Articles by JCS

Back Surgery Not Needed

Back Surgery Not Needed

Undoubtedly this stunning headline shocked the American public as well as medical professionals who might think these remarks came from the chiropractic profession that has long touted the benefit of non-invasive methods compared to spinal surgery. In fact, this conclusion came from American medical researchers who echoed similar recent studies from the UK[1], Norway[2] and Sweden[3] showing that people with ruptured disks in their lower backs usually recover whether or not they have surgery.

The American study, “Surgical vs. Non-operative Treatment for Lumbar Disk Herniation, The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial”[4]  published in The Journal of the American Medical Association on November 22, 2006 found that surgery appeared to relieve pain more quickly but that most people recovered eventually and that there was no harm in waiting.

This study has bolstered the 1994 USPHS report on low back pain in adults done by the AHCPR that suggested surgery was required in only one in 100 cases and recommended spinal manipulative therapy as a first line “proven method”.[5] As chiropractors we are also pleased to see a study that supports our profession’s role in the non-operative management of disc herniations.

With the emphasis on evidence-based healthcare, every health profession finds itself under scrutiny for both clinical and cost-effectiveness. An estimated 350,000 Americans a year have surgery to relieve these symptoms at an average cost of $50,000. Although it may have shocked some, this conclusion didn’t come as a surprise to many within the back pain industry who have long known of the excesses, expense, and complications with spinal surgery.

“The study is very complicated and the JAMA version of the conclusion is a bit misleading,” according to Scott Boden, MD, Emory participant in the SPORT study. [6]

“These were patients with confirmed disc herniations and severe leg pain that lasted more than 6 weeks to enter the study.  It was not a comparison of surgery versus nothing. It was a comparison of surgery versus continued non-operative care, some of which included chiropractic manipulations, injections, physical therapy, etc.  Rather than specify the non-operative care, we simply recorded what was done and future papers will report on that aspect of practice patterns.

“Also, since these were only patients with HNP and leg pain, it would not be appropriate to compare spinal fusion to any other treatment in this group. If you have surgeons that are routinely fusing their herniated discs, then you have a locally aggressive group that is adding unnecessary morbidity with previous studies that have shown fusion for HNP has a worse outcome than just discectomy.  Most stopped fusing HNPs back in the ‘80s. HNP with leg pain is an indication for hemi-laminectomy and discectomy if the pain lasts more than 6 weeks and correlates with a positive MRI finding.  Even a recurrent HNP is not an indication for fusion in today's mainstream.

“If a patient’s severe leg pain has lasted 6 weeks and can afford/tolerate waiting another 6 weeks, then continued non-operative care is reasonable.  On the other hand, if the patient feels the pain is too severe to bear for an additional 6 weeks, then surgery is the appropriate treatment.  What the study did not address is that patients with persistent leg pain for 12 weeks (less than 10 percent of those with HNP) most likely would benefit from surgery because the natural history for spontaneous improvement suggests that if it has not happened by 12 weeks then there is a small chance that it will happen.

“So to say that waiting or non-operative care is as good as surgery is misleading.  For the majority of the HNP population, they will get better without surgery.  However, for those with persistent pain at 6 weeks (SPORT study) or at 12+ weeks (prior natural history studies), in fact surgery would be the preferred treatment for persistent leg pain.”

The participants in the SPORT trial were typical of a vast majority of people with sciatica who are made miserable by searing pain. The study did not include people who had just lower back pain, which can have a variety of causes. Nor did it include people with conditions that would require immediate surgery like losing bowel or bladder control. For such patients, fear that delaying an operation could be dangerous ''was the 800-pound gorilla in the room,'' said Dr. Eugene J. Carragee, professor of orthopedic surgery at Stanford. He noted that he had never believed it himself, but that the concern was widespread among patients and doctors. [7]

Dr. James Weinstein of Dartmouth Medical School, lead researcher in this major study of over 1200 back pain cases, came up with some fascinating and to some troubling results. Not only did the recent study published in JAMA show that patients with low back and leg pain who underwent spinal surgery fared no better two years later than those who used non-invasive therapy, it also showed that surgery rates vary drastically region by region. A doctor in Idaho Falls, Idaho Missoula Montana or Mason City, Iowa is 20 times more likely to do surgery for back pain than a doctor in Newark, New Jersey, Bangor, Maine or Terre Haute, Indiana.

"It is so interesting that geography is destiny, and it's not rational." said Dr. Weinstein. "We basically found that people who had very significant symptoms, that surgery in fact was better. However what was really interesting is that patients who decided not to have surgery who could wait also did really well," said Weinstein. When asked if he thought people were too quick to have back surgery, he replied, "Sometimes I do and I think that it’s important for people to have good information."


Can Surgeons Handle the Truth?

Some doctors specializing in back surgery are quite critical of the study, to say the least. "I guess some of my colleagues were worried that I might find the wrong thing, I am not sure." said Weinstein. "That never was the intent. It was just to find the truth for our patients.”

''I think this will have an impact,'' said Dr. Steven R. Garfin, chairman of the department of orthopedic surgery 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.'' [8]

''The worry was not knowing,'' Dr. Carragee added. ''If someone had a big herniated disk, can you just say, 'Well, if it's not bothering you that much, you can wait?' It's kind of like walking on eggshells. What if something terrible did happen?'' With the new results, it is clear that the risk of waiting ''is, if not extraordinarily small, at least off the radar screen.”

The message, in the end, Dr. Weinstein said, was that no matter which treatment a patient received, ''nobody got worse.'' He added, ''We never knew that until we did the study.''

The researchers are also conducting a separate analysis on the cost effectiveness of surgery compared with waiting. Although that analysis has not been published, Dr. Anna N. A. Tosteson of Dartmouth, an author of the study, said that Medicare paid a total of $5,425 for the operation and that private insurers might pay three to four times that.

Although the results answered one question about the safety of waiting, they were also, in a sense, disappointing, said Dr. David R. Flum, a contributing editor at The Journal of the American Medical Association and an associate professor of surgery at the University of Washington. ''Everyone was hoping the study would show which was better,'' Dr. Flum said. [9]

''And everyone was surprised by the tremendous number of crossovers in both directions,'' he added, referring to the large number of participants who changed from surgery to waiting and vice versa. On the other hand, many patients in the SPORT study clearly improved without surgical intervention.

These findings suggest that in most cases there is no clear reason to advocate strongly for surgery apart from patient preference. For the patient with emotional, family, and economic resources to handle mild or moderate sciatica, surgery may have little to offer.

In fact, this was the profile of many patients who opted against surgery in the SPORT trial: older participants with higher income and higher education but with milder pain and disability. Furthermore, the SPORT data clearly show that the risk of serious problems (neurologic deterioration, cauda equina syndrome, or progression of spinal instability) when receiving non-operative care is extremely small. The fear of many patients and surgeons that not removing a large disk herniation will likely have catastrophic neurologic consequences is simply not borne out. Thus, these data help both clinicians and patients make better informed decisions based each patient's needs and expectations.

Hopefully these studies will enable patients and doctors to view back pain treatment in a different light—beginning with non-invasive methods such as active rehabilitation (SMT, exercise, axial decompression, etc.) before any type of surgical intervention.  Although many spine surgeons may oppose with these new findings from Europe and the US, the evidence shows that for low back pain, medical care is too high-tech, too costly, too varied, and too risky.

 

 



[1] UK Spine Stabilisation Trial Group

Fairbank J, Frost H, Wilson-MacDonald J, Ly-Mee Yu, Barker K, Collins R,  Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. BMJ  2005;330:1233 (28 May), doi:10.1136/bmj.38441.620417.8F (published 23 May 2005)

[2] Norway Spine Study

Brox JI, Sorensen R, Friis A, Nygaard O, Indahl A, Keller A, Ingebrigtsen T, Eriksen HR, Holm I, Koller AK, Riise R, Reikeras O. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine. 2003 Sep 1;28(17):1913-21

[3] Swedish Lumbar Spine Study

Fritzell P, Hagg O, Jonsson D, Nordwall A; Swedish Lumbar Spine Study Group , Cost-effectiveness of lumbar fusion and nonsurgical treatment for chronic low back pain in the Swedish Lumbar Spine Study: a multicenter, randomized, controlled trial from the Swedish Lumbar Spine Study Group.. Department of Orthopedic Surgery, Falun Hospital, Falun, Sweden.  Spine. 2004 Feb 15;29(4):421-34

[4]  James N. Weinstein, DO, MSc; Tor D. Tosteson, ScD; Jon D. Lurie, MD, MS; Anna N. A. Tosteson, ScD; Brett Hanscom, MS; Jonathan S. Skinner, PhD; William A. Abdu, MD, MS; Alan S. Hilibrand, MD; Scott D. Boden, MD; Richard A. Deyo, MD, MPH; JAMA. 2006;296:2441-2450.

[5] Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, December 1994

[6] Private communication, Nov. 28, 2006, Dec. 12, 2006.  

[7] Eugene Carragee, MD Surgical Treatment of Lumbar Disk Disorders; JAMA. 2006;296:2485-2487.

[8] Gina Kolata , NY Times, November 22, 2006; Surgery Need Is Questioned In Disk Injury

[9] Flum DR. Interpreting surgical trials with subjective outcomes: Avoiding unSPORTsmanlike conduct. JAMA 2006 Nov 22/29; 296:2483-5.

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