Category: Nonoperative management

Back pain, spinal surgery and where we’ve got it wrong.

Spinal surgery remains a powerful tool when used judiciously

The science of spinal surgery is much more advanced than biased commentators would like to admit, writes orthopaedic surgeon John Cunningham. As published today in Medical Observer:

In the last few weeks we’ve been bombarded with reports of what some consider to be the best treatments for back pain, and almost every time someone has mentioned spinal surgery, it has been in disparaging terms.

Apparently, the gloves are off when it comes to my profession, with an Australian vascualar surgeon who was commenting on a Lancet study that said back pain was often mistreated, claiming in the media last month that it was “almost certain” the medical industry influenced surgical decisions.

Armchair critics abound, it appears.

The truth is that the science of spinal surgery is much more advanced than biased commentators would like to admit.

Here I will declare my bias in that I only ever offer patients operations when the best available evidence supports that decision, with a diagnosis established by taking a careful history, a thorough examination and after assessing the results of judiciously ordered investigations and interventions.

That offer takes into account the patient’s wishes, their comorbidities, their functional status, psychological status and everything else that makes up an individual.

Spinal surgery is not easy, it’s not straightforward, and it’s notoriously difficult to generalise about. Experienced spinal surgeons do not, however, practice in a cowboy fashion.

The current best practice is that for trauma, both cervical and thoracolumbar, scoliosis and tumours we follow guidelines and treatment algorithms that are supported by solid evidence.

For the degenerative conditions that are currently being thrust before us, the best available studies are the SPORT trials. They show that people with degenerative spondylolisthesis, disc herniations and spinal canal stenosis who had surgery did better functionally than those who were managed non-operatively.

I’m not saying that surgery is for everyone, but that’s what the best available evidence tells us – warts and all.

The harsh reality is that back pain is a symptom and always has been a symptom. It has only been in recent times that it has become a diagnosis in the eyes of some.

By simplifying the complaints of many hundreds of thousands of patients a year to the umbrella term ‘back pain’, and vigorously promoting recipe medicine, many patients with surgically correctable pathology could miss out on a cure.

Choosing Wisely Australia, via the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists (ANZCA), quite rightly stated that surgery was not recommended for uncomplicated axial chronic low back pain (UACLBP).

In other words, when you have back pain that is not due to a structural defect, only in the axial spine, not claudicant, and not radicular, then surgery is not recommended. I don’t disagree.

However, the symptoms that accompany surgically treatable conditions are often confused with or dismissed as UACLBP.

Symptoms such as neurogenic claudication, sciatica, and the pain of tumours and sagittal imbalance are all concepts that any back physician should be familiar with, and be confident to differentiate from UACLBP. In spine “everything is in the history.”

If we want to do the best for our patients (and we do) then discussing back pain and surgery in the same paragraph makes a mockery of both the diagnosis and the treatment.

By losing the nuance and the subtlety of the causes of pain of spinal origin, and grouping all under the umbrella of ‘back pain’ we are doing patients and ourselves a disservice.

Spinal surgery can and is a very powerful tool that can help patients significantly, often restoring their level of function dramatically equivalent to that restoration commonly following hip and knee replacement.1

We’re all here to help our patients and it’s up to each of us to know our limitations and also our strengths.

We know spinal surgery works when applied judiciously, intelligently, with precision, with skill, and with heart.

 

1. Mokhtar SA, McCombe PF, Williamson OD, Morgan MK, Sears WR. Health related quality of life: A comparison of outcomes following lumbar fusion for degenerative spondylolisthesis with large joint replacement surgery and population norms [Journal Article] Spine J. 2010 Apr;10(4):306-12.

Can back pain be cured with antibiotics?

Over the next few months many of you will hear about a paper that has just been published in the European Spine Journal. The study, from the University of Southern Denmark, suggest that back pain can be cured with a 100 day course of antibiotics, and certainly they provide some good evidence for that.  Certainly some surgeons are calling for a Nobel prize, but I don’t think it’s that significant yet.  Maybe if you operate on a lot of people with back pain it’s significant, but those of you who know me, know that surgery for back pain is a last resort.

So, what about the study?

Well, it looked at people who had Modic type 1 changes on their MRI after having a disc herniation, whether or not they had surgery for the herniation.  A prior study from the same team, and others, showed that many disc herniations (about half) are infected with a very low grade bacteria called Proprionibacterium acnes which also causes… yep – acne.  It has a peculiar ability to be benign enough not to produce an acute inflammatory reaction, but at the same time it produces propionic acid, which is known to be able to dissolve bone.  Wow.  What a bug.

Now, modic type 1 changes are only about 10-40% of modic changes, the other types being 2, the most common, and 3, the least common.  Modic type 1 changes appear dark on the T1 films, and bright on the T2 films, and represent oedema.  One way of remembering this is that type 1 changes appear the same as the CSF.  See below.

Modic Type 1 changes

An example of Modic Type 1 changes

Anyway, back to the study.  They randomised the participants into three groups.  One group received a placebo, and the other two received the antibiotic (amoxicillin–clavulanate (500 mg/125 mg) tablets three times a day, at 8 h intervals, for 100 days) in two difference doses.  They found that the antibiotic subjects improved remarkably well, usually beginning at 6-8 weeks after commencement, after 100 days, and it appears that the improvement lasted out to one year – well after the antibiotics had ceased being taken.  Within the placebo group not much changed at all.  In addition, the amount of modic change visible on their MRI’s also decreased, which supports the notion that it is due to a chronic low grade infection.

Were there problems with the antibiotics?  Mostly gastrointestinal of nature – loose bowel movements and increased flatus.  Thanks for asking.

So what does that mean?  Well, if I had type 1 modic changes and back pain, I’d be considering this study carefully.  However, as a public health measure, we need to realise that this isn’t the cure for ALL back pain – maybe only 10 to 40% of back pain patients.  We know that back pain has many causes, but I think it’s just amazing that this subset may have found a cure.  Of course, we need to see that these results can be repeated.  Hold back on the Nobel prize for now…

John

How to look after your spine – updated!

Hi all.

Some of you will remember my four rules about looking after your spine. Four rules never really sat too well with me. Even though it’s an even number and the square of two, it needed to be five – i’m a decimal kind of guy after all. So after much deliberation, and some common sense, I’ve figured out my FIVE rules for looking after your back.

1. Don’t smoke.

2. Lose weight.

3. Do “Core” Exercises.

4. Maintain good posture, and lift things with a good technique, and at last

5. Avoid aggravating activities. This is the one that took me some time to realise needed to be in here. How many times do people say that their back is fine until they do gardening / lift an engine block / etc. It sounds simple, but if you can avoid those activities that cause back pain, then that’s a very simple and drug free way of looking after your back. Some activities can’t be avoided, sure, but try and not do the things that hurt. Does that mean you’re getting old? Well, how do I say it? I know – I wont.

All the best,

John

How to look after your spine

In many ways, this post may be the one to put me out of business, but it’s also the post which I’m sure should be my first – how to protect and look after your back.  In medicine the preference is always prevention over cure, yet many of us forget to emphasise the benefits of spine health.  In other words, how can we all look after the health of our spine in order to prevent injury, reduce the symptoms of spinal degeneration, and lastly to speed recovery following injury or surgery.  Let’s get to the point, and keep it simple.

1. Don’t smoke.  There is nothing healthy about smoking, and it is known that smoking leads to accelerated disc degeneration.  It also increases your chances of an adverse event during and after surgery, and may contribute to failure of spinal fusion surgery in the neck and lower back.  http://www.ncbi.nlm.nih.gov/pubmed/11339862

2. Lose weight.  Every kilo your carry leads to an extra 8 kilo’s of force going through your spine.  Thin people are putting less stress through their spine, and losing weight is often a very effective strategy to lessen the symptoms of a degenerating spine.

3. Exercise. Exercise will obviously help you control your weight, but strength training, particularly of the “core” muscle groups, will also help stabilise the spine and reduce some of the impacts that it sustains.  Some people wear a corset device to help them with their backs.  Improving your core strength works in a similar manner.

4. Maintain good posture.  Maintaining a good posture will allow the spine to take loads in the way that it was designed to.  Good posture also refers to good lifting techniques such as bending your knees, and holding heavy loads close to your body.  Core strength will help you to also maintain a good posture.

Is that all?  No.  Now that you’ve read this, it’s up to you to make a start.  Your GP can help you with quitting smoking, and there’s lots of resources available to you on the internet such as QUIT.  Your GP and physiotherapist can also help you to lose weight in a healthy and appropriate manner – some people are even electing to have “gastric banding”, but that is something you really need to see a specialist about.  Your local physiotherapist will be able to show you good core strengthening exercises, and there’s some available from the Mayo Clinic and the AAOS on the internet.

Some other great resources for learning about your spine are available via the links below:

All the best,

John