Should DWMRI Be Routinely Recommended For Modic 1 Changes?

Bones, joints and muscles
1

We have to use tools that are available, however, despite the remarkable findings of the study with Modic 1 and Claw Sign, as I stated to mft, this is not 100%. It is too early and we do not have enough information, both experimental and clinical, to recommend routine DWMRI for determining infectious from non-infectious Modic 1 changes.

Is the data correct? It looks very good, however, it may raise more questions than answers.

Is it possible for Modic 1 with p. acnes infection to coexist with staph? Theoretically, infections would react the same, however, it may be an indication of virulence. Would staph infection progress more rapidly than p. acnes?

DWMRI results are time dependent. So, the resulting claw sign is an indication of a process that is slower progressing than a typical infection. This would be the case most likely, however, the study indicated multiple methods to determine infection, only some of them biopsies. Furthermore, I am not getting an indication regarding specific pathogens resulting from biopsy. I have had communications with one of the authors and answers are somewhat nebulous.

So, are Modic 1 changes with infections by p. acnes considered spondylodiscitis, discitis, osteomyelitis? Is it possible Modic 1 infected with p. acnes is less virulent than staph, progressing at a slower rate, thus giving a false positive with a claw sign? According to a post by mft, the radiologist agreed that her Modic changes with a claw sign on DWMRI were not infectious.

We know that with osteomyelitis, fever and blood profiles are often abnormal. This is typically not the case with Modic 1 changes, even when infectious in nature. So, it is possible that we are looking at an infectious process that progresses at a slower rate than typical osteomyelitis or spondylodiscitis.

We just need more information. I would presume this is something Dr. Albert would find of vital interest. For now, it is possible that Modic 1 changes without a claw sign is an indication of a more virulent strain of bacteria. The treatment might be intravenous antibiotics and/or in some cases, surgery. This might indicate that Modic 1 changes with a claw sign are still infectious, however, the infection is of a less virulent nature. With no fever or altered blood profiles, you would have to consider this a possibility and the indication for antibiotics would be more dependent on the nature of presenting symptoms and objective findings matching the profile of those who were successfully treated with the antibiotics in Dr. Albert’s study, unless we can find subjective and objective findings that clearly indicate structural from infectious Modic 1 changes.

 So, the question of recommendations for further investigation, post-standard MRI, with DWMRI must remain questionable considering the costs, compared with a trial of antibiotics. Definitely less invasive that biopsy. Further investigations need to be done. This poses some foundations for future studies.

Probably way too early, nevertheless,  has anyone had a DWMRI with a positive claw sign, then responded to the antibiotics or had a biopsy indicating p. acnes?

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

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Hi mastdoc,

You are raising very important questions.

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

I agree that further invetigations need to be done.

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

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

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Hi Ana,

Vaccination is interesting. We know Corynebacterium propinquum is also involved, being of similar charachteristics as p. acnes. One of the authors of the DWMRI study indicated "My presumption is that type I changes are more indolent Than infection and thus create the claw".

Therefore, it seems we are dealing with an assumption regarding Modic 1 changes as not significant, nor related to infection as delineated by Dr. Albert. This seems to indicate they want to rule out Modic 1 changes as an entity requiring treatment. Indolent: "causing little or no pain".

Anybody out there with Modic 1 changes, claw sign, and no pain?

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Thank you Miss,

This is great to hear. It seems so many want to turn this into an expensive venture to make potential patients shy away. The best studies now are not the ones with more expensive and hazardous drugs, diagnostic testing, invasive injections and surgery, but the stories we are hearing from experience. We are finding that keeping it simple, as Dr. Albert has, the results are quite impressive in many cases.

One of the complaints I hear the most is that we are promoting antibiotic resistance. Well, has anyone caught Modic changes from a cough or sneeze? We are not putting others at risk because it is a self limiting disease and not a communicable one. As Dr. Albert points out, we could do far better by limiting antibiotics used in the agriculture business... pigs, chickens, cows; we don't get much of a choice about that.

Another complaint is that Dr. Albert is profiting from the study with her certification course. Having successfuly completed this, I can say it was one of the most interesting post-graduate certification courses I have ever taken. Furthermore, I can say without hesistation that Dr. Albert is not only a fine clinician and researcher, but a wonderful, caring person.

Very interesting post miss.... nice!

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

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

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

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

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

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

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

Maybe DWMRI is differentiating between aggressive and passive spondylodiscitis?

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

I thought I would share the following:

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

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Hey Miss!

Would be nice to hear a Dentist's perspective on this. They have been very quiet, so far. Not looking forward to my next cleaning. Note how they routinely use antibiotics after many dental procedures. To prevent oral infections or infections elsewhere?

I know there are spinal surgeons who will recommend not brushing after surgery. Interesting regarding prophylactic measures post back injury. Again, sometimes it is difficult to determine a torn disc from a "pulled muscle". But some herniations do not cause any pain.

Considering the bacteria are also present in hair follicles, one should probably refrain from shaving. Seems a bit crazy, hairy and toothless, but it would be nice to prevent the Modic changes from developing in the first place, at least those related to infection. Time will tell more regarding non-infectious Modic changes; genetic, biomechanical, responsive to new biological and genetic based therapies... stem cells. 

Sometimes it feels like we are living in the stone age. I'm still taking Bactrim. Tried to stop, but this recent worsening is stupid painful. I'll see my primary again soon. Always frustrating. Finally have him recognizing this, but any specialist blows it off. Complications taking antibiotics makes this a very frustrating endeavor. Would like to have antibiotics injected directly in the disc. I'm sure insurance will pay for that!

Are you doing normal dental hygiene now? If so; should you hurt your back, would you stop?

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Did mean to mention that I had a friend over for the holiday. He is not a professional, although very health conscious. But when I explained a bit about my Modic changes, bacteria, brushing teeth; he said he uses a toothpaste with coenzyme Q10 in it to help prevent bacteria, said it neutralizes it or something....can't remember, we did have a few. Anyway, I have not researched it, but I did get a tube and have been using it. Sound desperate?

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Dear mastdoc, 

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

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

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

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

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

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Hi Miss,

I have seen the study by Pate.; Tanenbaum is another author of this study, and it is he with whom I spoke and referenced above in reply to ana. Unfortunately, the study relegates Modic changes as an "indolent" entity. They want to rule out any confusion between Modic changes and the "important infections" requiring immediate attention regarding mortality. They are concerned with those Modic changes, infectious or not, that are possibly hiding a more serious condition, thus DWMRI.

Dr. Albert did say it would take about 10 years to become mainstream in the US. From my experience and what I see in current studies and trials, it may take more than a decade!

What I see is drug companies seeking to find more expensive drugs like biophosphonates; of course the side effects make antibiotics look like candy, and orthopedists seeking more expensive invasive procedures, making antibiotics look like vitamins.

There should be options for those for whom the antibiotics do not work; structural, allergic, atypical reactions, comorbid factors. The last orthopedic specialist I saw suggested epidural injections for mine. Forget the studies indicating lack of efficacy with Modic changes, in favor of intradiscal injections; the orthopedist said "I do epidurals" (non-guided in the spine). Basically, like it or leave it and quit trying to be smarter than me. I left!

I know someone who had the regenokine injection system for his Modic changes and he said he got about 80% relief. He then tried the antibiotics to get the other 20%, but it did not work. These injections are not covered by insurance and cost about $20,000.

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Very interesting. Sounds like a systemic reaction or hypersensitivty to the bacteria. Your story is fascinating, and I am very happy to hear you are doing so well.

Have you heard anything about the toothpaste with Co-Q10?

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

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

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For many years, they were considered a normal part of degeneration. They are getting better, some noting them as "reactive endplate changes". They are very machine dependent. Low fields are used for typing. High fields can see them, but not type. Some machines will not show them. So, not lack of training because most are going by what they learned, however; it seems some are just not keeping up and perhaps they haven't reached standard guidelines yet.

Does explain why exercises did not work. That's probably the most frustrating thing; all guidelines indicate exercise over passive therapies. However, Modic changes do not respond and, in fact, can be made worse. We've seen these patients; not responding to manual therapies, modalities, exercise/stretching, medications, non-specific diagnoses. Wish I had known this years ago. Centralization came along and medication helped with some, but not with active Modic symptoms. Prolotherapy is getting more attention.