Patients suffering from lower back pain could get the same benefits in pain relief and function from nonsurgical treatment as from back surgery, a new study shows.
Low back pain is one of the most common complaints doctors hear from their patients, but choosing the best treatment has long been a mystery. New research in The Journal of the American Medical Association today suggests that patients who opt for nonsurgical treatments can get the same benefits in pain reduction and function in the long term as those who chose surgery.
"This confirms what we already know about [back pain]," says Dr. William Richardson, an orthopedic surgeon at Duke University Medical Center. "Patients get better quicker with surgery, but long-term results are no different."
"These studies will become the worldwide standard of care for patients who suffer from herniated discs," says Dr. Mark Brown, chairman emeritus of the Department of Orthopaedics and Rehabilitation at the University of Miami in Florida. "This should eliminate the wide regional variation in numbers of disc surgeries performed in the U.S. today."
Options for Back Pain
Up to two-thirds of Americans experience back pain at some point in their lives, and sciatica can be one of its most debilitating complications. This condition of the lower back, characterized by pain and numbness that travel down the legs, is an extremely common complaint.
The main options for treatment range from popping a pill to a lumbar discectomy -- surgery to remove a part of the spine. In between are such options as injectable steroid treatments, physical therapy, or even counseling.
To look at whether surgical or nonsurgical treatments are better for treatment of sciatica, researchers combined the results of more than 1,200 patients across the country in the Spine Patient Outcomes Research Trial, or SPORT.
What they found was that while surgery offered quicker relief of sciatica-related leg pain in the short run, over time, both surgical and nonsurgical approaches delivered positive results.
"The issue is when to switch paths and consider surgery," says Dr. Scott Boden, professor of orthopedic surgery at the Emory University School of Medicine in Atlanta, and one of the studies lead investigators.
"So, for surgeons who previously did not believe in nonoperative treatment, this study should remind them that it is effective. For surgeons who would routinely wait 12 weeks before considering surgery, this study should suggest that it is reasonable to offer the patients the option of surgery after six weeks, and those that choose surgery will tend to do better than those that choose the 'continue to wait and see' approach."
"This trial confirms some of the earlier findings, suggesting results are similar with modern surgical and nonsurgical treatment techniques," says Dr. Richard Deyo, another of the study's authors and a professor of medicine and of health services at the University of Washington Harborview Medical Center in Seattle. "The results reinforce that most patients get better with either type of treatment, but that if symptoms persist for more than six weeks, surgery appears to offer faster relief."
However, some say the study's methods are flawed.
"SPORT is off the mark," says Dr. Andrew Haig, a rehabilitation physician at the University of Michigan. He says a design flaw of the study is that surgeons, not rehab physicians who are best trained for nonoperative management, are the ones managing the patients in the study who did not receive surgery.
"So it will be used by those who want to support more surgery, despite overwhelming evidence ... that spine surgery in America is overused and arbitrarily applied," he says.
The results of the study may also not apply to a broad audience. Patients were limited to only those adults considered eligible for surgery, and the majority of participants were white males with an average age of 42.
Doctors Should Let Patients Choose
Boden says an interesting aspect of the study is that it allowed patients to choose whether they wanted surgical or nonsurgical treatment after they watched an informational video. He and others say the research highlights the importance of giving patients a choice in their treatment.
"The study clearly shows that objectively informed patients make better decisions for themselves and tend to do well with the decisions they make," Boden says. "We believe it is very important to include the patients in the decision-making process."
"I honestly don't believe that this will fundamentally change the practice of medicine," says Dr. Charlie Branch, chairman of Wake Forest University's department of neurosurgery in Winston-Salem, N.C. "But it reaffirms the value of surgery and of the patient's right or privilege to choose an option."