Evidence, pain, and the poor old NHSBMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7281.307 (Published 03 February 2001) Cite this as: BMJ 2001;322:307
Eighteen months ago I suddenly developed severe pain in my left buttock, leg, and foot. It quickly became so severe that a friend drove me to the nearest cottage hospital—I was staying in the country at the time. Sciatica was diagnosed, and I was sent away with four pethidine tablets. My GP, consulted in London the next day, prescribed bed rest, analgesics, diazepam, and diclofenac, referred me for physiotherapy and an xray examination, and reassured me that I would get better in a few weeks.
Three weeks later the pain was intense and unremitting. I had to give a paper at a conference, and a medical colleague, spotting me lying on the floor in agony, arranged a scan. This showed what was described as a “nice” prolapsed disc. Again I was told that it would get better in a few weeks.
Why is there so little coherent knowledge about effective treatment regimens?
By this time, friends had advised an array of self help techniques, including osteopathy, chiropractic, acupuncture, the Alexander technique, yoga, physiotherapy, exercise, bed rest, ice packs, cannabis tea, a surgical corset, and a TENS (transcutaneous electrical nerve stimulation) machine. The last four worked best when the pain was worst. They relieved it much more effectively than the analgesics but without side effects.
I used the Cochrane Library to seek evidence as to what might work in helping me to get better. On the alternative side the evidence was patchy and inconsistent. As to orthodox treatments, I found one review of surgery for lumbar disc prolapse; this analysed 27 trials of surgical or injection techniques, many of which had methodological inadequacies and short periods of follow up. Only one compared surgery with conservative management, and this showed no differences in outcomes at four years. DARE (the Database of Abstracts of Reviews of Effectiveness) yielded other relevant studies, including one of epidural steroid injections which suggested inconsistent results.
At the end of July I saw a neurosurgeon, who said that if I was not better in three weeks he would operate. Hesitantly, I mentioned terms such as “Cochrane” and “injections.” “We don't do those here,” he said. “Those are done by the orthopaedic surgeons.”
So I asked my GP for a second referral. Meanwhile a medical friend faxed me a paper published in the BMJ entitled “Sciatica: which intervention?” which described a case that sounded exactly like mine, except that the sufferer was male and 27. The literature review reported in the paper concluded that long term results of surgery are only slightly better than after non-surgical intervention and that epidural steroid injections often produce short term relief.
I faxed my GP a copy of the paper, and he faxed it to the orthopaedic surgeon, who had it on his desk when I saw him in early August. He concluded that an injection would be worth trying, but unfortunately I would have to be referred to another consultant in pain management and anaesthetics. There was a three month waiting list for an appointment. When it was suggested that I might like to “go private,” with great reluctance (not because I am mean with money, but because I support the NHS) I paid £1455 for a dorsal root ganglion block and one night in a private hospital.
The most striking aspect of this story is how difficult it is to secure anything resembling coordinated evidence based care for what is an extremely common health problem.
Back pain in its various forms is, in fact, the most common health problem affecting people of working age worldwide, costing industry in the United Kingdom some £6bn, and the NHS between £265m and £480m annually.
I saw three consultants from different specialties, none of whom (to my knowledge) talked to each other about what to do, and each of whom seemed to be interested mainly in those treatments they could individually apply, rather than what would work best for me. Alternative medicine suffers from the same syndrome; in seven visits to an osteopath I was given various combinations of manipulation and acupuncture, but no evidence was offered as to why these might be effective.
I do not know whether the expensive private injection I had worked or not. A review which became available later concludes that existing evidence does not demonstrate effectiveness, but, given the positive results and minor side effects reported, there is no justification for abandoning the therapy. A few days after the injection I got back on my bicycle, so the health promoting effects of cycling provide a competing explanation for my improved ability to cope with the condition. Ten months after the start of the whole business I still had some pain most days. And these questions about what evidence is and who really cares about it are certainly continuing preoccupations.
I would like to thank Iain Chalmers, Robin Oakley, Sandy Oliver, Trevor Sheldon, and Daniel Toeg for their helpful comments
References for this article are on the BMJ website