Evidence based medicine…

Evidence based med
Dr. Michael J. O’Connell, New Hampshire, commented that if there is one feature about the changes in healthcare over the last five years, the concept of evidence based medicine (EBM) certainly stands out in graphic, often intrusive relief.  It is beyond naiveté to believe that medicine can be simply and reliably reduced to the conclusion of a 500 subject study of the comparison of surgical treatment of degenerative disc disease vs. NSAIDs and physical therapy.  This reduction is not possible due to the inherent complexity of the nature of the human body including its intracranial contents.

While it is admissible that some analyses that are relatively free of the subjectivity and emotion that is part and parcel of the interaction between caregiver and care recipient, most are not.  The use of antibiotic A vs antibiotic B in treating known bladder infection, is fairly straightforward, and is little affected by subjectivity and estimation since the pathology can be easily defined, the drug easily administered, and the outcome revealed in relatively short order.  But let’s consider the recent JAMA article looking at the efficacy of epidural steroids vs. epidural anesthetic for spinal stenosis.  All major media outlets are reporting this finding as though it were the final word, and spells the dramatic kibosh to such treatment.  Hardly!!  This is the problem with hanging our hats on the result of a single “scientific” investigation in this new world of EBM, and not examining the results in a larger context.

My criticism can be summed up in four points:

  1. This study is telling us that pure local anesthetic alone is a potentially valuable adjunct to the treatment of spinal stenosis.  The steroid may not be necessary.  Other studies have implied this as well eg., for facet joint arthropathy, radiculopathy and muscular trigger points.  Perhaps resetting the sensory nerve ending relieves the
    pain from these maladies.
  2. Spinal stenosis is not easily defined, contrary to the implications in this study.  Stenosis, or the constriction of the spinal canal, can be caused by bulging disc, redundant ligamentum flavum, enlargement of the facet joints, or a combination of all three.  Unless a study examines and separates out the specific factor(s) leading to the stenosis, and then evaluates the efficacy of steroid or local anesthetic injection vs. placebo (if this is even possible), no one really has gained useful information.  I am sure there are many patients who proclaim epidural injections have worked marvelously well for their stenosis.  Which factor contributes most to their stenosis and is this related to efficacy?
  3. The study fails to compare the outcome of the injection approach with the more invasive treatment, surgical laminectomy (so called “decompression”).  Surgery for spinal stenosis is very expensive and very risky in comparison, often fails to alleviate pain as reported by the literature, and if patients are followed long enough, clearly is problematic as surgery always leads to epidural adhesions (scar) which constrict the canal as easily as does disc, facet joints or ligament.
  4. No one can measure intensity of pain, and therefore no study can objectively demonstrate the difference in pain levels, pre and post treatment.  Pain is subjective, and every pain, even emotional pain, is truly in our brains.  This is where pain signals are interpreted, and often mitigated, inflated or otherwise distorted.

None of this is to say that apparently debilitating pain presumably from spinal stenosis should not be treated.  I have critical spinal stenosis at L4-5.  I learned it Evidence based me 4after a minor fall while rock climbing.  A tweak on my harness at the waist eased pain and prickly numbness that stretched from the right lower back, into the leg and thence onto the dorsum of my foot and the middle three toes.  An MRI revealed the severe stenosis.  I underwent three epidural injections with steroid, and after four weeks the symptoms progressively and totally resolved, and have yet to return despite one additional year of snow boarding and aggressive rock climbing.  Yet a repeat MRI in follow up last week, still revealed the exact same pathology, critical stenosis at L4-5.  I even received a phone call from the radiologist to be evaluated immediately!

The mystery of pain so far defies analytic study.  If I had known the results of this JAMA article before my fall last summer, I would likely have had surgery, the results of which are unpredictable at best.

 

About Dr. Michael J. O'Connell, New Hampshire
Dr. Michael J. O'Connell of Barrington, New Hampshire, has forged a distinguished career spanning over three decades, as entrepreneur, physician, businessman, philanthropist and healthcare consultant. As former owner, administrator and CEO of a 225+ employee multi-specialty medical practice, Dr. O'Connell has dedicated his entire professional life to helping patients with family medicine and especially those experiencing chronic pain and all aspects of addiction. Since selling his family of healthcare businesses, he has never once contemplated retirement despite his rich and fulfilling journey, but instead has turned his focus to consulting in an industry starved for courage and creativity. Having weathered many political, technological and legal challenges, there is hardly a storm he has not confronted, a tempest he has not quelled, an urgent need he has not met. While the talking heads and self-proclaimed experts in the field have assumed the conventions and standards of the times, Dr. O'Connell does not believe in merely reflecting the herd mentality, but rather in leading the charge. Eschewing political correctness, Dr. O'Connell says and does what needs saying and doing, and not what the mindless masses expect. In addition to the continual education afforded by his variegated life experiences, Dr O'Connell earned his BS in Biochemistry at the University of NH in 1975, his Medical Degree from Dartmouth College in 1981, interned at Walter Reed Medical Center in 1982, Residency/Fellowship at UCSF in1986, and finished his Masters in Healthcare Administration at UNH in 1995. Dr. O’Connell enjoys many outdoor activities, including rock climbing, snowboarding, hiking, and golf. Through the decades Dr. O'Connell has supported many non-profit charities to include the St. Charles Home in Rochester NH, the Tri City VNA and Hospice, Hyder House, and Cocheco Valley Humane Society. To the latter organization alone Dr. O'Connell has donated over $180,000 and pledged another $250,000 in the “Bring-Us-Home” campaign for a new building. His “Matching Donations Christmas drive” has generated over $175,000 in charitable giving from the community. In addition Dr. O'Connell has participated in many dozens of other volunteer and donation efforts locally as well as in Africa and the Dominican Republic. For a listing of how I gave back to the community during my career and continue to do see: https://michaeloconnellmdnh.wordpress.com/

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