Evidence in neurology

Abstract

When I began my training in neurology 30 years ago, we did experience-based medicine: information was passed from experienced neurologists to the next generation of trainees. Clinical trials were almost unheard of, and ideas like numbers needed to treat, numbers needed to harm, and evidence-based medicine did not exist. Fortunately, this situation has changed—we now have scientific evidence to show which therapies or procedures are effective and, even more importantly, which ones are not. Modern neurology depends on evidence-based medicine. Therefore, a textbook on this topic is welcome. In Evidence-based Neurology: Management of Neurological Disorders, 55 contributors addressed more than 100 questions about the management and treatment of neurological disorders. Each chapter aims to summarise the most recent and important findings on treatments for neurological diseases, to address treatment uncertainties, and to provide information on benefit and possible harm. The first part of the book discusses the potential drawbacks with methods used in evidence-based medicine. The second deals with common symptoms such as headache, pain, vertigo, sleep disorders, spasticity, and rehabilitation, and the third covers major neurological disorders. Most chapters include instructive tables that list important systematic reviews or randomised trials and give absolute and relative risk reductions, numbers needed to treat, and numbers needed to harm. I looked particularly closely at the topics I know most about. The migraine chapter summarises important trials and meta-analyses on the treatment of acute migraine and migraine prevention. I would have appreciated more guidance on how to translate this evidence into clinical practice. For example, which drug should be used with highest priority? I enjoyed the chapter on neuropathic pain, in which graphs show drug reliability versus net benefit for patients with painful polyneuropathy, postherpetic neuralgia, and central pain. The chapter on stroke prevention was disappointing, because combined use of slow-release dipyridamole and aspirin was not mentioned—despite large randomised trials (ESPS2 and ESPRIT) and recommendation by the UK National Institute for Health and Clinical Excellence that this combination should be a first-line therapy to prevent secondary ischaemic stroke. This chapter is otherwise a nice summary of evidence, but again would benefit from more guidance about translation of evidence into practice. References to treatment guidelines from scientific societies might also have been helpful. I highly recommend Evidence-based Neurology. This book is a great help when patients confront me with information from the internet and I have to provide data on benefit or risk within 60 seconds.