For the millions of Americans with slipped discs and lower back pain, 30-year-old Andrew Neitzke's story strikes a familiar nerve.
"My left leg hurt enough that I couldn't walk for more than a few minutes — sometimes even 30 seconds was difficult — and I also couldn't sit for long," he said. "The pain was even waking me during the night, and there were nights when I couldn't sleep at all."
Months of medications, physical therapy and steroid injections offered little relief. He was in a bind — should he wait it out, or go under the knife?
Two studies in the current issue of the New England Journal of Medicine may help patients like Neitzke with their decision. The studies compare surgical versus nonsurgical treatment for two common lower spine conditions that cause pain.
James Weinstein, of Dartmouth Medical School, and his colleagues studied more than 600 patients from 11 states with degenerative spondylolisthesis — a type of lower back pain caused by slippage of the bones of the spine. This slippage can cause parts of the backbone to press on nerves, potentially causing a great deal of pain.
What researchers found was that the patients who ended up in an operating room — about 60 percent of those in the study — experienced less pain and better physical function after two years compared with those who did not have surgery.
Those who opted for nonsurgical treatments — including pain medication, physical therapy, steroid injections and chiropractic treatment — also improved, but not to the same extent.
"There are two major treatment options: operative and nonoperative," Weinstein said. "This trial shows there is clearly a greater benefit of surgical versus nonsurgical treatment, but nonsurgical treatment is also an option.
"There were still many patients who never got surgery ... and it was good enough for them."
In a separate trial, Dr. Wilco Peul and his colleagues studied nearly 300 Dutch patients with sciatica — a radiating pain in the leg from compression of nerves in the lower back, often caused by a slipped disc.
Peul's group found that while pain relief and a sense of recovery occurred faster for those who went under the knife, recovery at the one-year point was the same whether a patient had had surgery or not.
Peul's study actually came to life for him, as he developed the very same back and leg pain he was investigating.
"I'd recommend what I did and what I would still do," he said. "Monitor your pain intensity and ability to function. Do not have surgery for at least a few weeks or months. Look for recovery. If there is no recovery, then choose surgery."
Peul himself improved with nonsurgical treatment after three months, which allowed him to avoid the operating room. He noted, though, that "if, at four months, my pain was the same, I would be apt to have surgery."
So, is there any definitive answer as to which patients with lower back problems should have surgery?
Dr. Richard Deyo of the University of Washington notes in an accompanying perspective on the two studies that patients with serious and worsening nerve damage need surgery.
"For these patients, surgery may preserve life or function," he said. But absent this, the answer is not clear and should be guided by patients making informed decisions.