April 2014

The Nation Reviewed

The trouble with miracle cures

By Karen Hitchcock
Can antibiotics really cure back pain?

Last year, when I read in the Guardian that antibiotics could cure chronic lower back pain, I thought it was some kind of joke. Might psychiatrists next declare that depression is caused by an infection of the heart and could be cured by penicillin?

I don’t normally keep my medical knowledge up to date with newspapers. Like most hospital doctors, I rely on meetings, conferences, corridor conversations and the heavyweight journals. But I needed a paper to present at journal club (a kind of book club for medical staff), so I looked for the original research.

The newspaper report was based on a double-blinded, placebo-controlled trial of antibiotics given to patients who suffered constant back pain and had MRI pictures that suggested vertebral disc inflammation. The results seemed astonishing: more than a third of the patients who took the antibiotics for 100 days showed marked improvement.

Lots of people with back pain get surgery and sometimes it’s successful. Neurosurgeons cut into your spine, in good faith, knowing it’s all they have to offer to treat your pain. But what if you could take three months of a standard sinusitis treatment instead? I emailed a neurosurgeon I know. He’d heard nothing about the trial and wondered if I was mistakenly referring to osteomyelitis (an acute infection of bone). I sent him the paper. He sent it around his department. That afternoon he forwarded me an email from one of the other neurosurgeons: “If this were truly paradigm-changing, it would have been reported in a more prestigious journal than this!”

A hypothesis is just a story put together from a number of facts with the gaps filled in. This story starts off with facts: some people with chronic back pain have MRI pictures that suggest a particular kind of inflammation of the vertebrae; some vertebral discs removed at surgery grow bacteria, including a skin dweller called Propionibacterium acnes. For the researchers’ story to work, P. acnes needs to lodge in a disc, cause pain, and then be obliterated by the antibiotic. They fill in the gaps like this: For years P. acnes was assumed to be a contaminant just catching a ride as the vertebral disc left the body. But when we brush our teeth or scratch at our skin, we send tiny sprays of bacteria into our bloodstreams. Usually our immune system destroys these bugs before they can lodge somewhere and cause damage, but when a disc is dislodged it causes inflammation of the bones around it. This inflammation causes extra blood flow, which delivers the bacteria. Vertebral discs are very low in oxygen, which is exactly the kind of environment in which P. acnes likes to grow. The bacteria therefore move into the disc and secrete propionic acid, which dissolves the surrounding bone and marrow and stops them healing. This causes pain. Kill the bug, the bones will heal and the pain will go away. It all adds up to a great story with a neat happy-ever-after ending.

In 2005, Barry Marshall and Robin Warren received the Nobel Prize for their work that proved a bacterium causes stomach ulcers. Initially, though, their studies were ridiculed and rejected. Gastric surgeons kept their operating theatres full, cutting out and discarding chunk after chunk of ulcerated stomach. Who could have believed that those deep ulcerations in the stomach lining – ulcerations that led to people bleeding to death or to cancer – had been caused by a bug? Changes in medical paradigms are slow and fraught: people lose their careers, their stocks, their standing. “If this is true,” my surgeon friend wrote about the findings of the back pain study, “a lot of neurosurgeons are going to find themselves out of work.”

Like most media beat-ups, there was more to this story than was initially reported. The researchers had hired a public relations company to launch their study results. There was no mention of the important point that most people with back pain don’t have MRI pictures of disc inflammation. Nor was there mention of the fact that at the end of the trial there was no reduction in the number of days any of the participants had to take off work because of pain. The methods were flawed: most of the patients who received antibiotics had very different MRI scans from those receiving the placebo. The researchers were accused of having serious commercial conflicts of interest: they’d opened a private clinic to treat back pain with antibiotics, coined a fancy acronym (MAST, for Modic Antibiotic Spinal Therapy) and launched a training academy. All of it based on a single, somewhat shaky study.

The infectious-diseases physicians urged caution. They are the hospital’s activists, forever reminding us that antibiotics are a precious resource. Spray the world with broad-spectrum antibiotics and you’ll breed resistant superbugs, and then we’ll be right back where we started: treating infections with fresh air and leeches. Sanatoriums in some countries are filled with patients who must be kept in isolation as their tuberculosis rots on despite treatment; patients in developed nations, in high-tech intensive care units, are dying from infections resistant to all known antibiotics. Every treatment has the potential to cause harm, but in the case of antibiotics it is not only to the individual – acute liver failure, for instance – but also to society.

A real paradigm change in medicine starts as a story that may one day be proven true. If that happens, the original storyteller becomes a prophet. But more often than not, the hypothesis proves false (think of mega-dose vitamin C, for instance). The story remains a distant tabloid miracle cure, rejected by the mainstream, practised on the fringes; the original storyteller is branded a quack.

Groups around the world are right now culturing all the vertebral discs they can get their hands on and organising larger, more robust trials.

I hope the story turns out to be true, but we’ll just have to wait and see. Until then, if you walk in the door with terrible back pain, most doctors won’t give you antibiotics, because we are only doctors: neither long-odds prophets nor quacks.

Karen Hitchcock

Karen Hitchcock is a doctor and writer. She is the author of a collection of short fiction, Little White Slips, and the Quarterly Essay ‘Dear Life: On Caring for the Elderly’.

April 2014

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