Feb. 25, 2005 -- Surgery for back pain is not the cure-all that many patients believe it to be, say orthopaedic experts.
Many patients who seek surgery for chronic back pain have other health problems, and failing to take them into account limits the usefulness of back surgery, they say. And the more problems they have, the less they benefit.
Back pain patients free of such problems benefit more but still remain far from normal one year after an operation, according to a study.
Researchers performed snapshot evaluations of more than 3,400 patients before and after back surgery. They presented their results at the annual meeting of the American Academy of Orthopaedic Surgeons in Washington, D.C.
James Slover, MD, and colleagues from Dartmouth Medical College found that factors such as a low education level, depression, smoking, frequent headaches, and a workers' compensation claim had a profound impact on patients' functional abilities. These were far more powerful than the influences of medical illnesses such heart disease or rheumatoid arthritis.
Psychology Plays Huge Role
Patients and doctors should be aware that such common psychological and social factors play a "huge role" in how patients fare before and after back surgery, notes co-author William A. Abdu, MD.
"Patients, doctors, and others who take care of patients need to understand that," says Abdu, associate professor and director of the Spine Center at Dartmouth Medical College in Hanover, N.H.
For those with multiple health problems, the new research shows, the outlook is not very good. "It's like Humpty Dumpty," he says. "You just can't put them back together again."
Although patients with no other health problems did better, back surgery failed to provide even those patients with complete relief of symptoms or normal function.
Treat the Whole Person
Should spine specialists portray back surgery as a procedure that generally delivers patients from pain and disability?
"Spine patients are nowhere near normal when they walk in the door," says Abdu. Their spinal condition and other problems are so burdensome that they don't function well. After back surgery, people don't return to normal and still have the psychological and social problems they had before back surgery, he says.
"The tone of this study is quite clear," says Nortin M. Hadler, MD, professor of medicine at the University of North Carolina and author of Last Well Person: How to Stay Well Despite the Healthcare System.
"We've got a real problem," Hadler says. "If surgeons are not careful about selecting patients who are free of all these [other illnesses], they're not going to help many people. I'm not sure there is a surgical solution to back pain. I am sure there's no surgical solution for any suffering that enshrouds the pain." Hadler was not involved in the study.
Other observers agree.
"Back pain is not a thing you can surgically cut out or pharmacologically kill. It's flavored by cognitive and social factors," notes Stanley A. Herring, MD, clinical professor and medical director of the Spine Center at the University of Washington in Seattle.
"You don't want medicine to be like the butcher chart, where you're just talking about one particular cut of meat. Medicine is about the whole person," says Michael Von Korff, ScD, a researcher with Group Health Cooperative in Seattle.
In a survey published in the February issue of the journal Pain, Von Korff and colleagues found that nearly nine out of 10 people with chronic back pain reported at least one chronic pain condition, chronic physical ailment, mental disorder, or substance abuse problem.
"There's the risk of focusing too much on the one particular anatomical problem when what influences quality of life is what's going on with the whole person," he explains.
One goal of this research is to give patients information so that they can make treatment decisions that fit their own values and preferences. Without this knowledge, "Patients may have inappropriate expectations of their treatment choices," say Abdu and colleagues. Co-researcher James N. Weinstein, DO, addressed this issue in a recent commentary in the journal Spine.
Unfortunately, most spine surgeons are either unaware of the importance of these psychological and social risk factors or for a variety of reasons don't employ methods to detect them in their patients, says Herring. "Some of this is due to a lack of understanding. Some of it is lack of a plan and resources to interpret the information. And some of it is time, which they don't have much of," he explains.
Fewer Problems, Better Results
The study's participants were selected from among 34,000 surgical patients treated at 26 centers in the National Spine Network, a U.S. research consortium of spine care providers. Each patient filled out several questionnaires before back surgery and then again one year later. Some of the questions helped to create a profile of emotional, psychological, and social characteristics. Others painted a picture of the patient's physical abilities and limitations.
The results raise another question. If the benefits of back surgery are so modest in so many, are there some candidates -- or many -- who simply should not undergo back surgery?
"I think the conclusion is that expectations need to be reasonable," says Dartmouth's Abdu. "We can't make these people normal -- that is, healthy with full function -- and we shouldn't think we can."
For the person with long-suffering chronic pain, he says surgery is a poor bet. "We're not going to cure back pain by operating on 40-year-old people with 20 years of back pain," he explained. "We can't cure them by operating on them."
If a spine surgeon doesn't ask you about your family, your work, and other aspects of your life, "seek a second opinion," advises Herring.