Will Surgery Stop Your Back Pain? Upcoming Study Could Reveal
by Jim Ritter
Chicago Sun Times
Your back hurts like hell, and all the exercises, pills, injections and massages haven't done much good.
Should you go under the knife?
There has been an explosion of new surgical techniques to relieve back pain, from artificial spinal discs to an outpatient surgery that cooks the back.
The field "is very rapidly evolving," said orthopedic surgeon Dr. Frank Phillips of Rush University Medical Center.
Hundreds of thousands of Americans undergo back surgery each year, and the number is increasing as baby boomers age. But there's still no proof surgery works better than more conservative treatments or doing nothing at all, said Dr. Jim Weinstein of Dartmouth Medical School.
But now Weinstein is wrapping up a landmark $16 million study that should provide some badly needed evidence. About a dozen hospitals, including Rush, are participating. Patients who have had operations for the most common lower back problems are being compared with similar patients who are getting physical therapy, home exercises, anti-inflammatory drugs, etc. Results are due next spring.
Surgeons disagree about who should get back surgery. If you live in Terre Haute, Ind., you are six times more likely to get back surgery than if you live in Bend, Ore. And you're nearly twice as likely to get back surgery in Hinsdale as you are in Chicago, according to the Dartmouth Atlas of Health Care.
Between 15 percent and 20 percent of Americans suffer back pain each year, and 80 percent suffer back pain at some time in their lives. More than 100 million workdays are lost each year from back pain, according to the American Academy of Orthopaedic Surgeons.
Most people, of course, get better without surgery. For example, at least 90 percent of people with herniated discs will improve on their own in three months, said Dr. Sheila Dugan, a professor of physical medicine at Rush.
"The body does a really nice job of healing itself," Dugan said.
AN INEXACT SCIENCE
For those who don't get better, surgery can be an option. But back pain is extremely complex, and pinpointing its origin is tricky. A deteriorated disc, for example, can be painful in some people but cause little or no discomfort in others.
In the right patient, back surgery can work wonders. But determining who will benefit remains an inexact science. Fixing a bad disc, for example, won't do any good if the pain is coming from a different source, such as muscles or ligaments.
While surgical techniques have improved, "we haven't made as many strides in identifying patients who will benefit from all the technology we have," said Dr. Noam Stadlan of the Chicago Institute of Neurosurgery and Neuroresearch.
One of the most common surgeries for back and neck pain is a spinal fusion, in which two or more vertebrae are welded into one solid bone. There were 325,000 fusions in 2003, a 26 percent increase over 1999.
The surgeon typically removes bone fragments from the patient's hip and inserts them between the vertebrae. This leaves some patients with hip soreness for months or years. However, a new product called Infuse eliminates the need for harvesting hip bone. Infuse contains a protein that induces bone growth.
In another advance, surgeons increasingly are using minimally invasive techniques that reduce damage to back muscle, speed recovery and leave smaller scars.
And now, orthopedic companies are introducing a new generation of high-tech devices such as artificial discs and spine stabilizers.
The devices can be extremely profitable, and financial incentives might be affecting doctors' judgments, said spine surgeon Dr. Charles Rosen of the University of California at Irvine. Rosen said some surgeons receive consulting fees from manufacturers, or own stock in distributorships.
Rosen also worries that many patients put too much faith in high- tech surgery.
"A lot of people believe in 'Star Trek' medicine," he said. "There's probably a lot more [back surgery] than needs to be done."
MAKING MATTERS WORSE: SURGERY CAN CAUSE EVEN MORE PAIN
By various estimates, between 10 percent and 50 percent of back surgery patients experience only partial pain relief, or no relief at all.
Mary Sienkiewicz's three failed back operations provide a cautionary tale of what can go wrong.
Sienkiewicz, of Schererville, Ind., suffered a herniated disc in a 1986 car accident. In her first operation, her surgeon shaved away a disc that was pinching a nerve.
"I was a little bit better but still had constant pain," she said.
She tried physical therapy, acupuncture, weight training, pain relievers, a chiropractor and a spiritual healer, but her pain just got worse.
In 2000, Sienkiewicz underwent surgery to fuse vertebrae above and below two deteriorated discs.
"I woke up and felt like I had gotten run over by a Mack truck," she said. "It brought about a pain I never had before the surgery."
Her back was better, but now she suffered deep aches in her legs that never let up and robbed her of sleep.
She underwent a third surgery in 2003 to remove hardware from the fusion. It didn't help.
Sienkiewicz, 42, was sinking into depression last June when she enrolled in a clinic at the Rehabilitation Institute of Chicago that includes physical therapy, exercise, biofeedback and pain meds. The pain has gone down considerably, and she's cutting back on her pain pills.
Her physician, Dr. Steven Stanos, said he sees other patients who also have failed back surgery.
"The spine is a very complicated structure," Stanos said. "There can be three or four reasons why you have back pain, and surgery might only fix one or two."
BEND, BUT DON'T HURT
How spine stabilizer works: A device screwed to vertebrae stabilizes the spine while still allowing movement. One system, Dynesys, is on the market, with others in development.
The case for: Eliminates excess motion that causes back pain. Keeps vertebrae in a more natural position than spinal fusion. Because it allows some flexibility, the device does not increase pressure on other discs. "Results are as good or better than
fusion," said Dr. Richard Lim of Midwest Orthopedic Consultants.
The case against: Because the device is new, it's unknown how it will work in the long run. One worry is that the screws could come loose.
One patient's story: Before surgery last year at Advocate Christ Medical Center, Darlene Fasano suffered such excruciating pain that she couldn't work at her desk job, sit in a car for more than 20 minutes or do housework. Now, she can clean house and play with her granddaughter. She still has some pain, but it's greatly reduced.
REPLACED BY PLASTIC
How artificial disc works: Replaces painful degenerated disc. The first approved model, Charite, consists of a hard plastic disc that floats between two metal plates that are pressed into the vertebrae above and below. Other discs are under development.
The case for: Compared with spinal fusion, recovery from surgery is faster. Provides flexibility, so there's no pressure on discs above and below. Patients can move as much as 21 degrees while bending forward and backward.
The case against: It's not known whether artificial discs will wear out, like artificial knees and hips. Another risk is that the disc will pop out of position, requiring a spinal fusion.
One patient's story: Gregg Bochat, 40, had two discs replaced at the Chicago Institute of Neurosurgery and Neuroresearch. Before surgery nine months ago, he had suffered horrible back pain for years, and was losing feeling in his legs. Now Bochat has little pain. "So far, it's gone great," he said. "I don't know how well it will go in the future. That's the risk you take."
HEAT IT UP, SHAPE IT UP
How disc heat treatment works: A catheter heats the spinal disc for about 15 minutes with gradually increasing temperatures. The heat destroys painful nerve endings, and stiffens and stabilizes the disc. Known as intradiscal electrothermal therapy, or IDET.
The case for: Patient goes home the same day. Much cheaper than spinal fusion. About 75,000 procedures have been done since 1998 approval.
The case against: Some surgeons question whether the heat does what it claims to do. A 2005 study in the journal Spine found that patients who received IDET did no better than a similar group who got a placebo catheter that did not deliver heat.
A spokesman for the manufacturer, Smith and Nephew Endoscopy, responded that about 60 studies have been published, and "the vast majority are positive."
BACK PAIN BY THE NUMBERS
- Doctor visits in 2003 31.4 million.
- Percent of patients who were female 59
- Hospitalizations in 2003 1.2 million
- Spinal fusion surgeries, 1999 258,000
- Spinal fusions, 2003 325,000
- Percent increase 26
- Average age of spinal fusion patients 50 years
- Average spinal fusion cost $50,000
- Total cost of spinal fusions in 2003 $16 billion.
- Number of workdays lost each year 100 million-plus
SOURCE: American Academy of Orthopaedic Surgeons
HOW TO TREAT A BACKACHE
- Use pain relievers such as aspirin, ibuprofen (Advil) or naproxen (Aleve).
- For first 24 to 48 hours, apply cold packs for 10 to 20 minutes at a time. After a day or two, switch to heat.
- Lie flat on your back on firm mattress or floor. Use no pillow or single flat pillow under your head. A pillow under your knees might help. If lying on your side, put a pillow between your knees and one under your head. Don't lie on your stomach.
- If resting your back during the day, walk around for at least a few minutes every hour or two.
- A brace helps some types of pain.
- An osteopathic physician, chiropractor or physical therapist might be able to relieve pain temporarily by manipulating vertebrae to take pressure off nerves.
SOURCE: American Medical Association Family Medical Guide
BACK SURGERY RATES
Number of surgeries per 1,000 Medicare enrollees, 2001
Blue Island 3.7
Melrose Park 3.7
National average . . 4.5
Bend, Ore. 1.6
Terre Haute, Ind. 10.2
SOURCE: Dartmouth Atlas of Health Care
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