The
words “low back pain” are all too familiar to between 70-80% of
Americans1. Often times this pain comes on without
warning when getting out of bed, turning the wrong way or
incorrectly lifting a heavy weight. However, there are still many
cases when an individual cannot recall involvement in any activity
which could have resulted in injury. Nevertheless, a MRI taken of
the spine of this individual will display what is known as a
herniated disc. Of these people, 2-10% will require surgery, most
receiving discectomies2. However, when >200,000 Americans
are receiving discectomies, we must consider the personal and
economical costs that will follow.
There are many advantages to the advances in medical technology in
which the U.S has to offer, but are we over utilizing and over
spending because of it? In this literature review we will explore
the pros and cons of surgical vs. non-surgical treatment of low back
pain (LBP) of various origins.
Low back pain can be due to a herniated disc, osteoarthritis (joint
degeneration), spondylolysis (vertebrae defect), spinal stenosis
(narrowing of the spinal canal), as well as many other diagnoses.
But what are the costs? Consideration must not only be given to the
costs of the operation, but the cost spent for the patient to take
off work, attend physical therapy before and after surgery and the
possibility of having a re-operation should the surgery fail.
Currently, the re-operation rate for a discectomy is 17-20%2.
Fusion is another surgical approach that doesn’t prove to have any
more success with an average success rate of 68%2, yet
this varies from study to study from 16-95%2. The bottom
line with cost is that LBP has shown to be the most expensive benign
condition in the U.S1. Therefore, patients need to
analyze all the benefits and risks associated with different
surgical options:
• Discectomy14 - removal of herniated disc
material that presses on a nerve root or the spinal cord.
– also used for bulging discs or ruptured discs.
– most effective type of surgery if failed nonsurgical treatment or
have severe, disabling pain.
• Laminotomy and laminectomy14 - relieves
pressure on the spinal cord and/or spinal nerve roots caused by
age-related changes in the spine.
– Laminotomy removes a portion of and
– Laminectomy removes all of the lamina on selected vertebrae and
also may remove thickened tissue that is narrowing the spinal canal.
• Percutaneous discectomy14
– A special tool is inserted through a small incision in the back
– Disc material is removed or destroyed to reduce pressure on the
nerve root.
– Percutaneous discectomy is considered less effective than open
discectomy3.
• Instrumented Posterior Lumbar Fusion14
– a posterior approach to stabilize the vertebrae
– metal screws and rods (hardware) hold the vertebrae
– in place intended to stop movement from occurring between the
vertebrae, give more stability to the fusion site and allow the
patient to be out of bed much sooner
Newer Method:
• Microendoscopic Discectomy(MED)
– METRx (Medtronic Sofamor Danek, Inc.) allows surgeons to address
contained and sequestered fragments and lateral recess stenosis,
with a minimally invasive approach (1/4 inch incision, using a
camera to see the disc, surgeon performs it by watching the TVscreen)
On average, nearly 50% of patients with LBP from herniated discs
will recover within 1 month, most will recover in 6 months5, yet 10%
with significant pain remaining after 6 weeks will consider one of
the above surgical options6. So, what does research tell
us about these surgeries vs. traditional/non-surgical rehab?
In 1999, Donceel et al10. published their research on
Return to work after surgery for lumbar disc herniation and found,
of 710 patients randomly selected for either surgical of
non-surgical treatment for a herniated lumbar disc, at 52 weeks only
10.1% of surgical patients had not returned to work vs. 18.1% of non
surgical patients.
Four years later, Ivar et al.13 brought us a study on
lumbar fusion vs. physical therapy for treatment of chronic LBP and
disc degeneration. Sixty-four patients aged 25-60yo were recruited
from Norway between 1997-2000, with LBP >1 year and evidence of
L4/L5 and L5/S1 disc degeneration, were randomized to fusion and
post-op physiotherapy (37 patients), or cognitive intervention
(lecture about safety and use of back) and exercise (3 daily
exercise sessions for 3 weeks). Results at 1 year indicated that
pain and disability was significantly reduced after fusion compared
to the control group, however, RTW, use of analgesics, emotional
distress and life satisfaction were not different.
In 2005, Filiz et al1. presented his findings on The
effectiveness of exercise programmes after lumbar disc surgery: a
randomized controlled study where they compared intensive, classical
and control group exercise programs and return to work (RTW) or
daily activities (if not employed). The intensive group was educated
and supervised in progressional dynamic stabilization exercises, the
classical group performed McKenzie and Williams exercises, and the
control group was told to be “as active as possible” in their daily
activities. Results indicated that RTW or daily activities were
significantly shorter (56 days) in the intensive group compared to
all the others, and the classical (75 days) was significantly
shorter than the control (86 days).
That same year, Atlas et al11 reported outcomes from a
1990-‘92 study of 507 patients comparing functional outcome measures
10yrs after patients received either a lumbar discectomy or
non-surgical treatment for LBP. Results indicated that patients’
predominant symptom (low back or leg pain) was either “much better”
or “completely gone” in 56% of surgical patients vs. 40% of
non-surgical. Satisfaction rate was also greater in the surgical
group, 70.5% vs. 55.5%. Yet disability and work status were similar
across groups, and as time passed (up to 10 years) non surgical
patients were functioning better than surgical patients with the
opposite seen early post-op, as indicated above.
Research on the Microendoscopic Discectomy (MED) was presented by Wu
et al.12 in 2006. It was determined that this approach
was most appropriate for single level radiculopathy, secondary to
lumbar disc herniation. There were 873 patients diagnosed with a
lumbar disc herniation recruited from 2000-2003, with an average age
of 41.5 yrs. These patients had experienced 6 weeks of unsuccessful
rehab and were randomly allocated to either the experimental group
receiving MED or the control group receiving an open posterior
lumbar discectomy (flavectomy, laminotomy, nerve root retraction and
discectomy). Results indicated that RTW/normal activities took 15
days for the MED group and was significantly fewer days than the
control group at 21 days. At 28 months, the MED group had 79% relief
of sciatica and 76% had no LBP. At 31 months, the control group had
72% relief of sciatica and 69% reported no LBP. Pain relief was
statistically lower from pre-op to post-op in both groups. However,
the surgeries performed later in the study had fewer complications
leading the authors to conclude that the surgeon should have
adequate knowledge and experience with the newer approach.
Other advanced surgical options in place of fusions are being used
today including: Dynesys (1994): pedicle-screw system for mobile
stabilization; Graf Ligamentoplasty: treats flexion instability
(degenerative lumbar disorder, minimal disc space narrowing and
facet arthrosis, but cannot correct vertebral slippage or deformity;
X-Stop: rigid interspinous process distraction device designed to
distract posterior elements of the stenotic lumbar segment and place
it in flexion to treat neurogenic claudication by keeping canal open
and limiting extension; and the 2004 FDA approved DePuy Spine’s
CHARITÉ™ Artificial Disc. However, long term studies clinical
research studies have not been conducted.
So what does this tell us? First, if there are no significant
neurological findings than the patient should attempt
conservative treatment for 4 wks to 3 months after onset of discogenic LBP before
considering surgery. Second, it is of economic importance to
research and choose the surgery that has evidence based research to
support its outcomes since every day earlier a patient returns to
work there is a $200 savings3. Lastly, remember that surgery cannot fix
muscle structure or function, successful rehabilitation is the key
to a holistic recovery.
Last revised: April 10, 2008
by Kathryn Greaves, MPT
References
1. Filiz M, Cakmak A, and Ozcan E. The effectiveness of
exercise programmes after lumbar disc surgery: a randomized controlled
study. Clinical Rehab 2005;19: 4-11.
2. Mayer T, McMahon M, Gatchel R, Sparks B, Wright A and Pegues P.
Socioeconomic outcomes of combined spine surgery and functional restoration
in workers’ compensation spinal disorders with matched controls. Spine 1998:
23 (5): 598-605.
3. Scheer S, Radack K, and O’Brien D. Randomized controlled trials in
industrial low back pain relating to return to work. Pat 1. Acute
interventions. Arch Phys Med Rehabil 1995; 76: 966-73.
4. Sheer S, Radack K, and O’Brien D. Randomized controlled trials in
industrial low back pain relating to return to work. Part 2. Discogenic low
back pain. Arch Phys Med Rehabil 1996; 77: 1189-97.
5. Hu SS, et al. (2003). Lumbar disc herniation section of Disorders,
diseases, and injuries
of the spine. In HB Skinner, ed., Current Diagnosis and Treatment in
Orthopedics, 3rd
ed., pp. 231-239. New York: McGraw-Hill
6. Jarvik JG, Deyo RA (2002). Diagnostic evaluation of low back pain with
emphasis on imaging. Annals of Internal Medicine, 137: 586–597
7. North American Spine Society Task Force on Clinical Guidelines (2000).
Herniated disc. North American Spine Society Phase III Clinical Guidelines
for Multidisciplinary Spine Care Specialists. La Grange, IL: North American
Spine Society
8. Atlas S, Keller R, Wu Y, Deyo R, Singer D. Long-term outcomes of surgical
and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results
from the Maine lumbar spine study. Spine 2005; 30(8): 936-943.
9.Molinari R. Dynamic stabilization of the lumbar spine. Curr Opin Orthop
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10. Donceel P, Du Bois M, Lahaye D. Return to work after surgery for lumbar
disc herniation. Spine 1999; 24 (9): 872-876.
11. Atlas S, Keller R, Wu Y, Deyo R, Singer D. Long-term outcomes of
surgical and nonsurgical management of lumbar disc herniation: 10 year
results from the Maine lumbar spine study. Spine 2005; 30(8): 927-35.
12. Wu X, Zhuang S, Mao Z, Chen H. Microendoscopic discectomy for lumbar
disc herniation. Spine 2006; 31 (23): 2689-2694.
13. Ivar Brox J, Sorensen R, Friis A, Nygaard O, Indahl A, Keller A,
Ingebrighgtsen T, Eriksen H, Holm I, Koller A, Riise R, Reikeras O.
Randomized clinical trial of lumbar instrumented fusion and cognitive
intervention and exercise in patients with chronic low back pain and disc
degeneration (randomized trial). Lippincott Williams & Wilkins, Inc. 2003;
28 (17): 1913-1921.
14. www.southeasternspinecenter.com/svcs-gic an S.B., Wilk K. (2003).
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