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Doctors Overly Optimistic About Back Surgery

Careful Patient Selection Needed, Says Surgeon

by Salynn Boyles ( WebMD Health News )

June 15, 2005

Surgeons tend to be "overly optimistic" when they counsel patients about the benefits of back surgery, a new study shows.

Almost 40% of patients in the study reported virtually no difference in back painback pain one year after having back surgery. But prior to surgery almost all of their surgeons predicted that they would have less pain and most said surgery would result in "a great deal of improvement."

The research is published in the June 15 issue of the journal Spine.

"Surgeons tended to give overly optimistic predictions, which were not correlated with patient outcome at one-year follow-up," wrote researcher Bertrand Graz, MD, and colleagues from Switzerland's University of Lausanne Medical Centre.

Back Surgery Failed to Help Many

A total of 197 patients who had surgery for low-back pain or sciaticasciatica were included in the study. Prior to operating, their surgeons were asked to predict how much the surgery would improve their patients' quality of life. The surgeons predicted that 79% of patients would have "a great deal of improvement" and 20% would have "moderate improvement."

A year after back surgery, the patients were questioned about their experience. More than half (56%) of those whose surgeons predicted a great deal of benefit reported no significant improvement in their general health.

Overall, the surgeons had predicted that 99% of patients would have some improvement with surgery. But a year later, 39% of the patients said the surgery did not help their back pain.

Ironically, the doctors were best able to predict surgical results for patients who were the poorest candidates for back surgery. Among the patients for whom surgery was considered inappropriate, based on strict guidelines, higher surgeon expectation was linked to greater improvement. Psychosocial Factors Important

The study is not the first to find that surgery is not the cure-all for low-back pain that many patients think it is, or the first to suggest that doctors do a poor job of predicting which patients will benefit the most from back surgery.

Research presented last winter at the annual meeting of the American Academy of Orthopaedic Surgeons found that factors such as patient education level, depression, smoking, and whether or not a patient had filed a workers' compensation claim all affected surgical results among low-back-pain patients.

A researcher of that study, William Abdu, MD, tells WebMD that surgeons need to be aware that a host of physical, psychological, and social issues unrelated to back pain can influence surgical results.

"There is a tendency among patients to think that if they have an operation everything will be normal," he says. "But the more medical and psychosocial [issues] a patient has, the lower the expectations for surgery should be."

Most Patients Are Poor Candidates

Orthopaedic surgeon Jeffery C. Wang, MD, agrees that doctors need to take medical and psychological issues into consideration when deciding whether a patient will benefit from back surgery.

Wang is chief of the spine service for the UCLA department of orthopaedic surgery and a spokesman for the American Academy of Orthopaedic Surgeons.

"The key to any successful surgery is patient selection," he tells WebMD, adding that psychologically distressed patients who otherwise appear to be good candidates for back surgery often have poor surgical results.

Wang says less than 10% of patients with low-back pain are appropriate surgical candidates. And he acknowledges that there are probably too many back surgeries being performed.

"There are certainly doctors who are performing too many surgeries, but that certainly isn't true of everyone," he says. There are very good studies out there showing that if you select the right patient for the right surgery, outcomes are very good."


Graz, B. Spine, June 15, 2005, online edition.
Bertrand Graz, MD, MPH, Institute of Social and Preventive Medicine, University of Lausanne Medical Center, Lausanne, Switzerland
William A. Abdu, MD, associate professor and director, Spine Center at Dartmouth Medical School, Hanover
N.H. Jeffery C. Wang, MD, chief of spine service, department of orthopedic surgery, UCLA; spokesman, American Academy of Orthopaedic Surgeons.

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