Surgery for Low Back Pain

EFFECTIVENESS: 2/5

Generally, the “gold standard” for scientific studies comparing different treatments, such as surgery, is to do a comparison of the treatment under study versus a “placebo” or fake treatment to see if there is a difference in outcomes. This is of course extremely difficult to do with surgery. There are serious ethical problems with doing a “fake” surgery to someone to see if it actually works. Surgery is therefore usually compared to other treatments, such as therapy, medication or other commonly used treatment approaches for low back pain.

Unfortunately, carefully done studies comparing various types of surgeries have not shown significant benefit from surgery. As one important review noted:

“Surgeons and others believe that surgery is effective for back pain. They base this belief either on their own experience or on observational studies. This belief is, by and large, not vindicated by the outcomes in well-reported clinical trials. Those trials indicate that only a small proportion of patients do well from surgery. If surgeons achieve better outcomes than those reported in the controlled trial literature, the community would benefit from the publication of those outcomes. In the absence of contradicting evidence, the benefits of surgery must be regarded as small. Because improvements from surgery are small and because not all patients benefit, it becomes critically important to carefully select patients in whom fusion surgery is performed for chronic back pain. Furthermore, it is important that patients have a clear understanding of the procedure and its potential results and complications so that they can participate in the decision.”

Source:

Nikolai Bogdukand Gunnar Andersson, Is spinal surgery effective for back pain? F1000 Med Rep. 2009; 1: 60. Published online 2009 Jul 27. doi:  10.3410/M1-60

A 2010 study looked at patients 4 years after either fusion surgery or psychological treatment and exercise and found no significant differences between the two groups.

Source:

Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Jens Ivar Brox,Øystein P Nygaard, Inger Holm, Anne Keller, Tor Ingebrigtsen, Olav Reikerås. Ann Rheum Dis 2010;69:1643–1648

The number of low back surgeries is increasing significantly, but there does not appear to be a corresponding reduction in disability or the incidence of low back pain. Still, for many patients, surgery may seem the only remaining option.

SELF CARE: 0/5

Back surgery is performed by medical doctors and osteopathic doctors who are board certified in either orthopedic surgery or neurological surgery. There are no self-care options.

COST: 1/5

Getting accurate cost estimates on low back surgery is extremely difficult due to many factors: type of surgery, complexity, complications and where the surgery is performed, as the same procedure will vary significantly depending on the area of the country where it is performed. In addition, the amount charged for the various components of the surgery  (hardware, surgeon fees, anesthesia fees, etc.) are often dramatically different than the reimbursement actually made by insurance carriers. Fees between $50,000 and $250,000 are not uncommon and may not include associated costs such as lost work time, disability payments, post-and pre-operative rehabilitation, medication and much more.

Few would argue that spinal surgery of whatever type is an expensive proposition.

USEFULNESS (overall rating): 3/5

Who provides this treatment?

• Medical doctors (MD) – surgeon
• Osteopathic doctors (DO) – surgeon
• Usually done by Board Certified orthopedic or neurosurgical surgeon with extensive experience; look for someone Fellowship trained in spine surgery

Except in rare emergency cases, low back surgery is the last thing you try when all else fails. For that reason, it has higher risks, much higher costs and may not always be successful. However, for patients with severe pain or neurological problems like weakness that are getting worse, it can be a Godsend. Patients should be carefully selected and have tried or at least considered all conservative options before proceeding with surgery.