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How beneficial is surgery for cervical radiculopathy and myelopathy?

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3108 (Published 13 July 2010) Cite this as: BMJ 2010;341:c3108

Surgery and spondylosis : inappropriate partners.

Dear Sirs

The continued relentless pursuit for a surgical solution to a problem
whose
pathology we understand so little is frustratingly disappointing. “Primum
non
nocere” is an admirable ethical standard which I had thought universally
drove
decision making in clinical practice, yet we still appear besotted with
the
concept that surgery is the answer to back pain.

Ioannis P Fouyas & colleagues, in their carefully reasoned
article last week
(BMJ 2010;341:c3108), admit the paucity of evidence to justify surgery as
a
therapeutic option for cervical spondylosis even in the presence of
neurological dysfunction. This failure is all the more notable when it is
appreciated that any thought of long term follow up is confined to 5
years,
spinal pain sufferers commonly living through their predicament for 5 or
ten
times this. Others elsewhere more culpably attempt to seek justification
even
without this deficit. The mistake that both make is to assume a direct
relationship between symptoms and structural deviation, as demonstrated by

such investigations as MRI scanning. The truth is that many, perhaps all
when
age for age comparisons are made, human individuals have such changes
which often are either associated with insignificant or accepted symptoms.

Surgery produces irreversible change even in the absence of unwanted
and
unexpected effects. It hungrily consumes health care resources. More than
that, it promulgates and reinforces the widely accepted concept that a
medical model is the most efficient when managing chronic disease. This
philosophy constitutes a major obstacle to the reform of health care if
not
universally, certainly in the western world.

Initial aggressive analgesia, closely followed by paced, functional
restoration
of activity and task completion, whilst addressing the relevant
psychosocial
factors relevant to that individual, is a pattern of care not only matched
by a
degree of logic, attended by a low risk profile but probably more
efficient in
its consumption of health care resource.

Yours faithfully

Mark J Turtle

Consultant Anaesthetist and Pain Management Specialist, West Wales General

Hospital, Carmarthen SA31 2AF

Mark.turtle@talk21.com

Competing interests:
None declared

Competing interests: No competing interests

27 July 2010
Mark J Turtle
Consultant Anaesthetist and Pain Management Specialist
West Wales General Hospital Carmarthen SA31 2AF