Treatment and Politics
Disc diagnosis and treatment is described above. Treatment of painful disc derangement is one of the most satisfying and frustrating things I do. Standard of care for disabling disc pain is no treatment or spinal fusion surgery or In some centres disc replacement surgery is undertaken but these are very major undertakings and are suitable for very few patients. Most need something less invasive and, along with the greater understanding of the pathologies causing such pain, several different techniques and technologies have been developed in recent years for this treatment. However, none of these have been subjected to large, double blind, placebo controlled or “pharmaceutical grade” trials and so in current UK practice are counted as unproven or experimental. I would comment that almost no surgical or interventional procedures are subjected to trials of this type which are really relevant to drug studies. However, the effect of this is that NICE, the governments healthcare watchdog, only gives these treatments an amber light ie it concludes they seem safe and that there is outcomes data to support use but not sufficient proof for them to mandate the distribution of such treatment through the NHS nationwide.
Therefore, this area of work is viewed by many as experimental, even if techniques have been in use for almost a decade and may have been extensively reported and followed up and you should be aware of this.
Access to Treatment
NHS: Once NICE have failed to insist that a treatment is made available, it is left open to healthcare providers (payers) to decide if they wish to provide the therapy and this has been the case, at least for me with the NHS providers (PCTs etc) in Kent. I am often therefore in the position of trying to decide whether it is kinder to tell a patient there is no treatment or that there is, but they can’t have it.
Privately: the position has been only slightly better. Until recently only a few insurers would cover these treatment falling back (you might say hiding behind) the NICE position that the treatments are “unproven”. Recently, to their great credit, BUPA have moved to allow certain treatments and I hope that others will do so also.
Finally, as an aside, I am more than aware that the way to establish treatments that one believes in is to provide the research evidence to back up clinical claims. I am therefore co-chairing a group of like-minded colleagues in the British pain Society’s Interventional Research Development group in an attempt to design, fund, and administer appropriately powerful clinical trials of the interventions described here. I am personally taking he lead in the design and conduct of a sham (placebo controlled) trial of coblation treatment in discogenic back pain. This is likely to take several years.