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So you think you need back surgery

About the author: 
Lynne Mctaggart Lynne McTaggart

Before you consent to going under the knife for your back problems, check out the evidence on the latest procedures, says Lynne McTaggart

At some point in our lives, 80 per cent of all of us living in the West will suffer from disabling lower back pain. In fact, every year, 13 million people in the US alone will go to the doctor about their back, making back pain the second most common reason people seek medical care and the most common cause of disability after cardiovascular disease.

Nevertheless, low-back pain has been called the ‘Cinderella’ of medicine—with good cause. In most cases, medicine itself has shown a shocking ineptitude in diagnosing and treating back problems, often simply making the problem worse. Although medicine tends to be circumspect about treatments that don’t work, some back pain specialists are so appalled by this terrible batting average that they’re not shy about speaking up.

Professor Gordon Waddell, a renowned Scottish orthopaedic and author of The Back Pain Revolution (Churchill Livingston, 1999), doesn’t like to mince words. “Back surgery,” he once remarked, “has been accused of leaving more tragic human wreckage in its wake than any other operation in history.”

As he noted decades ago, “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.”1

The latest evidence shows that this batting average hasn’t improved.

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 500,000 patients go under the knife in the US every year. That translates into up to 100,000 people who will emerge from back surgery every year in considerably more pain than they were before they went to their doctor.

Back-pain treatments follow fads relating to theories about the cause of the pain. In the early part of the 20th century, sacroiliac joint disease was believed to be the culprit in many cases of back pain, leading to fusions (joining one vertebra to another) of the sacroiliac joints.

This was followed by treatments including removal of the coccyx, injections for herniated or slipped discs (where the soft centre of the disc that cushions the shock of spinal movement protrudes from its fibrous outer covering), lengthy bed rest, traction, steroid injections into facet joints (the small stabilizing joints between and behind adjacent vertebrae) and even transcutaneous electrical nerve stimulation (TENS), a type of pain relief involving a mild electrical current.

The latest and greatest

The most popular operations now include: some form of laminectomy, where nearby bone and/or ligaments are removed to give the nerve branching off the central spinal cord more space to move without getting trapped by the spine; discectomy, removing all or part of a bulging or ‘slipped’ disc, the cushion separating each vertebra from another, that presses spinal nerve, causing back pain; disc replacement, where the disc is replaced by an artificial implant made of metal and plastic; and fusion, where a degenerated disc is removed and the vertebrae above and below it are joined together, leaving that segment of the spine locked in position.

Recent major reviews of all the evidence for the various kinds of surgery for back pain show that, like their predecessors, all these latest operations offer minimal advantages over doing nothing or undergoing rehabilitation.

How well does fusion work?

Actually, it usually makes things worse. In a 2010 study, researchers studied the records for 1,450 patients in the Ohio Bureau of Workers’ Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, where a nerve is pinched or irritated, causing tingling and weakness of the limbs.

Two years after surgery, only 26 per cent of those who’d had surgery had returned to work, compared with 67 per cent of patients who did not have surgery.

Of the patients who’d had fusion surgery, 36 per cent had complications, 27 per cent required another operation, 11 per cent were permanently disabled (compared with only 2 per cent of patients not having surgery) and 17 had died (compared with 11 of the controls).

In fact, after surgery, the researchers discovered a 41 per cent increase in the use of painkillers like morphine, while some three-quarters of patients continue taking opiates after surgery. “Lumbar fusion . . . is associated with significant increase in disability,” the researchers declared.2

Although many patients show success on X-rays after fusion, about a sixth of patients have a “sub-optimal outcome”.3 In another study, only 40 per cent of 151 patients achieved either a good or excellent result, and those who underwent a second operation had poor outcomes.4

When two independent reviewers surveyed all the available evidence on all major procedures, those patients with low back pain and common degenerative changes who’d undergone fusion fared no better than those who had intensive rehabilitation, with less than half having optimal outcomes.

As for patients with disc problems and spinal stenosis (narrowing of the spaces in the spine, causing pressure on the spinal cord and nerves), patients on average experience improvement either with or without surgery. As one study comparing fusion with intensive rehabilitation concluded, surgery only provides “short-term benefits” which “diminish with long-term follow-up”.5

How about surgery for a slipped disk

The jury’s out. One Cochrane review of major studies involving surgical removal of all or part of a vertebral disc found a slight advantage with disc removal in patients with sciatic nerve pain, “although any positive or negative effects on the lifetime natural history of the underlying disc disease are unclear,” it concluded. Furthermore, despite some trials providing only limited information on complications, a number of patients suffered a recurrence of symptoms and a need for additional surgery.6

How well does disk replacement work?

No better than fusion. In another Cochrane review of seven studies comparing fusion with disc replacement in a total of 1,474 patients, those getting their discs replaced had slightly better outcomes than those being fused, but the differences weren’t significant.

As the researchers cautioned, “because we believe that harm and complications may occur after years, we believe that the spine surgery community should be prudent about adopting this technology on a large scale”.7

What about laminectomy?

No good evidence here either. Back surgeons have a large palette of laminectomy techniques, such as removing the entire vertebral arch where the central aperture has narrowed around a nerve, or taking away less bone to minimize damage to back muscles and ligaments. But when another group of Cochrane researchers compared three new surgical techniques with the ‘gold-standard’ laminectomy, they found no differences between any of them, not to mention such poor study designs that they could not determine surgical outcomes in many instances.8

The Cochrane Database dealt back surgery a final hammer blow with a recent review of randomized controlled trials comparing surgery for spinal stenosis with non-surgical management. Although the studies were high quality, the researchers could find little benefit with surgery and, instead, found evidence of side-effects in 10–24 per cent of cases compared with none when patients were managed conservatively.

Side-effects included spinal fractures, coronary ischaemia (narrowed heart blood vessels), respiratory distress, blood clots, stroke and death due to fluid accumulation in the lungs.9

What to do instead

If you work at a desk, get a standing desk, sit on a Swiss ball or use a kneeling chair, preferably a rocker. One of the major causes of back pain has nothing to do with the spine, but an imbalance between muscles in the back and legs, often caused by hours of sitting at a desk. With its reduced base of support, a Swiss ball moves beneath you, requiring you to activate your balance and postural muscles to stay upright.

Look into rehabilitative systems like Egoscue therapy. This San Diego-based exercise therapy, based on the work of Peter Egoscue, is specifically designed to correct the postural issues that lead to pain, and has many testimonials of success. Similarly, the Alexander Technique, which teaches awareness of body movement and posture, is highly effective, particularly when combined with exercise.10

Keep moving. When researchers at the Nuffield Orthopaedic Centre in Oxford compared fusion surgery and gentle exercise (including individually tailored daily exercises) such as stretching, muscle strengthening and aerobic exercises like treadmill-walking, step-ups, cycling and rowing, plus hydrotherapy treatment every day, patients fared just as well as those having surgery.11 Other reviews have confirmed the effectiveness of exercise,12 particularly a programme individually designed and monitored by a professional.13

Get needled. Acupuncture has proved so successful in relieving lower back pain that it’s now listed in the guidelines of the UK’s National Institute for Health and Clinical Excellence (NICE).14

Try massage. Combined with exercise, massage can offer lasting benefits for back pain.15

Take up yoga or Pilates. Yoga classes twice a week can help improve function and lower back pain and the need for drugs, as can regular classes in Pilates.16

Consider prolotherapy. This treatment involves injecting growth-enhancing agents into specific tendons, ligaments, muscles and joints to stimulate the body’s own self-healing mechanisms. In one study, 30 out of 39 patients reported at least a 50 per cent improvement in pain and disability compared with 21 of the 40 controls receiving lidocaine.17

Get hydrated. When you sit in a chair for hours each day, the spine doesn’t move enough to recycle the fluid that keeps the discs lubricated. Drink water throughout the day.

Take supplements. In one trial, vitamin D eased back pain symptoms in virtually all of those with low levels of the sunshine vitamin.18

Consider working with a fully trained, qualified and experienced chiropractor, osteopath or physiotherapist first. Spinal manipulation can provide better “long-term functional improvement, and more pain relief than either back school or individual physiotherapy”.19 The Manga Report, compiled by Professor Pran Manga, former director-general of the Health and Social Policy Directorate of the Canadian government, offers an analysis of all the published evidence worldwide. One of the report’s conclusions is that “spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for [low-back pain].”20


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References

References

1

Weinstein JN, Wiesel SW, eds. The Lumbar Spine. Philadelphia, PA: WB Saunders Co, 1990

2

Spine [Phila Pa 1976], 2011; 36: 320–31

3

Internet Journal of Spine Surgery, 2004; 1; http://ispub.com/IJSS/1/2/10105

4

Eur Spine J, 1994; 3: 225–30

5

Spine [Phila Pa 1976], 2009; 34: 1094–109

6

Cochrane Database Syst Rev, 2007; 2: CD001350

7

Cochrane Database Syst Rev, 2012; 9: CD008326

8

Cochrane Database Syst Rev, 2015; 3: CD010036

9

Cochrane Database Syst Rev, 2016; 1: CD010264

10

Br J Sports Med, 2008; 42: 965–8

11

Spine J, 2013; 13: 1438–48

12

Joint Bone Spine, 2008; 75: 533–9

13

Ann Intern Med, 2005; 142: 776–85

14

Ann R Coll Surg Engl, 2010; 92: 595–8

15

Spine [Phila Pa 1976], 2009; 34: 1669–84

16

Spine [Phila Pa 1976], 2009; 34: 2066–76; J Bodyw Mov Ther, 2008; 12: 364–70

17

J Spinal Disord, 1993; 6: 23–33

18

Spine [Phila Pa 1976], 2003; 28: 177–9

19

Clin Rehabil, 2010; 24: 26–36

20

The Manga Report (1993); www.chiro.org/LINKS/GUIDELINES/Manga_93.shtml

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