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Back pain: the dangers of surgery

MagazineDecember 1993 (Vol. 4 Issue 9)Back pain: the dangers of surgery

At some point in our lives, 80 per cent of all of us living in the West will suffer from disabling low back pain

At some point in our lives, 80 per cent of all of us living in the West will suffer from disabling low back pain. Every year, 12 million Americans make new-patient visits to their doctor for chronic low back problems and 100 million patient visits are made to chiropractors. Indeed, more work days are lost from low back pain than any other form of disability in the US and the UK, and the number of working days lost has doubled every decade, currently standing at 60 million in the UK alone. This places back pain squarely in the number one slot as the most common cause of disability after cardiovascular disease.

Low back pain has been called the 'Cinderella' of medicine and with good cause. In most cases, medicine itself has shown a shocking ineptitude in diagnosing and treating back problems, often tending to make the problem worse. This terrible batting average has led a Canadian government report, which studied the available evidence to date, to conclude: 'Many medical therapies are of questionable validity or are clearly inadequate.'

In a scathing article published in 1990 by the International Society for the Study of the Lumbar Spine, Professor Gordon Waddell, orthopaedic surgeon at Glasgow's Western Infirmary summed up this appalling track record: '. . . dramatic surgical successes, unfortunately, apply to only some 1 per cent of patients with low back disorders. Our failure is in the remaining 99 per cent of patients with simple backache, for whom, despite new investigations and all our treatments, the problem has become progressively worse.' (The Lumbar Spine, James Weinstein and Sam Wiesel, eds., WB Saunders Co, Philadelphia, 1990.)

For back patients who undergo surgery, 15 to 20 per cent will fall into the category of 'the failed back' - the official nomenclature for people with chronic, considerable back pain that doctors can't fix. Some 200,000 to 400,000 patients go under the knife in the US every year. That translates into 30,000 people who will emerge from back surgery every year in considerably more pain than they were before they went to their doctor.

A special WDDTY review of the current literature about back treatment reveals that medicine has three ways of making things worse: dangerous diagnostics; inappropriate, unproven treatment and surgery; and poorly studied regional anaesthesia, often, ironically, used to relieve the pain.

In the main, back pain treatments are faddish, adopted in a flurry of enthusiasm and soon discarded in favour of the next new possibility when evidence proves they don't work.
An editorial in the New England Journal of Medicine (3 October 1991) says that earlier in this century, sacroiliac joint disease was believed the culprit in many cases of back pain, leading to fusions (the joining of one vertebra to another) of sacroiliac joints.

This was followed by treatments including the removal of the coccyx, injections for herniated or slipped discs (in which the cushiony centre of the disc, which softens the shock of spinal movement, protrudes out of the fibrous outside), lengthy bedrest, traction and even transcutaneous electrical nerve stimulation. The latest fad to be discredited in that same issue of the journal is steroid injections in the facet joints (the cartilage covering of the bony junction of two vertebrae), showing that injecting steroids is no better than injecting saline.

General practitioners, back specialists and orthopaedic surgeons have demonstrated that many haven't a clue as to what exactly causes most back conditions. In a general review of low back pain (BMJ, 3 April 1993), Andrew Frank, consultant physician in rheumatology and rehabilitation at Northwick Park Hospital in Harrow, England, concluded: 'Up to 85 per cent of patients with low back pain cannot be given a definitive diagnosis because of the poor associations between symptoms, signs, imaging results and pathological findings.'

Consequently, many causes of disastrous residual pain are caused by inappropriate surgery. The most popular operations include: laminectomy, in which a disc and nearby bone are removed to give the nerve branching off the central spinal cord more space to move without getting trapped or compressed by the spine; and fusion, in which one vertebrae is surgically joined to another to minimize what has been diagnosed as too much movement between them. After the operation, this segment of the spine will be unable to move.

Henry La Rocca, clinical professor of orthopaedic surgery at Tulane University in New Orleans, examining six studies of back operations found that removing discs only relieved back pain in about half of all patients (The Lumbar Spine, as above). He quotes a study in 1980 of 105 cases of failed spinal surgery, primarily disc removal. In 68 per cent of the patients, they concluded, surgery wasn't indicated (Spine, 1980; 5: 87-94). Three out of four studies comparing operating with or without lumbar (lower back) spinal fusion surgery found no advantage for fusion and that complications, including chronic pain, were common (JAMA, 19 August 1992).

US orthopaedic surgeon Dr Charles Burton of the Institute for Low Back Care in Minneapolis, Minnesota, in analyzing failure of surgery on the spine over 10 years, quotes from a June 1981 interinstitutional orthopaedic and neurosurgical study of 'failed-back surgery syndrome'. In more than half of all such cases, the diagnosis missed or the surgery itself caused a condition called 'lateral spinal stenosis', or narrowing of a portion of the spine causing compression of the spinal cord or an abnormally tight fit.

Finally, postsurgical scarring ('epidural fibrosis') can itself cause failed surgery and chronic pain. La Rocca also found substantial evidence that surgeons cause nerve root injury as the nerve is being separated from herniated disc material, causing scarring and therefore long-term pain and pressure on the nerve. 'Damage to the dura or the cauda equina [membranes covering the spinal cord] from poor surgical technique yielding possibly catastrophic results completes the list,' he writes.

This is precisely what happened to Sarah of Woking. Her back problems developed after a hysterectomy, so she consented to further surgery on her spine. The delicate layers of the spinal cord (meninges) became inflamed, and then thickened. This thickened membrane now presses constantly on her spine, incapacitating her with unbearable pain.

At Gordon Waddell's clinic in Glasgow in Scotland, '60 per cent believe or have been told that they have a disc prolapse, although only 11 per cent show any evidence of nerve root involvement,' he says. Gordon Waddell and others conclude that if there is a specific problem correctly identified, such as a spinal deformity or fracture or disc herniation, then surgery can help, but not for simple relief of unspecified back pain (Spine, 1986; 11: 712-19).

Many hundreds of thousands of cases of chronic, debilitating back pain were - and still are - caused by myelograms used purely for diagnosis. This diagnostic tool involves the use a contrast medium or dye. This is injected into the canal space and trickles into and around all the discs and nerve roots in the back, which is then x-rayed. Mounting evidence shows that a good percentage of myelogram patients will develop a condition called arachnoiditis, causing permanent, unrelenting pain and rendering many virtually unable to move.

Arachnoiditis is a little-understood condition in which the middle membrane protecting the spinal cord becomes scarred. Nerves atrophy and become enmeshed in dense scar tissue, which presses constantly on the spine. Minneapolis' Dr Burton, one of the few medics to make a study of lumbar sacral adhesive arachnoiditis (LSAA), estimates that it accounts for 11 per cent of patients with 'failed back surgery syndrome'.

Although LSAA results from a number of different causes, in Dr Burton's view, it essentially reflects the introduction of foreign substances into the human subarachnoid space. Dr Burton says the foreign body most often identified in victims is iophendylate (known as Pantopaque in the US, Myodil in the UK), the oil-based dye used for myelograms. In LSAA, he says, iophendylate is often found in a cyst within the scar tissue mass. In his view, a million people worldwide suffer from arachnoiditis caused by this dye, and this view could be conservative. Until the 1980s, nearly half a million myelograms were being performed in the US every year.

Pantopaque was introduced in the US in 1944 after one study convinced the medical profession that it was safe. This was despite animal studies showing that Pantopaque caused arachnoiditis, says Burton (the Swedes banned the product from use in humans in 1948). Even though the product is no longer manufactured by Glaxo, since the onset of water-based dyes and imaging techniques, iophendylate continues to be used around the world, says Burton, and many back specialists continue to maintain that iophendylate is safe.

The US Food and Drug Administration and the British government have made no moves to ban oil-based myelograms. 'Despite the fact that iophendylate was identified as being causally related to the production of arachnoiditis from the time of its introduction, its use in the US has never been restricted by industry, government or the medical profession,' says Burton.
It has needed patients with myelogram-induced LSAA to bring legal suits against the manufacturers before anyone else took notice. In the UK the Arachnoiditis Society now has some 1000 members and a class-action suit is underway against Glaxo.

The water-based dyes now being used instead are not without risk. One woman being investigated for sciatic (back-caused leg) pain with iopamidol (Niopam 200), a water-soluble contrast medium, was immediately rendered paraplegic (The Lancet 27 July 1991), as was another middle-aged woman given a myelogram with iohexol (Omnipaque), another water-soluble dye (The Lancet 16 March 1991). Burton says that some new mediums have caused such pain that they had to be performed under general anaesthesia.

He concludes: 'The medical profession has not yet succeeded in finding a benign, effective myelographic medium.'

Lynne McTaggart


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