Is Back Surgery Worth It? An interview with the country's leading back pain researcher
by Maryann Napoli
Center for Medical Consumers
Last year, two landmark studies showed that 75% of people with the severe back and leg pain of a herniated disk got better without surgery by three months, but those who underwent surgery typically enjoyed faster relief. By two to four years, however, the study participants had the same level of pain relief whether or not they had surgery. Yet another trial published last May produced similar results at one year. It is noteworthy that these study results generally replicate those of a Norwegian trial published 30 years ago.
That the generous fees paid to surgeons might motivate them to overuse back surgery has always been a consideration for those concerned about the fact that the U.S. has the highest rate of spine surgery in the world. The financial stakes were raised even higher with the introduction of expensive screws and other hardware used in spinal fusion surgery.
The New York Times revealed in December 2006 that a single screw sells for $1,000, which is at least ten times the cost of making it. (Six screws are typically used in a spinal fusion operation.) There are about 30 start-up companies that have begun selling spinal devices, including screws, in the last few years, and many of these companies have back surgeons among their investors, according to The Times. Typically, this financial conflict of interest is not disclosed to their patients.
To learn how people with back pain can avoid unnecessary treatment, Maryann Napoli interviewed Richard A. Deyo, MD, who has co-authored many of the most important clinical trials about back pain treatment. Formerly a professor and co-director of the Center for Cost and Outcomes Research, University of Washington, Seattle, Dr. Deyo is now the Kaiser Professor of Evidence-Based Medicine at the Oregon Health and Science University, Portland.
MN: You wrote last May in a New England Journal of Medicine commentary that "Patients and primary care physicians now need a more sophisticated understanding of the diagnostic possibilities, treatment options, range of surgical techniques, and expected results." How can people with back pain be expected to gain such a sophisticated understanding?
RD: It's not easy. I don't think people understand the expanding array of conditions that surgeons now intervene for and the somewhat differing results that are available from clinical trials.
MN: But how will they understand? There are so many good trials, but one would have to be a skilled Internet searcher to locate them and understanding them may be difficult. Can we start with a common scenario for unnecessary back surgery?
RD: It's hard to come up with a simplistic cut-point, but a patient can ask him- or herself: Do I have back and leg pain, or do I have back pain alone? And if it's back pain alone, the chances that surgery is going to be helpful are pretty small and may not be any better than a good rehab program. But surgery may be helpful if you have leg pain with sciatica due to a herniated disk, or if you have leg pain from degenerative stenosis or spondylolisthesis. Surgery speeds recovery, but patients are likely to improve-albeit more slowly-on their own. In the case of spinal stenosis, which is more common in older adults, surgery is moderately successful, and patients are less likely to improve on their own. For patients who just have worn out discs with back pain and no sciatica, it’s not clear whether surgery – usually a fusion operation—offers any advantage over rigorous rehabilitation.
MN: But doctors can look at the same scan and come up with different diagnoses.
RD: That's true. There is an important variability in interpretation among even expert radiologists and musculoskeletal specialists reading the same x-rays, MRI or CT scans with important consequences. More important, you can see things on an MRI or CT scan that look just awful but may not be the cause of pain. And we know that because some of those awful looking things show up in many people who don't have back pain.
MN: So how can one trust the diagnosis?
RD: What patients often don’t realize—and this is true of other conditions as well—is that imaging results alone do not mean a heck of a lot. What’s critical is their symptoms and the physical examination findings. So if those awful findings on the scan correspond with the leg symptoms and those leg symptoms correspond with neurologic deficits [e.g., weakness when lifting the foot], or at least, the symptoms are in the same distribution you’d expect from the scan—then it might be meaningful. So the imaging results, symptoms, physical exam and the medical history all have to line up.
MN: You wrote that back pain and disk degeneration are nearly universal with aging. Any advice specific to elderly people with back pain?
RD: For elderly people, the first thing to realize is that the range of things that can cause back pain is broader than it is in younger people. It's important for a doctor to rule out other causes of the back pain like cancer, osteoporosis, compression fractures, or an aortic aneurysm. The second thing, unlike young people, herniated disks are fairly uncommon in older people, whereas spinal stenosis starts to become much more common. That's a narrowing of the spinal canal which is the result of arthritic changes in the joints and the ligaments that surround the spinal cord. And if that's causing leg pain as well as back pain, then surgery might be a consideration. The challenging thing for older patients is to balance the possible benefits of surgery with the risks of surgery.
MN: How can they do that?
MN: Is there any type of decision aid—based on the studies—freely available to people who want to compare the risks of surgery with the benefits?
RD: Unfortunately, no, but it's clear from the studies we and others have done that the risk of complications increases as you get older. Certainly for people over age 80, the risk of complications jumps up. As for people in their 60s and 70s, the risks are still relatively small-a 5-10% complication rate. Add to that a 1-2% risk of serious permanent complications [e.g., new neurologic deficit like foot weakness or failure of implanted plates and screws] and then there's an additional few percent risk of MI [heart attack], pulmonary embolism and significant infection. It's major surgery.
MN: Those ads for microinvasive surgery give the impression that it's a minor procedure.
RD: I think you're right. Most of the microsurgical procedures that are being proposed are simple diskectomy, that is a much more minor operation, usually done on younger people with herniated discs. In seniors, with spinal stenosis surgery, you're often talking about multi-level laminectomy, a much more major procedure that can't be done as a microprocedure.
MN: You have been outspoken in the media and in medical journals about the introduction of the expensive screws and other hardware used in spinal fusion surgery and how they have dramatically increased both the frequency and cost of fusion surgery.
RD: Spinal fusion surgery might be done for patients with spondylolisthesis and sometimes spinal stenosis. It's important to realize that spinal fusion in addition to a laminectomy or diskectomy increases the invasiveness of the operation substantially and therefore its complications. Adding these screws to what otherwise would just be bone grafting increases the risks yet another notch. The best evidence suggests that the screws and the plates do result in better healing with the bone grafts and you're more likely to have a solid fusion. [But] that's true only by a few percents. So without the screws, the rate of solid fusion may be 85% and with the screws, it might be 90%. However, it's not at all clear that that translates into a higher rate of pain relief or functional improvement, and so there is a trade-off between an increased risk of complications and the likelihood of a solid fusion.
MN: Any ideas about getting a second opinion from someone other than another surgeon?
RD: Seek out an expert in rehabilitation medicine, a physiatrist who would not only offer a more objective opinion about back surgery but would also have suggestions for rehabilitation.
MN: About 20 years ago, you co-authored a ground-breaking study that challenged the standard medical treatment of that time-bed rest for back pain. Other similar studies followed. What's the final word on bed rest?
RD: There have been several randomized trials that were congruent with ours in suggesting no benefit from bed rest. This was also supported by a Cochrane review of all trials. If patients get some transient pain relief while they're lying down, it may be useful to do that for a couple of days. But more than that is more counterproductive than beneficial.
MN: As I recall the take-home message of those studies is try to go about your normal everyday activities as best you can.
RD: Yes, it does seem counterintuitive, but patients are more likely to recover well if they try to remain active. Obviously, there are certain things you can't do when you have a lot of pain, but the idea is to try to stay as active as you can. Do some walking, that sort of thing, which most people in pain can do.
For more on this article click here...