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?
Surgery May Speed Recovery
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."
Surgery a Personal Choice
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.
Dr. Stephen Ondra, professor of neurological surgery at Northwestern University, said that as long as pain is tolerable and there is no ongoing nerve damage, patients may not need to have surgery.
"The decision to have surgery is a quality-of-life choice and not a preservation-of-life-and-limb choice," Ondra noted.
"If a patient's pain is tolerable, and they can wait for recovery, surgery is rarely needed. If the pain is intolerable or a long recovery is not possible, surgery is a reasonable alternative to shorten the episode of pain."
Faster pain relief may be worth the risk of surgery for some patients, however.
Dr. Eugene Carragee, director of spinal surgery at Stanford University School of Medicine, said, "The shortening of a six or nine month illness to two or three weeks by surgical intervention may be the difference between keeping your job or losing it, between finishing a competitive program or being left behind, or between taking care of your own young children or having to pay a stranger to do so for months."
But for many, concern about the risk of surgery sways them to wait it out. Dr. James Sarni, a physiatrist at Massachusetts General Hospital, says that, when thinking about back surgery, patients should consider the risk of bad outcomes, such as scarring of the nerve root and development of instability, both of which can result in pain and impaired function.
More Informed Decisions
Physicians said the two studies should help patients and their doctors make more informed decisions when it comes to the question of surgery.
"Both studies are very significant and add to our understanding of two common, painful spinal disorders," noted Dr. James Rathmell, director of the Massachusetts General Hospital pain center.
"They help me, as a clinician, [to] better inform my patients regarding their options," said Dr. Mark Brown, professor and director of the Miami Center for Orthopaedic Research and Education, who has been practicing for over 35 years.
For Neitzke, the studies make surgery sound more reassuring, though he said he won't change his mind to take a nonsurgical approach.
"That's a comfort, but it probably wouldn't change my decision too much," he said. "What I really want to know is whether there are problems 15 years out. If the study also addresses that question, then it would be more interesting."
Weinstein and his colleagues already have that next step in mind. They are planning to track the patients in their study for a total of 10 years.