Does Anyone 'Need' Spine Surgery?

Few spine surgeons appreciate me for my way of thinking. I have some empathy. Years of technical training and the development of a special surgical perspective are trumped by the evidence. No wonder the two papers in a recent New England Journal of Medicine were met by fanfare in the press, and celebration in the spine surgery community.

Neither paper has anything to do with regional low back pain -- my forewarning still pertains. Each tackles a special regional low back disorder that need not cause low back pain, but is characterized by pain into the buttocks or legs.

One paper is an analysis of a subset of patients in a very large American randomized trial comparing surgery with medical treatment for various regional back disorders. This brilliantly designed trial was bedeviled by our cherished patient autonomy; many of the volunteers refused to stay with the treatment to which they were randomized. There was so much crossover that I'm sure the statisticians suffered indigestion. They massaged the data nonetheless and still could find no joy from surgery for regional low back pain.

Then they came up with this subset. It took four years for the doctors in 13 centers in 11 states to find 600 patients who had persistent pain into the buttocks or a leg when they walked and had very impressive degenerative changes in their spinal anatomy -- a combination that is considered a special disorder, "spinal stenosis."

The surgical remedy is somewhat drastic, particularly for a population that tends to be elderly and even frail. It usually involves fusing the spine and is associated with greater than 10 percent incidence of important complications.

The analysis suggests benefit of the surgery. I will accept that result only because of a similar trial from Finland with far less crossover. In the Finnish trial, patients improved regardless of the treatment. Those with the surgery reported a bit less discomfort but no more mobility.

If I develop spinal stenosis, I wouldn't let you operate on me for that piddling outcome. I'd swallow my pride and walk bent over a walker (which usually alleviates these symptoms) before I'd risk surgery.

The other paper is one of many looking at patients with sciatica: pain down the leg with or without back pain.

Most get better too quickly to justify surgery, even in America. For those who are hurting for a couple of months, surgery has something to offer. They are more likely to be better once they recover from the surgery than patients treated medically, though the medically treated patients catch up by year's end.

That's not much to write home about. I'd need to see a sham control before I'd believe the "surgery for subacute sciatica" mantra.

Based on the evidence, the currently available surgical remedies for regional spine disorders belong next to tonsillectomy in the archives.

Dr. Nortin Hadler is professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and an attending rheumatologist at University of North Carolina Hospitals. He is the author of The Last Well Person.

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