Journals Watch - Low back pain and osteoarthritis

Not had time to read the latest research? Dr Raj Thakkar brings you up to date on the journals.

X-ray showing disc prosthesis in the lumbar spine (Photograph: SPL)
X-ray showing disc prosthesis in the lumbar spine (Photograph: SPL)

Surgery versus rehabilitation for low back pain and degenerative disc disease
BMJ 2011; 342: d2786

Back pain is a common complaint. In the era of referral management, data on the effectiveness of interventions is more crucial than ever. This Norwegian study compared surgery with disc prosthesis and rehabilitation in patients with degenerative disc disease. Rehabilitation was carried out by a multidisciplinary team for 12 to 15 days.

After two years, patients randomised to the surgery arm had a significantly favourable Oswestry disability score compared with conservative measures.

However, and perhaps equally as important, while patients who received surgery felt more satisfied than those who had conservative treatment, there was no difference in patients returning to work, mental component scores, fear avoidance or the back performance scale.

Taking the risks of surgery into account, this study should help guide our decision-making in the consulting room.

Pertussis booster vaccination
Lancet Infect Dis 2011; doi:10.1016/S1473-3099(11)70007-X

Whooping cough continues to have a significant morbidity including pneumonia, bronchiectasis and bleeding secondary to paroxysmal coughing.

Despite vaccination, recent data have revealed that while the number of reported cases of pertussis infection in infants and children has fallen, the converse is true in teenagers and adults.

Arguably, this phenomenon is secondary to diminishing immunity beyond vaccination or indeed, after infection.

In addition, changing trends in reporting behaviour may also influence epidemiological data.

As a consequence of the increase in pertussis cases among teenage and adult patients, herd immunity is likely to be compromised.

The authors of this review article advocate a change in guidelines to account for booster pertussis vaccinations to achieve robust herd immunity.

Antiepileptic drugs and risk of birth defects
JAMA 2011; 305: 1996-2002

As GPs we are careful when prescribing drugs to pregnant women. In some cases, such as epilepsy, the risk of not prescribing may outweigh the risks of taking the drug. Nevertheless, supporting women faced with such difficult conditions is challenging.

This Danish study looked at newer-generation antiepileptic drugs. It reviewed more than 1,532 infants exposed to lamotrigine, oxcarbazepine, topiramate, gabapentin or levetiracetam in the first trimester.

Results showed that 3.2 per cent of these children had major birth defects compared with 2.4 per cent of the 836,263 in the control group. The difference was not statistically significant (OR 0.99, 95% CI 0.72-1.36). The study will help GPs reassure patients faced with epilepsy in pregnancy.

Lateral wedge insoles for medial knee osteoarthritis
BMJ 2011; 342: d2912

This Australian community-based study included patients with mild to moderately severe medial knee osteoarthritis.

Patients were randomised to either lateral wedge insole or flat shoe and followed for a year.

The main outcome measures were knee pain measured on a complex rating scale, and cartilage volume measured using MRI. Other measures included quality of life and function.

The researchers found no difference between the two groups which could either suggest a true finding or, given only 200 people took part in the study, that it was underpowered.

Nitrofurantoin as treatment for UTI
Mayo Clin Proc 2011; doi: 10.4065/mcp.2010.0800

Recent data have emerged that resistance to trimethoprim may be too high for it to be considered a good empirical treatment for UTI. This study used a decision analysis model to assess the costs of nitrofurantoin in the management of simple UTIs.

The researchers found that nitrofurantoin was cost effective compared with fluoroquinolones or trimethoprim when the resistance of these antibiotics exceeded 12 and 17 per cent respectively.

Given current levels of resistance, the authors conclude that nitrofurantoin is cost- effective for empirical management of simple UTI.

Treatment of heart failure with preserved ejection fraction
Mayo Clin Proc 2011; doi: 10.4065/mcp.2010.0841

Heart failure (HF) remains on the radar of both doctors and health economists alike. Clinical complexity and significant unplanned admissions make HF management challenging, not least due to the emergence of diastolic HF over the past 25 years.

Now known as HF with preserved ejection fraction (HF-PEF), the key to treatment of this condition has continued to elude researchers and clinicians.

Whether it be from intuition or lack of alternatives, medical treatment of HF-PEF has focused on the use of beta-blockers and inhibition of the renin-angiotensin-aldosterone (RAA) system, given its success in the treatment of systolic ventricular failure.

This paper, however, reviewed the literature on the effectiveness of RAA inhibition on HF-PEF and found no significant benefit.

The outcomes of this research have left doctors treating a condition with nothing more than trial and error to guide them.

  • Dr Thakkar is a GP in Wooburn Green, Buckinghamshire, and a member of our team who regularly review the journals.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning


These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Develop a patient pathway for those with degenerative disc disease, including the use of rehabilitation.
  • Contact your local microbiology unit to understand current trends in resistance to antibiotics to help guide your practice.
  • Research the causes and presentation of HF-PEF, discussing the condition with your practice colleagues.

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