The recent shooting of a spinal surgeon in Tulsa has highlighted the urgent need for more effective solutions for those suffering from low back pain. This terrible incident has also placed a spotlight on the immense feelings of desperation that many chronic low back pain patients often experience.
Low back pain affects around 80% of the population at some point in their lives and it is one of the leading causes of disability and lost work days. It is also known to cause depression and anxiety in sufferers as they feel increasingly isolated from society and because the pain prevents them from going about their daily lives.
It is not surprising that something as dramatic as surgery is often considered for low back pain sufferers. While there are many different treatments aimed at alleviating pain and rehabilitating the muscles, many of these treatments are ineffective and have no data to support their use in treating this condition.
Spine surgeries, like lumbar fusions and herniated disc surgeries, have long been considered as a last resort for many patients but more recently, studies from western countries are reporting a rapid increase in spinal surgery rates over the past 15 years or so, and this increase exceeds the growing incidence rates of spinal disorders.
Does Spine Surgery Work?
Spinal surgery is a controversial topic and rates of surgeries differ vastly among different counties. Norway has seen a dramatic increase in spinal surgery rates while other countries in Europe are trying their best to discourage the number of spinal surgeries performed. Typically, most cases of low back pain will resolve on their own within a few weeks, or months, but not everyone wants to wait and see what happens.
Unfortunately, the data around the effectiveness of spinal surgery is somewhat inconsistent. Most studies put the efficacy rates at around 50% but some studies have shown more promising results, while still others have shown less promising outcomes. Most success rates depend on a wide range of factors such as current health conditions, age, gender, and even levels of anxiety.
A report from Johns Hopkins Medicine actually suggests that fewer than 5 percent of people with back pain are actually good candidates for surgery. Surgery is generally the most successful in those who have more structural-based problems or disease.
Spinal Surgery - Better or Worse Outcomes Than PT?
In his recent Op Ed, published in MedPage Today (May 23, 2022) Vijay Yanamadala, MD, MBA wrote:
“... various clinical trials have shown that most spinal fusions do not lead to improved outcomes for patients over the long term. In many cases, surgery actually leads to worse outcomes than no surgery at all”.
In 2005, researchers Fairbank et al published the results of a randomized control trial involving 349 participants who were considered candidates for spinal fusion by an experienced surgeon. The clinicians found that the statistical difference between treatment groups in one of the two primary outcomes measures was marginal.
Another landmark study that looked at medical treatments, like surgeries, found that most board-certified doctors (almost 65% of those surveyed) believe that between 15-30% of medical care is actually unnecessary. Surgeries not only drive up medical costs overall, but the consequences can be devastating and include outcomes like post-surgical pain, injuries, and even mortality.
“Failed Back” - What Does That Even Mean?
In his book, ‘Low Back Disorders, Evidence Based Prevention And Rehabilitation’ Stuart McGill, PhD. writes about the concept of “failed backs”
“In practice I see the people who are worse off because of surgery. Surgeons refer to them as failed backs. …I strongly suspect that many had the surgery too soon. They thought they had exhausted conservative approaches, but a review of their files revealed that they had received inappropriate treatment. The therapeutic exercises prescribed to them were not matched to their specific pain mechanisms and caused more pain. They were not shown the specific causes of their pain, so they failed in preventing pain. …
Fusion is intended to stop motion and stop pain whereas replacement is intended to restore motion and stop pain. Justifiable guidance for patient selection remains lacking. Note that there were still failures resulting from both approaches”.
What Can Help With Low Back Pain?
For many who go on to try some of the thousands of products or solutions on the market it might seem as if nothing will ever work. It is easy to feel that you are doomed to a life of despair and disability and that surgery is your only option. Consider this? Perhaps those treatments weren’t the right fit for you? Maybe we are too quick to force a “one size fits all” approach to people struggling with this condition. What if we took a more personalized approach to care and spent time really listening to clients and asking them questions about how this all started?
There are several essays in medical literature that claim that patients are just making a big deal about nothing. That the pain is all in their minds. Well, this might be a little bit true but not in the way that they mean (look at our article on ‘Chronic Pain - Is It All In Your Head?’). There is definitely a psychological component to chronic pain that needs to be addressed but when doctors are only able to spend 3-4 minutes with a patient during a consult there is no way of getting to really understand what might be triggering the condition without asking detailed and in-depth questions.
A Better Alternative To Spinal Surgery
When healthcare professionals are able to spend time with their clients and fully understand the specific causes of their condition, only then can the healing begin. Treatment must ensure that the exacerbator is not replicated in therapy as this will lead to symptom magnification. This is what causes the pain to be increased - not just psychological concerns - although fear avoidance should also be addressed with some individuals. When treatment tries to restore function too quickly, without correcting the movement fault, treatment can fail and the client will want to give up.
Physical Therapy For Chronic Low Back Pain
Early on in the treatment conversation, healthcare providers should be advising their clients about the positive effects of physical therapy. Dr Yanamadala writes that ‘one of the most reliable and effective interventions is physical therapy. PT-based rehab frequently leads to better outcomes using fewer resources for patients with MSK pain when compared to operative procedures’.
Dr Yanamadala goes on to say that, ‘PT should be part of the conversation early on, and surgery should be positioned as a last resort, with the patient well aware of surgery’s risks and complications’.
McGill’s Rules For Patients Considering Low Back Surgery:
1. Consider surgery if there are neurological issues involved.
2. Consider surgery if there has been trauma and the structure of the spine is unstable and requires stabilization.
3. Consider surgery if the pain is unrelenting and has been severe for a substantial period of time. (McGill write that some patients have had surgery after suffering for just a few weeks and that these have been some of the most disabled postsurgical cases that he has seen.)
4. Discuss your pain with your surgeon. What is causing the pain? Can she/he cut it out? The more tissues that are involved - the lower your chances are of a successful procedure.
5. Clarify The Success Rate. The word success can mean different things to different people. In some cases success means that the patient did well for a brief period following the operation. For others it means that the patient did not die. It is vital to have this discussion with your surgeon and to be very clear about what your outcomes might be. You need to know what the long-term success rates are compared to any other treatment option, as well as what the risks and benefits of the operation will be.
Surgery is never something to be taken lightly, and low back surgery is no exception. Although the risks are relatively low and new techniques mean that many surgeons use minimally invasive techniques, patients can still end up experiencing complications such as blood clots, excessive bleeding, infections, or nerve and muscle damage. Even if everything goes perfectly there is no guarantee that the pain won’t pop up again at a later stage.
If you are considering low back surgery it is important to take a good amount of time to think things over, see if your back can get better on its own. See if non-invasive therapies like physical therapy and MBSR can help bring some relief. Most importantly, find a healthcare professional who will spend time listening to you and learning about how you got to where you are now. What type of activities or situations cause flare ups. A truly personalized approach to care could make all the difference and save you a lot of money and a lifetime of pain.