BMJ  2005;331:E372-E373 (13 August), doi:10.1136/bmj.331.7513.E372

BMJ USA: Commentary

Surgery for low back pain

¹ Tri-County Family Medicine Cohocton, NY University of Rochester School of Medicine and Dentistry Rochester, NY

A patient and primary care perspective

Like all primary care physicians who care for adults, I have a small group of chronic back pain patients in my practice who take up a disproportionate amount of my time and psychic energy. Frequently they have had multiple surgeries with no improvement or even a worsening of their condition. Most have had epidural steroid injections, physical therapy, acupuncture, or pain clinic referrals, and are on multiple medications. They are still miserable. For this reason, and also because I am an associate editor of BMJ USA, I read the articles in this issue by Fairbank (p 345) and Rivero-Arias (p 354) and the editorial by Koes (p 327) with interest. But the reason I read them with unusual care and thoroughness was that I was scheduled to have spinal surgery myself in two weeks, including laminectomy and lumbar fusion with pedicle screw fixation.

The Fairbank trial has some flaws, including recruitment problems, its pragmatic design, and patient crossovers, which are discussed both by the authors and in the Koes editorial. Nonetheless, it adds to the body of evidence reported by Deyo¹ in the United States that surgery—and specifically spinal fusion—is at best only marginally better than conservative therapy for chronic back pain. In addition, surgery is expensive and is associated with a significant risk of major complications.

With this experience and my knowledge of what can go wrong with spinal surgery, it is not surprising that I approached my upcoming surgery with great trepidation. I occasionally told friends I would rather have open heart surgery than back surgery because of more predictably good results. My trepidation was not assuaged by a well-meaning patient who told me of a relative of hers who had pedicle screw fixation, developed meningitis, and had been in a wheelchair ever since.

Importantly, however, my surgery was not being done solely for chronic pain. I had a combination of spondylolisthesis and spinal stenosis that was causing increasing weakness and numbness of my legs. This is a crucial distinction. The results of surgery and spinal fusion are much better when they are done to treat specific neurological deficits or spinal instability caused either by trauma or degenerative conditions. Conservative therapy is not likely to help in these situations.

I am happy to report three weeks post-surgery that I am feeling better. My numbness has decreased, I have no more severe muscle cramps, I have very little pain, and my strength is starting to increase. So far so good.

The message for primary care clinicians is that we need to assess our patients carefully. This includes a neurological examination evaluating gait, numbness, muscle weakness, and loss of reflexes. If the primary problem is pain, referral for surgery should be recommended only as a last resort. If the problem is a specific and objective neurological deficit, then imaging and possible surgical referral should be considered earlier in the patient's management.

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Editorial p 327

Papers p 345, p 354

Competing interests: None declared.

References

1. Deyo RA, Nachemson A, Mirza SK. Spinal-fusion surgery—the case for restraint. N Engl J Med 2004;350: 722-6.[Free Full Text]

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The challenge of low back pain

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bmj.com, 14 Aug 2005 [Full text]

Neurological deficits

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