SURGERY? NOT ... SO ... FAST
An aching back -- a dull twinge or a stabbing pain, lasting days or years -- is a source of annoyance, misery or even disability for millions of sufferers.
Eighty percent of the population will experience back pain at some point in their lives, and while the majority of cases resolve quickly, 30% recur, according to the North American Spine Society, an association of spinal health professionals based in Burr Ridge, Ill.
Those aching backs, in turn, cost Americans more than $80 billion in healthcare costs, time off from work and other expenses, the spine society says. There is evidence that the suffering is rising slightly -- perhaps because people spend more time hunched over computer keyboards. A 2008 study, published in the Journal of the American Medical Assn., found that the percentage of U.S. adults seeking medical help for spine problems rose from 12% in 2000 to 15% in 2005.
Rising significantly, meanwhile, are expensive treatments and surgeries that may not help patients much. The same study found that patients are spending more money on back pain treatment -- an average of $6,096 per patient in 2005, up from $4,695 in 1997 -- without seeing corresponding improvements in how they feel.
The research implies that expensive treatments with glossy advertising may not be as good as they sound, says study author Brook Martin, a health services researcher at the University of Washington in Seattle.
Surgery rates, in particular, are going up. More professionals now argue that doctors need to think more before they resort to the knife. They note that the U.S. has, by far, the highest frequency of back surgeries among developed nations: There are approximately 1.2 million spinal surgeries in the U.S. each year, double the rate in those other countries. Yet there is no evidence that Americans have a higher rate of back pain or injury.
“I don’t think you want to take the surgical option lightly,” says Dr. Gunnar Andersson, an orthopedic surgeon at the Rush University Medical Center in Chicago.
For the lucky ones who benefit from surgery, it’s certainly worth the risk and costs, he says. Others may not get the results they anticipate.
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Spine sets squeezed
The spine is a stack of bony vertebrae separated by gel-filled discs that act as shock absorbers. “It’s one of the major ways the human body fails,” says Dr. Aaron Filler, a spinal surgeon in Santa Monica. In part, back pain is the price mankind pays to stand upright. When the spine is horizontal, as it is in a four-legged animal, additional weight causes the vertebrae to spread out. But in people, more weight pushes the vertebrae and discs together -- and there is only so far the structure can compress.
Over time the effects of aging, use and gravity wear on the spine, making the 40-plus crowd most susceptible to back pain, though injury or stress can occur at any age.
Back pain is a symptom with many possible causes. Sprains, muscle tears and spasms are common. The discs, which cushion the vertebrae, can also suffer injury. In a herniated disc, the gel inside leaks out and irritates nearby nerves. Or the disc’s outer layer merely thins, allowing the gel inside to form a bulge, which may also poke a nerve.
The joints between vertebrae, called facet joints, are susceptible to wear and tear, particularly in people with arthritis. The joint’s cushioning cartilage can wear thin and the bone can jut out, causing pain in the back and thighs.
And as discs or bone protrude past their normal locations, the interior of the spine can narrow, putting pressure on nerves in a condition called stenosis.
Older people are more susceptible to back pain as are pregnant women, who carry added weight on the spine. Children, however, are not likely to suffer back pain without an obvious injury as the cause. “If I see a teenager with back pain, it really raises red flags,” says chiropractor Robert Hayden of Griffin, Ga.
Hayden believes part of the rise in back pain patients has to do with the personal computer. Leaning over to type or peer at the screen strains the extensor muscles in the neck and the trapezius and rhomboid muscles that hold up the shoulders. The extensors, in particular, are small, thin muscles, and with too much use they can run out of oxygen, causing irritation or spasms.
The postural muscles in the lower spine, such as the quadratus lumborum, can also get sore if a person leans forward or slumps for a long time.
Being inactive can contribute to back problems because the body’s core muscles -- the back and abdominal muscles that hold up the torso -- weaken and become more susceptible to tears or pulls. Weak muscles can also cause problems by forcing the spine to support extra weight -- as does obesity.
The good news is that most back pain goes away on its own. For minor complaints such as muscle strains, most doctors recommend over-the-counter painkillers, heat to relax the muscles, or ice to reduce swelling and numb pain.
In addition, it’s best to keep up with daily activities as much as possible. “Doctors used to recommend bed rest for back pain . . . It turns out people get worse with bed rest,” surgeon Filler says. Allowing the muscles to weaken can slow recovery -- whereas stretching and physical therapy can hasten it. A 2005 review found that patients who remained active, compared to those on bed rest, had a bit less pain and recovered a little more function.
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Sign of trouble
A primary-care physician can evaluate back pain and make sure it doesn’t signal something serious, such as an aneurysm, an ulcer, cancer or an infection. Numbness, pain that shoots down the legs (sciatica) or trouble controlling the bowel or bladder may indicate nerve damage and require medical attention. If the pain is the result of an injury or fall, one should also see a doctor to make sure nothing is broken.
When pain lasts more than three months, doctors classify it as chronic back pain. They will use a detailed history, physical exam and, sometimes, X-rays or other imaging tools to decipher what’s wrong.
There are several possible treatments for back pain, but more patients find themselves on the operating table.
Surgery rates rose sharply between 1992 and 2003, from three in 10,000 Medicare patients getting back surgery in 1992 to 11 in 10,000 in 2003, according to a 2006 study in the medical journal Spine.
If a disc is damaged, a surgeon can remove the leaking or bulging material, or take out the disc entirely. For a fracture, two vertebrae can be fused with bone grafts or metal hardware to stabilize the spine.
To treat people with stenosis, surgeons can remove some of the spine to relieve pressure on nerves. Doctors can also use a laser or radio signal to burn away pain nerves or the material inside a bulging disc, a less invasive form of surgery.
Sometimes back surgery brings relief. A study funded by the National Institutes of Health, published in 2006, 2007 and 2008 found that surgical patients recovered more quickly and fully than nonsurgical patients with herniated discs, stenosis and slipped vertebrae.
The study, done at 13 medical centers across the country, enrolled more than 1,700 patients who were surgical candidates for one of the three conditions. Some patients went under the knife; others had nonsurgical treatments such as medication, physical therapy or restricted activity.
Statistical analysis showed faster recovery in the surgical patients, though many nonsurgical patients experienced good recovery as well. All patients in the study were also experiencing sciatica, so the findings may not apply to people whose pain is only in the back.
Despite these results, there is a long-standing controversy among spinal specialists over how often surgery is the best option -- and some say surgeons can be too quick to sharpen their scalpels.
Part of the reason for the U.S.’ high rates is probably cultural. “We’re in a little bit of a quick-fix society,” says Dr. Steven Richeimer, chief of the division of pain medicine at USC. Doctors may also be seduced by flashy new drugs or devices because they genuinely want to help their patients, says Dr. Richard Deyo, an internist at the Oregon Health and Science University in Portland.
But many surgeries fail to heal the pain. Doctors even have a name for the problem -- failed back surgery syndrome.
The exact success rate for surgical intervention is difficult to calculate, but Deyo notes that approximately 20% of surgical patients will have another surgery within a decade, indicating that the first operation was unsuccessful.
Part of the problem is that the exact cause of the pain isn’t always known. For most back pain patients, Deyo says, doctors cannot discern a specific cause. And advanced imaging techniques -- though popular -- may be misleading.
“When you do magnetic resonance imaging or computerized tomography scans of the spine, you sometimes see horrible things in normal people,” Deyo says. One-fourth of people under 60 have a herniated disc, he says, and half have a bulging or degenerated disc. “And yet these are people who have no back pain.”
Those deformed discs may look like trouble to surgeons, though, so they may remove a disc that wasn’t even causing pain -- leaving the real problem unaddressed.
The vast majority of injured discs will heal without surgery, Hayden says. In addition, surgery carries its own small risk for complications, such as nerve damage or a tear in the tissue around the spinal cord, which could mean lasting numbness or further surgery.
Surgery also carries a high price tag. Spinal fusion, for example, runs about $60,000. Medicare pays out nearly $1 billion for spinal surgery each year. Many physicians and surgeons are concerned that some of their colleagues may push expensive procedures because they have a stake in companies that produce the necessary equipment or devices. Dr. James Weinstein, a spinal surgeon at Dartmouth Medical School in Hanover, N.H., cites as an example the metal cages for spinal fusion that came onto the market in 1996 and were touted to doctors in an aggressive ad campaign. Surgery rates soared.
“It certainly is good for Wall Street and the companies that are selling the equipment, and good for many of the highly paid consultants,” says Charles Rosen, director of the Spine Center at UC Irvine. “But it’s not the best for patients.”
Concerned with the rise in surgery rates, in 2006, Rosen founded the Assn. of Ethical Spine Surgeons (now the Assn. for Medical Ethics), which includes more than 200 spinal surgeons. The association calls for doctors who receive more than $50,000 in consulting fees to make their company connections known and consider recusing themselves from leadership positions such as editorship of scientific journals.
Doctors say the high-surgery trend is unlikely to change soon, but that education of doctors and patients is key. Deyo, among others, is developing patient decision-making guides, and studies have shown that patients who have more information are less likely to opt for an operation.
So how can doctors and patients define a good candidate for surgery? Andersson suggests patients should wait six months, trying other therapies, before opting for an operation. Deyo says a surgery candidate should have imaging studies that match the symptoms, and leg pain indicating nerve involvement. Filler says that one useful test is that if a localized anesthetic directed at the suspected problem does indeed numb the pain, it probably is the correct target for surgery.
There are plenty of treatment options to try before considering surgery. It is sometimes difficult to evaluate the effectiveness of therapies because most back pain fades regardless of treatment. And some newer treatments haven’t had much evaluation.
The main thing, experts say, is to be informed. “There’s been a big increase in the intensity of treatment for back pain,” Deyo says. That intensity, he says, would better serve many if it focused more on finding the best therapy for each patient -- and less on the surgical quick fix.
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To maintain a healthy back
Four out of five people will experience back pain at some point in their lives, but there are things you can do to avoid or minimize back troubles. Here are some tips:
KEEP FIT
Maintaining a healthy weight reduces strain on the spine. Walking, swimming and Pilates are low-impact exercises engaging core muscles that support the back. Stretch or try yoga to maintain flexibility.
STAND UP STRAIGHT
Good posture keeps the spine properly aligned. If you stand up for long periods of time, alternate putting one or the other foot forward or up on a step, and keep the knees slightly bent to reduce weight on the lower back.
SIT PROPERLY
That means straight -- with both feet flat on the floor, or on a footrest if necessary to keep your knees in line with your hips. A small pillow or folded towel at the small of your back can help support the spine. The computer screen should be at eye level so you don’t have to hunch to see it.
LIFT CAREFULLY
Hold heavy objects close to your body. Lift by squatting or kneeling, using the legs, not the back, to rise up. Don’t lift and twist at the same time. When moving heavy items across the floor, push; don’t pull. And if necessary, ask for help with large burdens.
SLEEP ON YOUR SIDE
Put a pillow between your legs and under your head to straighten the spine.
TAKE A BREAK
Get up and walk around every hour or so. When driving a long distance, pull over to walk around the vehicle and stretch.
TAKE YOUR VITAMINS
Vitamin C is important for connective tissue health. Avoid future osteoporosis by getting calcium for bones, and the vitamin D that helps bones absorb it.
QUIT SMOKING
Nicotine prevents discs from absorbing nutrients.
DITCH THE STILETTOS
Shoes that don’t properly cushion the foot, such as high heels or flip-flops, can alter posture and stress the spine. Stick to flats or shoes with heels of one inch or less.
-- Amber Dance
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latimes.com /health
When you’re aching for relief Standard medicine is just one option. Go online for a look at standard and alternative nonsurgical back therapies.
