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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Bringing home the bacon
- Richard Bartley (28 May 2008)
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What if back surgery was a drug?
- Michael Vagg (4 June 2008)
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Pictures and Plumbers
- Andrew J Ashworth (15 June 2008)
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New type of MRI scanner
- Neil R Aiton (15 June 2008)
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Dubious conclusions
- Wilfrid Treasure (17 June 2008)
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Re: Pictures and Plumbers
- Gabriel Symonds (1 September 2008)
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Richard Bartley, Physiotherapist Denbigh, Wales
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Two points. It is my experience that patients with moderate to severe nerve root pain do better with rest than work and do even better if they avoid physiotherapy/osteopathy/chiropractic. This is in complete contrast to patients with back pain as their main symptom. Secondly, if my job was at risk, I may well choose the surgical route. A 5% risk of increased pain (or a 1% risk of nerve damage) seems preferable to losing your income. Competing interests: None declared |
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Michael Vagg, VMO Pain Management Unit, Barwon Health Geelong, Australia 3220
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I find it fascinating that surgical treatments and medical treatments are evaluated very differently in the literature and by ethics committees. Let's say you told a HREC that you expected only a short-to-medium term reduction in radicular pain with no real improvement in disability or axial back pain for a drug treatment. You go on to say that treatment had a 70% chance of entrenching the axial back pain as permanent, a 5% chance of worsening the pain, 1% risk of permanent neurological damage, with lesser chances of major vessel damage or paraplegia, I wonder how many HRECs would approve it ? If you then presented a literature search which relied mainly on a 30 year old study with major design flaws and a couple of meta-analyses of poor data you could reasonably expect to be sent packing. By way of comparison, in Australia last year lumiracoxib was banned by the Therapeutic Goods Administration for causing fulminant hepatitis at a rate of 1 in 15 000, with 2 deaths out of an estimated 60 000 patients who received it. Without a standard battery of outcome measures which can be used in both surgical and non-surgical trials, and without sham surgical studies, which must measure pain-related disability and psychological outcomes (since there is clear evidence that these influence overal disability in a major way)it is difficult to interpret the vast but mostly useless back pain literature. Competing interests: Interventional pain physician |
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Andrew J Ashworth, GP Davidson's Mains Medical Centre, 5 Quality St, Edinburgh, EH4 5BP
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Perhaps the editor should look at the pictures as well as the words before going to press! The paper version of the BMJ supports this editorial about surgical intervention in prolapse of discs compressing (lateral) nerve roots with a diagram of a central prolapse compressing the spinal cord (a surgical emergency requiring rapid surgical decompression). Advice on the nebulous symptom of "back pain" even when complicated by "radicular pain" is similarly confused when faced by a self employed plumber in the surgery whose back hurts so much that he has taken time off to present to me. Whatever the evidence shows, I find it helpful to actually examine this complex organ clinically (imaging is mentioned here but not clinical examination ). In general there seem to be 3 common problems with reasonably effective associated interventions for my plumber whose pelvic organs are functioning normally. 1 If flexion is significantly reduced then an anterior cause (disc) is more likely and MacKenzie excercises are often rapidly effective. 2 If rotation is reduced with tenderness over the SI joint then the SI joint is likely to be dysfunctional (the plumber is happy with "0ut") and rotation around the affected joint usually helps immediately followed by extension and pelvic floor excercises to maintain the improvment. 3 If extenson is reduced with with tenderness or pain at a higher level then a facet joint may be dysfunctioning (the plumber will understand "a badly seated bearing") and, again, rotational manipulation often helps followed by extension exercises for maintainance. The self employed are intolerant of certified time off work. There seems to be a shortage of plumbers: there are clear social and environmental reasons for rapid and effective treatments in this group who cannot afford "six to eight weeks of conservative treatment". It is time we dispensed with the term "Back Pain" and took the radical step of actually trying to to diagnose the cause. Perhaps more accurate pictures would help! Competing interests: None declared |
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Neil R Aiton, Consultant Neonatologist Royal Sussex County Hospital Brighton. BN2 5BE
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Dear Sir, I was interested to read in this article that the author uses an MRI scanner to detect progressive neurological deficits. Please could you inform me where one can obtain such an advanced scanner which can detect findings previously only detectable on history and clinical examination? Yours sincerely, Dr Neil Aiton Competing interests: None declared |
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Wilfrid Treasure, GP principal Muirhouse Medical Group, Edinburgh EH4 4PL
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Dear Madam or Sir, The subtitle "evidence supports surgery after eight weeks if symptoms persist" is at the least simplistic and to my mind misleading. It is not clear to me whether Prof Fairbank's view is represented by this subtitle. The sentence ending paragraph 9 - "the results support the use of surgery" - may refer to Peul at al (BMJ 2008;336:1355-8) or to another study. Hout et al (BMJ 2008;336:1351-4) report QALY and economic benefit over the first year. Peul et al report more rapid sciatica relief over the first year but not beyond and no overall difference by any other criterion over two years with dissatisfaction amongst 20% of all patients at two years. These result clarify what benefit might be expected from surgery but do not provide unequivocal support for it. Prof Fairbank also seems to be not as clear as he might in differentiating the subjective from the objective and structure from function. He writes that "neurological deficit ... can be detected by magnetic resonance imaging": I don't think that is the case. "Up to 10% of people will report more serious back pain" but we are not told what it is more serious than, and, in any case, I wonder if a more suitable adjective would be "severe". The last sentence includes the phrase "perceived pain": this could be nothing but a harmless tautology except that the reality of pain for the sufferer contrasts glaringly with its invisibility to the doctor. Thank you, Competing interests: None declared |
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Gabriel Symonds, General practitioner Tokyo
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I hope that Dr Ashworth will allow me to correct him on a point of anatomy. The picture in the BMJ article shows a posterior disc prolapse at the L4/5 level. Since the spinal cord extends only to the upper border of L2, what is being compressed is not the spinal cord, but the dural sac and possibly one or more of the spinal nerve roots within it.Competing interests: None declared |
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