Is Low Back Surgery the Answer to Lower Back Pain?
Learn More About Low Back Surgery Before You Decide
Many people believe low back surgery is the “cure-all” for low back pain and leg pain. This includes pain from conditions such as ruptured discs, sciatica, stenosis, herniated discs, and bulging discs.
However, only a small percentage (less than 5%) of back pain sufferers undergo a low back surgery, while 95% don’t! Not only that, but studies show of the people having low back surgery, up to 70% may be unnecessary.
What Does Recent Research Say About Low Back Surgery for Lower Back Pain?
“Low back pain surgeons do not use clinical practice guidelines before performing spine surgery. Of 229 patients referred for surgical consultation for an elective lumbar spinal condition, medications were the most common modality prior to consultation (74.2% of patients), of which 46.3% received opioids. The majority (61.1%) of patients received two or less forms of treatment. Evidence-based non-operative treatments for patients with low back pain are not being taken advantage of prior to spine surgery consultation. If more patients were to undertake CPG-endorsed conservative modalities, it may result in fewer unnecessary referrals from primary care physicians, and patients might not deteriorate as much while lingering on long wait lists. Further studies incorporating knowledge translation or health systems pathway changes are necessary.”
(SOURCE: Layne EI, Roffey DM, Coyle MJ, Phan P, Kingwell SP, Wai EK: Activities Performed And Treatments Conducted Prior To Consultation With A Spine Surgeon: Are Patients And Clinicians Following Evidence‐ Based Clinical Practice Guidelines? Spine J 2017[Epub ahead of print])
So, what does that all mean? Let’s break that down piece by piece:
“Low back pain surgeons do not use clinical practice guidelines before performing spine surgery.”
As chiropractors we follow “Clinical Practice Guidelines” in practice, meaning we are required to perform certain tests to evaluate a condition. As a chiropractor, I do not prescribe drugs or perform surgery. Logically, if you are performing more complex and invasive procedures such as prescribing medications, performing injections, and performing surgery, you would be required to do at least what a chiropractor does, if not more. In reality, a lot of surgeons do not even do the basic clinical exam for their patients. Instead, they rely on the MRI and EMG findings and they schedule the surgery.
When my patients consult with a spinal surgeon or pain management doctor, I will ask if the doctor did a range-of-motion test (where the patient bends forward, backwards, to the sides, and rotates, a very basic required test for all low back and neck patients), and often the answer is “no” or “he had me try to touch my toes.” I proceed, did the doctor check your sensation like this (as I am performing a sensory exam), again the answer is “no.” Did the doctor check your muscle strength? “Well I stood on my heels and toes and that was it.”
Recently, I had a patient come back from the pain management doctor. She had told the doctor, “I have weakness in my foot. My chiropractor checks it, can you check it?” The doctor answered, “No, that doesn’t matter.” Doesn’t matter? We think it does.
When I reviewed an Orthopedic Spine Surgeon’s records, I would wonder, why they did not even do a basic clinical exam?
After our consultation we perform a postural exam, range-of-motion exam, Orthopedic testing, muscle testing, reflexes, sensory testing, leg length evaluation, and a palpatory exam at a minimum.
“Of 229 patients referred for surgical consultation for an elective lumbar spinal condition, medications were the most common modality prior to consultation (74.2% of patients), of which 46.3% received opioids.”
Go to you MD or a Spine Surgeon for low back pain and you will get medication. Medication in itself is not bad, but you don’t want to take it long term and you definitely don’t want to stay on opiods!
In previous blogs I have discussed the seriousness of opiod addiction and what a huge problem it is. Opiods should be taken as infrequently as possible and discontinued as soon as pain levels allow. Of course, check with your prescribing doctor. The FDA recently recommended their doctors try non-drug therapies for back pain including spinal manipulation, which is basically chiropractic care before using opiods.
“The majority (61.1%) of patients received two or less forms of treatment. Evidence-based non-operative treatments for patients with low back pain are not being taken advantage of prior to spine surgery consultation. If more patients were to undertake CPG-endorsed conservative modalities, it may result in fewer unnecessary referrals from primary care physicians, and patients might not deteriorate as much while lingering on long wait lists. Further studies incorporating knowledge translation or health systems pathway changes are necessary.”
It may not be in our lifetime, but that research is coming.
Years ago, a small Blue Cross Blue Shield study took 10 patients ready for low back surgery. Those 10 patients were then treated with the Cox Technic, a technique we use in our office. As a result, 70% of them did not need surgery!
When this study first came out, I though it we would see the biggest increase in utilization of chiropractic care and the Cox Technic in my lifetime. Surely, any doctor will do anything necessary to help their patients avoid having surgery, and they would send them out for a 2-4 week trial with the Cox Technic. I was wrong! A lot of doctors can only refer patients to other doctors in their corporate system, and some doctors are ignorant and just do not refer to chiropractors. Spine surgeons would rather do surgery than refer patients out for conservative care and watch that patient walk away.
Slowly, and I mean slowly, some insurance plans are starting to require a 2-6 week period of conservative care prior to MRI’s or surgery. Would a patient rather have several weeks of conservative care or a 4-12 week recovery period after their low back surgery? Would a patient rather come to an office for treatment and go home, or spend a few nights in the hospital after surgery? Would an insurance company rather pay $25,000-$100,000 for a low back surgery, or pay just a fraction of that? Conservative care is a no-brainer for everyone involved, and the only loser is the spine surgeon.
“Wait doc, if I don’t have surgery NOW. it will only get worse and then they won’t be able to help me!” This was studied, and they found that if a patient has surgery today or one year from now there is no difference in the outcomes!
Surgeons may tell you, “you need surgery now or you will be paralyzed,” “if you don’t have surgery you will have permanent nerve damage,” and “if you put surgery off you will end up in a wheelchair.”
Back pain and sciatica are very serious, but it is extremely unlikely you will become paralyzed, or have permanent nerve damage, or end up in a wheelchair. Do you know anyone who is paralyzed, has permanent nerve damage, or is in a wheelchair from low back pain?
These are scare tactics that surgeons use to coerce unknowing patients into having surgery. Now you know better.
Startling New Study Reveals That Low Back Surgery Fails 74% of the Time
Researchers reviewed records from 1,450 patients in the Ohio Bureau of Workers’ Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses.
After two years, only 26%of those who had surgery had actually returned to work. That’s compared to 67% of patients who didn’t have the surgery, even though they had the same exact diagnosis.
That translates to a resounding 74% failure rate! It also suggests that you have a 257% better chance of returning to work if you avoid surgery in the first place!
In another troubling finding, the researchers determined that there was a 41 percent increase in the use of painkillers, particularly opiates, in those who had the surgery (the exact opposite of what we are trying to do). Deaths from addictive painkillers have doubled in the last 10 years.
“The study provides clear evidence that for many patients, fusion surgeries designed to alleviate pain from degenerating discs don’t work”, says the study’s lead author Dr. Trang Nguyen, a researcher at the University of Cincinnati College of Medicine.
27 Million Adults with Back Problems
Experts estimate that nearly 600,000 Americans opt for back operations each year.
A recent report by the Agency for Healthcare Research and Quality, a federal organization, found that in 2007, twenty-seven million adults reported back problems, with $30.3 billion spent on treatments to ease the pain. Some studies estimate the United States spends $80-100 billion on low back pain!
While some of that money is spent on physical therapy, pain management, chiropractor visits, and other non-invasive therapies, a big chunk pays for spine surgeries.
Complicated spine surgeries that involve fusing two or more vertebrae are on the rise. In 15-year period, there was an eight-fold increase in this type of operation, according to a study published in Spine.
The European Guidelines for the Management of Acute and Chronic Nonspecific Low Back Pain were published in 2004 and the researchers conclusion was: “Surgery for non-specific CLBP cannot be recommended unless 2 years of all other recommended conservative treatments — including multidisciplinary approaches with combined programs of cognitive intervention and exercises — have failed”.
The European Guidelines recommends 2 years of conservative care prior to surgical intervention!
Let’s look at what is NOT recommended by the European Guidelines:
- Bed rest
- Intradiscal injections
- Epidural corticosteroid injections (these are performed frequently)
- Intra-articular (facet) steroid injections
- Local facet nerve blocks
- Trigger point injections
- Botulinum toxin
- Radiofrequency facet denervation
- Intradiscal radiofrequency lesioning
- Intradiscal electrothermal therapy
- Radiofrequency lesioning of the dorsal root ganglion
- Spinal cord stimulation
Chiropractic Beats Low Back Surgery for Low Back Pain
We see above that the success rate for some low back surgeries is low, the return to work rate is low, and opioid use increases. We also see physicians NOT following recommended low back pain guidelines, and at the same time we see chiropractic care is effective for these conditions.
We have a large group of low back pain sufferers who need chiropractic care, but we have doctors that do not refer their patients for chiropractic care.
In response, The University of Pittsburgh Medical Center (UPMC) Health Plan has mandated conservative care before even considering surgery for chronic Low Back Pain cases. As of Jan. 1, 2012, candidates for spine surgery must receive “prior authorization to determine medical necessity,” which includes verification that the patient has “tried and failed a 3-month course of conservative management that included physical therapy, chiropractic therapy, and medication.”
Now, those guidelines very likely did not make a lot of surgeons happy.
The University of Pittsburgh Medical Center was the first health plan to adopt such guidelines, so you may be interested in knowing what they recommend for low back pain. Here it is:
“A Conservative Strategy for Managing Chronic LBP
- PCP discussion related to self-care consisting of rest, ice, compression and elevation (RICE)
- Screening for psychosocial factors or “yellow flags” and incorporate behavioral interventions as appropriate with other treatment interventions
- Education on self-management techniques – functional ability assessment and education on return to work / usual activity and function
- Enrollment and graduation from UPMC Health Plan Health Coach’s Low Back Pain Program (mandatory) which may also include participation in other programs such as weight loss, physical activity, tobacco cessation, depression and/or stress
- Early referral to chiropractor or physical therapist, but before advanced imaging, for manipulation/ mobilization; stabilization exercises; directional preference strategies – member and/or provider movements that abolish or cause centralization of pain (McKenzie self-treatment repeated movements that centralize pain)
- Detailed documentation of extent and response to conservative treatment including chiropractor/physical therapy documentation”
(SOURCE: UPMC Health Plan Policy and Procedure Manual, October 2011: Surgical Management of Low Back Pain)
We can see from the few studies above that surgery is not the “cure-all” it is made out to be. Conservative care is safer and involves far fewer side-effects, less medications, less opiods. Additionally, in most cases it’s more effective and cheaper than surgical intervention for low back pain and sciatic pain.
Consider safe, effective chiropractic care for you and your family and stay away from opiods, injections and surgery! Call Algonquin Chiropractic Center for help with low back pain in Algonquin, IL today!