I vividly recall the first time I “scrubbed in” on a surgical case as a third year medical student. It was very early in the morning. I hadn’t eaten any breakfast, and the heavy surgical gown, the mask, the hat and gloves added to the bright lights, making me very hot. After the insides of the patient’s abdomen were exposed, I began to feel faint. Although the nurses were kind enough to help me sit down to avoid the embarrassment of falling to the floor, I had an inkling that surgery was not going to be my specialty.
During my training, the surgeons I met were extremely dedicated and caring doctors. They worked very hard and paid a great deal of attention to detail. They could do things that medical doctors could not do: fix structural problems such as an inflamed appendix or gall bladder. They only operated when they were convinced that it was necessary and they paid a great deal of attention to the balance between the potential gain and the risk of complications. For some patients, they decided that it was too risky to operate. These were often difficult decisions and I appreciated how they struggled with those decisions.
Neurosurgeons are required to take a very long and arduous path. They must have great hand-eye coordination and nerves of steel to put up with long operations that have the risk of catastrophic nerve damage if something goes awry. Their expertise in removing brain tumors or infections that are found when a patient has a neurological deficit, and CT or MRI scanning delineates the problem, is very impressive. The results of these operations are obvious: you know when the surgery is a success as the patient has improvement in their neurological functioning.
In recent years, an increased number of surgeries have been done for back pain and sciatic pain. Surgeons have used the same model of care as with brain tumors or infections, namely that the problem is identified by the symptoms of the patient and seen on CT or MRI scanning. If you have a good surgeon who has made a careful decision based on potential benefit and risk, and you have a symptom that is caused by a structural problem, the results should be similar. However, there are several problems with this model when it is applied to back and sciatic pain.
First, as discussed in my last blog, CT and MRI scans are not particularly accurate in the setting of pain, unless they identify a fracture, infection or tumor. Degenerated or herniated discs are seen in most adults, whether they have back pain or not. Therefore, it is extremely common for an MRI scan to show findings and it's virtually impossible to tell if they are actually the cause of pain or simply a sign of a normally aging back.
This problem may explain why back surgery has not been a panacea for patients with chronic back pain. The vast majority of those with chronic back pain do not have a fracture, infection or tumor. Some patients with back pain have a herniated disc that is clearly causing nerve damage, such as when there is evidence of decreased muscle strength, a loss of sensation or a deep tendon reflex. People who have a “foot drop” due to loss of muscle strength have a damaged nerve and usually need surgery. However, most people with back pain don’t have any evidence of nerve damage. They have pain and their MRI shows common changes. Should these people have back surgery?
Here is what research studies have shown. Studies that have randomized individuals with back pain to get either surgery or non-surgical treatments show little benefit to surgery. For example, Brox and colleagues compared fusion surgery to exercise and cognitive therapy for chronic back pain and there was no difference between the two groups after one year (both groups had improvement in how well they functioned). A study from Sweden showed no difference in long term outcomes for chronic low back pain.
Studies comparing surgery versus no surgery for sciatic pain presumed to be due to herniated intervertebral discs show similar results. In a study from Finland comparing early surgery to waiting and exercise/physical therapy for sciatic pain due to a herniated disc, the surgery group improved quicker, but at one year, there was no difference between the two groups (both groups improved significantly). Osterman and colleagues did a study in which they randomized those with herniated discs to get micro-discectomy or conservative non-surgical treatment. At a two-year follow up, there was no difference between the two groups. The SPORT trial also randomized individuals with sciatic pain due to a herniated disc to surgery versus no surgery groups and there were no differences in pain or disability at two years of follow up (when the study was analyzed statistically by the more conservative intention-to-treat type of analysis).
There are, of course, potential risks of surgery. A study from the state of Ohio found a complication rate of 36 percent and a reoperation rate of 27 percent. Those who had surgery were less likely to return to work and more likely to be permanently disabled, although this was not a randomized trial.
Despite these data, the rates of spinal surgery for back pain have increased dramatically over the past two decades. Spinal fusion surgery increased by 220 percent from 1990 to 2001. At the same time, rates of disability due to back pain have also increased. A study in Ontario found that the enthusiasm of surgeons for doing spinal surgery accounted for significant degrees of differences in rates of spinal surgery. In the U.S., rates of spinal surgery vary significantly. One study done in Maine found that areas with lower rates of surgery had better outcomes and areas with higher surgical rates had worse outcomes for patients.
Richard Deyo, one of the foremost experts on back pain in the U.S., summarized the research findings on back surgery in an article in the New England Journal of Medicine entitled “Back Surgery—Who Needs It?” He states that those with major spinal trauma or herniated discs that cause loss of muscle function in the legs due to nerve damage usually benefit from surgery. However, those with back pain who do not have loss of muscle function do not need surgery, even if they have evidence of spondylolisthesis, degenerated or herniated discs, or spinal stenosis. In another article, Deyo notes that expecting a cure for chronic back pain from a medication, an injection, or an operation is “generally wishful thinking.”
Some surgeons are beginning to understand that too many back surgeries are being done. Dr. David Hanscom is a spine surgeon who sees the results of overly aggressive treatment of chronic back pain. His excellent book, Back in Control, is must reading for anyone who is considering surgery for chronic back or sciatic pain. Dr. Hanscom has seen first hand that many patients can recover from back pain without surgery and he believes that surgery is only necessary for a small proportion of those with chronic back pain.
What does work for chronic back pain? There is evidence that a combination of exercise, physical therapy, and counseling makes a difference. Individuals who take charge of their own health and change how they view the pain and how they respond to it are generally much better off. The mind can have a powerful effect on back pain and many people can resolve their pain by a mind body approach.
To your health,
Howard Schubiner, MD