Answer to the Letter to the Editor of Svend Lings entitled “Antibiotics for low back pain?” concerning “Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized controlled trial of efficacy” by Albert HB et al., Eur Spine J (2013) 22:697–707

Abstract

The author of this Letter to the Editor claims that he felt that he needed to review this paper carefully because Professor Claus Manniche, in addition to his full-time job, recently started a clinic where he treats patients with Modic changes and chronic lower back pain. It is not true that Claus Manniche after the publishing of the paper has established a private clinic, but in June 2013 he has started a position as being responsible for the research activity in a private clinic, which specializes in treating patients with Modic changes who are not able to receive treatment in the national health system. We feel that this is confirmation of the results of the trial and that he should be praised for providing this service. A professor would not participate in any clinic if the study was not scientifically extremely sound and provide a treatment where this specific group of patients does experience meaningful improvement with conventional care. If Professor Claus Manniche did not support this treatment that would be rather more suspicious. An author of a Letter to the Editor has to obey same rules as authors of scientific papers. Postulations need to be proven. This letter is full of undocumented postulations. For example, SL states that on the website belonging to Modicklinikken.dk it says in Danish: ‘‘We can cure back pain...’’). This is the first of many incorrect postulations, because this clinic only concerns itself with patients with Modic changes and only writes about them. Furthermore, this wording is simply not present. Another faulty postulation is that SL claims that we write in our paper ‘‘the authors claim to have shown that AB (anarobi bacteria) is found quite frequently in degenerated discs’’. We do not claim any such thing. We have shown that bacteria have been found in extruded nucleus material in disc herniations. Disc degeneration is an extremely wide definition and we have not studied this. SL claims that we investigated ‘‘Whether AB would be present in degenerated discs removed surgically’’. We have not claimed any such thing. We investigated if any bacteria were present in the extruded herniated nucleus material. This is clearly stated in the title of the paper ‘‘Does nuclear tissue infected with bacteria following disc herniation lead to Modic changes in the adjacent vertebrae?’’. Furthermore, it is not true that we only looked for AB (anaerobic bacteria). In Table 1 it is clearly marked that the analysis was carried out for both anaerobic and aerobic bacteria. SL wonders why we did not study the association between a possible presence of bacteria at baseline and presence of Modic changes, and he thinks that we miss out on this opportunity. I presume that this stems from his previous misunderstanding where he thinks that we studied ‘‘degenerated discs removed surgically’’. We only had permission from The Ethical Committee to remove the extruded herniated disc material, and this was also our only interest. Patients would naturally get rather upset if after a surgery for a lumbar disc herniation they were told that lumps of their disc were removed or worse as SL describes ‘‘degenerated discs removed surgically’’. SL’s conclusion is that the bacteria are present as a result of contamination. SL claims that ‘‘Furthermore, as this bacterium is apparently also present inside the body, contamination could conceivably come from the body fluids’’ and doubts that it would be possible to have surgery without contamination. Well, only 44 % had infected nuclear material so it is indeed possible to undergo surgery H. B. Albert (&) C. Manniche Institute of Regional Health Services Research, University of Southern Denmark, Odense, Denmark e-mail: hanne.albert@galnet.dk