Opinion

Neurological surgeons: Back surgery is safe and effective when warranted

LETTER — Posted July 23, 2007

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Regarding "Delaying back surgery works for some" (Article, June 25): A reader of this article may incorrectly infer that patients suffering from a herniated lumbar disc or degenerative spondylolisthesis ultimately achieve comparable outcomes irrespective of whether they receive surgical or nonsurgical care.

In fact, the May 31 New England Journal of Medicine SPORT study reported that patients treated with surgery for lumbar degenerative spondylolisthesis with stenosis not only experienced rapid and effective symptom relief but demonstrated both statistically significant and clinically important superior outcomes compared with patients treated nonsurgically, on virtually all primary and secondary outcome measures. These substantial differences persisted throughout the entire study period.

Today, nearly all patients with new-onset painful sciatica or degenerative spondylolisthesis are managed nonoperatively. Those patients who do not improve, or who worsen, despite adequate nonsurgical treatment, may choose the exceptionally safe and highly effective option of surgery.

In both contemporary clinical practice and intent to treat randomized trials, nonoperative therapy will be consistently associated with successful outcomes because patients who fail to improve or worsen will eventually choose surgery. This was vividly documented in the Netherlands sciatica study where the 40% of patients who failed to improve or worsened with nonoperative therapy crossed over to surgery and experienced definitive pain relief and resolution or avoidance of neurological deficit.

Surgery and nonoperative therapy, therefore, are not comparable or competitive treatments for these conditions but represent a complementary management strategy supported by virtually all evidenced-based guidelines.

Our goal as physicians is to ensure that our patients continue to have access to treatments that provide relief for painful and often debilitating spinal conditions. We are committed to providing the safest and most effective surgical and nonsurgical treatment options for our patients based on their individual circumstances and informed choice, which clearly cuts to the core of both of these studies.

Jon H. Robertson, MD, president, American Assn. of Neurological Surgeons, Memphis, Tenn.

Douglas S. Kondziolka, MD, president, Congress of Neurological Surgeons, Pittsburgh

Joseph T. Alexander, MD, chair, AANS/CNS Section on Disorders of the Spine and Peripheral Nerves, Scarborough, Maine

Note: This item originally appeared at http://www.ama-assn.org/amednews/2007/07/23/edlt0723.htm.

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