This house believes that in 2014 antibiotics should be used to treat

certain specific types of chronic back pain

Philip Sell

What we have

http://www.google.co.uk/url?sa=i&source=images&cd=&cad=rja&docid=U53Qt1aTfnCqyM&tbnid=r-HjzfjRhgkz9M:&ved=0CAgQjRw&url=http://www.westmeademergency.org/links.html&ei=ChXlUtfkBofY7AbtyYDABQ&psig=AFQjCNHM0vejYyYbnnGOIxqf1naQTt6RDA&ust=1390831242189553

Archie Cochrane

CONFOUNDING FACTORS

http://www.google.co.uk/url?sa=i&source=images&cd=&cad=rja&docid=XfICSXu6RqZjpM&tbnid=SYiFDOc4q1mB5M:&ved=0CAgQjRw&url=http://alois.cochrane.org/&ei=TxXlUtGdE8eu7AbZqYCQAg&psig=AFQjCNHqL_0RouVLF6ehnXU-miZFOjmT2Q&ust=1390831311402685

The Evidence

• Level one Single study

• Quality of evidence– Consort– Grade

Systematic Review

Meta-analysis

Why the unease ?

• Why is it some have no doubts

• Why is it some have massive doubts?

Medically unexplained symptoms

Propioibacterium freudenreichii in Emmental cheese

The reason we are uncomfortable

Miracle cure for back pain: Agony ended by everyday antibioticsCHEAP antibiotics could end the agony of back pain for millions of Britons for ever.

DAILY EXPRESS

Press reports before peer acceptance

• MMR studies

• Steroids in cord injury

• Hence our doubts

Magical thinking in improvement

Need for a science-based approach• Rigorous theory and methods

• Fully specify interventions and mechanisms

• How much evidence is needed

Problem: childbed fever

Vienna Maternity Institution: rates of puerperal fever 1841-1849

Intervention was right; theory was wrong

• The logic of hand-washing with chlorine was right (the technical intervention worked)

• But the big theory of resorption of cadaveric particles was wrong

• And the adaptive work was disaster

Why we should wait for further evidence

Original Article Magnetic Resonance Imaging in Follow-up Assessment

of Sciatica

Abdelilah el Barzouhi, M.D., Carmen L.A.M. Vleggeert-Lankamp, M.D., Ph.D., Geert J. Lycklama à Nijeholt, M.D., Ph.D., Bas F. Van der Kallen, M.D., Wilbert B. van den Hout, Ph.D., Wilco C.H. Jacobs, Ph.D., Bart W. Koes, Ph.D., Wilco C. Peul,

M.D., Ph.D., for the Leiden–The Hague Spine Intervention Prognostic Study Group

N Engl J MedVolume 368

March 14, 2013

N Engl J MedVolume 368

March 14, 2013

How it all began.....

-4 0 4 8 12 16 20 24 28 32 36 40 44 48 52

4

8

12

16

AUC surgery=273.9 ± 20.7

AUC conservative 316.3 ± 18.8

Mean difference of Roland AUC’s (CI) 42.5 (-12.4—97.4) *

weeks

Conclusion

• MRI performed at 1-year follow-up in patients who had been diagnosed with sciatica and a herniated disc on MRI …… did not distinguish between those with a favorable outcome and those with an unfavorable outcome

Back pain’s association with vertebral endplate signal changes in sciatica

Abdelilah el Barzouhi, M.D., Carmen L.A.M. Vleggeert-Lankamp, M.D., Ph.D., Bas F. Van der Kallen, M.D., Geert J. Lycklama à Nijeholt, M.D., Ph.D., Wilbert B. van

den Hout, Ph.D., Wilco C.H. Jacobs, Ph.D., Bart W. Koes, Ph.D., Wilco C. Peul, M.D., Ph.D., for the Leiden–The Hague Spine Intervention Prognostic Study

Group

Eurospine 2013

Evolution of back pain in surgically treatedpatients according to VESC

Evolution of back pain in conservatively treated patients according to VESC

Backpain diminishes over time

The Trial

• Unusual Control group show no change

• Trial recruitment

• Not spontaneous presentation

• Trial entry Invite to attend to 347 patients known to the organisation. 162 recruited

Harmless?

Harmless?• MMR

• Poor uptake of vaccines

• Measles epidemic in Wales

This house believes that in 2014 antibiotics should be used to treat

certain specific types of chronic back pain

MORE STUDY REQUIREDBE OPEN MINDED

REJECT THE MOTION