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.