LOW BACK PAIN: SHARED DECISION MAKING

What follows below is an original version of the WhatsApp conversation along with the patient to understand the patient problem better and making a shared decision making using Evidence Based Medicine.



VP: http://bmjcaselogvivek.blogspot.com/2018/08/a-middle-aged-man-with-low-back-pain.html

VP: Amra ei group khulechi, upore blog e ullekkhito patient er low back pain er somossa solve korte. Ekhane ami add korechi Pradip babu. Amder sathe achen patient jar somossa amra somadhan korte jacchi.

RB: Vivek as this man had approached us directly I removed one of the participants to protect this patient's identity

RB: Confidentiality and privacy.

VP: Oh okay sir

VP: How are we going to take this case forward? @918910212173 @919051328746 Need your inputs.

RB: We need to talk to the patient here to understand his problem better. All of us here can communicate with him in Bengali. Once we go through his record we can ask him further queries regarding his problem which he can answer.

I will ask the first query

RB: Oh I just realized you have removed his hand written history in Bengali from the record. Why not add it if there is no issue with deidentification.

VP: Oh you asked me to keep add it. Then I forgot to add

VP: I will add that

VP: Updated with Bangla version of the history (notice at the bottom)

 VP: I will discuss it today

PT: Please suggest/Prescribe about my treatment

PT: Some doctors opinion:

Without operation it will be  go to paralysis

RB: Thanks. Amra apnake ekhane deidentify korechi (apnar privacy confidentiality protect korar jonye) tai bhabchilam apnake ki bhabe sombodhon korbo. Amader saathe ekhane aajke aneke achen ebong taader modhye holen Dr Pranab jini arek jone patient er similar backache sombondhe ekhane likhechen http://ubplj.org/index.php/ejpch/article/view/766

Site ta te gele puro lekha ta PDF download korte parben ebong okhane low back ache jei somosya ta apnaro hocche sheta niye arekta patient er bibaron apni pore aro kichu proshno apnar byatha sombondhe amader korte paren

RB: Apnar somosya ta sombondhe amra ekta shared decision making prakriya adopt korchi jeta niyeo amra bortomane likhchi ebong aei shared decision making prokriar pore apnar somosya ta koto ta bhalo hote pare shudhu aei prokriyatar jonye eta amra dekhar cheshta korchi

PT: Somebody says:

Spinal cord operation is highly riskeble

PT: I'm puzzled

RB: I can understand your puzzlement. Why and whether you would need to have a spinal cord surgery is the question we need to answer first.

PT: Two doctors (ortho & neuro ) suggest about surgery

RB: It is believed that surgery, presumably for the suspicion of disc prolapse, is only effective if the patient has a focal neurological deficit (aka paralysis). I don't think you have that issue right now? I feel your current issue is chiefly pain isn't it? Can you describe the location, frequency and duration of your pain?

PT: আমার এখন nerve এর সমস্যাই ভাবাচ্ছে

ডান পায়ের হাটু এবং কোমরের মাঝের অংশ

মাঝে মাঝেই ঘুমের মধ্যে

অবশ হচ্ছে

RB: Ghumer modhye maane ki apni majh raate ghum bhenge jawar por dekhchen je oi jaiga guno obosh lagche?

PT: বা পায়ের নীচের অংশ অবশভাব প্রথম থেকেই আছে

PT: হুম ।ঠিক তাই ।টের পাওয়ার পর movement করলে ঠিক হয়

RB: Haanthar somoi oi jaiga ta te ki tulor upor haanthchen aerokom mone hoi?

RB: Eta ki protidin raate hoi? Kotokkhon thaake?

PT: বা পায়ের বুড়ো আঙুল সবসময়ই ঝি ঝি ধরে থাকে

RB: 24 ghonta?

PT: আমি বুঝতে পারার কিছুক্ষণের মধ্যেই কমে যায়

PT: Yes

VP: Tar manay, 24 hours apnar angul gulo jhi jhi kore, kintu jokhon seta bujhte paren somossa thake na?

PT: বা পায়ের বুড়ো আঙুল সবসময়ই ঝি ঝি ধরে।

যেটা কমে যায় বলেছি

সেটা আলাদা

PT: অনেকসময় ঘুমের মধ্যেই

ডান পায়ের হাটু এবং কোমরের মাঝের অংশ

অবশ হয় ।বুঝতে পারার পর  movement করলে

কমে যায়

PT: না এরকম নয়

PT: হালকা ঝি ঝি ধরে থাকে।

অনেক সময় Electric shocking এর মত ঝিলিক

মারে

RB: Taar maane koshto ta samoyik? Dine koto baar bujhte paren?

PT: ডান পায়েরটা সাময়িক ।

বাম পায়ের নিচের অংশ এবং বুড়ো আঙুলের বিষয়টা 24 ঘণ্টার

RB: Etar jonye kono oshudh kheyechilen? 24 ghonta shojjo korte korte ki eta aekhon sohoniyo hoye geche?

PT: বা পায়ের নীচের অংশের অবশভাব এবং বুড়ো আঙুলের ঝি ঝি ধরা 24 ঘণ্টা থাকলেও সহ্য সীমার মধ্যেই থাকে । কিন্তু বুড়ো আঙুলের Electric shocking এর মত ঝিলিক মারাটা সহ্য করা যায় না ।এটা হঠাৎ হঠাৎ হয় ।

TB: Kokhono blood sugar level kora hoyeche ki apnar?

PT: Yes.Sugar always normal

TB: okay.

TB: Kono MRI of Spine hoeche kokhono?

PT: দুবার হয়েছিল ।report গুলো পাঠিয়েছিলাম।আবার পাঠাচ্ছি।

VP: Sir also available here http://bmjcaselogvivek.blogspot.com/2018/08/a-middle-aged-man-with-low-back-pain.html

TB: just saw the MRI. seems to be compressive. which was also apparent from the symptoms?

RB: Perhaps a sensory root compression going by his symptoms?

In patients with such symptoms and signs (P of pico) What is the efficacy of decompression surgery (I of pico) as opposed to sham surgery (C of pico) in alleviating the sensory symptoms (O of pico)? Vivek any studies?

VP: Looking for it. Founf till now two systematic review looking for surgery vs no surgery for lumber spinal stenosis

RB: It should be surgery vs placebo surgery aka sham surgery

VP: I meant surgery versus non-surgical treatment. Seems no sham procedure was tested to compare

VP: "The aim of this randomised placebo-controlled trial is to establish the efficacy, safety and cost-effectiveness of decompressive surgery compared to placebo surgery in improving pain, function and quality of life in people with chronic symptoms due to central lumbar spinal canal stenosis". A study is still undergoing. https://www.georgeinstitute.org/projects/success-surgery-for-spinal-stenosis-a-randomised-placebo-controlled-trial

VP: "Current evidence comparing surgical versus non‐surgical care for lumbar spinal stenosis is of low quality. For this reason, we cannot conclude whether a surgical or a conservative approach is better for lumbar spinal stenosis, nor can we provide new recommendations to guide clinical practice. Nevertheless, given the high rates of side effects associated with surgery, clinicians should be cautious when proposing surgery for LSS, and patients should be properly informed about the risks."

 VP: "Low‐quality evidence from the meta‐analysis performed on two trials using the Oswestry Disability Index (pain‐related disability) to compare direct decompression with or without fusion versus multi‐modal non‐operative care showed no significant differences at six months (mean difference (MD) ‐3.66, 95% confidence interval (CI) ‐10.12 to 2.80) and at one year (MD ‐6.18, 95% CI ‐15.03 to 2.66). At 24 months, significant differences favoured decompression (MD ‐4.43, 95% CI ‐7.91 to ‐0.96)" https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010264.pub2/full

VP: [Surgical versus non‐surgical treatment for lumbar spinal stenosis]

VP: "The SPORT trial of surgery for prolapsed lumbar disc found standard open discectomy or microdiscectomy (technique left to discretion of the surgeon) no better than nonoperative treatment for pain relief and improvement in function after three months, in an intention-to-treat analysis [37]. Patients in both groups improved an average of 20 to 30 points (on a 100 point scale) on pain and functional status scores. Results up to four [42] and eight [43] years showed persistent, comparable benefits for surgical and nonoperative treatment in an intention-to-treat analysis for the study primary outcomes of bodily pain, physical function, and disability index." [Uptodate]

RB: So till now the evidence suggests that we can go without surgery for the symptoms presented here?

VP: Yes sir. Till now most of the studies (RCT, SR) came across, they suggest surgery in specific situations when symptoms are very severe.

VP: "We suggest not performing surgery for most patients with chronic symptoms attributed to nonspecific low back pain (Grade 2B). Decisions regarding surgery should be based on shared decision-making. We suggest that surgery be limited to patients with nonspecific low back pain who meet the following criteria: persistent symptoms with associated disability for at least one year despite nonsurgical interventions; appropriate surgical candidate; and intensive rehabilitation with a cognitive behavioral therapy component is either not available or has not been effective (Grade 2B). (See 'Indications for spinal surgery' above and 'Nonspecific low back pain with degenerative disc changes' above.)"

VP: In patients with lumbar disc prolapse and radiculopathy who do not have severe or progressive neurologic deficits, there is no evidence that early referral for surgery improves outcomes. Outcomes for patients who undergo discectomy, compared to nonsurgical therapy, favor surgery at short-term follow-up but are equivalent at one to two years. (See 'Lumbar disc prolapse' above.)

RB: This is what I often tell my patients but it may not be shared decision making but here our patient can be given the links to click on and access the evidence and seek further clarifications if necessary? This is a positive way forward?

Globally how commonly tried and tested is this form of shared decision making that we have been trying here?

VP: I think most of the SDMs are tried offline one-to-one unlike to our approach online "collective" shared-decision making with patients without being travelling to us.

VP: @918910212173 @919051328746 Based on our discussion around this low backache patient, can we consider moving ahead with conservative management? How about going with patients preferences on it?

RB: Hope the patient can share his own preference with us here

VP: Also what we have discussed what is the most important information patient should take into account?

VP: I would tell this with associated complications that may arise from it!

VP: Amra apnar somossa niye alochona korechi and eti niye amra evidence alochona korechi. Ekhane apnar preference amader jana dorkar.

PT: যে চিকিৎসায় ভবিষ্যতে paralysis হওয়ার সম্ভাবনা নেই সেই ধরনের চিকিৎসা করাতে চাই ।সেটা nonsurgical হলে বেশী ভাল ।

RB: Shetai habe

PT: আমার কি এরমধ্যে আসতে হবে?

RB: Amader sharir amader sab theke beshi boro chikitsak. Amra apnar shorir ke sujog kore dite pari jaate she nijeke aaste aaste shariye tole ebong apnar symptom gunor jonye apnake kichu oshudh dewa jete pare. Etukur jonye hoito na aashleo cholbe kintu aashle apnar songe ekbar dekha hoye jeto aarki

PT: আমার চিকিৎসার জন্য কোনও সিদ্ধান্তে পৌঁছানো গেল কি?

RB: Aermodhye aaste parben?

PT: এর আগে যাওয়ার দরকার নেই বলেছিলেন ।তাই যাবার চেষ্টা করিনাই ।চিকিৎসার জন্য একান্ত দরকার হলে অবশ্যই যাব

RB: Hain apni aashle apnar saathe ekbar dekha hoye jeto ebong tarpor next step ta apnar jonye ki habe ota aro bhalo bhabe bojha jeto. Etao hote pare je next step ta amra etai siddhanto nite pari je just oshudh (tao khub dorkar porle) niye gelei apnar sob theke beshi bhalo habe

VP: Shuvo bijoyar shuvvhecha.

TB: sobai ke shubho bijoya r shubhechha o Rakesh Sir ke amar pronam janai

RB: 🙂👍

PC: Shobaike amar bijoyar pronam ar Tamoghna ke happy birthday janai.

RB: 🙏👍

VP: The middle-aged man from West Bengal got connected to us through WhatsApp. The patient had a chronic intermittent low backache since the winter of 2014. It was associated with a dragging-type pain and numbness in the left leg and foot toes. He reported intermittent tingling sensations bilaterally in the sole of feet that gets worse on prolonged standing and at night which improves after a postural change. He also reported a right shoulder and hand pain due to cervical spondylosis which has improved after doing Yoga. The patient had sustained back injury ten years back after being fallen from a low bench seat which he reported to have revealed normal in the x-ray. His all the present problems started back in the winter of 2014 when after taking a physiotherapy he got injury in his leg during walking followed after which he fell down and had been bedridden with traction for 15 days. An magnetic resonance (MR) imaging showed L4-L5 disc prolapse suggesting a lumbar radiculopathy and local physician insisted him to undergo operation to prevent paralysis. The patient being in dilemma left the hospital for a second opinion to a tertiary care center where the doctors advised him conservative management including pharmacological management and physiotherapy. He continued them until two months back before approaching us as they were ineffective and during this period several doctors reiterated the same advice to undergo spinal surgery and approached to our CBBLE platform as he was puzzled between the surgery and conservative management.

The patient’s complete medical history, which is translated, de-identified and detailed in the blog here, was shared in our current CBBLE platform between global health professionals and student participants. An encryption-protected online dedicated group was created with the participants and the patient was involved in the discussion toward making a shared decision making. A concerted team communication and collaborative learning between healthcare stakeholders around patient requirement generated evidence-based, patient-centered collective inputs to derive an optimal output.

Our team had shared a similar patient backache experience with this patient so that he can understand his problem and better describe his problem. The patient was worried as to why and whether he would need to have a spinal cord surgery as orthopediatrician and a neurosurgeon have advised. We shared with the patient that spinal surgery, presumably for the suspicion of disc prolapse, is only effective if the patient has a focal neurological deficit (aka paralysis). The team tried to dig deeper into understanding his current problem as to whether he has any focal neurological deficits and asked to describe the location, frequency and duration of the pain which was suggesting a radiculopathy due to sensory root compression. This was the point we looked at Cochrane library, Pubmed, Google scholar and UptToDate as to what is the efficacy of decompression surgery as opposed to sham surgery/placebo in alleviating his sensory symptoms.  After a literature review, we found “in patients with lumbar disc prolapse and radiculopathy who do not have severe or progressive neurologic deficits, there is no evidence that early referral for surgery improves outcomes. Outcomes for patients who undergo discectomy, compared to nonsurgical therapy, favor surgery at short-term follow-up but are equivalent at one to two years.”