Surgery vs. conservative tx

[Kwijibo]

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great news for interventional pain physicians.

http://jama.ama-assn.org/cgi/content/full/296/20/2441

 

[Spine Specialist]

great news for interventional pain physicians.

http://jama.ama-assn.org/cgi/content/full/296/20/2441

^^^^^^

I think, this is wonderful news for patients than interventional pain physicians.

 

[lobelsteve]

Read the articles last night and reviewing it with the fellows today.
Carregee has a nice editorial.

I hate when they say conservative care and list a mish-mosh of treatments without any APPROPRIATE plan of care. I'd like to do the same study with patients in MY plan of care, not random treatment consisting of a variety of modalities of care.

My arrogance. I know. Were any of the ESI performed without contrast or fluoro- scratch them out of the study? Were ESI performed with a standarized technique, identical medications, etc. What PT regimen was used? Who evaluated the patients?

Frustrating...

 

[ParaVert]

With crossover between randomized arms was almost 50% in both directions, who can interpret such data? The observational cohort data shows a significant improvement in all measured outcomes regardless of therapy, but shows some benefit of surgery over whatever quack, unstandardized conservative therapy their PCP recommended.


The moral to the story--people who got the treatment THEY WANTED got better regardless of what that treatment was.

How many millions of dollars were spent on this study, published in a highly regarded journal, featured on CBS Evening News, which cannot account for a placebo effect?


QUESTION: What do you call two orthopedic surgeons reading an EKG?
ANSWER: A double-blinded study

 

[ParaVert]

.

 

[Mister Mxyzptlk]

I hate to burst the bubble, but you may recall that a paper came out a while back showing that sham arthroscopy was as effective as arthroscopic meniscectomy. It was well-designed, blinded, prospective, etc. Have you seen a decline in the number of arthroscopies? Me neither.

Despite papers like Riew's showing that there is no superiority to using steroid vs plain LA for ESIs, how many of us have stopped using steroids for our epidurals? How many have converted over to dexamethasone after reading Dreyfuss's paper?

One study does not move the world off its axis. One of the key tenets of the scientific method is that the results must be reproducible by others. In the case of not using steroids I tried that 8-10 years ago and I couldn't reproduce the results. Same for using dexamethasone instead of particulate steroids - I couldn't reproduce the results in my own practice. The outcomes were so bad that my nurse started commenting on it within a few weeks. Actually I tried dex several years ago before the study was published, so technically speaking he couldn't reproduce my results. 😉

 

[Aether2000]

Here is another article: a meta-analysis fusion vs conservative therapy for low back pain...

Int Orthop. 2006 Nov 21; [Epub ahead of print]

Surgical versus non-surgical treatment of chronic low back pain: a meta-analysis
of randomised trials.

Ibrahim T, Tleyjeh IM, Gabbar O.

Department of Orthopaedic Surgery, Leicester General Hospital, Gwendolen Road,
Leicester, LE5 4PW, UK, [email protected].

We performed a meta-analysis of randomised controlled trials to investigate the
effectiveness of surgical fusion for the treatment of chronic low back pain
compared to non-surgical intervention. Several electronic databases (MEDLINE,
EMBASE, CINAHL and Science Citation Index) were searched from 1966 to 2005. The
meta-analysis comparison was based on the mean difference in Oswestry Disability
Index (ODI) change from baseline to the specified follow-up of patients
undergoing surgical versus non-surgical treatment. Of the 58 articles
identified, three studies were eligible for primary analysis and one study for
sensitivity analysis, with a total of 634 patients. The pooled mean difference
in ODI between the surgical and non-surgical groups was in favour of surgery
(mean difference of ODI: 4.13, 95%CI: -0.82 to 9.08, p = 0.10, I(2) = 44.4%).
Surgical treatment was associated with a 16% pooled rate of early complication
(95%CI: 12-20, I(2) = 0%). Surgical fusion for chronic low back pain favoured a
marginal improvement in the ODI compared to non-surgical intervention. This
difference in ODI was not statistically significant and is of minimal clinical
importance. Surgery was found to be associated with a significant risk of
complications. Therefore, the cumulative evidence at the present time does not
support routine surgical fusion for the treatment of chronic low back pain.