Delaying back surgery works for some

Studies of patients experiencing back and leg pain suggest that postponing an operation most likely does no harm, and some do just as well without surgery.

By — Posted June 25, 2007

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Patients with back and leg pain may do just as well with a treatment strategy involving pain-relieving medications, anti-inflammatories and physical therapy as they would with surgery, according to a pair of studies published in the May 31 New England Journal of Medicine. Also, delaying surgery does not appear to cause additional damage.

"Time is on their side," said Trish Palmer, MD, a family physician and assistant professor of sports medicine with Midwest Orthopaedics at Rush University Medical Center in Chicago. "The majority of people get better, but sometimes it takes longer."

For one study, researchers in the Netherlands randomized patients with severe sciatica to either undergo early surgery or have their treatment managed medically. Those in the latter arm could receive a surgical procedure if the sciatica did not resolve within six months, or sooner if they did not respond to medications or developed progressive neurologic defects. Those who had surgery sooner got better faster, but both groups had similar levels of recovery after one year.

The second study, by researchers participating in the Spine Patient Outcomes Research Trial funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, examined several hundred patients with lumbar degenerative spondylolisthesis. About half were in an observational cohort while the other half were randomized either to surgery or to medical management. All patients improved, but those who received surgery -- either because they were randomized to receive it or switched out of the medical therapy arm -- had more substantial improvement in pain and function when compared to those who received medical management alone.

"What it does suggest is that people do just as well if they start out on a path aimed at surgery or aimed at nonoperative treatment," said Jon Lurie, MD, one of the authors and associate professor of community and family medicine, Dartmouth Medical School in Hanover, N.H. "And if they wait, they're not going to be any worse off. ... If they choose to have the surgery, they have a greater improvement in symptoms and function. People who don't have surgery on average get a little bit better but not a lot better."

Adding to the discourse

Experts praised these papers for taking on the increasingly controversial question of the best strategy to manage back and leg pain. The outcome of the Dartmouth project in particular illustrated just how challenging this concept can be. This study of lumbar degenerative spondylolisthesis was initially set up with both randomized and observational cohorts. Crossover was so high between surgical and nonsurgical arms that an analysis measuring outcomes based on patients' initial treatment assignment could find no differences between strategies. Assessing the data based on what a patient actually received did indicate that surgery was beneficial.

Despite these difficulties, experts say the studies may guide physician decision-making and ease patient fears. Notably, most patients will get better. For instance, in the study of sciatica, 16 of the 141 randomized to receive surgery had their procedures canceled because they recovered before having it done. In the lumbar degenerative spondylolisthesis study, medical management patients experienced some symptom improvement even if, as a group, they did not do as well as those who received surgery.

"Patients who are in this kind of pain fear they are going to be paralyzed or that this will lead to them being in a wheelchair. These studies show that, in general, that doesn't happen," said Steven Atlas, MD, MPH, an internist at Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School in Boston. "There are good treatments for these conditions, and one of the options can be surgical, but by no means is that the only option."

An accompanying editorial emphasized that, without an impending urgency for surgery, for patients who do not have major neurological problems, the decision really comes down to the patient's inclination.

"Both surgical and nonsurgical strategies are reasonable options, and patient preferences should play an important role in the decision-making here," said Richard Deyo, MD, MPH, who wrote the editorial. He is a professor of medicine at the University of Washington, Seattle.

But, in light of these studies, along with previously published ones, experts also expressed concern about the increasing rate of spine surgery that varies significantly across the country. Some suggested that not all of these surgeries may be needed. The situation highlights another challenge of managing back pain -- that it's not always clear who is the most appropriate candidate for surgery.

"Is there a group who truly would only benefit from surgery? These studies don't really tell us who they are," said Scott Kinkade, MD, MSPH, assistant professor of family medicine at the University of Texas Southwestern Medical School in Dallas.

Physicians who perform these kinds of procedures challenged the idea that increasing rates or numbers that vary from region to region are indicative of a significant number of unnecessary operations, because it's unknown what the ideal rate should be. Also, although these papers suggest that many patients will get better eventually, for quite a few, a faster recovery makes surgery worth it.

"How much do you enjoy living with the pain? If you don't, surgery is a reasonable, reliable, relatively low-risk option that provides a reasonable amount of benefit," said David Polly, MD, a spokesman for the American Academy of Orthopedic Surgeons and chief of spine surgery at the University of Minnesota. "There is no question that there are some people who would rather go without, but many people benefit from spine surgery."

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Surgery or no surgery, that is the question

Objective: Determine the effectiveness of surgery for degenerative spondylolisthesis.

Methods: Researchers recruited patients with at least three months of symptoms who had the condition confirmed by imaging; 304 patients were randomized to either medical management or a standard decompressive laminectomy, with or without fusion. Another 303 signed up to be in an observational arm.

Results: About 40% of patients who were in the randomized part of the project switched from medical management to surgery or vice-versa. This circumstance meant that an analysis based on the patient's original treatment assignment had little meaning. However, an as-treated analysis of all participants showed an advantage for surgery at 3 months and 1 year, although this began to wane at the 2-year mark.

Conclusions: Patients with the disorder treated surgically showed substantial improvement in pain and function in comparison with those who did not receive the procedure.

Objective: Assess the appropriate timing of surgery for severe sciatica.

Methods: Scientists randomized 283 patients who had experienced sciatic pain for six to 12 weeks to early lumbar disk surgery or conservative treatment with surgery if needed.

Results: Of 142 patients directed towards medical management, 55 eventually had surgery. Of the 141 selected for early operations, 125 ended up having these procedures. No overall difference was found in disability scores. Early surgery patients felt they had recovered after an average of four weeks, but those on medical management waited for 12.1 weeks. After one year, both groups reported similar rates of recovery and resolution of pain.

Conclusions: Patients whose pain is controlled by nonsurgical means may decide to postpone an operation without affecting their chances for recovery at one year.

Source: New England Journal of Medicine, May 31

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