Artikkel i magasinet The Lancet, Volume 357, Issue 9273
23 June 2001 Pages 2024-2025. PII: S0140-6736(00)05109-6
Copyright © 2001 Elsevier Science Ltd. All rights reserved.
En studie i det Britiske medisinske tidsskriftet Lancet, rapporterer at smerter som går fra nedre del av ryggen til det ene benet, kalt isjas, kan være forårsaket av en infeksjon. Når du har smerter fra ryggen til benet, gir legen deg ofte diagnosen isjas. Han vil undersøke om den store isjas nerven er i klem. Han vil også se etter om nerven er i klem fra en muskel i sete regionen, kalt piriformis. Som regel er imidlertid MR negativ og viser ingen nerve i klem og ved berøring er heller ikke piriformis muskelen smertefull. Men legen din kaller det gjerne isjas likevel og sender deg til fysioterapi.
Forskere i England har funnet ut at 31 prosent av pasienter med isjas har en bakterie kalt Propionibacterium acnes. 51 prosent av de som hadde skiven fjernet hadde også denne bakterien. Hvis ryggsmertene skyldes infeksjon vil behandlingen være Zithromax, Biaxin or Dynabec antibiotika for flere måneder. Man venter nå på flere studier.
Les på engelsk her:
Research Letters
Association between sciatica and Propionibacterium acnes
Alistair Stirlinga, Tony Worthingtonb, Mohammed Rafiqa, Peter A. Lambertc and Tom S. J. Elliott, , b
a Royal Orthopaedic Hospital, Northfield, Birmingham, UK
b Department of Clinical Microbiology, University Hospital, Edgbaston, Birmingham, B15 2TH, UK
c Department of Pharmaceutical and Biological Sciences, Aston University, Aston Triangle, Birmingham, UK
Available online 25 June 2001.
Abstract
We hypothesised that the inflammation seen around the nerve root in patients with sciatica may be caused by microbial infection. We used a newly developed serological test to diagnose deep-seated infections caused by low virulent gram-positive microorganisms. 43 of 140 (31%) patients with sciatica tested positive. Intervertebral disc material from a further 36 patients with severe sciatica who had undergone microdiscectomy was cultured for the presence of microorganisms. 19 of these patients (53%) had positive cultures after long-term incubation. Propionibacterium acnes was isolated from 16 of the 19 (84%) positive samples. Low virulent microorganisms, in particular P acnes, might be causing a chronic low-grade infection in the lower intervertebral discs of patients with severe sciatica. These microorganisms could have gained access to the spinal disc after previous minor trauma.
Although low back pain and sciatica are some of the most common reasons for consultation in primary care,1 their cause is poorly understood. Marshall and colleagues2 have shown raised serum immunoglobulin concentrations in patients with sciatica. Discogenic radiculitis, which is caused by pressure, is also associated with an inflammatory process, and cytokines, including interleukin-1, have been linked to lumbar disc herniation. Surgically induced disc lesions in animals have also resulted in an inflammatory reaction in the nucleus pulposus, with the production of IgG in surrounding tissues. Inflammation around the nerve root may be due to a local autoimmune reaction.
The inflammation associated with sciatica could also have a microbial cause, possibly low virulent microorganisms, as seen in prosthetic hip infections. We used an ELISA based on an exocellular antigen produced by gram-positive bacteria (lipid S) for the diagnosis of deep-seated infections caused by low virulent pathogens, including coagulase-negative staphylococci and propionibacteria. The ELISA had previously facilitated diagnoses of prosthetic hip3 and central venous catheter infections,4 endocarditis, and pyogenic spondylodiscitis.
We used this serological test to investigate 140 patients with sciatica presenting to a specialist clinic. These patients were originally selected as controls for a study on spondylodiscitis, however, 43 of 140 (31%) had raised serum IgG titres to the lipid S antigen. No patient had reported any infection in the past 6 months.
A further 36 patients with severe sciatica were clinically assessed, and had lumbar magnetic resonance imaging. Discogenic radiculitis was subsequently diagnosed and the patients had microdiscectomies to relieve the pain. Disc tissue (about 2x2x5 mm) removed during operation was examined for presence of microorganisms. Stringent aseptic precautions were taken to minimise the risk of contamination in clean wound culture.
All samples were cultured in Robertson's cooked meat enrichment broth, incubated at 37°C and subcultured at 2, 7, and 21 days onto blood agar plates containing 7% defibrinated horse blood (Oxoid Ltd, Basingstoke, UK). Subcultures were incubated at 37°C under anaerobic conditions for 7 days, and inspected for microbial growth. Tissue samples that were large enough (n=11) were also cultured directly by impression onto 7% blood agar plates, and embedded into nutrient agar (Oxoid Ltd, Basingstoke, UK). We also prepared thin sections, which were gram-stained and examined for presence of microorganisms.
Tissue from 19 of 36 patients (53%) gave positive cultures in the enrichment technique within 7 days of incubation. Proprionibacterium acnes, coagulase-negative staphylococci, and Corynebacterium propinquum were isolated from 16 (84%), two (11%), and one (5%) of 19 positive cultures, respectively. Blood samples were obtained for lipid S antibody estimation from 15 of 19 patients with positive cultures. Seven (47%) had positive serological tests. 16 of the 17 (94%) patients with negative cultures had negative tests to the lipid S antigen. More patients with positive cultures had positive serological tests than did those with negative cultures (36% [7/19] vs 5% [1/17], p=0·0438; Fisher's exact test). C-reactive protein was measured in 25 of the 36 (69%) patients. Two of these 25 (8%) had C-reactive protein concentrations above 10 mg/L, and P acnes was isolated in both.
Discetomy tissue was concurrently examined from 14 controls presenting with other spinal disorders, including scoliosis (n=3), trauma (3), myeloma (2), and degenerative disc disease (6). None of these samples yielded positive cultures after long incubation. There was a significant difference between the number of patients with sciatica who had positive tissue cultures (53% [19/36]) as compared with controls (0% [0/14] p=0·0003). Additionally, 12 of 14 (86%) controls had negative serum antilipid S IgG titres.
P acnes was seen in six of 11 (55%) tissue samples that were cultured directly onto blood agar. Between 10 and 100 colony forming units were isolated from each sample. Gram-stained smears of the tissue samples embedded in agarose also showed gram-positive branching rods after incubation (average size 3·0x0·3 µm) (figure). Microorganisms were not detected in any of the 11 gram-stained thin sections examined by direct microscopy, suggesting that they are present only in low numbers.
In this preliminary study we have detected raised concentrations of a specific serum antibody to a glycerophospholipid (lipid S), an exocellular bacterial cell-wall component. We also recorded a corresponding presence of low virulent microorganisms, predominantly propionibacteria, in a high proportion of patients with sciatica.
Light photomicrograph of microdiscectomy tissue showing Proprionibacterium acnes (x1000)
We postulate that patients with sciatica sustain a breach in the mechanical integrity of a spinal disc, possibly from minor trauma, which allows access by low virulent microorganisms, thereby initiating or stimulating a chronic inflammatory response with accompanying symptoms. This hypothesis is consistent with the anatomical distribution of disc degeneration, with greater stresses on the distal regions of the spine. The observation that disc protrusions detected by magnetic resonance imaging are frequently symptomless, perhaps becoming symptomatic only after infection, also lends support to this hypothesis.
Previous epidural injections could be a further source of microorganisms. However, 53% (10/19) from whom bacteria were isolated had not had a pre-operative epidural injection, and 41% (7/17) of the tissue culture negative patients had. These findings suggest that epidural injections were not the source of the microorganisms.
Over the past two decades the skin commensals coagulase-negative staphylococci and propionibacteria, mainly thought of as contaminants when isolated from patients, are increasingly being recognised as agents of infection. Tunney and colleagues5 have shown the presence of P acnes and coagulase-negative staphylococci in situ on prosthetic joints studied at revision arthroplasty. Our results also suggest that these microorganisms, particularly P acnes, might be associated with chronic low-grade infection in the lower intervertebral discs of patients with severe sciatica.
The need to incubate disc material from patients for up to 7 days to isolate the propionibacteria might be why these microorganisms have not been previously associated with sciatica. The long generation time of propionibacteria makes these microorganisms ideal candidates for chronic infection. P acnes produces many exocellular virulence factors (including lipase, proteinase, hyaluronidase, neuramidase, and phospholipase C), which may contribute to its pathogenicity. These microorganisms may cause prosthetic hip infections, but also might be associated with the inflammation seen in sciatica, and may possibly even be a primary cause of this disorder.
This study was funded by BackCare and the National Back Pain Association, and was presented at 7th Conference of the Federation of Infection Societies, Manchester, Nov 29, 2000. We thank colleagues at Royal Orthopaedic Hospital for allowing us to study their patients.
1 Office of Population Censuses and Surveys (OPCS). Morbidity statistics from general practice, 4th National Study. Royal College of General Practitioners, OPCS, Department of Health. London. HM Stationery Office, 1995.
2 Marshall LL, Trethewie ER, Curtain CC. Chemical radiculitis: a clinical, physiological and immunological study. Clin Orthop Rel Res 1977; 129: 61-67. [PubMed]
3 Rafiq M, Worthington T, Tebbs SE, et al. Serological detection of gram-positive bacterial infection of prosthetic joints. J Bone Joint Surg Br 2000; 82: 1156-61. [PubMed]
4 Elliott TSJ, Tebbs SE, Moss HA, et al. A novel serological test for the diagnosis of central venous catheter associated sepsis. J Infect 2000; 40: 262-66. [PubMed]
5 Tunney MM, Patrick S, Gorman SP, et al. Improved detection of infection in hip replacements. J Bone Joint Surg Br 1998; 80: 568-72 [PubMed]
Royal Orthopaedic Hospital, Northfield, Birmingham, UK (A Stirling FRCS, M Rafiq FRCS); Department of Clinical Microbiology, University Hospital, Edgbaston, Birmingham, B15 2TH, UK (T Worthington PhD, Prof T S J Elliott FRCPath); Department of Pharmaceutical and Biological Sciences, Aston University, Aston Triangle, Birmingham, UK (P A Lambert DSc)
Correspondence to: Prof T S J Elliott; email: tom.elliott@university-b.wmids.nhs.uk
Gabe Mirkin is one of my favorites. Here is his overview
of research on infection and sciatica. If you have never checked out his website here it is:
www.drmirkin.com/
INFECTION AND SCIATICA
Gabe Mirkin, M.D.
A study in the British medical journal, Lancet, reports that pain going down the back of one leg, called sciatica, may be caused by infection.
When you have a pain that goes down the back of your leg or the front of your lower leg, your doctor often diagnoses sciatica. He looks for a pinch of the huge sciatic nerve at the back or by a muscle in your buttocks, called the piriformis. However, most of the time, the MRI test does not show
a pinch of the nerve in your back and it doesn't hurt when you touch the piriformis muscle, at a spot two inches from the center of your backside at the height of your hip bone. But your doctor calls it sciatica, tells you that you have pinched nerve in the back and sends you for physical therapy.
Researchers in Birmingham England found bacteria called Propionibacterium acnes in 31 percent of people with sciatica. Fifty-three percent of discs removed at surgery contained this bacteria also. If infection really causes
sciatica, the treatment would be to take Zithromax, Biaxin or Dynabec antibiotics for many months. We will see if other studies confirm these findings.
Association between sciatica and Propionibacterium acnes. Lancet, 2001, Vol 357, Iss 9273, pp 2024-2025. A Stirling, T Worthington, M Rafiq, PA Lambert,
TSJ ElliottAddress Elliott TSJ, Univ Hosp, Dept Clin Microbiol, Birmingham B15 2TH, W Midlands, ENGLAND
Health Topics from ? The Dr. Gabe Mirkin Show and DrMirkin.com? Box 10,
Kensington MD 20895
23 June 2001 Pages 2024-2025. PII: S0140-6736(00)05109-6
Copyright © 2001 Elsevier Science Ltd. All rights reserved.
En studie i det Britiske medisinske tidsskriftet Lancet, rapporterer at smerter som går fra nedre del av ryggen til det ene benet, kalt isjas, kan være forårsaket av en infeksjon. Når du har smerter fra ryggen til benet, gir legen deg ofte diagnosen isjas. Han vil undersøke om den store isjas nerven er i klem. Han vil også se etter om nerven er i klem fra en muskel i sete regionen, kalt piriformis. Som regel er imidlertid MR negativ og viser ingen nerve i klem og ved berøring er heller ikke piriformis muskelen smertefull. Men legen din kaller det gjerne isjas likevel og sender deg til fysioterapi.
Forskere i England har funnet ut at 31 prosent av pasienter med isjas har en bakterie kalt Propionibacterium acnes. 51 prosent av de som hadde skiven fjernet hadde også denne bakterien. Hvis ryggsmertene skyldes infeksjon vil behandlingen være Zithromax, Biaxin or Dynabec antibiotika for flere måneder. Man venter nå på flere studier.
Les på engelsk her:
Research Letters
Association between sciatica and Propionibacterium acnes
Alistair Stirlinga, Tony Worthingtonb, Mohammed Rafiqa, Peter A. Lambertc and Tom S. J. Elliott, , b
a Royal Orthopaedic Hospital, Northfield, Birmingham, UK
b Department of Clinical Microbiology, University Hospital, Edgbaston, Birmingham, B15 2TH, UK
c Department of Pharmaceutical and Biological Sciences, Aston University, Aston Triangle, Birmingham, UK
Available online 25 June 2001.
Abstract
We hypothesised that the inflammation seen around the nerve root in patients with sciatica may be caused by microbial infection. We used a newly developed serological test to diagnose deep-seated infections caused by low virulent gram-positive microorganisms. 43 of 140 (31%) patients with sciatica tested positive. Intervertebral disc material from a further 36 patients with severe sciatica who had undergone microdiscectomy was cultured for the presence of microorganisms. 19 of these patients (53%) had positive cultures after long-term incubation. Propionibacterium acnes was isolated from 16 of the 19 (84%) positive samples. Low virulent microorganisms, in particular P acnes, might be causing a chronic low-grade infection in the lower intervertebral discs of patients with severe sciatica. These microorganisms could have gained access to the spinal disc after previous minor trauma.
Although low back pain and sciatica are some of the most common reasons for consultation in primary care,1 their cause is poorly understood. Marshall and colleagues2 have shown raised serum immunoglobulin concentrations in patients with sciatica. Discogenic radiculitis, which is caused by pressure, is also associated with an inflammatory process, and cytokines, including interleukin-1, have been linked to lumbar disc herniation. Surgically induced disc lesions in animals have also resulted in an inflammatory reaction in the nucleus pulposus, with the production of IgG in surrounding tissues. Inflammation around the nerve root may be due to a local autoimmune reaction.
The inflammation associated with sciatica could also have a microbial cause, possibly low virulent microorganisms, as seen in prosthetic hip infections. We used an ELISA based on an exocellular antigen produced by gram-positive bacteria (lipid S) for the diagnosis of deep-seated infections caused by low virulent pathogens, including coagulase-negative staphylococci and propionibacteria. The ELISA had previously facilitated diagnoses of prosthetic hip3 and central venous catheter infections,4 endocarditis, and pyogenic spondylodiscitis.
We used this serological test to investigate 140 patients with sciatica presenting to a specialist clinic. These patients were originally selected as controls for a study on spondylodiscitis, however, 43 of 140 (31%) had raised serum IgG titres to the lipid S antigen. No patient had reported any infection in the past 6 months.
A further 36 patients with severe sciatica were clinically assessed, and had lumbar magnetic resonance imaging. Discogenic radiculitis was subsequently diagnosed and the patients had microdiscectomies to relieve the pain. Disc tissue (about 2x2x5 mm) removed during operation was examined for presence of microorganisms. Stringent aseptic precautions were taken to minimise the risk of contamination in clean wound culture.
All samples were cultured in Robertson's cooked meat enrichment broth, incubated at 37°C and subcultured at 2, 7, and 21 days onto blood agar plates containing 7% defibrinated horse blood (Oxoid Ltd, Basingstoke, UK). Subcultures were incubated at 37°C under anaerobic conditions for 7 days, and inspected for microbial growth. Tissue samples that were large enough (n=11) were also cultured directly by impression onto 7% blood agar plates, and embedded into nutrient agar (Oxoid Ltd, Basingstoke, UK). We also prepared thin sections, which were gram-stained and examined for presence of microorganisms.
Tissue from 19 of 36 patients (53%) gave positive cultures in the enrichment technique within 7 days of incubation. Proprionibacterium acnes, coagulase-negative staphylococci, and Corynebacterium propinquum were isolated from 16 (84%), two (11%), and one (5%) of 19 positive cultures, respectively. Blood samples were obtained for lipid S antibody estimation from 15 of 19 patients with positive cultures. Seven (47%) had positive serological tests. 16 of the 17 (94%) patients with negative cultures had negative tests to the lipid S antigen. More patients with positive cultures had positive serological tests than did those with negative cultures (36% [7/19] vs 5% [1/17], p=0·0438; Fisher's exact test). C-reactive protein was measured in 25 of the 36 (69%) patients. Two of these 25 (8%) had C-reactive protein concentrations above 10 mg/L, and P acnes was isolated in both.
Discetomy tissue was concurrently examined from 14 controls presenting with other spinal disorders, including scoliosis (n=3), trauma (3), myeloma (2), and degenerative disc disease (6). None of these samples yielded positive cultures after long incubation. There was a significant difference between the number of patients with sciatica who had positive tissue cultures (53% [19/36]) as compared with controls (0% [0/14] p=0·0003). Additionally, 12 of 14 (86%) controls had negative serum antilipid S IgG titres.
P acnes was seen in six of 11 (55%) tissue samples that were cultured directly onto blood agar. Between 10 and 100 colony forming units were isolated from each sample. Gram-stained smears of the tissue samples embedded in agarose also showed gram-positive branching rods after incubation (average size 3·0x0·3 µm) (figure). Microorganisms were not detected in any of the 11 gram-stained thin sections examined by direct microscopy, suggesting that they are present only in low numbers.
In this preliminary study we have detected raised concentrations of a specific serum antibody to a glycerophospholipid (lipid S), an exocellular bacterial cell-wall component. We also recorded a corresponding presence of low virulent microorganisms, predominantly propionibacteria, in a high proportion of patients with sciatica.
Light photomicrograph of microdiscectomy tissue showing Proprionibacterium acnes (x1000)
We postulate that patients with sciatica sustain a breach in the mechanical integrity of a spinal disc, possibly from minor trauma, which allows access by low virulent microorganisms, thereby initiating or stimulating a chronic inflammatory response with accompanying symptoms. This hypothesis is consistent with the anatomical distribution of disc degeneration, with greater stresses on the distal regions of the spine. The observation that disc protrusions detected by magnetic resonance imaging are frequently symptomless, perhaps becoming symptomatic only after infection, also lends support to this hypothesis.
Previous epidural injections could be a further source of microorganisms. However, 53% (10/19) from whom bacteria were isolated had not had a pre-operative epidural injection, and 41% (7/17) of the tissue culture negative patients had. These findings suggest that epidural injections were not the source of the microorganisms.
Over the past two decades the skin commensals coagulase-negative staphylococci and propionibacteria, mainly thought of as contaminants when isolated from patients, are increasingly being recognised as agents of infection. Tunney and colleagues5 have shown the presence of P acnes and coagulase-negative staphylococci in situ on prosthetic joints studied at revision arthroplasty. Our results also suggest that these microorganisms, particularly P acnes, might be associated with chronic low-grade infection in the lower intervertebral discs of patients with severe sciatica.
The need to incubate disc material from patients for up to 7 days to isolate the propionibacteria might be why these microorganisms have not been previously associated with sciatica. The long generation time of propionibacteria makes these microorganisms ideal candidates for chronic infection. P acnes produces many exocellular virulence factors (including lipase, proteinase, hyaluronidase, neuramidase, and phospholipase C), which may contribute to its pathogenicity. These microorganisms may cause prosthetic hip infections, but also might be associated with the inflammation seen in sciatica, and may possibly even be a primary cause of this disorder.
This study was funded by BackCare and the National Back Pain Association, and was presented at 7th Conference of the Federation of Infection Societies, Manchester, Nov 29, 2000. We thank colleagues at Royal Orthopaedic Hospital for allowing us to study their patients.
1 Office of Population Censuses and Surveys (OPCS). Morbidity statistics from general practice, 4th National Study. Royal College of General Practitioners, OPCS, Department of Health. London. HM Stationery Office, 1995.
2 Marshall LL, Trethewie ER, Curtain CC. Chemical radiculitis: a clinical, physiological and immunological study. Clin Orthop Rel Res 1977; 129: 61-67. [PubMed]
3 Rafiq M, Worthington T, Tebbs SE, et al. Serological detection of gram-positive bacterial infection of prosthetic joints. J Bone Joint Surg Br 2000; 82: 1156-61. [PubMed]
4 Elliott TSJ, Tebbs SE, Moss HA, et al. A novel serological test for the diagnosis of central venous catheter associated sepsis. J Infect 2000; 40: 262-66. [PubMed]
5 Tunney MM, Patrick S, Gorman SP, et al. Improved detection of infection in hip replacements. J Bone Joint Surg Br 1998; 80: 568-72 [PubMed]
Royal Orthopaedic Hospital, Northfield, Birmingham, UK (A Stirling FRCS, M Rafiq FRCS); Department of Clinical Microbiology, University Hospital, Edgbaston, Birmingham, B15 2TH, UK (T Worthington PhD, Prof T S J Elliott FRCPath); Department of Pharmaceutical and Biological Sciences, Aston University, Aston Triangle, Birmingham, UK (P A Lambert DSc)
Correspondence to: Prof T S J Elliott; email: tom.elliott@university-b.wmids.nhs.uk
Gabe Mirkin is one of my favorites. Here is his overview
of research on infection and sciatica. If you have never checked out his website here it is:
www.drmirkin.com/
INFECTION AND SCIATICA
Gabe Mirkin, M.D.
A study in the British medical journal, Lancet, reports that pain going down the back of one leg, called sciatica, may be caused by infection.
When you have a pain that goes down the back of your leg or the front of your lower leg, your doctor often diagnoses sciatica. He looks for a pinch of the huge sciatic nerve at the back or by a muscle in your buttocks, called the piriformis. However, most of the time, the MRI test does not show
a pinch of the nerve in your back and it doesn't hurt when you touch the piriformis muscle, at a spot two inches from the center of your backside at the height of your hip bone. But your doctor calls it sciatica, tells you that you have pinched nerve in the back and sends you for physical therapy.
Researchers in Birmingham England found bacteria called Propionibacterium acnes in 31 percent of people with sciatica. Fifty-three percent of discs removed at surgery contained this bacteria also. If infection really causes
sciatica, the treatment would be to take Zithromax, Biaxin or Dynabec antibiotics for many months. We will see if other studies confirm these findings.
Association between sciatica and Propionibacterium acnes. Lancet, 2001, Vol 357, Iss 9273, pp 2024-2025. A Stirling, T Worthington, M Rafiq, PA Lambert,
TSJ ElliottAddress Elliott TSJ, Univ Hosp, Dept Clin Microbiol, Birmingham B15 2TH, W Midlands, ENGLAND
Health Topics from ? The Dr. Gabe Mirkin Show and DrMirkin.com? Box 10,
Kensington MD 20895
ops Og ingen
av disse flere tusen har etter det de kunne finne ut
på dette seminaret noen gang vært
undersøkt for om det kunne være denne
infeksjonen som er årsak til problemene, og
såvidt de kunne finne ut så var det INGEN i
Norge som hadde blitt behandlet med disse
antibiotikaene......
Nei sa
jeg, men er du klar over hvor mange som begår
selvmord fordi de ikke klarer smertene mer.
dette mener
min lege også. Selv om ikke MR bildene viser nerve i
klem, har jeg alle symptomer på at isjas nerver ER i
klem. Blir spennende å høre hva nevro-kirurgen
på Riksen vil si om dette,når jeg skal til han
i høst.
