To Cut Or Not To Cut
by Karen Springen
November 21, 2006
About 300,000 Americans have surgery each year for herniated disks. With total hospital, anesthesia and surgery costs running around $10,000 to $15,000 per operation, that works out to up to $4.5 billion worth of surgery annually. Is it worth it? Maybe. And maybe not. A report in this week's issue of the Journal of the American Medical Association (JAMA) found that herniated disk patients who did not opt for surgery did nearly as well as those who went under the knife after a two-year period. And the researchers said the differences in outcome between the two approaches were "small and not statistically significant."
The multi-center Spine Patient Outcomes Research Trial (SPORT) enrolled 501 surgical candidates with severe leg pain and operated on half of them. The randomized clinical trial found that patients who had surgery and patients who did not both "improved substantially over a two-year period." However, a second, observational trial (also in JAMA this week), in which patients chose which treatment they wanted, showed a different result. The 528 patients who had surgery reported greater improvements than the 191 patients who did not have an operation. In general, researchers put less stock in observational studies than in randomized ones, in part because of the possibility of a placebo effect.
So where does that leave all those folks with aching backs who are trying decide whether to get surgery for a herniated disk? "It's clearly a patient's choice," says the lead author of both studies, Dr. James Weinstein of Dartmouth Medical School. With either approach, "patients got remarkably better," says Dr. David Flum, director of the Surgical Outcomes Research Center at the University of Washington and author of one of the editorials accompanying the studies. "Both approaches are reasonable."
Surgery to remove an errant piece of disk is straightforward. Surgeons make a three-quarter-inch incision and pluck out the offending piece of disk with forceps. They do not insert plates and screws or remove much, if any, bone. "All they're doing is removing a part of the disk and not doing much else," says Dr. Rick Deyo, professor of medicine and health services at the University of Washington and a co-author of the two studies. "You're just taking out a bad part of the disk." Surgery generally takes 45 minutes to an hour. Patients go under general anesthesia, but often go home the day of the operation.
So, who should get surgery, and who should just say no? "It's got to be a very individualized decision that involves a patient's own priorities," says Deyo. "Are you risk averse and prefer to avoid surgery? If so, you'll probably get better. Are you a risk taker and prefer surgery. If so, you'll probably get better faster, and it'll cost a little bit more." Doctors generally advise patients to wait six weeks from the time they develop the pain to see how much they improve on their own.
If the pain is bearable, patients may want to forgo the operation. "Patients often don't realize that they're very likely to get better, even without surgery. It's just likely to be slower," says Deyo. "Time is on their side." If he had a herniated disk, Deyo would make his decision based on how much it "interfered" with his life. He might "ride it out" if he had some tingling in his leg that didn't interfere too much, he says. "They really are individual decisions." Even without surgery, there can be complications. People who skip surgery may continue to visit the doctor for treatments, including epidural steroids and anti-inflammatory drugs. In some cases, their spouses need to take off from work to care for them.
For patients with mild sciatica, whose jobs don't involve twisting and bending, letting nature take its course may work best. For a carpenter who is unable to work as a result of back pain, though, surgery and immediate relief may be preferable. "If you're out of work for six to nine months, you'll lose all your business," says Dr. Eugene Carragee, professor of orthopedic surgery at Stanford Medical School and author of an editorial accompanying the studies. Health insurance and disability coverage are also factors.
"One person may have great disability insurance and can stand to be out of work that long," says Carragee. "Even though the data shows that after six, nine, 12 months, the outcomes of people who had surgery vs. people who did not becomes very similar, and by two years, they're even more similar, that's small comfort if in the interim you spent your children's college fund."
Internet marketing consultant David Haas, 45, says he will never forget the "knifing, searing pain" in his calf, triggered by a herniated disk in his spine. He had moved a couch, which caused a piece of disk about the size of a chick pea to break off and press against a nerve. Occasionally, the pain was so bad he had to have his wife drive him the 250 steps from his home to his office. He tried getting acupuncture, visiting a chiropractor, walking in a pool and reading Dr. John Sarno's "Healing Back Pain: The Mind-Body Connection." Nothing worked. A friend introduced him to Dr. Alexander Vaccaro, professor of orthopedics and neurosurgery at Thomas Jefferson University in Philadelphia. Vaccaro took out the offending piece of disk. And Haas felt instant relief. "I almost liken it to the thorn in the tiger's paw," he says. "When they took that thorn out, I was a new person."
Haas's experience with the couch is not unusual. Typically herniated disks are "random events," says Carragee. "Usually it is something completely benign-leaning over to pick up a piece of tissue off the ground." That event is more of a trigger than a cause. "Whatever the final event is, that is the end of a long, degenerative process. It isn't that you went from a good disk to a herniation," he says. The disk cracks, and a piece that's less than a tenth of the size of it migrates out of position and leans on the nerves. The body eventually absorbs that chick pea-sized piece, and the patient usually feels better from the simple "passage of time," says Carragee.
To Sarno, author of "The Divided Mind" and "Healing Back Pain: The Mind-Body Connection" and a New York University professor of rehabilitation medicine, the study validates his surgery-isn't-the-answer position. "If you leave most patients alone, they'll get better," he says. He considers the pain attributed to herniated disks a symptom of another painful condition, called Tension Myositis Syndrome or TMS, from the "stress in our lives."
Usually, herniated disk patients are in their early 40s-prime candidates to bounce back. Terry Rombalski, now 46, first hurt his disk six years ago, when he picked up his daughter. A couple weeks later, he took a practice golf shot and "bang," he says, "shooting pain down my leg and lower back." He talked to doctors and friends about surgery but decided against it. "The final analysis was, if the pain is at a point where you can't function, you should have surgery," he says. "Don't do it unless you have to." Instead, he took up yoga. "I can now go down and touch my toes," he says. Though he needs to stretch for a while before he can lean over and tie his shoes in the morning, he is able to play golf again. He has no regrets about saying no to surgery. "I think it was the right move," he says.
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