Neurology

An urgent imperative to close the gap

Robert M Parker

Clinical guidelines are ideally suited to electronic publication and updating

Richard I Lindley · Richard G Larkins · Erin Lalor

The advent of thrombolytic treatment has focused global research and public awareness on ischaemic events rather than other stroke subtypes

Linda J Nichols · Lindsay Smith · Penny L Allen

Current national monitoring excludes subarachnoid haemorrhage, but a separate national registry to monitor process of care may be warranted

Dominique A Cadilhac · Craig S Anderson

To the Editor: In their review, Harris and Buchbinder call for a ban on all spinal injections of steroids.1 These injections are not a singular procedure; they differ by indications, technique, and the evidence that serves each. For the treatment of low back pain, no evidence supports the use of epidural steroids, and intra-articular injections of steroids are clearly no more effective than sham therapy.2 Disavowing ...

Nikolai Bogduk

To the Editor: We thank Harris and Buchbinder for their focus on interventional pain procedures.1 However, their description of the procedure they discuss has not been standard practice in pain medicine in Australia for many years. They misrepresent the Medicare Benefits Schedule (MBS) number 39013 to solely include facet joint injections, whereas it includes local anaesthetic medial branch blocks, which are an evidence-based diagnostic test for posterior elements as a source of spinal pain, and can be therapeutic in their own right.2 The number needed to treat (NNT) is the number of patients that need to be treated for one to benefit compared with a placebo or sham in a clinical trial. The ideal NNT is one. After a positive medial branch block response, radiofrequency medial branch neurotomies — a procedure with an NNT ranging from two patients3 to 4.4 patients4 treated for one patient to receive effective relief of spinal pain — creates a “therapeutic window” in which ongoing spinal rehabilitation can occur. From the 35 000 MBS number 39013 procedures performed in 2012, we can infer that fewer than 0.5% of Australians with spinal pain have facet joint injections and medial branch blocks in a 12-month period. Contrary to the comments of Harris and Buchbinder, lumbar transforaminal epidural steroid injections are effective for the treatment of radicular pain associated with disc protrusion, with an NNT of 2.7,5 and in conjunction with active pain strategies may forestall spinal surgery. Before impeaching facet joint injections and medial branch blocks, and thereby medial branch neurotomies, as well as lumbar transforaminal epidural steroid injections, Harris and Buchbinder should consider: interprofessional patient-centred approaches are key; pharmacological management is often ineffective; their view does not reflect the current practice of Australian pain medicine physicians; these procedures help people struggling to continue in social roles and maintain quality of life, so they help to reduce the economic impact of spinal pain on Australian society. We support education to improve evidence-based practice of interventional procedures.

Stephanie J Davies · Malcolm N Hogg · Eric J Visser

In reply: We thank Bogduk for his comments, but, based on previous reviews and some comparative studies,1-4 do not consider the transforaminal route to be clearly and consistently superior to the interlaminar route for radiculopathy. Further, we note that when the evidence for transforaminal injections is isolated to placebo-controlled trials, the evidence is based on very few studies. The largest of these showed marginal short-term (2-week) improvement in the steroid and local anaesthetic group over the saline group for the primary outcome (leg pain), an effect that was not sustained by 4 weeks.5 Short-term relief is a common finding in studies that use local anaesthetic in the active group. We consider the evidence for the effectiveness of transforaminal steroids over placebo to be neither strong nor consistent (within or between studies). We suggest that the gem in the bathwater be subject to more scrutiny and weighed against the risks and costs. We thank Davies and colleagues for their comments about medial branch blocks and transforaminal epidural steroid injections. We have addressed the latter in our response above. Our article does not extend beyond the use of steroids to procedures such as neurotomy, so we have not commented on this procedure here. Regarding medial branch blocks, we note that in a systematic review mentioned by Davies and colleagues, each of the randomised trials showed no significant difference in the response between groups treated with steroid and those treated with local anaesthetic alone.6 This reinforces our point that steroid injections in the spine have no specific therapeutic effect beyond natural history, the effect of any concomitant treatment or any placebo effect.

Ian A Harris · Rachelle Buchbinder

Harmonising national data collection processes and establishing reliable linkage of data from different repositories has the potential to improve efficiency in monitoring the quality of stroke care.

Dominique A Cadilhac PhD, MPH, BN · Karen M Moss BBSc(Hons) · Christopher J Price BSc, BSW · Natasha A Lannin PhD, BSc(OT), GradDip · Joyce Y K Lim RN, GradDipComHlth, MNurs · Craig S Anderson BMedSci, MB BS, PhD

The case of a woman who developed severe rhabdomyolysis shortly after the addition of pregabalin to a stable atorvastatin regimen serves as a reminder to clinicians to be aware of possible adverse drug reactions.

Roshan Gunathilake MB BS, MD · Laura E Boyce BPharm · Anne T Knight MB BS(Hons), FRACP

We report the first known Australian case of probable neurobrucellosis, in a young feral-pig shooter who presented with episodic left-sided visual loss and left-sided numbness and headache. Treatment with intravenous ceftriaxone and oral rifampicin, doxycycline and trimethoprim–sulfamethoxazole resulted in a good clinical response.Clinical recordIn September 2011, a 29-year-old man from rural western Queensland suddenly developed left-sided visual loss. This lasted 15 minutes and was followed by ...

Wendy J Munckhof PhD, FRACP, FRCPA · Amy V Jennison BSc(Hons), PhD · John R Bates BAppSc, ADipComp · Ian Gassiep MB BS(Hons)

Family stories provide the key to understanding the patient’s wishes and open doors to plain speaking, in this reflection on caring for a woman who is unable to communicate.

Matthew J Links MB BS, PhD, FRACP · Theodora Bikou BSW

A neurosurgeon’s personal account of the experience of, treatment for and recovery from a basilar artery occlusion provides a unique "insiders view" into acute locked-in syndrome.

Gordon Stuart MB BS, FRACS