Modic changes Type 1&2 are treatable

Just published:

Lassen MR, Scarborough M, Gilchrist N, Tripathi SS, Price C, Horcajadas A, DeAndres J, Baranidharan G, Ahuja S, Otte KS et al: Intradiscal linezolid (PP353) treatment for chronic low back pain associated with Modic change type 1: an international, first-in-human, randomised, sham procedure-controlled, double-blind, phase 1b clinical trial. eClinicalMedicine 2026, 0(0).[1]

Also, you should read a valuable lead-up paper by Lloyd Czaplewski et al. (2023)[2]

These two papers provide a convincing arguments that support the original hypothesis that Modic changes identify a subset of back-dominant pain patients with low grade bacterial infection of the vertebral endplates as an aetiology of the problem[3, 4].

With regards to the most recent paper by Lassen et al (2026):

I was peripherally involved and contributed 2 patients in the New Zealand arm of the Persica study. I have a personal connection with one of the principal authors - Lloyd Czaplewski - who sent me the paper. I also know that Professor Hanne Albert was involved in the design phase.   

I have read the new paper. It is a very substantial report and IMHO, a significant contribution to the science.

The numbers were small (40), and the selection process excluded most - a good thing IMO, but it will probably be misinterpreted by some. In any event, the 95% CIs at 12 months are miles apart, which gives the appropriate perspective. The efficacy of injecting antibiotics contained within a linezolid preparation (PP353) into the intervertebral discs adjacent to endplates with Modic changes is now established. It is a significant step forward I believe. See copied graph:

There are other graphs showing different outcome measures, but the pain intensity score changes are representative.

Of equal importance is the proportion receiving substantial benefit. 60% at 12 months tells me that Modic 1 & 2 is an image of pathology that has 80-90%% chance of being symptomatic (ref to the 2023 paper I co-authored with Lloyd Czaplewski ), but only 60% are likely caused by infection. It seems that a substantial minority of symptomatic cases of MC1 +/-MC2 that are not a consequence of infection treatable by injected PP353.

I urge you to read this new paper.

It is now clear to me that the lumbar spine anterior column can be symptomatic, and several different aetiologies have been identified.

1. Those cases that demonstrate directional preference/centralisation - mechanical pain causation. (specificity to prov discography >85%).[5, 6]

2. HIZ / annular tears - an MRI visible ligament injury (specificity to prov discography >85%)[7-9]

3. Modic 1 +/- Modic 1 secondary to low virulence bacterial infection treatable by PP353. (specificity to prov discography >85%)[2, 10]

4. Modic 1 +/- Modic 1 of unknown aetiology. (specificity to prov discography >85%)

5. Discitis - caused by virulent infection

6. Endplate disruption - ? aetiology of disc herniation through the endplate or fracture

7. Vertebral body pathologies - fractures, Paget's etc.

These are identifiable subsets of anterior column pain. There may be more. 

Is that it for LBP? No. Further subsets exist:

• There is the posterior column (Z-joints, stress reactions and Baastrup's disease). There are at least 2 subsets of facet joint sprain: OA-like pathology and joint sprain/injury.

• There are the canal pathologies - what I call the intermediary zone - stenosis and disc herniations.

• There is SIJ pain, which is not in the lumbar spine. At least 2 subsets there too.

Non-specific LBP" is a fiction or self-induced blindness

to the known facts

References.

1. Lassen MR, Scarborough M, Gilchrist N, Tripathi SS, Price C, Horcajadas A, DeAndres J, Baranidharan G, Ahuja S, Otte KS et al: Intradiscal linezolid (PP353) treatment for chronic low back pain associated with Modic change type 1: an international, first-in-human, randomised, sham procedure-controlled, double-blind, phase 1b clinical trial. eClinicalMedicine 2026, 0(0).

2. Czaplewski LG, Rimmer O, McHale D, Laslett M: Modic changes as seen on MRI are associated with nonspecific chronic lower back pain and disability. J Orthop Surg Res 2023, 18(1):351.

3. Albert HB, Kjaer P, Jensen TS, Sorensen JS, Bendix T, Manniche C: Modic changes, possible causes and relation to low back pain. Med Hypotheses 2008, 70(2):361-368.

4. Albert HB, Sorensen JS, Christensen BS, Manniche C: Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy. Eur Spine J 2013, 22(4):10.

5. Laslett M, Oberg B, Aprill CN, McDonald B: Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. The Spine Journal 2005, 5:370-380.

6. Deneuville JP, Billot M, Cervantes A, Peterlongo P, Meyer M, Kolder M, Escande M, Bourgeois M, Pallot A, David R et al: Dynamic behavior of the nucleus pulposus within the intervertebral disc loading: a systematic review and meta-analysis exploring the concept of dynamic disc model. Frontiers in Bioengineering and Biotechnology 2025(June):16.

7. Aprill C, Bogduk N: High-intensity zone: a diagnostic sign of painful disc on magnetic resonance imaging. Br J Radiol 1992, 65(773):361-369.

8. Teraguchi M, Cheung JPY, Karppinen J, Bow C, Hashizume H, Luk KDK, Cheung KMC, Samartzis D: Lumbar high-intensity zones on MRI: imaging biomarkers for severe, prolonged low back pain and sciatica in a population-based cohort. Spine J 2020, 20(7):1025-1034.

9. Sima S, Chen X, Sheldrick K, Kuan J, Diwan AD: Reconsidering high intensity zones: its role in intervertebral disk degeneration and low back pain. Eur Spine J 2024, 33(4):1474-1483.

10. Braithwaite I, White J, Saifuddin A, Renton P, Taylor BA: Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography. Eur Spine J 1998, 7(5):363-368.