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Introduction-Recently, there has been both immense interest and controversy regarding a randomised, controlled trial which
showed antibiotics to be effective in the treatment of chronic low back pain (disc herniation with Modic Type 1 change).
While this research has the potential to result in a paradigm shift in the treatment of low back pain, several questions remain
unanswered.rnrnPurpose/AimrnThis systematic review aims to address these questions by examining the role of bacteria in
low back pain and the relationship between bacteria and Modic change.rnrnMaterials and MethodsrnWe conducted electronic
searches of MEDLINE and EMBASE and included studies that examined the relationship between bacteria and back pain or
Modic change. Studies were rated based on their methodological quality, a best-evidence synthesis was used to summarise the
results, and Bradford Hill\'s criteria were used to assess the evidence for causation.rnrnResults rnEleven studies were identified.
The median (range) age and percentage of female participants was 44.7 (41-46.4) years and 41.5% (27-59%), respectively,
and in 7 of the 11 studies participants were diagnosed with disc herniation. Nine studies examined the presence of bacteria
in spinal disc material and all identified bacteria, with the pooled estimate of the proportion with positive samples being
34%. Propionibacterium acnes was the most prevalent bacteria, being present in 7 of the 9 studies, with median (minimum,
maximum) 45.0% (0-86.0) of samples positive. The best evidence synthesis found moderate evidence for a relationship between
the presence of bacteria and both low back pain with disc herniation and Modic Type 1 change with disc herniation. There was
modest evidence for a cause-effect relationship.rnrnConclusion(s)rnWe found that bacteria were common in the spinal disc
material of people undergoing spinal surgery. There was moderate evidence for a relationship between the presence of bacteria
and both low back pain with disc herniation and Modic Type 1 change associated with disc herniation and modest evidence for
causation. However, further work is needed to determine whether these organisms are a result of contamination or represent
low grade infection of the spine which contributes to chronic low back pain.rnrnKeywordsrnBacteria, Disc, Infection, Low
back pain, Modic changernrnFundingrnDU is the recipient of an NHMRC Career Development Fellowship (1011975). This
work was funded by the Monash University Strategic Grant Scheme (SPG-L 070).
Donna Urquhart is a National Health and Medical Research Fellow in the Monash University Department of Epidemiology and Preventive Medicine and a physiotherapist with over 15 years of experience in the management of chronic pain. She has published more than 70 peer-review papers and has been awarded 5 prestigious national grants (2 as CIA). She has authored an invited book chapter in an international text and has been awarded an international investigator award for her novel work on body composition and pain. She is on the International Editorial Board for Journal of Physiotherapy and a reviewer for international/national treatment guidelines, grants and conferences.