ASV010 [Staphylococcus (unc.)] from dry skin was a risk factor for LBP and sciatica; ASV045 [Acinetobacter (unc.)] from dry skin and Genus Rothia from dry skin exhibited potential protective effects against LBP; ASV065 [Finegoldia (unc.)] from dry skin was a protective factor for IVDD and LBP. ASV054 [Enhydrobacter (unc.)] from moist skin, Genus Bacteroides from dry skin and Genus Kocuria from dry skin were identified as being associated with an increased risk of IVDD. Genus Streptococcus from moist skin was considered to be associated with an increased risk of sciatica. CONCLUSIONS This study identified a potential causal relationship between skin microbiota and IVDD, LBP, and sciatica. No evidence suggests skin-derived P.acnes is a risk factor for IVDD, LBP and sciatica. At the same time, IVDD can potentially cause an increase in P.acnes abundance, which supports the contamination theory.
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Affiliation(s)
- Yuchao Jia
- Department of Graduate School, Tianjin Medical University, Tianjin, 300070, China
| | - Houcong Chen
- Department of Graduate School, Tianjin Medical University, Tianjin, 300070, China
| | - Shengbo Huang
- Department of Graduate School, Tianjin Medical University, Tianjin, 300070, China
| | - Zhenxin Huo
- Department of Graduate School, Tianjin Medical University, Tianjin, 300070, China
| | - Baoshan Xu
- Department of Minimally Invasive Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, 300211, China.
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Astur N, Martins DE, Kanas M, Doi AM, Martino MDV, Filho ENK, Wajchenberg M, Lenza M. Bacterial identification in herniated intervertebral discs: a prospective cohort study. Spine J 2024:S1529-9430(24)00270-5. [PMID: 38843958 DOI: 10.1016/j.spinee.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 05/07/2024] [Accepted: 05/28/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND CONTEXT Reports of Cutibacterium acnes isolated in cultures of intervertebral disc samples suggest it as possibly responsible for inflammatory conditions causing Modic changes on spinal magnetic resonance imaging (MRI). PURPOSE Our objective was to investigate the prevalence of C. acnes in samples of intervertebral disc of patients with lumbar disc herniation; to investigate prognostic factors and the relationship of Modic changes with infection 1 year after microdiscectomy. STUDY DESIGN Prospective cohort study. PATIENT SAMPLE In this single-center study, patients consecutively operated on for disc herniation had samples of the disc, multifidus muscle and ligamentum flavum (as an indication of contamination) extracted for culture. OUTCOME MEASURES Age, sex, alcohol and tobacco consumption, body mass index; function, pain, and Modic chances in MRI before surgery and MRI 1 year later; rate of disc, muscle and ligament infection (primary outcome); diabetes and corticoid use (confoundings). METHODS The protruded disc, muscle and ligament samples were sent for culture analysis in up to 30 minutes. A subsample of 17 patients underwent next-generation sequencing (NGS) molecular analysis too. We performed descriptive analysis and comparison of groups of patients with and without infection or contamination using Student's t, Mann-Whitney, chi-square, or Fisher's exact tests as appropriate, and pre- and postsurgical comparisons with the Wilcoxon test. RESULTS From January 2018 to September 2019, 112 patients underwent open lumbar microdiscectomy, 67 (59.8%) men. Cultures showed 7 (6.3%) positive cases in the disc (2 with C. acnes), 3 (2.7%) in the ligament, and 12 (10, 7%) in muscle. No evidence of a difference in Modic alterations pre- or postoperatively was found between patients with and without positive culture 1 year after surgery. No association was found between culture positivity and functional or pain differences either. NGS results were all negative for C. acnes. CONCLUSIONS We identified infective bacterial presence in the herniated disc in less than 2% of patients with disc herniation. C. acnes was not identified in any disc microbiome analysis. No significant association was observed between positivity for tissue infection and any clinical prognostic factor.
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Affiliation(s)
- Nelson Astur
- Department of Orthopaedics and Traumatology, Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - Delio Eulalio Martins
- Department of Orthopaedics and Traumatology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Michel Kanas
- Department of Orthopaedics and Traumatology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - André Mario Doi
- Department of Orthopaedics and Traumatology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | - Marcelo Wajchenberg
- Department of Orthopaedics and Traumatology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Mario Lenza
- Department of Orthopaedics and Traumatology, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Zhang M, Jia J, Deng L, Cao Z, Hu X, Lei S, Zhang G, Zhu D, Duan Y, Kang X. Risk factors associated with low-grade virulent infection in intervertebral disc degeneration: a systematic review and meta-analysis. Spine J 2024; 24:1034-1045. [PMID: 38365007 DOI: 10.1016/j.spinee.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/26/2023] [Accepted: 02/06/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND An increasing number of research indicates an association between low-grade bacterial infections, particularly those caused by Propionibacterium acnes (P. acnes), and the development of intervertebral disc degeneration (IDD). However, no previous meta-analysis has systematically assessed the risk factors for low-grade bacterial infections that cause IDD. PURPOSE This study reviewed the literature to evaluate the risk factors associated with low-grade bacterial infection in patients with IDD. STUDY DESIGN Systematic review and meta-analysis. METHODS The systematic literature review was conducted using the PubMed, Web of Science, Embase, and Cochrane Library databases. Eligible articles explicitly identified the risk factors for low-grade bacterial infections in IDD patients. Patient demographics and total bacterial infection rates were extracted from each study. Meta-analysis was performed using random- or fixed-effects models, with statistical analyses conducted using Review Manager (RevMan) 5.4 software.aut. RESULTS Thirty-three studies involving 4,109 patients were included in the meta-analysis. The overall pooled low-grade bacterial infection rate was 30% (range, 24%-37%), with P. acnes accounting for 25% (range, 19%-31%). P. acnes constituted 66.7% of bacteria-positive discs. Fourteen risk factors were identified, of which 8 were quantitatively explored. Strong evidence supported male sex (odds ratio [OR] = 2.15; 95% confidence interval [CI]=1.65-2.79; p<.00001) and Modic changes (MCs) (OR=3.59; 95% CI=1.68-7.76; p=.0009); moderate evidence of sciatica (OR=2.31; 95% CI=1.33-4.00; p=.003) and younger age (OR=-3.47; 95% CI=-6.42 to -0.53; p=.02). No evidence supported previous disc surgery, MC type, Pfirrmann grade, smoking, or diabetes being risk factors for low-grade bacterial infections in patients with IDD. CONCLUSIONS Current evidence highlights a significant association between IDD and low-grade bacterial infections, predominantly P. acnes being the most common causative agent. Risk factors associated with low-grade bacterial infections in IDD include male sex, MCs, sciatica, and younger age.
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Affiliation(s)
- Mingtao Zhang
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China.
| | - Jingwen Jia
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China
| | - Liangna Deng
- Department of Radiology, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730000, Gansu, China
| | - Zhenyu Cao
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China
| | - Xuchang Hu
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China
| | - Shuanhu Lei
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China
| | - Guangzhi Zhang
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China
| | - Daxue Zhu
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China
| | - Yanni Duan
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China
| | - Xuewen Kang
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou 730000, Gansu, China; Orthopaedics Key Laboratory of Gansu Province, No. 82 Cuiyingmen, Chengguan District, Lanzhou, Gansu, 730000, China.
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Rolfsen MP, Gammelsrud KW, Espeland A, Bråten LC, Mjønes SB, Austevoll I, Dolatowski FC, Årrestad MB, Toppe MK, Orlien IE, Holberg-Petersen M, Fagerland M, Zwart JA, Storheim K, Hellum C. Bacterial growth in patients with low back pain and Modic changes: protocol of a multicentre, case-control biopsy study. BMJ Open 2024; 14:e082244. [PMID: 38719329 PMCID: PMC11086543 DOI: 10.1136/bmjopen-2023-082244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/22/2024] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION Bacterial infection and Modic changes (MCs) as causes of low back pain (LBP) are debated. Results diverged between two randomised controlled trials examining the effect of amoxicillin with and without clavulanic acid versus placebo on patients with chronic LBP (cLBP) and MCs. Previous biopsy studies have been criticised with regard to methods, few patients and controls, and insufficient measures to minimise perioperative contamination. In this study, we minimise contamination risk, include a control group and optimise statistical power. The main aim is to compare bacterial growth between patients with and without MCs. METHODS AND ANALYSIS This multicentre, case-control study examines disc and vertebral body biopsies of patients with cLBP. Cases have MCs at the level of tissue sampling, controls do not. Previously operated patients are included as a subgroup. Tissue is sampled before antibiotic prophylaxis with separate instruments. We will apply microbiological methods and histology on biopsies, and predefine criteria for significant bacterial growth, possible contamination and no growth. Microbiologists, surgeons and pathologist are blinded to allocation of case or control. Primary analysis assesses significant growth in MC1 versus controls and MC2 versus controls separately. Bacterial disc growth in previously operated patients, patients with large MCs and growth from the vertebral body in the fusion group are all considered exploratory analyses. ETHICS AND DISSEMINATION The Regional Committees for Medical and Health Research Ethics in Norway (REC South East, reference number 2015/697) has approved the study. Study participation requires written informed consent. The study is registered at ClinicalTrials.gov (NCT03406624). Results will be disseminated in peer-reviewed journals, scientific conferences and patient fora. TRIAL REGISTRATION NUMBER NCT03406624.
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Affiliation(s)
- Mads Peder Rolfsen
- Division of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo Faculty of Medicine, Oslo, Norway
| | - Karianne Wiger Gammelsrud
- Department of Microbiology, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway
- University of Oslo Faculty of Medicine, Oslo, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen Faculty of Medicine and Dentistry, Bergen, Norway
| | | | | | - Ivar Austevoll
- Kysthospitalet in Hagavik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | | | | | | | - Ingvild Elise Orlien
- Department of Microbiology, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway
| | - Mona Holberg-Petersen
- Department of Microbiology, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway
| | - Morten Fagerland
- Biostatistics & Epidemiology, Oslo University Hospital, Oslo, Norway
| | - John-Anker Zwart
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - Kjersti Storheim
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - Christian Hellum
- Division of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
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Jaume Guichard P, Guichard E, Fouquet B. Evaluation of the efficacy, in terms of pain and disability, of a functional restoration programme in patients with chronic low back pain according to the presence of Modic 1 discopathy. Joint Bone Spine 2023; 90:105567. [PMID: 36963749 DOI: 10.1016/j.jbspin.2023.105567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 03/26/2023]
Abstract
OBJECTIVES Modic type 1 disc disease (MD1) appears to be related to severe Chronic Low Back Pain (CLBP). Functional Restoration Programmes (FRP) recommended in CLBP may not be suitable for patients with MD1. The main objective was to evaluate the effectiveness of a FRP, on the perceived incapacity and the pain intensity, in patients with non-specific CLBP according to the presence of MD1. METHODS We performed a single-centre retrospective cohort study in which 271 patients were included. After one month in the FRP, this programme was considered "successful" if the pain visual analog scale had decreased by at least 20/100 millimetres and if the score of the French version of the Roland-Morris disability questionnaire had decreased by at least 4/24 points. RESULTS The 271 patients had an average age of 43.2 (8.0) years and 58.3% were women. Out of our entire population, 128 (47.2%) patients were considered successful, and 51 (18.8%) patients had MD1. In patients without MD1, there was 49.1% success while this rate was 39.2% in those with MD1, but this difference was not statistically significant. CONCLUSIONS We found no significant difference in the combination of pain and perceived disability after one month of a FRP in patients with CLBP without MD1 compared to those with CLBP with MD1. It therefore seems legitimate to offer FRP-type rehabilitation in patients with non-specific CLBP with MD1.
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Affiliation(s)
- Pauline Jaume Guichard
- University of Tours, 37000 Tours, France; Department of Physical and Rehabilitation Medicine (PRM), CHRU Tours, 37044 Tours cedex 9, France.
| | - Elie Guichard
- Inserm 1415, Clinical Investigation Center, CHRU Tours, 37000 Tours, France
| | - Bernard Fouquet
- University of Tours, 37000 Tours, France; Department of Physical and Rehabilitation Medicine (PRM), CHRU Tours, 37044 Tours cedex 9, France
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Magno da Rocha V, Lima COGX, Ferreira EDO, de Farias GC, Nogueira FCS, Martha Antunes LC, Cassiano KM, Fiorelli RKA. Colonization of intervertebral discs by Cutibacterium acnes in patients with low back pain: Protocol for an analytical study with microbiological, phenotypic, genotypic, and multiomic techniques. PLoS One 2023; 18:e0271773. [PMID: 36848344 PMCID: PMC9970075 DOI: 10.1371/journal.pone.0271773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 11/15/2022] [Indexed: 03/01/2023] Open
Abstract
Lumbar disc degeneration (LDD) and low back pain (LBP) are two conditions that are closely related. Several studies have shown Cutibacterium acnes colonization of degenerated discs, but whether and how these finding correlates with LBP is unknown. A prospective study was planned to identify molecules present in lumbar intervertebral discs (LLIVD) colonized by C. acnes in patients with LDD and LBP and correlate them with their clinical, radiological, and demographic profiles. The clinical manifestations, risk factors, and demographic characteristics of participants undergoing surgical microdiscectomy will be tracked. Samples will be isolated and pathogens found in LLIVD will be characterized phenotypically and genotypically. Whole genome sequencing (WGS) of isolated species will be used to phylotype and detect genes associated with virulence, resistance, and oxidative stress. Multiomic analyses of LLIVD colonized and non-colonized will be carried out to explain not only the pathogen's role in LDD, but also its involvement in the pathophysiology of LBP. This study was approved by the Institutional Review Board (CAAE 50077521.0.0000.5258). All patients who agree to participate in the study will sign an informed consent form. Regardless of the study's findings, the results will be published in a peer-reviewed medical journal. Trials registration number NCT05090553; pre-results.
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Affiliation(s)
- Vinícius Magno da Rocha
- Departamento de Cirurgia geral e especializada, Escola de Medicina, Universidade Federal do Estado do Rio de Janeiro (UniRio), Rio de Janeiro- RJ, Brazil
| | - Carla Ormundo Gonçalves Ximenes Lima
- Departamento de Microbiologia Médica, Institito de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro-RJ, Brazil
| | - Eliane de Oliveira Ferreira
- Departamento de Microbiologia Médica, Institito de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro-RJ, Brazil
- * E-mail:
| | | | | | | | - Keila Mara Cassiano
- Departamento de Estatística, Instituto de Matemática, Universidade Federal Fluminense (UFF), Niterói- RJ, Brazil
| | - Rossano Kepler Alvim Fiorelli
- Departamento de Cirurgia geral e especializada, Escola de Medicina, Universidade Federal do Estado do Rio de Janeiro (UniRio), Rio de Janeiro- RJ, Brazil
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Amoxicillin Did Not Reduce Modic Change Edema in Patients With Chronic Low Back Pain: Subgroup Analyses of a Randomised Trial (the AIM Study). Spine (Phila Pa 1976) 2023; 48:147-154. [PMID: 36223435 PMCID: PMC9812422 DOI: 10.1097/brs.0000000000004513] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 10/05/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Exploratory subgroup analyses of a randomised trial [Antibiotics in Modic changes (AIM) study]. OBJECTIVE The aim was to assess the effect of amoxicillin versus placebo in reducing Modic change (MC) edema in patients with chronic low back pain. SUMMARY OF BACKGROUND DATA The AIM study showed a small, clinically insignificant effect of amoxicillin on pain-related disability in patients with chronic low back pain and MC type 1 (edema type) on magnetic resonance imaging (MRI). MATERIALS AND METHODS A total of 180 patients were randomised to receive 100 days of amoxicillin or placebo. MC edema was assessed on MRI at baseline and one-year follow-up. Per-protocol analyses were conducted in subgroups with MC edema on short tau inversion recovery (STIR) or T1/T2-weighted MRI at baseline. MC edema reductions (yes/no) in STIR and T1/T2 series were analyzed separately. The effect of amoxicillin in reducing MC edema was analyzed using logistic regression adjusted for prior disk surgery. To assess the effect of amoxicillin versus placebo within the group with the most abundant MC edema on STIR at baseline ("STIR3" group), we added age, STIR3 (yes/no), and STIR3×treatment group (interaction term) as independent variables and compared the marginal means (probabilities of edema reduction). RESULTS Compared to placebo, amoxicillin did not reduce MC edema on STIR (volume/intensity) in the total sample with edema on STIR at baseline (odds ratio 1.0, 95% CI: 0.5, 2.0; n=141) or within the STIR3 group (probability of edema reduction 0.69, 95% CI: 0.47, 0.92 with amoxicillin and 0.61, 95% CI: 0.43, 0.80 with placebo; n=41). Compared with placebo, amoxicillin did not reduce MC edema in T1/T2 series (volume of the type 1 part of MCs) (odds ratio: 1.0, 95% CI: 0.5, 2.3, n=104). Edema declined in >50% of patients in both treatment groups. CONCLUSIONS From baseline to one-year follow-up, amoxicillin did not reduce MC edema compared with placebo. LEVEL OF EVIDENCE 2.
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Li J, Chen Y, Wu H, Shan Z, Bei D, Gan K, Liu J, Zhang X, Chen B, Chen J, Zhao FD. Different responses of cervical intervertebral disc caused by low and high virulence bacterial infection: a comparative study in rats. Bioengineered 2022; 13:12446-12461. [PMID: 35587595 PMCID: PMC9275948 DOI: 10.1080/21655979.2022.2075305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The aims of this study were to investigate the outcomes of low- and high-virulence bacterial cervical intervertebral discs (IVDs) infection and its association with cervical IVDs degeneration in rats. A total of 75 clean grade male rats were used to establish the corresponding animal models of low and high virulent bacterial cervical disc infection via an anterior cervical approach, with injection of Propionibacterium acnes (P. acnes) and Staphylococcus epidermidis (S. epidermidis) with a 29 G needle to cervical IVDs. Specimens were collected for evaluation of Blood routine (Blood-RT), histological staining, and gene expression assays after a magnetic resonance imaging (MRI) scan. There were no statistical differences in all groups in white blood cells (WBC) at 2 and 6 weeks postoperatively (P = 0.136). The highest percentage of neutrophils was found in the S. epidermidis group at 2 weeks postoperatively (P = 0.043). MRI and histology showed that at 6 weeks postoperatively, the puncture group and P. acnes group had similar disc degeneration. In the S. epidermidis group, the disc and subchondral bone structure had been destroyed and bony fusion had occurred after the discitis. The upregulation of pro-inflammatory factor expression had the strongest effect of S. epidermidis on the early stage, while the upregulation in the puncture and P. acnes groups was more persistent. P. acnes infection of the cervical IVDs can lead to degenerative changes, whereas S. epidermidis infection leads to the manifestation of septic discitis. The correlation between P. acnes infection and cervical IVDs degeneration found in clinical studies was confirmed.
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Affiliation(s)
- Jie Li
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou, Zhejiang, China.,Department of Orthopaedic Surgery, Ningbo Medical Center Li Huili Hospital, Ningbo, Zhejiang, China
| | - Yilei Chen
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Hao Wu
- Department of Orthopaedics and Traumatology, the University of Hong Kong, Hong Kong, SAR, China
| | - Zhi Shan
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Dikai Bei
- Department of Orthopaedic Surgery, Ningbo Medical Center Li Huili Hospital, Ningbo, Zhejiang, China
| | - Kaifeng Gan
- Department of Orthopaedic Surgery, Ningbo Medical Center Li Huili Hospital, Ningbo, Zhejiang, China
| | - Junhui Liu
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Xuyang Zhang
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Binhui Chen
- Department of Orthopaedic Surgery, Ningbo Medical Center Li Huili Hospital, Ningbo, Zhejiang, China
| | - Jian Chen
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Feng-Dong Zhao
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou, Zhejiang, China
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Senker W, Aspalter S, Radl C, Pichler J, Doppler S, Weis S, Webersinke C, Wagner H, Hermann P, Aichholzer M, Aufschnaiter-Hießböck K, Thomae W, Stroh N, Hauser T, Gruber A. Frequency and characteristics of bacterial and viral low-grade infections of the intervertebral discs: a prospective, observational study. J Orthop Traumatol 2022; 23:15. [PMID: 35303173 PMCID: PMC8933588 DOI: 10.1186/s10195-022-00633-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 02/26/2022] [Indexed: 12/03/2022] Open
Abstract
Study design Monocentric, prospective, observational study. Objective The clinical relevance of bacterial colonization of intervertebral discs is controversial. This study aimed to determine a possible relationship between bacterial and viral colonization and low-grade infection of the discs. Methods We investigated 447 disc samples from 392 patients. Microbiological culture was used to examine the samples for bacterial growth, polymerase chain reaction (PCR) was used for detection of herpes simplex virus types 1 and 2 (HSV-1, HSV-2) and Cytomegalovirus (CMV), and histopathological analysis was used to detect signs of inflammation. The results were compared between subgroups organized according to gender, age, location of the samples, surgical approach, preoperative C-reactive protein (CRP), preoperative and 6 months postoperative Oswestry Disability Index (ODI) and Neck Disability Index (NDI), and Modic changes (MC) of the corresponding endplates. Also, we assessed the occurrence of postoperative infections within 6 months. Results Microbiological culture was positive in 38.78% of the analyzed intervertebral discs. Altogether, 180 bacteria were isolated. Coagulase-negative staphylococci (CONS) (23.41%) and Cutibacterium acnes (18.05%) were the most frequently detected microorganisms. None of HSV-1, HSV-2, or CMV were detected. Male patients (p = 0.00036) and cervical segments (p = 0.00001) showed higher rates of positive culture results. Ventral surgical approaches ( p < 0.001) and Type 2 MC (p = 0.0127) were significantly associated with a positive microbiological result ( p< 0.001). Neither pre- nor postoperative ODI and NDI are associated with positive culture results. In 4 (1.02%) patients, postoperative spondylodiscitis occurred. Conclusions With 447 segments from 392 patients, we present one of the largest studies to date. While disc degeneration caused by HSV-1, HSV-2, and CMV seems unlikely, we found positive microbiological culture results in 38.78% of all discs. The role of local skin flora and sample contamination should be the focus of further investigations. Level of Evidence III. Trial registration: The study was registered at ClinicalTrials.gov (ID: NCT04712487, https://www.clinicaltrials.gov/ct2/show/study/NCT04712487). Supplementary Information The online version contains supplementary material available at 10.1186/s10195-022-00633-y.
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Affiliation(s)
- Wolfgang Senker
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Wagner-Jauregg Weg 15, 4020, Linz, Austria
| | - Stefan Aspalter
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Wagner-Jauregg Weg 15, 4020, Linz, Austria.
| | - Christian Radl
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Wagner-Jauregg Weg 15, 4020, Linz, Austria
| | - Josef Pichler
- Department of Internal Medicine, Kepler University Hospital, Johannes Kepler University, Wagner-Jauregg Weg 15, 4020, Linz, Austria
| | - Stefan Doppler
- Institute of Pathology and Microbiology, Kepler University Hospital, Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
| | - Serge Weis
- Institute of Pathology and Neuropathology, Kepler University Hospital, Johannes Kepler University, Wagner-Jauregg Weg 15, 4020, Linz, Austria
| | - Christine Webersinke
- Institute of Pathology and Neuropathology, Kepler University Hospital, Johannes Kepler University, Wagner-Jauregg Weg 15, 4020, Linz, Austria
| | - Helga Wagner
- Center for Clinical Studies (CCS Linz), Johannes Kepler University, Huemerstrasse 3-5, 4020, Linz, Austria.,Department of Medical Statistics and Biometry, Institute of Applied Statistics, Johannes Kepler University, Altenberger Strasse 69, 4040, Linz, Austria
| | - Philipp Hermann
- Center for Clinical Studies (CCS Linz), Johannes Kepler University, Huemerstrasse 3-5, 4020, Linz, Austria
| | - Martin Aichholzer
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Wagner-Jauregg Weg 15, 4020, Linz, Austria
| | - Kathrin Aufschnaiter-Hießböck
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Wagner-Jauregg Weg 15, 4020, Linz, Austria
| | - Wolfgang Thomae
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Wagner-Jauregg Weg 15, 4020, Linz, Austria
| | - Nico Stroh
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Wagner-Jauregg Weg 15, 4020, Linz, Austria
| | - Thomas Hauser
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Wagner-Jauregg Weg 15, 4020, Linz, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Wagner-Jauregg Weg 15, 4020, Linz, Austria
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10
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Granville Smith I, Danckert NP, Freidin MB, Wells P, Marchesi JR, Williams FMK. Evidence for infection in intervertebral disc degeneration: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 31:414-430. [PMID: 34862912 PMCID: PMC8873132 DOI: 10.1007/s00586-021-07062-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 09/30/2021] [Accepted: 11/10/2021] [Indexed: 12/19/2022]
Abstract
Purpose Back pain is a major problem worldwide and is linked to intervertebral disc degeneration and Modic change. Several studies report growth of bacteria following extraction of degenerate discs at spine surgery. A pathophysiological role for infection in back pain has been proposed. Method We conducted a PRISMA systematic review. MEDLINE, PubMed, Scopus and Web of Science were searched with the terms Modic change, intervertebral dis*, bacteria, microb*, and infect*. Date limits of 2001–2021 were set. Human studies investigating the role of bacteria in disc degeneration or Modic change in vertebrae were included. Results Thirty-six articles from 34 research investigations relating to bacteria in human degenerate discs were found. Cutibacterium acnes was identified in pathological disc material. A ‘candidate bacterium’ approach has been repeatedly adopted which may have biased results to find species a priori, with disc microbial evidence heavily weighted to find C. acnes. Conclusion Evidence to date implicates C. acnes identified through culture, microscopy and sequencing, with some suggestion of diverse bacterial colonisation in the disc. This review found studies which used culture methods and conventional PCR for bacterial detection. Further agnostic investigation using newer methods should be undertaken. Supplementary Information The online version contains supplementary material available at 10.1007/s00586-021-07062-1.
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Affiliation(s)
- Isabelle Granville Smith
- Department of Twin Research and Genetic Epidemiology, King's College London, 3rd and 4th Floor, Block D, South Wing, St. Thomas' Hospital, Westminster Bridge Rd., London, SE1 7EH, UK.
| | - Nathan P Danckert
- Department of Metabolism, Digestion and Reproduction, Imperial College, London, UK
| | - Maxim B Freidin
- Department of Twin Research and Genetic Epidemiology, King's College London, 3rd and 4th Floor, Block D, South Wing, St. Thomas' Hospital, Westminster Bridge Rd., London, SE1 7EH, UK
| | - Philippa Wells
- Department of Twin Research and Genetic Epidemiology, King's College London, 3rd and 4th Floor, Block D, South Wing, St. Thomas' Hospital, Westminster Bridge Rd., London, SE1 7EH, UK
| | - Julian R Marchesi
- Department of Metabolism, Digestion and Reproduction, Imperial College, London, UK
| | - Frances M K Williams
- Department of Twin Research and Genetic Epidemiology, King's College London, 3rd and 4th Floor, Block D, South Wing, St. Thomas' Hospital, Westminster Bridge Rd., London, SE1 7EH, UK
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11
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Ortiz AO, Levitt A, Shah LM, Parsons MS, Agarwal V, Baldwin K, Bhattacharyya S, Boulter DJ, Burns J, Fink KR, Hunt CH, Hutchins TA, Kao LS, Khan MA, Lo BM, Moritani T, Reitman C, Repplinger MD, Shah VN, Singh S, Timpone VM, Corey AS. ACR Appropriateness Criteria® Suspected Spine Infection. J Am Coll Radiol 2021; 18:S488-S501. [PMID: 34794603 DOI: 10.1016/j.jacr.2021.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/01/2021] [Indexed: 10/19/2022]
Abstract
Spine infection is both a clinical and diagnostic imaging challenge due to its relatively indolent and nonspecific clinical presentation. The diagnosis of spine infection is based upon a combination of clinical suspicion, imaging evaluation and, when possible, microbiologic confirmation performed from blood cultures or image-guided percutaneous or open spine biopsy. With respect to the imaging evaluation of suspected spine infection, MRI without and with contrast of the affected spine segment is the initial diagnostic test of choice. As noncontrast MRI of the spine is often used in the evaluation of back or neck pain not responding to conservative medical management, it may show findings that are suggestive of infection, hence this procedure may also be considered in the evaluation of suspected spine infection. Nuclear medicine studies, including skeletal scintigraphy, gallium scan, and FDG-PET/CT, may be helpful in equivocal or select cases. Similarly, radiography and CT may be appropriate for assessing overall spinal stability, spine alignment, osseous integrity and, when present, the status of spine instrumentation or spine implants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- A Orlando Ortiz
- Chairman, Department of Radiology, Jacobi Medical Center, Bronx, New York.
| | - Alex Levitt
- Research Author, Jacobi Medical Center, Bronx, New York
| | - Lubdha M Shah
- Panel Chair, University of Utah, Salt Lake City, Utah
| | - Matthew S Parsons
- Panel Vice-Chair, Mallinckrodt Institute of Radiology, Saint Louis, Missouri
| | - Vikas Agarwal
- Vice-Chair of Education, Chief, Neuroradiology, and Director, Spine Intervention, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Keith Baldwin
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, American Academy of Orthopaedic Surgeons
| | - Shamik Bhattacharyya
- Brigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts, American Academy of Neurology
| | - Daniel J Boulter
- Clinical Director, MRI, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Judah Burns
- Program Director, Diagnostic Radiology Residency Program, Montefiore Medical Center, Bronx, New York
| | | | | | - Troy A Hutchins
- Chief Value Officer, Department of Radiology, University of Utah Health, Salt Lake City, Utah
| | - Lillian S Kao
- Chief, Division of Acute Care Surgery, The University of Texas Health Science Center at Houston, Houston, Texas; and American Association for the Surgery of Trauma
| | - Majid A Khan
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Bruce M Lo
- Sentara Norfolk General/Eastern Virginia Medical School, Norfolk, Virginia; Board Member, American Academy of Emergency Medicine; and American College of Emergency Physicians
| | | | - Charles Reitman
- Medical University of South Carolina, Charleston, South Carolina; and Board of Directors, North American Spine Society
| | - Michael D Repplinger
- University of Wisconsin, Madison, Wisconsin; President, Dane County Medical Society; Councillor, American College of Emergency Physicians; and Society for Academic Emergency Medicine
| | - Vinil N Shah
- University of California San Francisco, San Francisco, California; and Executive Committee, American Society of Spine Radiology
| | - Simranjit Singh
- Indiana University School of Medicine, Indianapolis, Indiana; Secretary, SHM, Indiana Chapter; Secretary, SGIM, Midwest Region; and American College of Physicians
| | - Vincent M Timpone
- Co-Director, Neuroradiology Spine Intervention Service, Department of Radiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Amanda S Corey
- Specialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
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12
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Liu C, Abdel Shaheed C, Braten LC, Hancock MJ, Underwood M, Jarvik JG, Elliott J, Maher CG, Buchbinder R, Lin CWC. Antibiotic treatment for low back pain or radicular pain, or both. Hippokratia 2021. [DOI: 10.1002/14651858.cd014221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Chang Liu
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- School of Public Health; Faculty of Medicine and Health, The University of Sydney; Sydney Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- School of Public Health; Faculty of Medicine and Health, The University of Sydney; Sydney Australia
| | - Lars Christian Braten
- Research and Communication Unit for Musculoskeletal Health (FORMI); Oslo University Hospital; Oslo Norway
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
| | - Mark J Hancock
- Faculty of Medicine, Health and Human Sciences; Macquarie University; Sydney Australia
| | - Martin Underwood
- Warwick Clinical Trials Unit; University of Warwick; Coventry UK
| | - Jeffrey G Jarvik
- Radiology and Neurological Surgery, Clinical Learning, Evidence And Research (CLEAR) Center; University of Washington School of Medicine; Seattle USA
| | - Julian Elliott
- Cochrane Australia; School of Public Health & Preventive Medicine; Melbourne Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- School of Public Health; Faculty of Medicine and Health, The University of Sydney; Sydney Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- School of Public Health; Faculty of Medicine and Health, The University of Sydney; Sydney Australia
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13
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Clinicoradiographic predictors of percutaneous bone biopsy results among patients with suspected thoracolumbar spine infection. Skeletal Radiol 2021; 50:1801-1808. [PMID: 33576862 DOI: 10.1007/s00256-021-03735-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/26/2021] [Accepted: 02/04/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Image-guided percutaneous thoracolumbar spine biopsy is frequently performed in the setting of suspected septic facet arthritis or discitis osteomyelitis (DOM). There are limited data regarding factors associated with a positive biopsy result among these patients. MATERIALS AND METHODS Patients with suspected DOM who underwent spine biopsy were identified. Samples yielding a positive culture and/or histopathology suggestive of acute osteomyelitis were considered positive. The associations between selected medical comorbidities, laboratory values, pre-biopsy antibiotic administration, imaging findings and biopsy results were investigated. RESULTS 121 patients underwent percutaneous biopsy with 35.5% yielding positive results. Biopsy results showed no correlation with comorbidities. The only laboratory value that correlated with a positive biopsy yield was blood culture positivity (p = 0.03). The imaging findings that correlated with a positive biopsy yield were the presence of a paraspinal fluid collection or epidural abscess (p = 0.003 and 0.018, respectively). Sampling paraspinal fluid collections, when present, resulted in a higher rate of a positive biopsy yield compared to sampling of bone or disc (p = 0.006). Patients who received antibiotics had a higher rate of a positive biopsy yield (p = 0.014). In those with positive blood cultures, biopsy yielded the same antimicrobial susceptibility profile in 13/14 cases. CONCLUSION The presence of a paraspinal fluid collection or epidural abscess is correlated with positive biopsy yield, and paraspinal fluid collections should be targeted for biopsy. Other imaging findings did not correlate with biopsy yield. Biopsy may not offer additional information for patients with positive blood cultures.
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14
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Jha SC, Sairyo K. The role of Propionibacterium acnes in and Modic type 1 changes : A literature review. THE JOURNAL OF MEDICAL INVESTIGATION 2021; 67:21-26. [PMID: 32378611 DOI: 10.2152/jmi.67.21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Propionibacterium acnes (P. acnes) is part of the normal flora of human skin, oral cavity, intestinal tract and external ear canal. However, breach in the mucosa as well as ruptured annulus fibrosus provide favorable pathway for P. acnes to nucleus pulposus where it can proliferate under anaerobic condition. In past two decades many authors have identified P. acnes in routine culture of discs. There studies showed that almost 50% of discs cultured were positive for various organism, and in vast majority of culture positive disc, P. acnes was the primary organism isolated. However, there are few studies that refute the hypothesis that P. acnes has a role in pathogenesis of Modic type 1 changes. Identification of P. acnes in culture indicates the infective patho-mechanism in the pathogenesis of Modic type 1 changes, which may be ameable to antibiotic treatment. However, it is still difficult to identify which subset of these patients (patients with low back pain with type 1 Modic change) are infective in nature. Further investigation and more clinical trails will be required for clear identification of the infective subgroup among low back patient in general. J. Med. Invest. 67 : 21-26, February, 2020.
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Affiliation(s)
- Subash Chandra Jha
- Department of Orthopedics, Birat Medical College and Teaching Hospital, Biratnagar, Nepal
| | - Koichi Sairyo
- Department of Orthopedics, Tokushima University, Tokushima, Japan
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15
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Gilligan CJ, Cohen SP, Fischetti VA, Hirsch JA, Czaplewski LG. Chronic low back pain, bacterial infection and treatment with antibiotics. Spine J 2021; 21:903-914. [PMID: 33610802 DOI: 10.1016/j.spinee.2021.02.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/14/2021] [Accepted: 02/15/2021] [Indexed: 02/03/2023]
Abstract
The contribution of bacterial infection to chronic low back pain and its treatment with antibiotics have generated considerable controversy in literature. If efficacious, antibiotics have the potential to transform the treatment of chronic low back pain in a significant subset of patients. Some microbiology studies of disc tissue from patients with CLBP have shown that bacteria are present, most likely due to infection, while others conclude they are absent or if found, it is due to surgical contamination. Clinical studies testing the efficacy of oral antibiotics to treat CLBP have either shown that the treatment is efficacious leading to significantly reduced pain and disability or that their effect is modest and not clinically significant. Critical review of the literature on CLBP, bacterial infection and treatment with antibiotics identified five well-designed and executed microbiology studies characterizing bacteria in disc samples that demonstrate that bacteria do infect herniated disc tissue, but that the bacterial burden is low and may be below the limits of detection in some studies. Two randomized, controlled clinical trials evaluating oral antibiotics in patients with CLBP indicate that for certain subsets of patients, the reduction in pain and disability achieved with antibiotic therapy may be significant. In patients for whom other therapies have failed, and who might otherwise progress to disc replacement or fusion surgery, antibiotic therapy may well be an attractive option to reduce the individual suffering associated with this debilitating condition. Additional clinical research is recommended to refine the selection of patients with CLBP caused or complicated by bacterial infection and most likely to respond to antibiotics, to optimize antibiotic therapy to maximize patient benefit, to minimize and manage side effects, and to address legitimate concerns about antibiotic stewardship.
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Affiliation(s)
- Christopher J Gilligan
- Brigham and Women's Hospital, Department of Anesthesiology, Perioperative and Pain Medicine, Boston, MA, USA
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 550 N. Broadway, Ste 301, Baltimore, MD 21029, USA; Department of Anesthesiology, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Vincent A Fischetti
- Laboratory of Bacterial Pathogenesis and Immunology, The Rockefeller University, New York, New York
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Lloyd G Czaplewski
- Persica Pharmaceuticals Ltd, 7 Denne Hill Business Centre, Womenswold, Canterbury, Kent, CT4 6HD, UK.
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16
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Manniche C, Hall GM. Chronic low back pain, Modic changes and low-grade virulent infection: efficacy of antibiotic treatment. Future Sci OA 2021; 7:FSO703. [PMID: 34046205 PMCID: PMC8147823 DOI: 10.2144/fsoa-2021-0026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/11/2021] [Indexed: 11/23/2022] Open
Abstract
Chronic low back pain (CLBP) has consistently been associated with the longest number of years lived with a disability in global studies, while commonly used treatments for CLBP are largely ineffective. In 2013 a randomized, double-blind, controlled study demonstrated significant improvements in CLBP patients demonstrating Modic changes type 1 on their MRI scans and undergoing long-term oral antibiotic treatment (100 days). Much of the ensuing debate has focused on whether this was a true infection or contamination. Newer and more advanced technologies clearly point to an ongoing low-grade infection. We have reviewed all of the clinical trials published in the recent past and conclude that there is compelling evidence for the effect of long-term oral antibiotic treatment for this patient group.
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Affiliation(s)
- Claus Manniche
- Department of Occupational & Environmental Medicine, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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17
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Bivona LJ, Camacho JE, Usmani F, Nash A, Bruckner JJ, Hughes M, Bhandutia AK, Koh EY, Banagan KE, Gelb DE, Ludwig SC. The Prevalence of Bacterial Infection in Patients Undergoing Elective ACDF for Degenerative Cervical Spine Conditions: A Prospective Cohort Study With Contaminant Control. Global Spine J 2021; 11:13-20. [PMID: 32875844 PMCID: PMC7734272 DOI: 10.1177/2192568219888179] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVES To determine the prevalence of bacterial infection, with the use of a contaminant control, in patients undergoing anterior cervical discectomy and fusion (ACDF). METHODS After institutional review board approval, patients undergoing elective ACDF were prospectively enrolled. Samples of the longus colli muscle and disc tissue were obtained. The tissue was then homogenized, gram stained, and cultured in both aerobic and anaerobic medium. Patients were classified into 4 groups depending on culture results. Demographic, preoperative, and postoperative factors were evaluated. RESULTS Ninety-six patients were enrolled, 41.7% were males with an average age of 54 ± 11 years and a body mass index of 29.7 ± 5.9 kg/m2. Seventeen patients (17.7%) were considered true positives, having a negative control and positive disc culture. Otherwise, no significant differences in culture positivity was found between groups of patients. However, our results show that patients were more likely to have both control and disc negative than being a true positive (odds ratio = 6.2, 95% confidence interval = 2.5-14.6). Propionibacterium acnes was the most commonly identified bacteria. Two patients with disc positive cultures returned to the operating room secondary to pseudarthrosis; however, age, body mass index, prior spine surgery or injection, postoperative infection, and reoperations were not associated with culture results. CONCLUSION In our cohort, the prevalence of subclinical bacterial infection in patients undergoing ACDF was 17.7%. While our rates exclude patients with positive contaminant control, the possibility of contamination of disc cultures could not be entirely rejected. Overall, culture results did not have any influence on postoperative outcomes.
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Affiliation(s)
- Louis J. Bivona
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jael E. Camacho
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Farooq Usmani
- Department of General Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Alysa Nash
- Department of Orthopaedics, University of North Carolina at Chapel Hill, NC, USA
| | - Jacob J. Bruckner
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Meghan Hughes
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Amit K. Bhandutia
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eugene Y. Koh
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kelley E. Banagan
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel E. Gelb
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Steven C. Ludwig
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA,Steven C. Ludwig, Department of Orthopaedics, University of Maryland, 110 South Paca Street, 6th Floor, Suite 300, Baltimore, MD 21201, USA.
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Rao PJ, Maharaj M, Chau C, Taylor P, Phan K, Choy WJ, Scherman D, Mews P, Scholsem M, Coughlan M, Mobbs R. Degenerate-disc infection study with contaminant control (DISC): a multicenter prospective case-control trial. Spine J 2020; 20:1544-1553. [PMID: 32339766 DOI: 10.1016/j.spinee.2020.03.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/14/2020] [Accepted: 03/16/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND A bacterial cause of disc degeneration has evoked several controversies and, if true, would lead to a major shift in treatment paradigm. Earlier studies analyzing the relationship of bacterial disc infection within a degenerative cohort featured prolonged cultures susceptible to contamination. The degenerate-disc infection study with contaminant control (DISC) trial aims to investigate this theory further by examining infection rates using a non-degenerative control cohort in comparison to a degenerative internal control cohort and a sham cohort (sampling only sterile paraspinal tissue). To our knowledge, the current study is the largest evaluating the growth of organisms (or possible contamination rate) in paraspinal tissue if prolonged cultures are performed. Protocols on methodology have been previously published. PURPOSE (1) To investigate the infection rates across cohorts (degenerative vs. nondegenerative control; paraspinal and/or disc controls vs. combined sampling cohorts) using stringent standardized aseptic surgical technique and laboratory processing. (2) To compare our findings to that of the literature and make a statement in support and/or against a possible contamination theory to positive cultures. STUDY DESIGN Multicenter, multisurgeon case-control trial. PATIENT SAMPLE In all, 812 surgical samples were retrieved across a 3.5-year period (2013-2016) including 25 trauma controls (nondegenerative), 550 "disc and paraspinal" samples (degenerative cases with internal control), 190 disc-only samples (degenerative cases without internal control), and 46 paraspinal only controls (sham group). OUTCOME MEASURES Growth and/or Contamination rate (%) per cohort. Chi-square of growth in disc versus paraspinal samples as a means of examining the distribution of false positive and contaminant growth. The impact of previous injections and/or surgery on positive disc or paraspinal growth. Correlation of Modic changes with positive growth rates analyzed with the Kruskal-Wallis Test. The distribution of species in positive samples were also analyzed. METHODS The DISC trial is registered under Australian and New Zealand clinical trials registry-ACTRN12616000541404. Institutional ethics review was obtained (HREC northern sector 13/218) at the primary center and further centers (n=6) were recruited. Patients undergoing spinal surgery with discectomy were eligible for trial entry with tissue specimens obtained using strict aseptic technique for microbiological examination. All specimens were handled with sterile instruments only and by a fresh instrument to a sterile pot that was closed immediately. Separate pots were used for the disc and paraspinal tissue respectively with similar stringent processing during microbiological assessment. A cohort of the degenerative cases at one single institution also underwent an additional histopathological examination. RESULTS There was an expected significant difference in gender and age associated with the non-degenerative control group (due to trauma patients) compared with other cohorts. There was a higher percentage of positive-growth in the control group in comparison to the disc and paraspinal and disc only groups across positive disc growth (48% vs. 27% vs. 17%, p<.001). A similar infection rate was observed in the paraspinal samples across the equivalent controls (44% vs. 36% vs. 37%, p=.739). There was a significant difference in the proportions of positive growth with a large proportion of false positives (growth in both disc and paraspinal samples; p<.001). There was no difference in true positive growth between the case and control groups (16.0 vs. 7.7%, p=.112). These trends were preserved across all cohorts and when stratifying by spinal segment (cervical or lumbar). There was no correlation between Modic changes and positive disc culture growth (p=.398, n=144 samples). Cutibacterium (formerly Propionibacterium) acnes was the most dominant pathogen isolated, representing between 50% and 70% of positive disc and paraspinal specimens, followed by staphylococcal species. CONCLUSIONS Our study failed to find a difference in true infection rates between the nondegenerative and degenerative disc populations. These findings are suggestive of a contamination theory and against a common infective etiology in the setting of discogenic back and neck pain. We believe the rationale for antibiotic therapy in the management of discogenic back pain warrants further evidence to establish efficacy.
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Affiliation(s)
- Prashanth J Rao
- School of Medical Sciences, University of New South Wales, Sydney, Australia; Neurosurgical Research Group (NSURG), Sydney, Australia
| | - Monish Maharaj
- School of Medical Sciences, University of New South Wales, Sydney, Australia; Neurosurgical Research Group (NSURG), Sydney, Australia; Department of Neurosurgery, Prince of Wales Public and Private Hospitals, Suite 7, Level 7, Randwick 2031, Australia.
| | - Christine Chau
- Department of Pathology, Prince of Wales Hospital Randwick, Australia
| | - Peter Taylor
- Department of Neurosurgery, The Canberra Hospital, Canberra, Australia
| | - Kevin Phan
- School of Medical Sciences, University of New South Wales, Sydney, Australia; Neurosurgical Research Group (NSURG), Sydney, Australia; Department of Neurosurgery, Prince of Wales Public and Private Hospitals, Suite 7, Level 7, Randwick 2031, Australia
| | - Wen Jie Choy
- School of Medical Sciences, University of New South Wales, Sydney, Australia; Neurosurgical Research Group (NSURG), Sydney, Australia
| | - Daniel Scherman
- Department of Neurosurgery, Westmead Hospital, Sydney, Australia
| | - Peter Mews
- School of Medical Sciences, University of New South Wales, Sydney, Australia; Dept Microbiology NSW Health Pathology, St George Hospital, Kogarah, Australia
| | - Martin Scholsem
- Department of Neurosurgery, St George Hospital, Kogarah, Australia
| | - Marc Coughlan
- Department of Neurosurgery, Prince of Wales Public and Private Hospitals, Suite 7, Level 7, Randwick 2031, Australia
| | - Ralph Mobbs
- School of Medical Sciences, University of New South Wales, Sydney, Australia; Neurosurgical Research Group (NSURG), Sydney, Australia; Department of Neurosurgery, Prince of Wales Public and Private Hospitals, Suite 7, Level 7, Randwick 2031, Australia
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Schwarz-Nemec U, Friedrich KM, Stihsen C, Schwarz FK, Trattnig S, Weber M, Grohs JG, Nemec SF. Vertebral Bone Marrow and Endplate Assessment on MR Imaging for the Differentiation of Modic Type 1 Endplate Changes and Infectious Spondylodiscitis. J Clin Med 2020; 9:jcm9030826. [PMID: 32197459 PMCID: PMC7141365 DOI: 10.3390/jcm9030826] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/16/2020] [Indexed: 12/11/2022] Open
Abstract
On magnetic resonance (MR) imaging, Modic type 1 (MT1) endplate changes and infectious spondylodiscitis share similar findings. Therefore, this study investigated vertebral bone marrow and endplate changes to enable their differentiation. The lumbar spine MR examinations of 91 adult patients were retrospectively included: 39 with MT1; 19 with early spondylodiscitis without abscess; and 33 with advanced spondylodiscitis with abscess. The assessment included percentage of bone marrow edema on sagittal short tau inversion recovery images, and the signal ratio of edema to unaffected bone and endplate contour (normal; irregular, yet intact; blurred; destructive) on sagittal unenhanced T1-weighted images. Differences were tested for statistical significance by Chi-square test and mixed model analysis of variance. The MR diagnostic accuracy in differentiating MT1 and spondylodiscitis was assessed by cross-tabulation and receiver-operating characteristic analysis. The endplate contours, edema extents, and T1-signal ratios of MT1 (extent, 31.96%; ratio, 0.83) were significantly different (p < 0.001) from early spondylodiscitis (56.42%; 0.60), and advanced spondylodiscitis (91.84%; 0.61). The highest diagnostic accuracy (sensitivity, 94.87%; specificity, 94.23%; accuracy, 94.51%) in identifying MT1 was provided by an irregular, yet intact endplate contour. This may be a useful MR feature for the differentiation between MT1 and spondylodiscitis, particularly in its early stage.
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Affiliation(s)
- Ursula Schwarz-Nemec
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria; (U.S.-N.); (F.K.S.); (M.W.); (S.F.N.)
| | - Klaus M. Friedrich
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria; (U.S.-N.); (F.K.S.); (M.W.); (S.F.N.)
- Correspondence: ; +43-140400-48950
| | - Christoph Stihsen
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, A-1090 Vienna, Austria; (C.S.); (J.G.G.)
| | - Felix K. Schwarz
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria; (U.S.-N.); (F.K.S.); (M.W.); (S.F.N.)
| | - Siegfried Trattnig
- MR Center of Excellence, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria;
| | - Michael Weber
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria; (U.S.-N.); (F.K.S.); (M.W.); (S.F.N.)
| | - Josef G. Grohs
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, A-1090 Vienna, Austria; (C.S.); (J.G.G.)
| | - Stefan F. Nemec
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria; (U.S.-N.); (F.K.S.); (M.W.); (S.F.N.)
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Viswanathan VK, Shetty AP, Rajasekaran S. Modic changes - An evidence-based, narrative review on its patho-physiology, clinical significance and role in chronic low back pain. J Clin Orthop Trauma 2020; 11:761-769. [PMID: 32879563 PMCID: PMC7452231 DOI: 10.1016/j.jcot.2020.06.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Lumbar degenerative spinal ailments are the most important causes for chronic low back pain. Modic changes (MC) are vertebral bone marrow signal intensity changes seen on MRI, commonly in association with degenerative disc disease (DDD). Despite being widely studied, majority of issues concerning MC are still controversial. The current narrative, evidence-based review comprehensively discusses the various aspects related to MC. LITERATURE SEARCH An elaborate search was made using keywords "Modic changes", "lumbar Modic changes", "Modic changes in lumbar spine", and "vertebral Endplate Spinal Changes", on pubmed and google (scholar.google.com) databases on the 3rd of March 2020. We identified crucial questions regarding Modic changes and included relevant articles pertaining to these topics for this narrative review. RESULTS The initial search using the keywords "Modic changes", "lumbar Modic changes", "Modic changes in lumbar spine", and "vertebral Endplate Spinal Changes" on pubmed yielded a total of 568, 412, 394 and 216 articles on "pubmed" database, respectively. A similar search using the aforementioned keywords yielded a total of 3650, 3548, 3726 and 21570 articles on "google scholar" database. The initial screening involved exclusion of duplicate articles, articles unrelated to MC, animal or other non-clinical studies, and articles in non-English literature based on abstracts or the titles of articles. This initial screening resulted in the identification of 405 articles. Full manuscripts were obtained for all these selected articles and thoroughly scrutinised at the second stage of article selection. All articles not concerning Modic changes, not pertaining to concerned questions, articles concerning other degenerative phenomena, articles discussing cervical or thoracic MC, case reports or animal studies, articles in non-English language and duplicate articles were excluded. Review articles, randomised controlled trials and level 1 studies were given preference. Overall, 69 articles were included in this review. CONCLUSION Modic change (MC) is a dynamic phenomenon and its true etiology is still not definitely known. Disc/end plate injury, occult discitis and autoimmune reactions seem to trigger an inflammatory cascade, which leads to their development. Male sex, older age, diabetes mellitus, genetic factors, smoking, obesity, spinal deformities, higher occupational loads and DDD are known risk factors. There is no conclusive evidence on the causative role of MC in chronic low back pain (LBP) or any influence on the long term outcome in patients with LBP or lumbar disc herniations (LDH). Patients with MC have been reported to have less satisfactory outcome following conservative treatment or discectomy, although the evidence is still unclear.
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Affiliation(s)
| | - Ajoy Prasad Shetty
- Department of Spine Surgery, Ganga Medical Center and Hospitals, Coimbatore, India,Corresponding author.
| | - S. Rajasekaran
- Department of Spine Surgery, Ganga Medical Center and Hospitals, Coimbatore, India,Department of Orthopedics, Ganga Medical Center and Hospitals, Coimbatore, India
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Liu J, Wei X, Huang B, Wu H, Zhang X, Chen J, Shan Z, Fan S, Zhao F. Lubricin expression in the lumbar endplate and its association with Modic changes. J Orthop Translat 2019; 22:124-131. [PMID: 32440508 PMCID: PMC7231957 DOI: 10.1016/j.jot.2019.10.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/03/2019] [Accepted: 10/18/2019] [Indexed: 12/02/2022] Open
Abstract
Objective To explore the expression of lubricin in the lumbar endplate and its association with Modic changes (MCs). Methods Human endplate specimens harvested from patients undergoing surgery for thoracolumbar spine fractures or lumbar interbody fusion were divided into two groups: MCs group and normal group. Lubricin expression was examined by immunohistochemistry, and differences between the groups were analysed using quantitative polymerase chain reaction (qPCR). Lubricin expression and differences between endplates with MCs and normal endplates were confirmed using a rabbit model. In a final experiment, rabbit endplate chondrocytes were cocultured with Propionibacteria acnes (P. acnes) supernatant, and the expression of lubricin and endplate degeneration related genes were evaluated. In addition, the expression of matrix metalloproteinase 1(MMP-1), A disintegrin-like and metalloproteinase with thrombospondin type 5 motif (ADAMTS5) and inflammatory factors (Interleukin- 1β (IL-1β) and Interleukin-6 (IL-6)) were evaluated after lubricin overexpression. Results Lubricin was found in human lumbar endplates and its expression was lower in the MCs group compared to the normal group. In the rabbit model, lubricin was also found in the endplate. In rabbits injected with P. acnes (the MCs group), lubricin expression of endplate decreased compared to the normal group. In the culture of rabbit endplate chondrocytes with P. acnes supernatant, the expression of lubricin, aggrecan, sox9 and collagen type-II decreased significantly, while that of MMP-1 and ADAMTS5 increased significantly. Moreover, lubricin overexpression could downregulate the expression of MMP-1, ADAMTS5 and inflammatory factors (IL-1β and IL-6) compared to negative control. Conclusion Lubricin is present in the lumbar endplate where it may have an anti-inflammatory role. P. acnes infection inhibits lubricin expression by cartilage endplate cells and this may facilitate the progression of MCs and endplate degeneration. The translational potential of this article Lubricin may have an anti-inflammatory role. P. acnes infection inhibits lubricin expression by cartilage endplate cells and this may facilitate the progression of MCs and endplate degeneration.
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Affiliation(s)
- Junhui Liu
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, No. 3, Qingchun Road East, Hangzhou, 310016, PR China
| | - Xiaoan Wei
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, No. 3, Qingchun Road East, Hangzhou, 310016, PR China
| | - Bao Huang
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, No. 3, Qingchun Road East, Hangzhou, 310016, PR China
| | - Hao Wu
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, No. 3, Qingchun Road East, Hangzhou, 310016, PR China
| | - Xuyang Zhang
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, No. 3, Qingchun Road East, Hangzhou, 310016, PR China
| | - Jian Chen
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, No. 3, Qingchun Road East, Hangzhou, 310016, PR China
| | - Zhi Shan
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, No. 3, Qingchun Road East, Hangzhou, 310016, PR China
| | - Shunwu Fan
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, No. 3, Qingchun Road East, Hangzhou, 310016, PR China
| | - Fengdong Zhao
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, No. 3, Qingchun Road East, Hangzhou, 310016, PR China
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Ahmed-Yahia S, Decousser JW, Flouzat-Lachaniette CH, Dervin G, Roubineau F, Audureau E, Hourdille A, Royer G, Eymard F, Chevalier X. Is the discopathy associated with Modic changes an infectious process? Results from a prospective monocenter study. PLoS One 2019; 14:e0221030. [PMID: 31415619 PMCID: PMC6695213 DOI: 10.1371/journal.pone.0221030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/29/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The local infectious origin and the putative role of Cutibacterium acnes (CA) of a particular subtype of discopathy (Modic 1) are still debated. PURPOSE To establish the association of CA in intervertebral disc (IVD) and Modic 1 discopathy in patients with low back pain. METHODS The prevalence of bacteria in IVD samples obtained by anterior approach in patient with chronic low back pain harboring Modic type 1, 2 or no Modic changes was compared to that measured in IVD samples obtained by posterior approach for sciatica. From 45 patients included in the study, 77 discs samples were obtained: 58 by anterior approach (32 Modic 1/2 changes, 26 without Modic change) and 19 by posterior approach. Conventional microbial cultures, universal 16S rRNA molecular detection and a CA specific PCR were performed. RESULTS 12 /77 (15.6%) disc samples were culture positive. Among the 10 CA positive cultures, 5 out of 58 (8.6%) were identified from specimens obtained by anterior approach and 5/19 (26.3%) from posterior approach (p = 0.046). Moreover, the percentage of CA culture positive sample was statistically no different between the patient with or without Modic changes. The CA prevalence was lower through molecular, culture-free approaches: the universal 16S rRNA PCR was positive for 6 specimens, including one CA positive sample and the CA specific PCR was positive for one specimen obtained by posterior approach. CONCLUSIONS In spine surgery the prevalence of CA in culture was significantly higher in IVD samples collected through a posterior approach compared to an anterior approach, suggesting a contamination process. This study did not support the CA related local infectious origin of Modic 1 discopathy.
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Affiliation(s)
- Salim Ahmed-Yahia
- Rheumatology Departement, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Jean-Winoc Decousser
- Department of Bacteriology and Infection Control, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
- EA 7380 Dynamyc Université Paris-Est Créteil (UPEC), Ecole nationale vétérinaire d’Alfort (EnvA), Faculté de Médecine de Créteil, Créteil, France
- * E-mail:
| | | | - Guillaume Dervin
- Rheumatology Departement, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - François Roubineau
- Orthopaedic Departement, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Etienne Audureau
- Public Health Departement, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Alexia Hourdille
- Rheumatology Departement, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Guilhem Royer
- Department of Bacteriology and Infection Control, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Florent Eymard
- Rheumatology Departement, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Xavier Chevalier
- Rheumatology Departement, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
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A review of microscopy-based evidence for the association of Propionibacterium acnes biofilms in degenerative disc disease and other diseased human tissue. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:2951-2971. [PMID: 31359216 DOI: 10.1007/s00586-019-06086-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/18/2019] [Accepted: 07/20/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE Recent research shows an increasing recognition that organisms not traditionally considered infectious in nature contribute to disease processes. Propionibacterium acnes (P. acnes) is a gram-positive, aerotolerant anaerobe prevalent in the sebaceous gland-rich areas of the human skin. A ubiquitous slow-growing organism with the capacity to form biofilm, P. acnes, recognized for its role in acne vulgaris and medical device-related infections, is now also linked to a number of other human diseases. While bacterial culture and molecular techniques are used to investigate the involvement of P. acnes in such diseases, definitive demonstration of P. acnes infection requires a technique (or techniques) sensitive to the presence of biofilms and insensitive to the presence of potential contamination. Fortunately, there are imaging techniques meeting these criteria, in particular, fluorescence in situ hybridization and immunofluorescence coupled with confocal laser scanning microscopy, as well as immunohistochemistry. METHODS Our literature review considers a range of microscopy-based studies that provides definitive evidence of P. acnes colonization within tissue from a number of human diseases (acne vulgaris, degenerative disc and prostate disease and atherosclerosis), some of which are currently not considered to have an infectious etiology. RESULTS/CONCLUSION We conclude that P. acnes is an opportunistic pathogen with a likely underestimated role in the development of various human diseases associated with significant morbidity and, in some cases, mortality. As such, these findings offer the potential for new studies aimed at understanding the pathological mechanisms driving the observed disease associations, as well as novel diagnostic strategies and treatment strategies, particularly for degenerative disc disease. These slides can be retrieved under Electronic Supplementary Material.
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Jiao Y, Lin Y, Zheng Y, Yuan Y, Chen Z, Cao P. The bacteria-positive proportion in the disc tissue samples from surgery: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:2941-2950. [PMID: 31312913 DOI: 10.1007/s00586-019-06062-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 04/08/2019] [Accepted: 06/10/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE The role of bacteria, especially Propionibacterium acnes (P. acnes), in human intervertebral disc diseases has raised attention in recent years. However, limited sample size of these studies and diverse bacteria-positive proportion made this topic still controversial. We aimed to review related articles and summarize the bacteria-positive proportion in these studies. METHODS We searched the PubMed, Cochrane Library, Embase for related literature from January 2001 to May 2018, and the reference articles were also searched. The random effects or fixed effects meta-analysis was used to pool the overall positive proportion or odds ratio of these studies. RESULTS We found 16 relevant articles and 2084 cases of the bacteria culture from surgery. Within the 16 included studies, 12 studies' results supported the infection in the discs. The pooled bacterial infection rate was 25.3%. The pooled P. acnes infection rate was 15.5%. The overall pooled P. acnes proportion in bacteria-positive discs was 56.4%. We also found that the presence of bacteria may contribute to the development of Modic change with the odds ratio as 1.27 (95% CI: 0.44-3.64), but this result is not significant due to heterogeneity, so further study is needed. CONCLUSION The existence of bacteria in the intervertebral discs was proved by many studies. However, the variety in sample collecting and culture methods is still obvious and the positive rate also fluctuated within the studies. Standardized and reliable methods should be taken to promote the study in the future. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Yucheng Jiao
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.,Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases with Integrated Chinese-Western Medicine, Shanghai Institute of Traumatology and Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Yazhou Lin
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.,Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases with Integrated Chinese-Western Medicine, Shanghai Institute of Traumatology and Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Yuehuan Zheng
- Department of Orthopedics, Ruijin Hospital North, Shanghai Jiaotong University School of Medicine, Shanghai, 201800, China
| | - Ye Yuan
- Department of Orthopaedics, Chang Gung Hospital, Tsinghua University, Beijing, 102202, China
| | - Zhe Chen
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China. .,Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases with Integrated Chinese-Western Medicine, Shanghai Institute of Traumatology and Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China.
| | - Peng Cao
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China. .,Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases with Integrated Chinese-Western Medicine, Shanghai Institute of Traumatology and Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China.
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Abstract
Cutibacterium acnes, long thought to be skin flora of pathological insignificance, has seen a surge in interest for its role in spine pathology. C acnes has been identified as a pathogen in native spine infection and osteomyelitis, which has implications in the management compared with more commonly recognized pathogens. In addition, It has also been recognized as a pathogen in postoperative and implant-associated infections. Some evidence exists pointing to C acnes as an unrecognized source of otherwise aseptic pseudarthrosis. Recently, it is hypothesized that low virulent organisms, in particular C acnes, may play a role in degenerative disk disease and the development of Modic end plate changes found in MRI. To this end, controversial implications exist in terms of the use of antibiotics to treat certain patients in the setting of degenerative disk disease. C acnes continues to remain an expanding area of interest in spine pathology, with important implications for the treating spine surgeon.
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Capoor MN, Lochman J, McDowell A, Schmitz JE, Solansky M, Zapletalova M, Alamin TF, Coscia MF, Garfin SR, Jancalek R, Ruzicka F, Shamie AN, Smrcka M, Wang JC, Birkenmaier C, Slaby O. Intervertebral disc penetration by antibiotics used prophylactically in spinal surgery: implications for the current standards and treatment of disc infections. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 28:783-791. [PMID: 30506486 DOI: 10.1007/s00586-018-5838-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 11/21/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE The presence of Propionibacterium acnes in a substantial component of resected disc specimens obtained from patients undergoing discectomy or microdiscectomy has led to the suggestion that this prominent human skin and oral commensal may exacerbate the pathology of degenerative disc disease. This hypothesis, therefore, raises the exciting possibility that antibiotics could play an important role in treating this debilitating condition. To date, however, little information about antibiotic penetration into the intervertebral disc is available. METHODS Intervertebral disc tissue obtained from 54 microdiscectomy patients given prophylactic cefazolin (n = 25), clindamycin (n = 17) or vancomycin (n = 12) was assayed by high-performance liquid chromatography, with cefaclor as an internal standard, to determine the concentration of antibiotic penetrating into the disc tissue. RESULTS Intervertebral disc tissues from patients receiving the positively charged antibiotic clindamycin contained a significantly greater percentage of the antibacterial dose than the tissue from patients receiving negatively charged cefazolin (P < 0.0001) and vancomycin, which has a slight positive charge (P < 0.0001). CONCLUSION Positively charged antibiotics appear more appropriate for future studies investigating potential options for the treatment of low-virulence disc infections. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Manu N Capoor
- Laboratory of Bacterial Pathogenesis and Immunology, Rockefeller University, 1230 York Avenue, New York, NY, USA.
- Central European Institute of Technology (CEITEC), Masaryk University, Kamenice 753/5, 625 00, Brno, Czech Republic.
| | - Jan Lochman
- Department of Biochemistry, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Andrew McDowell
- Northern Ireland Centre for Stratified Medicine, School of Biomedical Sciences, Ulster University, Londonderry, UK
| | - Jonathan E Schmitz
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Martin Solansky
- Department of Biochemistry, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Martina Zapletalova
- Department of Biochemistry, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Todd F Alamin
- Department of Orthopedic Surgery, Stanford University Medical Center, Stanford University, Stanford, CA, USA
| | - Michael F Coscia
- Department of Orthopedic Surgery, OrthoIndy Hospital, Indianapolis, IN, USA
| | - Steven R Garfin
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Radim Jancalek
- Department of Neurosurgery, Masaryk University, St. Anne's University Hospital, Brno, Czech Republic
| | - Filip Ruzicka
- Department of Microbiology, Masaryk University, St. Anne's University Hospital, Brno, Czech Republic
| | - A Nick Shamie
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Martin Smrcka
- Department of Neurosurgery, University Hospital Brno, Masaryk University, Brno, Czech Republic
| | - Jeffrey C Wang
- Department of Orthopedic Surgery, University Southern California, Los Angeles, CA, USA
| | - Christof Birkenmaier
- Department of Orthopedics, Physical Medicine and Rehabilitation, University of Munich (LMU), Munich, Germany
| | - Ondrej Slaby
- Central European Institute of Technology (CEITEC), Masaryk University, Kamenice 753/5, 625 00, Brno, Czech Republic.
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Current concepts for lumbar disc herniation. INTERNATIONAL ORTHOPAEDICS 2018; 43:841-851. [PMID: 30506088 DOI: 10.1007/s00264-018-4247-6] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 11/20/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE To present the pathophysiology, biology, clinical presentation, diagnosis, and current treatment options for lumbar disc herniation. METHODS A thorough literature search was undertaken in PubMed and Google Scholar to summarize the current knowledge and future perspectives on lumbar disc herniation. RESULTS Several changes in the biology of the intervertebral disc are thought to contribute to disc herniation; nevertheless, the exact inciting event leading to disc herniation is yet to be discovered. Non-operative treatments have stood the test of time as the first-line treatment for most patients with lumbar disc herniation; however, operative treatment remains the current gold standard, with minimally invasive endoscopic microdiscectomy techniques showing best results with respect to postoperative pain and function. CONCLUSIONS The exact event leading to disc herniation remains unclear. Non-operative treatments should be the first-line treatment for most patients with lumbar disc herniation. Operative treatment remains the current gold standard, with minimally invasive endoscopic microdiscectomy techniques showing best results with respect to postoperative pain and function. Regenerative medicine is promising.
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Capoor MN, Ruzicka F, Sandhu G, Rollason J, Mavrommatis K, Ahmed FS, Schmitz JE, Raz A, Brüggemann H, Lambert PA, Fischetti VA, Slaby O. Importance of Propionibacterium acnes hemolytic activity in human intervertebral discs: A microbiological study. PLoS One 2018; 13:e0208144. [PMID: 30496247 PMCID: PMC6264842 DOI: 10.1371/journal.pone.0208144] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 11/11/2018] [Indexed: 11/18/2022] Open
Abstract
Most patients with chronic lower back pain (CLBP) exhibit degenerative disc disease. Disc specimens obtained during initial therapeutic discectomies are often infected/colonized with Propionibacterium acnes, a Gram-positive commensal of the human skin. Although pain associated with infection is typically ascribed to the body's inflammatory response, the Gram-positive bacterium Staphylococcus aureus was recently observed to directly activate nociceptors by secreting pore-forming α-hemolysins that disrupt neuronal cell membranes. The hemolytic activity of P. acnes in cultured disc specimens obtained during routine therapeutic discectomies was assessed through incubation on sheep-blood agar. The β-hemolysis pattern displayed by P. acnes on sheep-blood agar was variable and phylogroup-dependent. Their molecular phylogroups were correlated with their hemolytic patterns. Our findings raise the possibility that pore-forming proteins contribute to the pathogenesis and/or symptomology of chronic P. acnes disc infections and CLBP, at least in a subset of cases.
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Affiliation(s)
- Manu N. Capoor
- Laboratory of Bacterial Pathogenesis and Immunology, Rockefeller University, New York, New York, United States of America
- Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
| | - Filip Ruzicka
- Department of Microbiology, Faculty of Medicine, Masaryk University, St. Anne's University Hospital, Brno, Czech Republic
| | - Gurpreet Sandhu
- Faculty of Health and Life Sciences, School of Life Sciences, Coventry University, Coventry, United Kingdom
| | - Jess Rollason
- Faculty of Health and Life Sciences, School of Life Sciences, Coventry University, Coventry, United Kingdom
| | - Konstantinos Mavrommatis
- Celgene Corporation, Information Knowledge and Utilization, San Francisco, California, United States of America
| | - Fahad S. Ahmed
- Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
| | - Jonathan E. Schmitz
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Assaf Raz
- Laboratory of Bacterial Pathogenesis and Immunology, Rockefeller University, New York, New York, United States of America
| | | | - Peter A. Lambert
- The School of Life and Health Sciences, Aston University, Aston Triangle, Birmingham, United Kingdom
| | - Vincent A. Fischetti
- Laboratory of Bacterial Pathogenesis and Immunology, Rockefeller University, New York, New York, United States of America
| | - Ondrej Slaby
- Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
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Talbott JF, Shah VN, Uzelac A, Narvid J, Dumont RA, Chin CT, Wilson DM. Imaging-Based Approach to Extradural Infections of the Spine. Semin Ultrasound CT MR 2018; 39:570-586. [PMID: 30527522 DOI: 10.1053/j.sult.2018.09.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jason F Talbott
- Department of Radiology and Biomedical Imaging, Zuckerberg San Francisco General Hospital, San Francisco; Department of Radiology and Biomedical Imaging, University of California, San Francisco.
| | - Vinil N Shah
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Alina Uzelac
- Department of Radiology and Biomedical Imaging, Zuckerberg San Francisco General Hospital, San Francisco; Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Jared Narvid
- Department of Radiology and Biomedical Imaging, Zuckerberg San Francisco General Hospital, San Francisco; Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Rebecca A Dumont
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Cynthia T Chin
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - David M Wilson
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
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Georgy MM, Vaida F, Stern M, Murphy K. Association between Type 1 Modic Changes and Propionibacterium Acnes Infection in the Cervical Spine: An Observational Study. AJNR Am J Neuroradiol 2018; 39:1764-1767. [PMID: 30139754 PMCID: PMC7655275 DOI: 10.3174/ajnr.a5741] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 06/08/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Research on the association between Propionibacterium acnes in the disc space and type 1 Modic changes in adjacent vertebrae is limited and has produced mixed results. The prevalence of bacteria in intervertebral discs contradicts the prior understanding that skeletal areas in the human anatomy are sterile; yet it opens new treatment possibilities. We investigated the relationship of P acnes and type 1 Modic changes in the cervical spine. MATERIALS AND METHODS Over a 36-month period, we collected intraoperative biopsies of patients undergoing a routine cervical spine operation for degenerative disc diseases. The disc material was cultured aerobically and anaerobically for 7 days. All preoperative MR images were evaluated for Modic changes by a board-certified neuroradiologist. Medical records were reviewed for other spine interventions before the operation. RESULTS The study population consisted of 48 patients. Of these, 14 patients tested positive for P acnes (29%) at ≥1 level. Additionally, 13 patients had type 1 Modic changes (27%) at ≥1 level; 54% (95% CI, 27%-84%) of patients who had type 1 Modic changes were also positive for P acnes compared with 20% (95% CI, 7%-33%) of patients without type 1 Modic changes. The difference between these proportions was 34% (95% CI, 4%-64%). The Fisher exact test produced a P value of .03 for the association between P acnes and MC1, and .53 for the association between P acnes and prior procedures. CONCLUSIONS We conclude that P acnes was prevalent in the degenerated cervical spine and that type 1 Modic changes were predictive of a culture positive for P acnes. We also found that the prevalence of P acnes was not associated with previous interventions. If these results are validated by future studies, they could have a major impact on the standard of care for back and neck pain.
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Affiliation(s)
- M M Georgy
- From the Division of Biostatistics and Bioinformatics (M.M.G., F.V.), Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, California
- Southern California Institute of Neurological Surgery (M.M.G., M.S.), Escondido, California
| | - F Vaida
- From the Division of Biostatistics and Bioinformatics (M.M.G., F.V.), Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, California
| | - M Stern
- Southern California Institute of Neurological Surgery (M.M.G., M.S.), Escondido, California
| | - K Murphy
- Joint Department of Medical Imaging (K.M.), University Health Network, Toronto, Ontario
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Modic changes-Their associations with low back pain and activity limitation: A systematic literature review and meta-analysis. PLoS One 2018; 13:e0200677. [PMID: 30067777 PMCID: PMC6070210 DOI: 10.1371/journal.pone.0200677] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 07/02/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Previous systematic reviews have reported positive associations between Modic changes (MCs) and low back pain (LBP), but due to their narrow scope and new primary studies, there is a need for a comprehensive systematic review. Our objectives were to investigate if MCs are associated with non-specific LBP and/or activity limitation and if such associations are modified by other factors. METHODS A protocol for this review was registered at PROSPERO prior to commencing the work (PROSPERO record: CRD42015017350). The MEDLINE, CINAHL and EMBASE databases were searched for relevant studies from first record to June 15th 2016. Prospective or retrospective cross-sectional cohort studies and case-control studies including people of all ages from general, working and clinical study populations were eligible for inclusion. Risk of bias assessment and data extraction for associations and potential modifiers were completed independently by pairs of reviewers. Meta-analysis was performed for homogeneous studies and presented as odds ratios (OR) with 95% CI. RESULTS In all, 5210 citations were identified and 31 studies were included. One study had low risk of bias. Fifteen studies (48%) reported statistically significant positive associations between MCs and LBP and one study found a statistically significant negative association. Meta-analysis performed for studies using concordant pain with provocative discography as the clinical outcome resulted in an OR of 4.01 (1.52-10.61). One of seven studies reported a statistically significant positive association between MCs and activity limitation. Lumbar disc level and disc degeneration were found to modify the association between MCs and LBP. CONCLUSIONS The results from this comprehensive systematic review indicate that the associations between MCs and LBP-related outcomes are inconsistent. The high risk of bias and the heterogeneity in terms of study samples, clinical outcomes and prevalence estimates of MCs and LBP may explain these findings. It is likely that new studies with low risk of bias will affect the direction and strength of these associations.
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32
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Barth M, Weiß C, Bouma GJ, Bostelmann R, Kursumovic A, Fandino J, Thomé C. Reply to the letter to the editor of E. Shiban and B. Meyer regarding "Endplate changes after lumbar discectomy with and without implantation of an annular closure device" by Barth M et al., (Acta Neurochir (Wien) 2018 Apr;160(4):855-862). Acta Neurochir (Wien) 2018; 160:1611-1612. [PMID: 29882013 DOI: 10.1007/s00701-018-3583-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 06/01/2018] [Indexed: 10/14/2022]
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Ohrt-Nissen S, Fritz BG, Walbom J, Kragh KN, Bjarnsholt T, Dahl B, Manniche C. Bacterial biofilms: a possible mechanism for chronic infection in patients with lumbar disc herniation - a prospective proof-of-concept study using fluorescence in situ
hybridization. APMIS 2018; 126:440-447. [DOI: 10.1111/apm.12841] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 03/06/2018] [Indexed: 02/02/2023]
Affiliation(s)
- Søren Ohrt-Nissen
- Department of Orthopaedic Surgery; Spine Unit; Rigshospitalet; Copenhagen Denmark
| | - Blaine G. Fritz
- Faculty of Health Sciences; Department of Immunology and Microbiology; University of Copenhagen; Copenhagen Denmark
| | - Jonas Walbom
- Department of Orthopaedic Surgery; Spine Unit; Rigshospitalet; Copenhagen Denmark
| | - Kasper N. Kragh
- Faculty of Health Sciences; Department of Immunology and Microbiology; University of Copenhagen; Copenhagen Denmark
| | - Thomas Bjarnsholt
- Faculty of Health Sciences; Department of Immunology and Microbiology; University of Copenhagen; Copenhagen Denmark
- Department of Clinical Microbiology; Rigshospitalet; Copenhagen Denmark
| | - Benny Dahl
- Department of Orthopaedic Surgery; Texas Children's Hospital; Houston TX USA
| | - Claus Manniche
- Spine Centre of Southern Denmark; Institute of Regional Health Service; University of Southern Denmark; Odense Denmark
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Low virulence bacterial infections in cervical intervertebral discs: a prospective case series. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:2496-2505. [PMID: 29675672 DOI: 10.1007/s00586-018-5582-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 03/04/2018] [Accepted: 04/03/2018] [Indexed: 10/17/2022]
Abstract
STUDY DESIGN A prospective cross-sectional case series study. OBJECTIVE To investigate the prevalence of low virulence disc infection and its associations with characteristics of patients or discs in the cervical spine. BACKGROUND Low virulence bacterial infections could be a possible cause of intervertebral disc degeneration and/or back pain. Controversies are continuing over whether these bacteria, predominantly Propionibacterium acnes (P. acnes), represent infection or contamination. However, the current studies mainly focus on the lumbar spine, with very limited data on the cervical spine. METHODS Thirty-two patients (20 men and 12 women) who underwent anterior cervical fusion for degenerative cervical spondylosis or traumatic cervical cord injury were enrolled. Radiological assessments included X-ray, CT, and MRI of the cervical spine. Endplate Modic changes, intervertebral range of motion, and disc herniation type were evaluated. Disc and muscle tissues were collected under strict sterile conditions. Samples were enriched in tryptone soy broth and subcultured under anaerobic conditions, followed by identification of the resulting colonies by the PCR method. RESULTS Sixty-six intervertebral discs were excised from thirty-two patients. Positive disc cultures were noted in eight patients (25%) and in nine discs (13.6%). The muscle biopsy (control) cultures were negative in 28 patients and positive in 4 patients (12.5%); three of whom had a negative disc culture. Seven discs (10.6%) were positive for coagulase-negative Staphylococci (CNS) and two discs were positive for P. acnes (3.0%). A younger patient age and the extrusion or sequestration type of disc herniation, which represented a complete annulus fibrous failure, were associated with positive disc culture. CONCLUSIONS Our data show that CNS is more prevalent than P. acnes in degenerative cervical discs. The infection route in cervical discs may be predominantly through an annulus fissure. Correlation between these infections and clinical symptoms is uncertain; therefore, their clinical significance needs to be investigated in the future. These slides can be retrieved under Electronic Supplementary Material.
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Gao X, Li J, Shi Y, Li S, Shen Y. Asymmetrical degenerative marrow (Modic) changes in cervical spine: prevalence, correlative factors, and surgical outcomes. J Orthop Surg Res 2018; 13:85. [PMID: 29661220 PMCID: PMC5902959 DOI: 10.1186/s13018-018-0807-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 04/06/2018] [Indexed: 01/14/2023] Open
Abstract
Background The current study aimed to discuss the prevalence and surgical outcomes of the asymmetrical Modic changes and identify its correlative factors by multivariate logistic regression analysis. Methods Two hundred seventy-eight patients with single-level Modic changes and nerve compression symptoms were reviewed retrospectively from January 2008 to January 2015. 1.5-T MRI was performed to determine the Modic changes. Multivariate logistic regression analysis was used to identify the correlative factors of asymmetrical Modic changes. Surgeries were performed according to the surgical indications. The outcomes were recorded by Japanese Orthopaedic Association (JOA) score, Neck Disability Index (NDI) score, and recovery rate. Results Asymmetrical Modic changes were observed in 76 patients (27.34%) with 4 type 1, 69 type 2, and 3 type 3. C5/6 was the most frequently affected segment with 39 patients showing signal changes on MRI. Statistically significant difference was showed in conservative rehabilitation rate between two groups (p = 0.043). Multiple logistic regression analysis identified disc herniation and neurological symptoms as correlative factors of asymmetrical Modic changes, and the adjusted odds ratios (95% CI) were 2.079 (1.348–3.208) and 0.231 (0.143–0.373) respectively. No statistically significant difference was found in JOA scores and NDI scores between the two kinds of Modic changes. Conclusions C5/6 was the most commonly affected level by Modic changes. Disc herniation and nerve root compression symptom were more closely correlated with asymmetrical Modic changes than conventional Modic changes. Asymmetrical Modic changes indicated poor result in conservative treatment; however, the final operation rate was similar between the two kinds of Modic changes. The outcomes of surgical treatment were satisfactory both in patients with asymmetrical Modic changes and conventional Modic changes.
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Affiliation(s)
- Xianda Gao
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Jia Li
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Yiqing Shi
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Shaoqing Li
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Yong Shen
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, China.
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Benoist M. The Michel Benoist and Robert Mulholland yearly European Spine Journal Review : A survey of the "medical" articles in the European Spine Journal, 2017. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:19-27. [PMID: 29270702 DOI: 10.1007/s00586-017-5422-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 12/09/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Michel Benoist
- Département de Rhumatologie, Service de Chirurgie Orthopédique, Hôpital Beaujon, 100 Boulevard Général Leclerc, 92118, Clichy, France.
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Storheim K, Espeland A, Grøvle L, Skouen JS, Aßmus J, Anke A, Froholdt A, Pedersen LM, Haugen AJ, Fors T, Schistad E, Lutro O, Marchand GH, Kadar T, Vetti N, Randen S, Nygaard ØP, Brox JI, Grotle M, Zwart JA. Antibiotic treatment In patients with chronic low back pain and Modic changes (the AIM study): study protocol for a randomised controlled trial. Trials 2017; 18:596. [PMID: 29246188 PMCID: PMC5732434 DOI: 10.1186/s13063-017-2306-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 11/01/2017] [Indexed: 11/25/2022] Open
Abstract
Background A previous randomised controlled trial (RCT) of patients with chronic low back pain (LBP) and vertebral bone marrow (Modic) changes (MCs) on magnetic resonance imaging (MRI), reported that a 3-month, high-dose course of antibiotics had a better effect than placebo at 12 months’ follow-up. The present study examines the effects of antibiotic treatment in chronic LBP patients with MCs at the level of a lumbar disc herniation, similar to the previous study. It also aims to assess the cost-effectiveness of the treatment, refine the MRI assessment of MCs, and further evaluate the impact of the treatment and the pathogenesis of MCs by studying genetic variability and the gene and protein expression of inflammatory biomarkers. Methods/design A double-blinded RCT is conducted at six hospitals in Norway, comparing orally administered amoxicillin 750 mg, or placebo three times a day, over a period of 100 days in patients with chronic LBP and type I or II MCs at the level of a MRI-confirmed lumbar disc herniation within the preceding 2 years. The inclusion will be stopped when at least 80 patients are included in each of the two MC type groups. In each MC type group, the study is designed to detect (β = 0.1, α = 0.05) a mean difference of 4 (standard deviation 5) in the Roland Morris Disability Questionnaire score between the two treatment groups (amoxicillin or placebo) at 1-year follow-up. The study includes cost-effectiveness measures. Blood samples are assessed for security measures and for possible inflammatory mediators and biomarkers at different time points. MCs are evaluated on MRI at baseline and after 12 months. A blinded intention-to-treat analysis of treatment effects will be performed in the total sample and in each MC type group. Discussion To ensure the appropriate use of antibiotic treatment, its effect in chronic LBP patients with MCs should be re-assessed. This study will investigate the effects and cost-effectiveness of amoxicillin in patients with chronic LBP and MCs at the level of a disc herniation. The study may also help to refine imaging and characterise the biomarkers of MCs. Trial registration ClinicalTrials.gov, ID: NCT02323412. Registered on 21 November 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2306-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital Ullevål, Pb 4950, Nydalen, 0424, Oslo, Norway.
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Pb 7804, 5020, Bergen, Norway
| | - Lars Grøvle
- Department of Rheumatology, Østfold Hospital Trust, Pb 300, 1714, Grålum, Norway
| | - Jan Sture Skouen
- Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway.,Department of Global Public Health and Primary Care, Physiotherapy Research Group, University of Bergen, Bergen, Norway
| | - Jörg Aßmus
- Competence Center for Clinical Research, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway
| | - Audny Anke
- Department of Rehabilitation, University Hospital of North Norway, Tromsø, Norway.,Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Anne Froholdt
- Department of Neurology, Rheumatology and Habilitation (NRH), Drammen Hospital, Vestre Viken Hospital Trust, Pb 800, 3004, Drammen, Norway
| | - Linda M Pedersen
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital Ullevål, Pb 4950, Nydalen, 0424, Oslo, Norway
| | - Anne Julsrud Haugen
- Department of Rheumatology, Østfold Hospital Trust, Pb 300, 1714, Grålum, Norway
| | - Terese Fors
- Department of Rehabilitation, University Hospital of North Norway, Tromsø, Norway
| | - Elina Schistad
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Ulleval, Pb 4950, Nydalen, 0424, Oslo, Norway
| | - Olav Lutro
- Medical Department, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway.,Medical Department, Stavanger University Hospital, Pb 8100, 4068, Stavanger, Norway
| | - Gunn Hege Marchand
- Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Thomas Kadar
- Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway
| | - Nils Vetti
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Pb 7804, 5020, Bergen, Norway
| | - Sigrun Randen
- Department of Neurology, Rheumatology and Habilitation (NRH), Drammen Hospital, Vestre Viken Hospital Trust, Pb 800, 3004, Drammen, Norway
| | - Øystein Petter Nygaard
- Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway.,National Advisory Unit on Spinal Surgery, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Neuroscience, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Ulleval, Pb 4950, Nydalen, 0424, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Margreth Grotle
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital Ullevål, Pb 4950, Nydalen, 0424, Oslo, Norway.,Oslo and Akershus University College of Applied Sciences, Faculty of Health Sciences, Department of Physiotherapy, Oslo, Norway
| | - John-Anker Zwart
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital Ullevål, Pb 4950, Nydalen, 0424, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
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Astur N, Martins DE, Wajchenberg M, Ferretti M, Menezes FG, Doi AM, Rosemberg LA, Santos DCB, Iutaka AS, Rodrigues LMR, Martino MDV, Pagura JR, Kihara Filho EN, Lenza M. Subclinical Propionibacterium acnes infection estimation in the intervertebral disc (SPInE-ID): protocol for a prospective cohort. BMJ Open 2017; 7:e017930. [PMID: 29151051 PMCID: PMC5701985 DOI: 10.1136/bmjopen-2017-017930] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Low back pain and vertebral endplate abnormalities are common conditions within the population. Subclinical infection caused by indolent pathogens can potentially lead to these findings, with differentiation between them notably challenging from a clinical perspective. Progressive infection of the intervertebral disc has been extensively associated with increasing low back pain, with Propionibacterium acnes specifically implicated with in relation to sciatica. The main purpose of this study is to identify if the presence of an infective pathogen within the intervertebral disc is primary or is a result of intraoperative contamination, and whether this correlates to low back pain. METHODS AND ANALYSIS An open prospective cohort study will be performed. Subjects included within the study will be between the ages of 18 and 65 years and have a diagnosis of lumbar disc herniation requiring open decompression surgery. Excised herniated disc fragments, muscle and ligamentum flavum samples will be collected during surgery and sent to microbiology for tissue culture and pathogen identification. Score questionnaires for pain, functionality and quality of life will be given preoperatively and at 1, 3, 6 and 12 months postoperatively. A MRI will be performed 12 months after surgery for analysis of Modic changes and baseline comparison. The primary endpoint is the rate of disc infection in patients with symptomatic degenerative disc disease. The secondary endpoints will be performance scores, Modic incidence and volume. ETHICS AND DISSEMINATION This study was approved by our Institutional Review Board and was only initiated after it (CAAE 65102617.2.0000.0071). Patients agreeing to participate will sign an informed consent form before entering the study. Results will be published in a peer reviewed medical journal irrespective of study findings. If shown to be the case, this would have profound effects on the way physicians treat chronic low back pain, even impacting health costs. TRIALS REGISTRATION NUMBER NCT0315876; Pre-results.
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Affiliation(s)
- Nelson Astur
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Delio E Martins
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Marcelo Wajchenberg
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Mario Ferretti
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Fernando G Menezes
- Serviço de Controle de Infecção Hospitalar, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Andre M Doi
- Serviço de Microbiologia do Laboratório Clínico, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Laercio A Rosemberg
- Departamento de Diagnostico por Imagem, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Durval C B Santos
- Departamento de Diagnostico por Imagem, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Alexandre S Iutaka
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | | | - Marines D V Martino
- Serviço de Microbiologia do Laboratório Clínico, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Jorge R Pagura
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Eduardo N Kihara Filho
- Departamento de Diagnostico por Imagem, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Mario Lenza
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
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Georgy M, Stern M, Murphy K. What Is the Role of the Bacterium Propionibacterium acnes in Type 1 Modic Changes? A Review of the Literature. Can Assoc Radiol J 2017; 68:419-424. [PMID: 28985974 DOI: 10.1016/j.carj.2017.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 07/16/2017] [Accepted: 07/23/2017] [Indexed: 01/13/2023] Open
Abstract
This review presents a summary of the pathology and epidemiology of Modic changes and the possible role of Propionibacterium acnes. This information is followed by a synthesis of the most recent clinical research involved in culturing the discs of patients with degenerative disc disease for the presence of bacteria. We also discuss a randomized controlled trial that investigates the effects of antibiotics on patients with chronic low back pain and type 1 Modic changes. We conclude with a brief discussion of the difficulties involved in this research and the significance of the findings.
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Affiliation(s)
- Mark Georgy
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, California; Southern California Institute of Neurological Surgery, Escondido, California.
| | - Mark Stern
- Southern California Institute of Neurological Surgery, Escondido, California
| | - Kieran Murphy
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
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40
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Chen AF, Nana AD, Nelson SB, McLaren A. What's New in Musculoskeletal Infection: Update Across Orthopaedic Subspecialties. J Bone Joint Surg Am 2017; 99:1232-1243. [PMID: 28719563 DOI: 10.2106/jbjs.17.00421] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Antonia F Chen
- 1Rothman Institute, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania 2John Peter Smith Hospital, Fort Worth, Texas 3Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 4University of Arizona, College of Medicine-Phoenix, Phoenix, Arizona
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Ribosomal PCR assay of excised intervertebral discs from patients undergoing single-level primary lumbar microdiscectomy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:2038-2044. [PMID: 28567591 DOI: 10.1007/s00586-017-5141-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 03/07/2017] [Accepted: 05/15/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine the presence of infectious microorganisms in the herniated discs of immunocompetent patients, using methodology that we hoped would be of higher sensitivity and specificity than has been reported in the past. Recent studies have demonstrated a significant rate of positive cultures for low virulent organisms in excised HNP samples (range 19-53%). These studies have served as the theoretical basis for a pilot trial, and then, a well done prospective randomized trial that demonstrated that systemic treatment with antibiotics may yield lasting improvements in a subset of patients with axial back pain. Whether the reported positive cultures in discectomy specimens represent true positives is as yet not proven, and critically important if underlying the basis of therapeutic approaches for chronic low back pain. METHODS This consecutive case series from a single academic center included 44 patients with radiculopathy and MRI findings of lumbar HNP. Patients elected for lumbar microdiscectomy after failure of conservative management. All patients received primary surgery at a single spinal level in the absence of immune compromise. Excised disc material was analyzed with a real-time PCR assay targeting the 16S ribosomal RNA gene followed by amplicon sequencing. No concurrent cultures were performed. Inclusion criteria were as follows: sensory or motor symptoms in a single lumbar nerve distribution; positive physical examination findings including positive straight leg raise test, distributional weakness, and/or a diminished deep tendon reflexes; and magnetic resonance imaging of the lumbar spine positive for HNP in a distribution correlating with the radicular complaint. RESULTS The PCR assay for the 16S rRNA sequence was negative in all 44 patients (100%). 95% CI 0-8%. CONCLUSIONS Based on the data presented here, there does not appear to be a significant underlying rate of bacterial disc infection in immunocompetent patients presenting with radiculopathy from disc herniation.
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Capoor MN, Ruzicka F, Schmitz JE, James GA, Machackova T, Jancalek R, Smrcka M, Lipina R, Ahmed FS, Alamin TF, Anand N, Baird JC, Bhatia N, Demir-Deviren S, Eastlack RK, Fisher S, Garfin SR, Gogia JS, Gokaslan ZL, Kuo CC, Lee YP, Mavrommatis K, Michu E, Noskova H, Raz A, Sana J, Shamie AN, Stewart PS, Stonemetz JL, Wang JC, Witham TF, Coscia MF, Birkenmaier C, Fischetti VA, Slaby O. Propionibacterium acnes biofilm is present in intervertebral discs of patients undergoing microdiscectomy. PLoS One 2017; 12:e0174518. [PMID: 28369127 PMCID: PMC5378350 DOI: 10.1371/journal.pone.0174518] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 03/10/2017] [Indexed: 01/31/2023] Open
Abstract
Background In previous studies, Propionibacterium acnes was cultured from intervertebral disc tissue of ~25% of patients undergoing microdiscectomy, suggesting a possible link between chronic bacterial infection and disc degeneration. However, given the prominence of P. acnes as a skin commensal, such analyses often struggled to exclude the alternate possibility that these organisms represent perioperative microbiologic contamination. This investigation seeks to validate P. acnes prevalence in resected disc cultures, while providing microscopic evidence of P. acnes biofilm in the intervertebral discs. Methods Specimens from 368 patients undergoing microdiscectomy for disc herniation were divided into several fragments, one being homogenized, subjected to quantitative anaerobic culture, and assessed for bacterial growth, and a second fragment frozen for additional analyses. Colonies were identified by MALDI-TOF mass spectrometry and P. acnes phylotyping was conducted by multiplex PCR. For a sub-set of specimens, bacteria localization within the disc was assessed by microscopy using confocal laser scanning and FISH. Results Bacteria were cultured from 162 discs (44%), including 119 cases (32.3%) with P. acnes. In 89 cases, P. acnes was cultured exclusively; in 30 cases, it was isolated in combination with other bacteria (primarily coagulase-negative Staphylococcus spp.) Among positive specimens, the median P. acnes bacterial burden was 350 CFU/g (12 - ~20,000 CFU/g). Thirty-eight P. acnes isolates were subjected to molecular sub-typing, identifying 4 of 6 defined phylogroups: IA1, IB, IC, and II. Eight culture-positive specimens were evaluated by fluorescence microscopy and revealed P. acnes in situ. Notably, these bacteria demonstrated a biofilm distribution within the disc matrix. P. acnes bacteria were more prevalent in males than females (39% vs. 23%, p = 0.0013). Conclusions This study confirms that P. acnes is prevalent in herniated disc tissue. Moreover, it provides the first visual evidence of P. acnes biofilms within such specimens, consistent with infection rather than microbiologic contamination.
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Affiliation(s)
- Manu N Capoor
- Laboratory of Bacterial Pathogenesis and Immunology, Rockefeller University, New York, New York, United States of America.,Department of Molecular Oncology, Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
| | - Filip Ruzicka
- Department of Microbiology, Faculty of Medicine, Masaryk university, St. Anne's Faculty Hospital, Brno, Czech Republic
| | - Jonathan E Schmitz
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Garth A James
- Center for Biofilm Engineering, Montana State University, Bozeman, Montana, United States of America
| | - Tana Machackova
- Department of Molecular Oncology, Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
| | - Radim Jancalek
- Department of Neurosurgery, St. Anne's University Hospital, Masaryk University, Brno, Czech Republic
| | - Martin Smrcka
- Department of Neurosurgery, University Hospital Brno, Masaryk University, Brno, Czech Republic
| | - Radim Lipina
- Department of Neurosurgery, University Hospital Ostrava, Ostrava University, Ostrava, Czech Republic
| | - Fahad S Ahmed
- Department of Molecular Oncology, Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
| | - Todd F Alamin
- Department of Orthopedic Surgery, Stanford University Medical Center, Stanford University, Stanford, California, United States of America
| | - Neel Anand
- Cedars-Sinai Institute for Spinal Disorders, Los Angeles, California, United States of America
| | - John C Baird
- Department of Molecular Oncology, Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
| | - Nitin Bhatia
- Department of Orthopaedic Surgery, University of California Irvine, School of Medicine, Irvine, California, United States of America
| | - Sibel Demir-Deviren
- Spine Center, UCSF Medical Center, San Francisco, California, United States of America
| | - Robert K Eastlack
- Scripps Clinic Division of Orthopedic Surgery, San Diego, California, United States of America
| | - Steve Fisher
- Center for Biofilm Engineering, Montana State University, Bozeman, Montana, United States of America
| | - Steven R Garfin
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, California, United States of America
| | - Jaspaul S Gogia
- Department of Orthopedic Surgery, Kaiser Permanente-San Jose Medical Center, San Jose, California, United States of America
| | - Ziya L Gokaslan
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Calvin C Kuo
- Department of Orthopedic Surgery, Kaiser Permanente-Oakland Medical Center, Oakland, California, United States of America
| | - Yu-Po Lee
- Department of Orthopaedic Surgery, University of California Irvine, School of Medicine, Irvine, California, United States of America
| | - Konstantinos Mavrommatis
- Celgene Corporation, Information Knowledge and Utilization, San Francisco, California, United States of America
| | - Elleni Michu
- Department of Molecular Oncology, Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
| | - Hana Noskova
- Department of Molecular Oncology, Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
| | - Assaf Raz
- Laboratory of Bacterial Pathogenesis and Immunology, Rockefeller University, New York, New York, United States of America
| | - Jiri Sana
- Department of Molecular Oncology, Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
| | - A Nick Shamie
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Philip S Stewart
- Center for Biofilm Engineering, Montana State University, Bozeman, Montana, United States of America
| | - Jerry L Stonemetz
- Department of Anesthesia, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Jeffrey C Wang
- Department of Orthopedic Surgery, University Southern California, Los Angeles, California, United States of America
| | - Timothy F Witham
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Michael F Coscia
- Department of Orthopedic Surgery, OrthoIndy Hospital, Indianapolis, Indiana, United States of America
| | - Christof Birkenmaier
- Department of Orthopedics, Physical Medicine & Rehabilitation, University of Munich (LMU), Munich, Germany
| | - Vincent A Fischetti
- Laboratory of Bacterial Pathogenesis and Immunology, Rockefeller University, New York, New York, United States of America
| | - Ondrej Slaby
- Department of Molecular Oncology, Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
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Histological Identification of Propionibacterium acnes in Nonpyogenic Degenerated Intervertebral Discs. BIOMED RESEARCH INTERNATIONAL 2017; 2017:6192935. [PMID: 28401158 PMCID: PMC5376442 DOI: 10.1155/2017/6192935] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 02/08/2017] [Accepted: 02/16/2017] [Indexed: 11/18/2022]
Abstract
Purpose. Low-virulence anaerobic bacteria, especially the Propionibacterium acnes (P. acnes), have been thought to be a new pathogeny for a series of disc diseases. However, until now, there has been no histological evidence to confirm this link. The purpose of this study was to confirm the presence of P. acnes in nonpyogenic intervertebral discs via histological observation. Method. Degenerated intervertebral discs were harvested from 76 patients with low back pain and/or sciatica but without any symptoms of discitis or spondylodiscitis. The samples were cultured under anaerobic conditions and then examined using 16S rDNA PCR to screen for P. acnes. Samples found to be positive for P. acnes were stained with hematoxylin-eosin (HE) and modified Brown-Brenn staining and observed under a microscope. Results. Here, 16 intervertebral discs were found to be positive for P. acnes via 16S rDNA PCR and the prevalence was 21.05% (16/76). Among them, 7 samples had visible microbes stained with HE and modified Brown-Brenn staining. Morphological examination showed the bacteria to be Gram-positive and rod-shaped, so they were considered P. acnes. Conclusion. P. acnes is capable of colonizing some degenerated intervertebral discs without causing discitis, and its presence could be further confirmed by histological evidence. Targeting these bacteria may be a promising therapy method for some disc diseases.
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Mulholland RC. The Michel Benoist and Robert Mulholland yearly European Spine Journal Review: a survey of the "surgical and research" articles in the European Spine Journal, 2016. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:11-19. [PMID: 28062915 DOI: 10.1007/s00586-016-4942-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 11/18/2016] [Indexed: 11/28/2022]
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45
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Benoist M. The Michel Benoist and Robert Mulholland yearly European Spine Journal Review: a survey of the "medical" articles in the European Spine Journal, 2016. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:1-10. [PMID: 27900554 DOI: 10.1007/s00586-016-4886-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 11/14/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Michel Benoist
- Département de Rhumatologie, Service de Chirurgie Orthopédique, Hôpital Beaujon, 100 Boulevard Général Leclerc, 92118, Clichy, France.
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Lambert P, Elliott T, Worthington T, Vernallis A, Rollason J. Letter to the Editor concerning "Prospective study using anterior approach did not show association between Modic 1 changes and low grade infection in lumbar spine" by Rigal J, et al.: Eur Spine J; 2016 Apr; 25(4):1000-5. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:3377-3378. [PMID: 27566298 DOI: 10.1007/s00586-016-4750-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 08/20/2016] [Indexed: 10/21/2022]
Affiliation(s)
| | - Tom Elliott
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
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Prevalence of Propionibacterium acnes in Intervertebral Discs of Patients Undergoing Lumbar Microdiscectomy: A Prospective Cross-Sectional Study. PLoS One 2016; 11:e0161676. [PMID: 27536784 PMCID: PMC4990245 DOI: 10.1371/journal.pone.0161676] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 08/09/2016] [Indexed: 11/20/2022] Open
Abstract
Background The relationship between intervertebral disc degeneration and chronic infection by Propionibacterium acnes is controversial with contradictory evidence available in the literature. Previous studies investigating these relationships were under-powered and fraught with methodical differences; moreover, they have not taken into consideration P. acnes’ ability to form biofilms or attempted to quantitate the bioburden with regard to determining bacterial counts/genome equivalents as criteria to differentiate true infection from contamination. The aim of this prospective cross-sectional study was to determine the prevalence of P. acnes in patients undergoing lumbar disc microdiscectomy. Methods and Findings The sample consisted of 290 adult patients undergoing lumbar microdiscectomy for symptomatic lumbar disc herniation. An intraoperative biopsy and pre-operative clinical data were taken in all cases. One biopsy fragment was homogenized and used for quantitative anaerobic culture and a second was frozen and used for real-time PCR-based quantification of P. acnes genomes. P. acnes was identified in 115 cases (40%), coagulase-negative staphylococci in 31 cases (11%) and alpha-hemolytic streptococci in 8 cases (3%). P. acnes counts ranged from 100 to 9000 CFU/ml with a median of 400 CFU/ml. The prevalence of intervertebral discs with abundant P. acnes (≥ 1x103 CFU/ml) was 11% (39 cases). There was significant correlation between the bacterial counts obtained by culture and the number of P. acnes genomes detected by real-time PCR (r = 0.4363, p<0.0001). Conclusions In a large series of patients, the prevalence of discs with abundant P. acnes was 11%. We believe, disc tissue homogenization releases P. acnes from the biofilm so that they can then potentially be cultured, reducing the rate of false-negative cultures. Further, quantification study revealing significant bioburden based on both culture and real-time PCR minimize the likelihood that observed findings are due to contamination and supports the hypothesis P. acnes acts as a pathogen in these cases of degenerative disc disease.
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