Do these results apply to the ‘intervention naive’ patient?

I read the study by Albert et al. [1] with great interest and the authors must be commended for their excellent piece of work. I do, however, feel there is a danger in applying these results to all patients with chronic low back pain and vertebral bone oedema (Modic type 1 changes). The reason for this is that around 50 % of the study patients had had previous disc herniation surgery and the results may not apply to ‘intervention naive’ spine. There is also little solid evidence that Propionibacterium acnes (P. acnes) is likely to be highly prevalent in the ‘intervention naive’ patient who has received neither local injections nor surgery. The earlier study by Albert et al. [2] links P. acnes with Modic changes, but does not mention how many patients had had previous local injections other than an epidural. It is also arguable that other work linking P. acnes with sciatica [3] and shoulder osteoarthritis [4] may well have been confounded by previous injections. I would therefore urge caution before applying these results to the ‘intervention naive’ patient.