Back Surgery — Who Needs It?
Richard A. Deyo, M.D., M.P.H.
Back surgery is not the final common pathway for everyone with persistent back pain. It offers specific therapy for specific anatomical derangements associated with specific complexes of symptoms. When surgery ranges beyond carefully defined situations, we can expect disappointed patients.
Two articles in this issue of the Journal (text deleted) — bolsters the case that surgery is effective for patients with sciatica owing to herniated disks. Investigators studied patients with sciatica who had not had sufficient improvement after 6 to 12 weeks of nonsurgical treatment. Excluding patients with briefer episodes was important, because even without surgery, sciatica improves within 3 months in 75% of patients.
Even among patients with persistent sciatica, recovery was likely whether or not surgery was performed. Studies involving repeated imaging show that most herniated disks shrink over time. But surgery accelerates the pace of recovery, and for some patients, faster recovery may be worth the risks.
After a year, recovery was about the same with surgery as with nonsurgical care, though almost 40% of patients who were initially assigned to the nonsurgical group later underwent surgery. A similar convergence of results after 2 to 4 years was apparent in earlier randomized, controlled trials. Thus, for patients with persistent sciatica, there seems to be a reasonable choice between surgical and nonsurgical treatment, which may be influenced by aversion to surgical risks, the severity of symptoms, and willingness to wait for spontaneous healing.
Patients in this spondylolisthesis trial tended to have improvement with nonsurgical therapy but to a smaller degree than the authors observed in their previous trial of surgery for herniated disks. Previous studies of nonsurgical treatment for spinal stenosis similarly suggest a low rate of improvement, in contrast to studies in patients with herniated disks. The less favorable prognosis of spinal stenosis may be an important factor for patients considering surgery.
In the two trials presented here, both back pain and leg pain were ameliorated by surgery, but leg pain resolved more quickly and fully than back pain. Thus, benefits are likely to be greatest for nerve-root–associated symptoms.
Degenerative spondylolisthesis with stenosis is primarily a condition of older adults rather than of younger patients, who typically have herniated disks with sciatica. In addition, fusion surgery is more invasive than diskectomy, with a higher complication rate. Surgical complication rates increase substantially after 80 years of age, which changes the risk–benefit equation — a problem that has yet to be addressed directly by researchers.
So who needs back surgery? The consensus seems to be that patients who were excluded from these trials because of major motor deficits need surgery, as do some with major spine trauma. For these patients, surgery may preserve life or function. Absent major neurologic deficits, patients with herniated disks, degenerative spondylolisthesis, or spinal stenosis do not need surgery, but the appropriate surgical procedures may provide valuable pain relief. In such situations, decisions should be made jointly by well-informed patients and their physicians.