THE decision to consider back surgery should always come after trying non-surgical or “conservative” options - you might talk to your doctor about surgery when the pain is persistent and clearly related to a mechanical problem in the spine, says the July 2014 issue of the Harvard Medical School Harvard Men’s Health Watch.
While there are a variety of procedures for spine-related back problems, spinal fusion has become the 800-pound gorilla in the room during any discussion of back surgery, adds the health letter.
In spinal fusion, the surgeon joins two adjacent vertebrae (the large bones of the spine) to form a single unit, which may involve metal screws and rods to stabilize the spine - a common indication for fusion is spondylolisthesis, a misalignment of the vertebrae.
Unfortunately, spinal fusion, a major operation that often fails to offer a lasting solution, has become the poster child for expensive, risky and unnecessary back surgery - in spite of this, the number of spinal fusion has risen sharply over the years, says the health letter.
Dr. Steven Atlas, an associate professor of Medicine at Harvard Medical School, says, “Based on the evidence, the indications for fusion are few and far between, but that doesn’t stop surgeons from doing them or patients from getting them.”
But men with aging spines should be wary of fusion and its false promises, he adds.
While, in some cases, the spine may show signs of changes that potentially could explain the pain - such as breakdown of the cushioning spinal disc between the vertebrae - sometimes it’s difficult to clearly trace the pain to a specific cause.
“You can say that half of those who have fusion will have specific pain relief, but flipping a coin is not such a great thing,” Dr. Atlas says.
“Your pain is typically reduced by 50 percent,” Dr. Atlas says, “but there are very few people who really have no pain after spinal fusion.”
The relief may last only a few years before the condition worsens again.
Another concern about fusion is that joining the vertebrae transfers the motion of the spine to the adjacent joints - this can speed up the wear-and-tear in those other locations.
An intense, long-term rehabilitation program to control pain and maintain function works, as well as fusion, but doesn’t involve surgery and the risk of complications - “For people with nonspecific low back pain in their 40s, 50s and 60s, conservative measures are hard to beat,” says Dr. Atlas...“and if new procedures become available, you are still able to have them.”
Unfortunately, high-quality back rehab programs involving a team of specialists can be expensive - and health insurance may not fully cover it, while surgery is generally paid for if a doctor signs off on it.
Spinal surgery may be indicated in:
• Damaged discs - If the pain can be traced to a specific spinal disc, the prospects for surgery improves - but, in this case, the right repair is not fusion; it is usually a procedure called discectomy.
As spinal discs stiffen and start to break down, a) the sides may protrude outward, pressing on nearby nerves or b) the walls sometimes split open (herniate), allowing the softer, gelatinous material inside to squeeze outward and press on adjacent nerves.
The telltale sign of a disc problem is sciatica - pain that radiates down the buttock, thigh, back of the leg, or calf - for new disc pain, conservative care is the best first step.
If sciatica persists or worsens despite conservative care, you might consider discectomy to relieve pain by removing the portion of the disc pressing on nearby nerves.
However, studies suggest that a year of conservative therapy is about as effective as discectomy - thus, the decision to have discectomy depends on whether you prefer more immediate relief, adds the health letter.
• Spinal stenosis- A common problem in the aging spine, stenosis means the space around the spinal cord has narrowed due to bulging discs and overgrowth of bone and ligaments - this narrowing presses on the nerves and causes pain.
The signs of stenosis include:
1) pain when standing that gets better when you sit down
2) pain that gets worse when you lean back but decreases when you lean forward
3) pain in the groin, buttocks and upper thigh but not radiating pain down the back of the legs.
If conservative measures such as pain relievers and physical therapy fail to provide relief and it affects your ability to get around, surgery may be worth considering.
The most common procedure for stenosis is called laminectomy which involves removing the bony plate (lamina) on the back of a vertebra - this opens up more space for the spinal nerves.
“It’s a simpler procedure that is just as effective but safer than fusion, with 80% to 90% relief of pain,” Dr. Atlas says.
• Spondylolisthesis - is a condition where a vertebra has slipped forward with respect to its neighbor, resulting in spinal stenosis.
“If you can’t see that on an X-ray and you have spinal stenosis, you should be having a laminectomy,” Dr. Atlas says.
“If your doctor is recommending spinal fusion even though you have no spondylolisthesis, get a second opinion.”
Dr. Atlas warns that older individuals should be especially wary of “complex” fusions that involve more than two vertebrae being joined with hardware, instead of a simple laminectomy - the risk of death rises from around two to three deaths for every 1,000 procedures to 10 to 20 deaths per thousand, which is a significant jump.
For new back pain or a recurrence of an existing back pain condition, these measures are offered before surgery:
• Wait - The most time-tested cure for back pain is time itself - oftentimes, back pain gets better on its own.
However, don’t wait to see a doctor if you have “red flag” symptoms with back pain, such as fever or loss of bowel or bladder control, warns the health letter.
• Apply ice and heat - In the early or “acute” stage of a bout with back pain, ice can numb the pain and ease swelling (inflammation) of the injured tissues.
After a few days, heat may provide more comfort, get the blood flowing in the injured area, and reduce stiffness.
• Take pain relievers as needed - Over-the-counter pain relievers ease discomfort and some also reduce inflammation - Acetaminophen (Tylenol) is gentle on the stomach but does not reduce inflammation; an anti-inflammatory pain reliever like ibuprofen (Advil, Motrin), naproxen (Aleve), or aspirin is the other option.
• Stay physically active - During the acute phase, short periods of bed rest or sitting may be helpful, but extended bed rest isn’t - keep moving as much as you can manage: the movement will help to keep you functioning.
• Stretch and strengthen gently - As the intense pain subsides, introduce gentle stretching and strengthening exercises - ask your doctor or a physical therapist for detailed guidance.
Thus, since spinal fusion (like any surgical procedure) comes with risks, as well as potential benefits, instead of rolling the dice with “last resort” surgery, make sure you know what’s causing the pain and whether fusion is a reasonable option, the health letter concludes.