Radiating low back pain in general practice: incidence, prevalence, diagnosis, and long-term clinical course of illness.

OBJECTIVE: The aim of this study was to calculate the incidence and prevalence of radiating low back pain, to explore the long-term clinical course of radiating low back pain including the influence of radiculopathy (in a subsample of the study population) and non-radiating low back pain thereon, and to describe general practitioners' (GPs') treatment strategies for radiating low back pain. DESIGN: A historic prospective cohort study. SETTING: Dutch general practice. SUBJECTS: Patients over 18 years of age with a first episode of radiating low back pain, registered by the ICPC code L86. MAIN OUTCOME MEASURES: Incidence and prevalence, clinical course of illness, initial diagnoses established by the GPs, and treatment strategies. RESULTS: Mean incidence was 9.4 and mean prevalence was 17.2 per 1000 person years. In total, 390 patients had 1193 contacts with their GPs; 50% had only one contact with their GP. Consultation rates were higher in patients with a history of non-radiating low back pain and in patients with a diagnosis of radiculopathy in the first five years. In this study's subsample of 103 patients, L86 episodes represented radiculopathy in 50% of cases. Medication was prescribed to 64% of patients, mostly NSAIDs. Some 53% of patients were referred, mainly to physiotherapists and neurologists; 9% of patients underwent surgery. CONCLUSION: Watchful waiting seems to be sufficient general practice care in most cases of radiating low back pain. Further research should be focused on clarifying the relationship between radicular radiating low back pain, non-radicular radiating low back pain, and non-radiating low back pain.

Epidural steroids for lumbosacral radicular syndrome compared to usual care: quality of life and cost utility in general practice.

OBJECTIVE: To investigate the effect of adding segmental epidural steroid injections (SESIs) to usual care compared with usual care alone on quality of life and cost utility in lumbosacral radicular syndrome (LRS) in general practice. DESIGN: A pragmatic randomized controlled trial. Results were analyzed using mixed models. SETTING: Primary care. PARTICIPANTS: Patients (N=50) in the acute phase of LRS. INTERVENTIONS: One epidural injection containing 80mg of triamcinolone in normal saline. MAIN OUTCOME MEASURE: Back pain at 4 weeks after the start of the treatment. RESULTS: Both groups experienced a significant increase in quality of life in (especially) the physical domains of the Medical Outcomes Study 36-Item Short-Form Health Survey. The intervention group scored significantly better than the control group at certain time points in the physical domain. The differences were small. The cost-utility analysis showed that with a negligible loss of utility (3d in perfect health), societal costs (193,354 euros per quality-adjusted life year lost) would be saved because of more productivity in the intervention group. CONCLUSIONS: Although the beneficial effects of SESIs are small and the natural course of LRS is predominantly favorable, we think decision makers can consider implementing SESIs in daily practice with the purpose of saving resources. Caution must be taken, and further research should be directed at identifying patient subgroups who might benefit from SESIs, with additional focus on (costs of) complications and adverse effects.

Steroid injections added to the usual treatment of lumbar radicular syndrome: a pragmatic randomized controlled trial in general practice.

BACKGROUND: Lumbosacral radicular syndrome (LRS) is a self-limiting, benign, painful and impairing condition caused by lumbar disc herniation and inflammatory processes around the nerve root. Segmental epidural steroid injections (SESIs) are helpful to reduce radicular pain on a short-term basis. It is unknown whether SESIs are an effective addition to usual pain treatment of LRS in general practice. In our study, we assessed the effectiveness of SESIs on pain and disability as an addition to usual care for acute LRS in general practice. METHODS: A pragmatic, single-blinded, randomized controlled trial in Dutch general practice was conducted. Circumstances of daily practice were closely followed. Care as usual (CAU) was compared to care as usual combined with an additional SESI in 63 patients in the acute phase of LRS. To detect a minimal clinically important difference of 1.2 points on a numerical rating scale for back pain and a common within-group standard deviation of 1.7 with a two-tailed alpha of 0.05 and a power of 0.80, we needed 33 subjects in each group. Statistical analysis was carried out using mixed models. RESULTS: A small significant effect in favour of the intervention, corrected for age, sex and baseline values, was found for back pain, impairment and Roland-Morris disability score. The differences, though statistically significant, were too small to be considered clinically relevant. Patients from the intervention group were significantly more satisfied with the received treatment than patients from the control group. CONCLUSION: We found a small, statistically significant, but not clinically relevant positive effect of SESIs on back pain, impairment and disability in acute LRS. We do not recommend implementing SESIs as an additional regular treatment option in general practice.

Costs and cost-effectiveness of epidural steroids for acute lumbosacral radicular syndrome in general practice: an economic evaluation alongside a pragmatic randomized control trial.

STUDY DESIGN: A pragmatic, randomized, controlled, single-blinded trial in Dutch general practice. OBJECTIVE: Assessing the costs and cost-effectiveness of adding segmental epidural steroid injections to care as usual in radiculopathy in general practice. SUMMARY OF BACKGROUND DATA: Lumbosacral radicular syndrome (radiculopathy) is a benign, generally self-limiting but painful condition caused by a herniated lumbar intervertebral disc, which results in an inflammatory process around the nerve root. Segmental epidural steroid injections could lessen pain. Low back pain and sciatica form a large financial burden on national health care systems. Improving pain treatment could lower costs to society by diminishing loss of productivity. METHODS: Patients with acute radiculopathy were included by general practitioners. All patients received usual care. Patients in the intervention group received one segmental epidural steroid injection containing 80 mg of triamcinolone as well. Follow-up was performed using postal questionnaires at 2, 4, 6, 13, 26, and 52 weeks. Main outcomes were pain, disability and costs. Economic evaluation was performed from a societal perspective with a time horizon of 1 year. RESULTS: Sixty-three patients were included in the analysis. Mean total costs were €4414 or $5985 in the intervention group and €5121 or $6943 in the control group. This difference was mostly due to loss of productivity. The point estimate for the incremental cost-effectiveness ratio was -€730 or -$990 (1-point diminishment on the numerical rating scale back pain score in 1 patient in the course of 1 yr would save €730 or $990). Bootstrapping showed a 95% confidence interval of -€4476 to €951 or -$6068 to $1289. The cost-effectiveness acceptability curve showed that without additional investment the probability that epidural steroids are cost-effective is more than 80%. CONCLUSION: The effect on pain and disability of epidural steroids in lumbosacral radicular syndrome is small but significant, and at lower costs with no reported complications or adverse effects. Segmental epidural steroid injections could be considered by policy makers as an additional treatment option.

Patients' views on dyspepsia and acid suppressant drug therapy in general practice.

OBJECTIVES: To do an inventory on the opinion of long-term acid suppressant drug (ASD) users on their condition and drug treatment, and from that angle to reflect on possibilities to reduce usage and costs of long-term acid suppressant drug therapy. METHODS: In the year 2001, in seven general practices, patients who chronically used ASDs without proper indication were identified. A postal questionnaire based on the literature was sent to these patients (n=498). RESULTS: 318 (64%) returned questionnaires were fit for analysis. Patients experienced dyspepsia as unpleasant and restraining, and were extremely positive about ASDs without differences between H2-receptor antagonists (H2RAs) and proton pump inhibitors (PPIs). ASD use was very compliant. Patients smoked and drank less than the normal population. They did not continue unhealthy habits simply because ASDs enable them to. Most patients were not motivated to stop their ASDs. CONCLUSION: Dyspeptic complaints should not be underestimated. Improving lifestyle is not likely to generate much effect on ASD use. Due to a lack of motivation, discontinuing long-term ASD use may not be an efficient way to reduce the use and costs of ASDs. Patient-centred possibilities are prescribing H2RAs instead of PPIs as a first step, as they are perceived by patients to be equally effective, and encouraging patients to self-regulate drug treatment through on-demand regimes.