Surgery best option to treat common back ailment
Surgery is twice as effective as physical therapy and drugs for relieving pain and improving mobility in one of the most common back problems, researchers reported today.
The study, published in the New England Journal of Medicine, gives “us more confidence in recommending surgery to our patients,” said Dr. Mark J. Spoonamore of USC’s Keck School of Medicine. The recommendation is “not just our gut feeling but based on a strong scientific foundation.”
Dr. Arya Shamie of UCLA’s David Geffen School of Medicine added, “This is a great study ... confirming what doctors have believed all along.”
The condition, called degenerative spondylolisthesis with spinal stenosis, occurs when one lumbar vertebra in the back slips forward relative to the one next to it, pinching the spinal cord and producing severe pain in the legs.
The condition affects as many as 600,000 Americans, although only about half of those seek medical treatment and perhaps only a quarter of them undergo surgery, according to Dr. James W. Weinstein of the Dartmouth-Hitchcock Medical Center in Hanover, N.H., who led the study.
The bulk of the patients are older than 50, and women are six times as likely as men to suffer from it, with African American women at greatest risk.
Conventional treatment involves physical therapy, steroids to reduce swelling and anti-inflammatory drugs. But only about 20% of patients get better and 20% stay the same without surgery, according to Shamie, who was not involved in the study.
Surgery relieves pain by removal of bone and soft tissue in a procedure called a decompressive laminectomy.
Because of the aging American population, back surgeries are one of the fastest-growing areas of medical care, with hospital costs totaling more than $21 billion per year, according to Dr. Richard A. Deyo of the University of Washington.
The federally funded study enrolled 607 patients at 13 medical centers in 11 states. Of those, 372 underwent surgery and 235 did not.
Two years after their enrollment in the study, the patients who did not undergo surgery reported only modest improvements in their condition.
Those who had surgery reported significantly reduced pain and improved functionality. Major improvements were seen within six weeks after the surgery. The most common complication of the surgery was a tear in the lining of the spinal cord.
“Up until now, we suspected surgery produced better results, but we had little objective data to support that,” Weinstein said.
“With the results of this study, we can now discuss much more fully the surgical and nonsurgical options available to our patients so that they can make an informed choice.”
In a second study in the journal, a Dutch team led by Dr. Wilco C. Peul of the Leiden University Medical Center studied 283 patients with severe sciatica, which produces a burning pain in the sciatic nerve that runs down the outside of the leg. The pain is caused by herniated disks in the spine that put pressure on the sciatic nerve.
Peul and his colleagues reported that sciatica patients undergoing surgery got much faster relief from the pain than those receiving only physical therapy and drugs, but that at the end of a year, 95% of patients in both groups were largely free of pain.
Those results were similar to findings reported by Weinstein and his colleagues last year in a much larger study -- although Weinstein found a small but persistent benefit from surgery.
In a third track of the U.S. study, Weinstein and colleagues will report later this year on the benefits of surgery for patients with spinal stenosis -- a narrowing of the spinal column -- caused by degenerative arthritis.
The team is also following all of the patients in the three tracks for 10 years to see how well the treatments hold up with time.