The Truth About Back Surgery
Danger Ahead: The Diagnosis
Back surgeries can fail for a devastatingly simple reason: The operation was
not the right treatment, because the surgeon never pinpointed the source of the
pain. As a result, patients may be just as miserable as they were before — or
worse off — and a desperate number choose to try again. By two years after
their first surgery, about 8 percent of patients have had another operation; by
10 years after, the rate jumps to 20 percent, an analysis of Washington State
hospital data found.
That's why it's critical to have a thorough workup — to get a sense of the
root cause of your pain, says Arnold J. Weil, M.D., director of the
Non-Surgical Orthopaedic & Spine Center in Atlanta. X-rays and MRI scans
can be helpful, too — but only if your doctor has good reason to suspect a
particular problem. Go on a fishing expedition, and you could end up with the
wrong diagnosis — and ineffective treatment. That's because high-tech images
routinely uncover bulging discs and other scary-looking "abnormalities."
Trouble is, those often have nothing to do with what's hurting. "If you took
100 people off the street and gave them MRIs, a third of them — even if they
had no back pain whatsoever — would have obvious structural problems," says Dr.
Rosen. At best, your doctor might be misled by your abnormal X-ray or MRI, or
hope that the abnormality is the cause of your pain and that by fixing
it, he'll make you better. At worst, says Dr. Rosen, "the doctor knows full
well that the image could be a red herring, but the chance to 'fix' something,
and get paid for it, is just too good to pass up."
Surgery: Just Say "Not So Fast"
Here's the crux of the problem: We tend to think of back surgery as the Big
Fix — the treatment that will, if other approaches aren't successful, work.
Sometimes, in our desperation to get our lives back, it may seem like a good
idea to jump over those less invasive procedures and go right to the big one.
That's a good call in a few cases — where there's a risk of paralysis, for
example — but those types of emergencies are rare. Otherwise, "surgery offers
specific therapy for specific conditions," says Dr. Deyo. It should never be
seen as "worth trying" for pain. Such hope on the part of patients — too often
reinforced by surgeons — leads to operations that offer no relief.
Discectomies (removal of the herniated part of the disc) are the most common
back surgery. But spinal fusions (operations that involve joining the
surrounding vertebrae) have been rising — from just over 150,000 in 1993 to
350,754 in 2007. And so has the controversy over their use. Fusions that are
done for certain very specific conditions, such as spondylolisthesis (in which
one vertebra has slipped forward over the one below), can have success rates of
more than 80 percent. But that's not the usual case. When the surgery's done
for a "simple" degenerated disc, the results are far less happy. Fewer than
half of fusions are appropriate, experts estimate, and fewer than half are
successful, research confirms. And surgical fusions don't come cheap: The
average cost is about $75,000, not to mention months of rehab and weeks lost