Features March 2010 Issue

Back Surgery: Not Always a Last Resort

In some situations, you might consider surgery sooner rather than later.

When is it appropriate to forego non-surgical treatment and spring for surgery for back pain? According to a study published in the June 2009 Journal of Bone and Joint Surgery, patients with spinal stenosis (narrowing of the spinal canal, causing nerve compression) and degenerative spondylolisthesis (a slipped disk, usually due to arthritis) who chose to have surgery had substantially greater pain relief compared with those who did not

Spondylolisthesis (left), is caused by a slipped disc. Stenosis (right) often results from a herniated disc that impinges on the spinal canal. Both conditions can benefit from surgery.

choose surgery. The patients who had surgery also had better function, less pain, and higher satisfaction two and four years later compared with those who chose not to have surgery.

Does that mean patients with painful degenerative spondylolisthesis and spinal stenosis should opt for surgery instead of pain relievers, exercise, and other non-surgical measures? "In general, conservative treatment is the best initial choice for most spine conditions," says Gordon Bell, MD, director of the Center for Spine Health at Cleveland Clinic. "However, if you experience progressive weakness—for example, foot drop from a weakening of the muscles that flex the ankle—or bowel or bladder impairment as a result of nerve compression, you’re a candidate for surgery."


Other Factors to Consider

If your main complaint is pain, and you don’t experience progressive weakness, bowel or bladder problems, "it’s better to give conservative treatment a trial first," Dr. Bell stresses. "You should not be persuaded or dissuaded by what the magnetic resonance imaging (MRI) looks like. We commonly see people who show severe neurocompression in an MRI scan, where the space available for nerves is nearly completely obliterated, but they have little or no pain. On the other hand, some people with relatively little compression have very severe pain."

Work and family issues also play a role in treatment decisions, Dr. Bell notes. "People who are symptomatic often say they don’t have the luxury of trying conservative therapy and waiting for three months, only to find out that they’re not better. During that time, they might miss an opportunity to have surgery done when it’s convenient for them. Their attitude is that they can’t afford that and would rather have surgery done right away so they feel they’re on their way to recovery, although that may or may not be the case."


Informed Decision

Frequently a doctor may suggest surgery before you’ve exhausted all other options. If that happens, Bell advises that you ask the following questions to help you make an informed decision: What happens if I do nothing? Am I at risk for a serious complication? Am I likely to experience progressive weakness or bowel/bladder impairment if I wait?

"Degenerative spondylolisthesis is a progressive condition. This means that if you look at an X-ray or MRI five years down the road, it would likely look worse than it does now. But that doesn’t necessarily mean your pain will be worse," Bell says.

As degeneration progresses, you may notice increased walking intolerance. "You may be able to walk several city blocks without problems today," says Dr. Bell, "but in a year or two, you may only be able to walk half that, and eventually just a block or two. In this case, you’re making a lifestyle decision. You either modify your lifestyle to suit what’s wrong with your back, or you modify your back—with surgery—so you can get back to the lifestyle you’ve been accustomed to."

Other considerations are your age and your current and projected health status. If you have degenerative spondylolisthesis and you’re in your 60s or 70s, "the condition will likely get worse. So the question is whether you undergo surgery now when your health is relatively good, or roll the dice and wait to see if your back gets worse in a few years. But by then, your health may be worse, so the same operation would then pose greater risks," Dr. Bell explains.


Study Inconsistencies

If conservative treatments or lifestyle changes should be tried before surgery, why did the patients in the study have mostly positive outcomes from surgery? "The study was a Herculean effort to try to put together a prospective randomized trial—that is, a study that randomized people to surgery or non-surgical treatment—and followed them for several years to assess the results," Dr. Bell explains.

However, during the course of the study, many people decided to move out of the group they were randomized to—surgery or non-surgical treatment—into the other group. And the researchers couldn’t dissuade them because doing so would be unethical. "In fact, of people randomized to have surgery, only two-thirds actually had surgery. Of those randomized to non-surgical treatment, about half decided to have surgery. There was crossover both ways, so interpretation was difficult and not generalizable to the general population," Dr. Bell explains.

"The bottom line is that the decision to have surgery is multifactorial," he says. It depends on 1) how bad your symptoms are, which is subjective, 2) neurological findings, which are objective, 3) imaging findings, which are also objective but often don’t correlate with subjective symptoms, and 4) social factors, such as work and family issues.

"It’s a complex decision that should not be based on one factor to the exclusion of everything else. Barring progressive weakness and/or bowel/bladder impairment, there is no reason to rush into surgery," Dr. Bell says. A physician who does so isn’t doing the patient a favor," he cautions. "With surgery, you have the risk of nerve damage, new weakness, pain, and infection. Waiting won’t generally have adverse effects, except that your disability may get worse."