Study questions need to operate for back pain
by Gina Kolata
The New York Times
November 22, 2006
NEW YORK: People with ruptured disks in their lower backs usually recover whether or not they have surgery, researchers reported Wednesday.
The study, a large trial, found that surgery appeared to relieve pain more quickly, but that most people recovered eventually and that there was no harm in waiting.
And that, surgeons said, is likely to change medical practice.
The study, published in The Journal of the American Medical Association, is the only large and rigorous randomized trial to compare surgery with waiting as a treatment for sciatica, which is characterized by an often agonizing pain in the buttocks or a leg or weakness in a leg.
The study was controversial from the start, with many surgeons saying they knew that the operation worked and that it would be unethical for their patients to participate.
In the end, though, neither waiting nor surgery was a clear winner, and most patients could safely decide what to do based on personal preference and level of pain. Although many patients did not stay with their assigned treatment, most fared well with whatever treatment they had.
Patients who had surgery often reported immediate relief. But by three to six months, patients in the two groups reported marked improvement.
After two years, about 70 percent of the patients in the two groups said they had a "major improvement" in their symptoms. No one who waited had serious consequences, and no one who had surgery had a disastrous result.
Many surgeons had long feared that waiting would cause severe harm, but those fears were proved unfounded.
"I think this will have an impact," said Dr. Steven Garfin, chairman of the orthopedic surgery department at the University of California, San Diego. "It says you don't have to rush in for surgery."
"Time is usually your ally, not your enemy," Garfin added.
Sciatica is caused when a ruptured disk impinges on the root of the sciatic nerve, which runs down the back of the leg. Patients often are told that if they delay surgery they may risk permanent nerve damage, perhaps a weakened leg or even the loss of bowel or bladder control. But nothing like that occurred in the two-year study comparing surgery with waiting in nearly 2,000 patients.
The patients did not include people who had just lower back pain, which can have a variety of causes. Nor did they include patients with conditions that would require immediate surgery like loss of bowel or bladder control or significant or sudden leg weakness. Instead, they were typical of a vast majority of people with sciatica who are made miserable by searing pain. For such patients, fear that delaying an operation could be dangerous "was the 800-pound gorilla in the room," said Dr. Eugene Carragee, professor of orthopedic surgery at Stanford University.
Carragee never believed it himself, he said, but the concern was there and it was widespread among patients and doctors.
With the new results, it is clear that the risk of waiting "is, if not extraordinarily small, at least off the radar screen," Carragee said.
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