Antibiotic Treatment for Chronic Low Back Pain…what does the evidence say?

Low back pain remains one of the most disabling conditions worldwide, with substantial socioeconomic consequences.  A major consideration in treating low back pain is the use of pharmacological interventions such as opioids, which is especially pertinent in the treatment of chronic low back pain (CLBP).  Given the increasingly common use of opioids for chronic pain, a better understanding of conditions such as CLBP and the available pharmacological management strategies is warranted.
 
LBP is a multifaceted condition and pain-generating mechanisms vary, with Modic changes (MC) – vertebral bone marrow changes detected by MRI – recognized as an important factor, especially when considering specialized treatment for CLBP.  A link between LBP and MC has been observed, with MC present in up to 45% of CLBP cases.  MC-induced low back pain can be generalized as “vertebrogenic LBP” and is thought to have a substantial impact on the global health burden of LBP, including chronic cases.
 
The etiology of CLBP is varied, however, bacterial infection has gained attention as a potential causal mechanism due to findings of recent studies.  As a result of the uptick in research on this topic, the use of antibiotics in CLBP has been the focus of several randomized clinical trials (RCTs), resulting is substantial debate regarding the role of antibiotics in managing CLBP.  To date, however, no systematic reviews have been conducted on this subject.  To address this gap, these authors completed a systematic review and meta-analysis of randomized controlled trials investigating the effectiveness of oral antibiotics used in patients with CLBP with Modic changes.

Comment from Dr. Thistle:

“This topic emerged in the literature several years ago and has been controversial since. On the surface, the concept is appealing and seems logical – a long-term bacterial infection in a spinal structure (the disc?) could result in symptomatic back pain. As noted here, the literature has evolved a little bit, however we need more definitive answers before this sort of treatment is incorporated into clinical guidelines. My suspicion is that not all CLBP patients would need this form of treatment and just like other therapies for low back pain, it is about applying the right treatment at the right time in the right patient. One important step in this literature would be to reliably and accurately identify patients who may have a bacterial contribution to their CLBP.“

RESEARCH REVIEW: Antibiotic Treatment for Chronic Low Back Pain – Systematic Review & Meta-Analysis

This paper was published in JOR Spine (2023). 

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