Late infections after dynamic stabilization of the lumbar spine with Dynesys

Evaluation of the biomechanical effects and stability of titanium and carbon fiber-reinforced polyetheretherketone mini plates in Le Fort I advancement osteotomy fixation using finite element analysis

AIM

This study aimed to investigate the biomechanical properties of 60 % carbon fiber-reinforced polyetheretherketone (Cfr-PEEK), which exhibits high mechanical strength and can address the limitations of titanium mini plates used in Le Fort I osteotomy.

MATERIAL AND METHOD

Models were created using the FEA method based on tomography images of adult individuals. A 5 mm maxillary advancement was applied to the models following Le Fort I osteotomy. Mini plates made of titanium and 60 % Cfr-PEEK were used. Support was provided by the nasomaxillary and zygomaticomaxillary buttresses to fix a total of four l-shaped mini plates. Oblique loads of 125 N, directed from palatal to buccal, and a total of 250 N compression loads were applied to the central fossa of the premolar and molar teeth in the maxillary model at a 30° angle relative to the long axis of the teeth. Displacement values at the osteotomy line, Von Mises stresses in the mini plate-screws, and principal stresses in the bone were compared.

RESULTS

Examination of stress values in the fixation systems of the models revealed higher stress values in the Cfr-PEEK model compared to the titanium model. However, these stresses did not reach levels that would deform the Cfr-PEEK fixation systems. Stress and displacement values in the bone were lower in the Cfr-PEEK model compared to the titanium model.

CONCLUSION

According to the findings of our study, Cfr-PEEK represents a viable alternative to titanium for mini plate material in Le Fort I osteotomy, offering biomechanical advantages.

Innovative technologies in thoracolumbar and lumbar spine surgery failing to reach standard of care: state-of-art review

PURPOSE

To evaluate previously popular technologies in the field of spine surgery, and to better understand their advantages and limitations to the current standards of care. Spine surgery is an ever-evolving field that serves to resolve various spinal pathologies in patients of all ages. While there are established treatments for various conditions, such as lumbar spinal stenosis, idiopathic scoliosis, and degenerative lumbar disease, there is always further research and development in these areas to produce innovative technologies that can lead to better outcomes. As this process progresses, we must remind ourselves of previously tried and tested inventions and their outcomes that have fallen short of becoming a standard to ensure we are able to learn lessons from the past.

METHODS

A thorough literature review was conducted with the aim of compiling literature of previously utilized technologies in spine surgery. Biomedical databases were utilized to gather relevant articles including PubMed, MEDLINE, and EMBASE. Emphasis was placed on gathering articles with technologies or therapeutics aimed at treating common spinal pathologies including lumbar spinal stenosis (LSS), adolescent idiopathic scoliosis (AIS), and other degenerative lumbar spine diseases. The keywords used were: "failed technologies", "historical technologies", "spine surgery", "spinal stenosis", "adolescent idiopathic scoliosis", and "degenerative lumbar spine disease". A total of 47 articles were gathered after initial review.

RESULTS

Different technologies pertaining to spine surgery were identified and critically evaluated. Some of these technologies included X-STOP, Vertiflex, Vertebral Body Stapling, and Dynesys. These technologies were evaluated for their strengths and limitations across their spinal pathology applications. While each type of technology had their benefits, the data tended to be mixed with various limitations across studies.

CONCLUSION

These technologies have been trialed in the field of spine surgery across various spinal pathologies, but still prove of limited efficacy and shortcomings to the current standards of care.

Evaluation of outcomes of discectomy with a dynamic neutralization system in treatment of lumbar disk herniation

OBJECTIVE

The study aimed to explore the clinical outcomes of discectomy with dynamic neutralization system (Dynesys) for single-segmental lumbar disk herniation (LDH) versus simple discectomy.

METHODS

The eligible patients with single-segmental LDH were randomly divided into the discectomy with Dynesys group (group A) and the simple discectomy group (group B). The Oswestry disability index (ODI), visual analog score (VAS), radiological results of intervertebral height and range of motion (ROM) of the treated segment were evaluated pre- and post-operatively in both groups. Operation duration and blood loss were recorded. Complications, reoperation, and mortality were also assessed. All patients received a 2-year follow-up.

RESULTS

123 (96.1%) participants completed the follow-up. The operation duration and blood loss of group B were significantly lower than those of group A (p<0.05). After operation, ODI and VAS were improved significantly in both groups, and there was no significant difference between the two groups immediately after surgery. But a rising trend was found in ODI and VAS of group B, especially after the 1-year follow-up (p<0.05). X-rays showed a continuing loss of intervertebral height of the treated segment in group B, while it was preserved in group A (p<0.05). ROM of the treated segment was also maintained stable in group A.

CONCLUSION

Discectomy with Dynesys is safe and effective for LDH treatment.

Diagnosis of orthopaedic-implant-associated infections caused by slow-growing Gram-positive anaerobic bacteria - a clinical perspective

Slow-growing Gram-positive anaerobic bacteria (SGAB) such as Cutibacterium acnes are increasingly recognized as causative agents of implant-associated infections (IAIs) in orthopaedic surgeries. SGAB IAIs are difficult to diagnose because of their non-specific clinical and laboratory findings as well as the fastidious growth conditions required by these bacteria. A high degree of clinical suspicion and awareness of the various available diagnostic methods is therefore important. This review gives an overview of the current knowledge regarding SGAB IAI, providing details about clinical features and available diagnostic methodologies. In recent years, new methods for the diagnosis of IAI were developed, but there is limited knowledge about their usefulness in SGAB IAI. Further studies are required to determine the ideal diagnostic methodology to identify these infections so that they are not overlooked and mistakenly classified as aseptic failure.

High Failure Rates of a Unilateral Posterior Peri-Apical Distraction Device (ApiFix) for Fusionless Treatment of Adolescent Idiopathic Scoliosis

BACKGROUND

Conventional surgical treatment for adolescent idiopathic scoliosis (AIS) consists of correction of the spinal deformity with rigid spinal instrumentation and fusion. Less-invasive and fusionless surgery could potentially improve patient outcomes. The purpose of the present study was to evaluate the efficacy of a recently U.S. Food and Drug Administration (FDA)-approved posterior peri-apical self-distracting device (ApiFix) that is designed to gradually correct the deformity without spinal fusion.

METHODS

In a prospective cohort study of 20 patients with AIS (Risser stage 1-4; Lenke 1 or 5; major curve Cobb angle, 40° to 55°; and Bunnell scoliometer rotation, <15°) were managed with the ApiFix device. Clinical and radiographic performance was assessed.

RESULTS

Twenty patients with a mean age (and standard deviation) of 14.8 ± 1.4 years were followed for a mean of 3.4 ± 1.0 years. The average major curve was reduced from 45.4° preoperatively to 31.4° at 2 weeks postoperatively and 31.0° at the time of the latest follow-up. The average minor curve measured 31.3° preoperatively, 26.1° at 2 weeks postoperatively, and 24.2° at the time of the latest follow-up. Ten patients had serious complications that required revision surgery, including osteolysis (n = 6), screw and/or rod breakage (n = 2), failure of the ratchet mechanism (n = 1), and pain without explainable cause (n = 1). During revision surgery, metallosis was observed in all patients and cultures showed growth of Cutibacterium acnes in 6 patients. Because of the high failure rate, the study was terminated early.

CONCLUSIONS

The use of the unilateral peri-apical concave self-distracting ratchet rod initially was associated with promising clinical and radiographic results. However, no distraction was observed and the high rate of serious adverse events within 2 years was considered to be unacceptable for further clinical application of this device in our institution, despite recent FDA approval.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Low-Grade Infection and Implant Failure Following Spinal Instrumentation: A Prospective Comparative Study

BACKGROUND

Spinal instrumentation can be associated with complications, including implant loosening. Hitherto, implant loosening has mainly been attributed to mechanical overload.

OBJECTIVE

To examine the role of low-grade infections as the cause of implant failure in suspected aseptic implant loosening following spinal instrumentation.

METHODS

A prospective single center observational study was performed. All patients who had revision surgery following spinal instrumentation between August 2015 and February 2018 were screened. Patients with revision surgery due to screw loosening on the computed tomograhy scan constituted the study group. Patients in which the screws where not loosened but removal was performed for other reasons formed the comparison group. Intraoperative swabs were taken and sonication was performed with the explanted material. Results of microbiological cultivation were analyzed.

RESULTS

A total of 59 patients were included in the study group and 34 in the comparison group. In the study group in 42.4% of the cultures a bacterium was detected, while in the comparison group only in 17.6%. 84%, and 83.3% of these germs were detected by sonication in the study and comparison group, respectively. The rate of positive cultures was significantly higher in the study group compared to the comparison group (P = .001). The most frequent bacterium cultivated in both groups was Propionibacterium acnes, followed by Staphylococcus species.

CONCLUSION

For patients with screw loosening a high level of suspicion for a low-grade infection should be raised. Cultures should be performed from the sonication fluid of the explanted devices in all patients with symptomatic screw loosening.

High Infection Rates in Patients with Long-Segment Dynesys System

BACKGROUND

Infection follow-up in patients stabilized with the Dynesys system. Infection rates were determined in patients who had ≥5 segments stabilized with the Dynesys system.

METHODS

Eighty-three patients with various etiologies were stabilized with the Dynesys system. Long-level stabilization patients were separated from the main group as a result of their high rates of infection.

RESULTS

Long-level stabilizations were performed in 8 of 83 patients. Five patients were determined to have infections including 4 deep infections and 1 superficial infection. In patients with deep infections, 3 of them exhibited chronic infections that lasted for approximately 2 years and the system was removed. A deep infection in 1 patient and a superficial infection in 1 patient were diagnosed after 1 month. The early-diagnosed deep infection patient was treated with wound irrigation and antibiotics. The system was not removed, and the wound was closed with daily dressing after 45 days. One superficial infection patient was only treated with daily dressing, and the infection healed within 2 weeks. The infectious agent was determined in 2 patients. Three patients in the chronic infection group underwent a surgical procedure to remove the system. Specific antibiotic treatments were administered to patients whose infectious agents were identified. The remaining patients were treated with wide-spectrum antibiotics.

CONCLUSIONS

We report that long-level stabilization with the Dynesys system results in a high infection rate.

Posterolateral fusion versus Dynesys dynamic stabilization: Retrospective study at a minimum 5.5years' follow-up

INTRODUCTION

Lumbar fusion is one of the most widespread techniques to treat degenerative lumbar pathology. To prevent complications such as non-union or adjacent segment degeneration, dynamic stabilization techniques were developed, but with controversial results. The aim of the present study was to compare long-term radiologic and clinical results between fusion and dynamic stabilization.

MATERIAL AND METHODS

A single-center retrospective study included patients with recurrent lumbar discal hernia or lumbar canal stenosis managed by posterolateral fusion or by dynamic stabilization associated to neurologic release. Patients were seen in follow-up for radiological and clinical assessment: visual analog pain scale (VAS), Oswestry Disability Index (ODI), Short Form-12 (SF-12), adjacent segment disease (ASD), and intervertebral range of motion (ROM).

RESULTS

Fifty-eight patients were included: 25 in the fusion group (FG), and 33 in the Dynesys^® group (DG). VAS scores were significantly lower in DG than FG. ODI was 14.6±2.8 in DG, versus 19.4±3.3 in FG (P=0.0001). SF-12 physical subscore was significantly higher in DG. ROM was 4.1±2° in DG, vs. 0.7±0.5° in FG (P=0.001). Radiologic ASD was significantly greater in FG than DG (36% vs. 12.1%; P=0.012), without difference in clinical expression (DG, 1 case; FG, 2 cases).

CONCLUSION

Dynamic stabilization provided clinical and radiological results comparable to those of posterolateral fusion in these indications (although level L5-S1 was not studied).

LEVEL OF EVIDENCE

IV.

Do Sublaminar Polyester Bands Affect the Outcomes of Postoperative Infections After Adolescent Idiopathic Scoliosis Surgery?

BACKGROUND

The incidence of surgical site infections (SSI) after adolescent idiopathic scoliosis (AIS) surgery ranges from 0.5% to 7%. There is currently a regain of interest in hybrid constructs, combining lumbar pedicle screws and thoracic sublaminar bands, but some authors have raised concerns about the risk of SSI and the difficulty of bacterial eradication. The goal of this study was therefore to assess the outcomes of SSI after AIS surgery using sublaminar bands.

METHODS

A total of 524 consecutive patients operated for AIS using sublaminar bands between June 2006 and June 2014 were included. SSI cases were identified and analyzed retrospectively. Radiologic and functional outcomes were evaluated at follow-up using EOS imaging and SRS 30 scores, and compared with a control group.

RESULTS

The overall SSI rate was 5.3%, with a majority of monomicrobial (86%) infections occurring in the first 6 weeks postoperative (93%). The most frequent pathogens were skin germs (Staphylococcus aureus and Propionibacterium acnes) with a community profile. Patients were treated successfully with surgical debridement without implants removal, associated with 6 weeks of antibiotherapy. However, 25% of patients required >1 surgical debridement. Instrumentation removal was decided in the 2 cases with late SSI, and performed uneventfully. Radiologic and functional outcomes at follow-up were not affected by the occurrence of SSI.

CONCLUSIONS

Sublaminar bands are not associated with a higher risk of infection. However, the SSI rate in the current study stands in the upper range of the literature, and other preventive strategies should be considered. In case of early infection, bands removal is not necessary to obtain pathogen eradication, but the sublaminar implants can be pulled out safely in case of late SSI. The occurrence of SSI does not alter the outcomes at follow-up.

LEVEL OF EVIDENCE

Level III.

Propionibacterium acnes biofilm is present in intervertebral discs of patients undergoing microdiscectomy

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.

Complications associated with the Dynesys dynamic stabilization system: a comprehensive review of the literature

The Dynesys dynamic stabilization system is an alternative to rigid instrumentation and fusion for the treatment of lumbar degenerative disease. Although many outcomes studies have shown good results, currently lacking is a comprehensive report on complications associated with this system, especially in terms of how it compares with reported complication rates of fusion. For the present study, the authors reviewed the literature to find all studies involving the Dynesys dynamic stabilization system that reported complications or adverse events. Twenty-one studies were included for a total of 1166 patients with a mean age of 55.5 years (range 39-71 years) and a mean follow-up period of 33.7 months (range 12.0-81.6 months). Analysis of these studies demonstrated a surgical-site infection rate of 4.3%, pedicle screw loosening rate of 11.7%, pedicle screw fracture rate of 1.6%, and adjacent-segment disease (ASD) rate of 7.0%. Of studies reporting revision surgeries, 11.3% of patients underwent a reoperation. Of patients who developed ASD, 40.6% underwent a reoperation for treatment. The Dynesys dynamic stabilization system appears to have a fairly similar complication-rate profile compared with published literature on lumbar fusion, and is associated with a slightly lower incidence of ASD.

Evaluation of a Hybrid Dynamic Stabilization and Fusion System in the Lumbar Spine: A 10 Year Experience

INTRODUCTION

The development of adjacent-segment disease is a recognized consequence of lumbar fusion surgery. Posterior dynamic stabilization, or motion preservation, techniques have been developed which theoretically decrease stress on adjacent segments following fusion. This study presents the experience of using a hybrid dynamic stabilization and fusion construct for degenerative lumbar spine pathology in place of rigid arthrodesis.

METHODS

A clinical cohort investigation was conducted of 66 consecutive patients (31 female, 35 male; mean age: 53 years, range: 25 - 76 years) who underwent posterior lumbar instrumentation with the Dynesys Transition Optima (DTO) implant (Zimmer-Biomet Spine, Warsaw, IN) hybrid dynamic stabilization and fusion system over a 10-year period. The median length of follow-up was five years. DTO consists of pedicle screw fixation coupled to a rigid rod as well as a flexible longitudinal connecting system. All patients had symptoms of back pain and neurogenic claudication refractory to non-surgical treatment. Patients underwent lumbar arthrodesis surgery in which the hybrid system was used for stabilization instead of arthrodesis of the stenotic adjacent level.

RESULTS

Indications for DTO instrumentation were primary degenerative disc disease (n = 52) and failed back surgery syndrome (n = 14). The most common dynamically stabilized and fused segments were L3-L4 (n = 37) and L5-S1 (n = 33), respectively. Thirty-eight patients (56%) underwent decompression at the dynamically stabilized level, and 57 patients (86%) had an interbody device placed at the level of arthrodesis. Complications during the follow-up period included a single case of screw breakage and a single case of pseudoarthrosis. Ten patients (15%) subsequently underwent conversion of the dynamic stabilization portion of their DTO instrumentation to rigid spinal arthrodesis.

CONCLUSION

The DTO system represents a novel hybrid dynamic stabilization and fusion construct. This 10-year experience found the device to be highly effective as well as safe. The technique may serve as an alternative to multilevel arthrodesis. Implantation of a motion-preserving dynamic stabilization device immediately adjacent to a fused level instead of extending a rigid construct may reduce the subsequent development of adjacent-segment disease in this patient population.

Market approval processes for new types of spinal devices: challenges and recommendations for improvement

BACKGROUND

Spinal pathology and related symptoms are among the most common health problems and are associated with high health care costs and productivity losses. Due to the aging population, these costs are further increasing every year. Another important reason for the increasing costs is the market approval of new technologies, such as spinal devices that are usually more expensive than the existing technologies. Previous cases of medical device failure led to concern about possible deficiencies in the market approval process.

OBJECTIVE

The objective is to provide an overview of U.S. Food and Drug Administration (FDA) regulation regarding spinal implants to delineate the challenges and opportunities that spine surgery currently faces.

METHODS

In this paper, two cases of market entries of spinal devices are presented and evaluated to illustrate these deficiencies.

RESULTS

Spinal implant regulation is facing several challenges. New spinal devices should increase patient outcomes and safety at reasonable societal costs. The main challenge is to have a rigorous evaluation before dissemination, while still leaving room for innovative behavior that thrusts the healthcare practice forward.

CONCLUSION

We have provided recommendations to enhance spinal implant regulation and improve and ensure the patient's safety and the future of spine surgery.

Propionibacterium acnes: from commensal to opportunistic biofilm-associated implant pathogen

Propionibacterium acnes is known primarily as a skin commensal. However, it can present as an opportunistic pathogen via bacterial seeding to cause invasive infections such as implant-associated infections. These infections have gained more attention due to improved diagnostic procedures, such as sonication of explanted foreign materials and prolonged cultivation time of up to 14 days for periprosthetic biopsy specimens, and improved molecular methods, such as broad-range 16S rRNA gene PCR. Implant-associated infections caused by P. acnes are most often described for shoulder prosthetic joint infections as well as cerebrovascular shunt infections, fibrosis of breast implants, and infections of cardiovascular devices. P. acnes causes disease through a number of virulence factors, such as biofilm formation. P. acnes is highly susceptible to a wide range of antibiotics, including beta-lactams, quinolones, clindamycin, and rifampin, although resistance to clindamycin is increasing. Treatment requires a combination of surgery and a prolonged antibiotic treatment regimen to successfully eliminate the remaining bacteria. Most authors suggest a course of 3 to 6 months of antibiotic treatment, including 2 to 6 weeks of intravenous treatment with a beta-lactam. While recently reported data showed a good efficacy of rifampin against P. acnes biofilms, prospective, randomized, controlled studies are needed to confirm evidence for combination treatment with rifampin, as has been performed for staphylococcal implant-associated infections.

Etiology of lumbar lordosis and its pathophysiology: a review of the evolution of lumbar lordosis, and the mechanics and biology of lumbar degeneration

The goal of this review is to discuss the mechanisms of postural degeneration, particularly the loss of lumbar lordosis commonly observed in the elderly in the context of evolution, mechanical, and biological studies of the human spine and to synthesize recent research findings to clinical management of postural malalignment. Lumbar lordosis is unique to the human spine and is necessary to facilitate our upright posture. However, decreased lumbar lordosis and increased thoracic kyphosis are hallmarks of an aging human spinal column. The unique upright posture and lordotic lumbar curvature of the human spine suggest that an understanding of the evolution of the human spinal column, and the unique anatomical features that support lumbar lordosis may provide insight into spine health and degeneration. Considering evolution of the skeleton in isolation from other scientific studies provides a limited picture for clinicians. The evolution and development of human lumbar lordosis highlight the interdependence of pelvic structure and lumbar lordosis. Studies of fossils of human lineage demonstrate a convergence on the degree of lumbar lordosis and the number of lumbar vertebrae in modern Homo sapiens. Evolution and spine mechanics research show that lumbar lordosis is dictated by pelvic incidence, spinal musculature, vertebral wedging, and disc health. The evolution, mechanics, and biology research all point to the importance of spinal posture and flexibility in supporting optimal health. However, surgical management of postural deformity has focused on restoring posture at the expense of flexibility. It is possible that the need for complex and costly spinal fixation can be eliminated by developing tools for early identification of patients at risk for postural deformities through patient history (genetics, mechanics, and environmental exposure) and tracking postural changes over time.

Pedicle screw loosening: a clinically relevant complication?

PURPOSE

Literature studies showed a very wide range of pedicle screw loosening rates after thoracolumbar stabilization, ranging from less than 1 to 15 % in non-osteoporotic patients treated with rigid systems and even higher in osteoporotic subjects or patients treated with dynamic systems. Firstly, this paper aims to investigate how much this complication is affecting the success rate of pedicle screw fixation, in both non-osteoporotic and osteoporotic patients, and to discuss the biomechanical reasons which may be related to the variability of the rates found in the literature. The secondary aim was to summarize and discuss the published definitions and conventions about screw loosening from a clinical and radiological point of view.

METHODS

Narrative literature review.

RESULTS

Screw loosening appears to be a minor problem for fixation and fusion of healthy, non-osteoporotic bone. Pedicle screw fixation in osteoporotic bone is believed to be at risk of loosening, but clinical data are actually scarce. Both expandable and augmented screws may be a viable option to reduce the risk of loosening, but clinical evidence is missing. Posterior motion-preserving implants seems to have a significant risk of screw loosening. Standardization appears to be lacking regarding the radiological assessment. Marked differences in the loosening rates found based either on planar radiography or on CT scanning were observed.

CONCLUSIONS

Reported loosening rates primarily depended on the protocol used for the clinical examination during follow-up and on the conventions used for the radiological assessment. Aiming to a better comparability of published data, we recommend the authors of clinical studies to describe which criteria were used to assess a loosened screw, as well as the protocol of the clinical follow-up examination. Low-dose CT should be used for the assessment of screw loosening whenever possible.

Should we start treating chronic low back pain with antibiotics rather than with pain medications?

For those of us who have read the 2 recently published articles by a Danish - British research group, it might appear that we are observing an impending paradigm shift on the origins of chronic low back pain. The results of this research indicate, that chronic low back pain associated with bone marrow edema in vertebral endplates that are adjacent to herniated intervertebral discs may be caused by infections with anaerobic bacteria of low virulence. According to these articles, treatment with certain antibiotics is significantly more effective than placebo against this low back pain. If these findings are to hold true in repeat studies by other researchers, they stand to fundamentally change our concepts of low back pain, degenerative disc disease and in consequence the suitable therapies for these entities. It may in fact require pain specialists to become familiarized with the details of antibiotic treatments and their specific risks in order to be able to properly counsel their patients. While this seems hard to believe at first glance, bacteria have been implicated in the pathogenesis of other conditions that do not primarily impose as infectious diseases such as gastric ulcers. While the authors refer to a few previous studies pointing into the same direction, the relevant research is really only from one group of collaborating scientists. Therefore, before we start prescribing antibiotics for chronic low back pain, it is imperative that other researchers in different institutions confirm these results.