The Faulty Rationale for Most Surgery for Back Pain

Spinal Surgery for Back Pain

About 500,000 Americans undergo surgery each year for low back pain alone. The number of spinal surgeries has been steadily increasing in recent decades. In just one five-year period, from 1997 to 2002, the annual number of spinal surgeries more than tripled, from 317,000 to more than 1 million.[1]

Even before these increases, back surgery rates were two to five times higher in the United States than in other industrialized nations.[2]

Many of these surgeries are unsuccessful and result in worse outcomes for the patients. This is likely because of the faulty rationale behind many back surgeries.

Failed back surgery syndrome (FBSS) is a term used to describe the persistence or recurrence of low-back pain after spinal surgery. Research has shown that the more surgeries a patient has, the less likely an operation is to successfully relieve pain.

In one study, the success rate for initial surgeries was over 50%; success of second surgeries was 30%; third surgeries 15%; and fourth surgeries 5%.[3]

Different kinds of spinal surgery have differing success rates, with the worst success rate in spinal fusion. One review found that the failure rate of lumbar fusion surgery was between 30% and 46%; disc surgery, 19% and 25%; and decompression surgery for spinal stenosis, 35% and 36%.[4]

Another review noted that, despite advances in surgical technology, there has been no decline in the rate of failed back surgery.[5]

According to two randomized controlled trials of disc surgery, the short-term outcome for surgery was superior to nonsurgical management; however, two years later the nonsurgical group had outcomes similar to those of the surgical group.[6],[7]

Authors of a 2002 systematic review of disc-replacement surgery were unable to find reports of any controlled trials. They found the evidence on effectiveness so sparse and the complication rates so high that they recommended that total disc replacements be considered experimental procedures used only in “strict clinical trials.”[8]

Surgery may not only fail to help but it can also worsen the patient’s condition by creating spinal instability or misalignment, injuring nerve roots, or tearing the covering of the spinal cord, or because of wound infection.[9]

MRIs Don’t Accurately Identify the Source of Back Pain

People with chronic back pain are often sent for MRIs and when degenerative, bulging or herniated discs are found, surgery is often recommended. However, these disc “abnormalities” might not have anything to do with the pain.

The relationship between spinal abnormalities, often targeted with surgery, and low-back pain has long been controversial. Over a period of more than 20 years, between 1984 and 2005, many MRI and CT scan studies were conducted on asymptomatic people from all walks of life.

All of these studies found a large percentage of people with disc bulges or protrusions (contained herniations) or degenerated discs who had no back pain.

For instance, a 1990 MRI study of asymptomatic adults found that of those younger than 60, 22% had herniated discs, 54% had bulging discs, and 46% had a degenerative disc.

The same study found that among asymptomatic adults older than 60, 36% had a herniated disc, 79% had a bulging disc, and 93% had a degenerative disc.[10]

A 1994 study evaluated the frequency of abnormal MRI scans of the lumbar (lower) spine in people without back pain. Only 36% of the 98 asymptomatic participants had normal discs at all levels. The older the individual, the more likely he/she was to have structural abnormalities of the spine.

The authors of the study concluded that given the high prevalence of abnormal findings in asymptomatic individuals and the high prevalence of back pain, the discovery of disc abnormalities in people with back pain may frequently be coincidental, and have nothing to do with their back pain.[11]

Finding that more than 90% of lower-spine MRIs in adults are abnormal, authors of a 1997 review of MRIs for back pain came to similar conclusions.[12]

The hypothesis that those with abnormal findings would soon develop back pain was disproved in a 2001 study that followed studied individuals for seven years. The findings on the initial MRIs did not predict the development or duration of low-back pain.[13]

When Back Surgery Might Be Necessary

Surgery should be considered when a herniated disc squeezes a nerve in the back that causes pain from the buttock to the toes and there is numbness, weakness, muscle shrinkage, and reduced reflexes, along with loss of control of urination and defecation.

Similarly, surgery should be considered when a herniated disc presses upon a nerve in the neck and causes numbness, weakness, reduced reflexes, and muscle shrinkage in the arms and hands.[14]

Even when some of these signs and symptoms are present, surgery may not relieve the pain if the herniated disc is not the true source of the problem.[15]

Another instance in which surgery might be considered for back pain is when the spine is unstable because of slippage of the vertebrae, a condition known as spondylolisthesis. Too much movement of the vertebrae back and forth can cause pain.

Small amounts of movement back and forth may not be the real cause of the pain, and spinal fusion, the recommended procedure for this problem, may cause more problems later on because of the stress a partially immobilized spine puts on other parts of the spine.[16]

What Really Causes Back Pain?

Common causes of chronic back pain include:

Chronic emotional stress
Muscle imbalances
Trigger points
Poor posture
Muscle weakness, stiffness or spasm
Nerve impingement due to spinal subluxations
Central sensitization (where the brain keeps sending pain signals despite the injury being healed)
Poor nutrition
Infection
Toxicity

The Most Ignored Cause of Back Pain and Failed Back Surgery

Chronic emotional distress from past trauma or ongoing life stressors can cause chronic muscle tension, restricted blood flow to the extremities and suppression of healing and bodily maintenance. These factors can both cause pain and interfere with surgical recovery.

Studies have shown that psychological factors predict disability due to low-back pain better than structural abnormalities.[17] Patients with significant levels of anxiety or depression or who have poor coping skills or somatization (conversion of emotional distress into physical symptoms) have poor outcomes for spinal surgery.[18],[19]

An association has also been seen between the presence of a workers’ compensation claim and poor surgical outcome.[20],[21],[22],[23] The latter may be due to the extreme stress associated with being on workers’ compensation, more than a desire to not work and to collect benefits.

A 1992 study of 86 patients who had lumbar spine surgery found a highly significant correlation between unsuccessful surgery and a history of childhood trauma. The more types of childhood trauma experienced, the higher the rate of unsuccessful surgery.

Patients in the study had psychiatric evaluations to determine the presence or absence of five types of childhood trauma: physical abuse, sexual abuse, alcohol or drug abuse by a primary caregiver, abandonment, and emotional neglect or abuse.

Patients with no childhood trauma had a surgical success rate of 95%. Patients with one type of childhood trauma had a success rate of 75%. With two types of trauma, patients’ surgical success rate declined to 43%. Those with three types of childhood trauma had a 20% success rate; with four types, 7%; and with five, 0%.

The authors recommended a preoperative psychological review, and suggested that if three or more psychological factors are present, surgery should be avoided “unless there is overwhelming spinal pathology.”[24]

A study published in 1998 found that experienced British spinal surgeons subjectively identified psychologically distressed patients only 26% of the time.[25]

A study published in 2000 evaluated how well a presurgical screening instrument could predict whether a spinal surgery would be successful.

Presurgical psychological screening (PPS) was performed on 204 spinal surgery patients to evaluate the presence of psychological and medical risk factors for each patient, and a surgical prognosis of good, fair, or poor was determined.

The PPS predicted poor surgical outcome with 82% accuracy. Of 53 patients predicted to have a poor outcome, only 9 achieved fair or good results from their surgery.[26]

A 2017 study also found that patients with psychological distress has poorer outcomes from lumbar spine surgery.[27]

Despite all the evidence of the importance of psychological factors in surgical success, a 2012 U.S. study found that only 37% of surgeons responding to a survey used presurgical psychological screening.

Use was highest among those in practice more than 14 years and those who performed more than 200 surgeries annually.[28]

What Helps Back Pain

Successful intervention for back pain occurs when the true cause of the pain is identified and treated. As noted above, often the cause is inaccurately identified as disc disease and patients not only suffer from failed back surgery but also don’t get the treatments they really need.

Treatments that successfully resolve back pain include:

All of these therapies are safe and are effective if targeted correctly. When multiple factors are contributing to pain, multiple therapies may be needed to fully address the problem.

Find Providers Who Can Help Relieve Back Pain Naturally

The author, Cindy Perlin, is a Licensed Clinical Social Worker, certified biofeedback practitioner and chronic pain survivor. She is the founder and CEO of the Alternative Pain Treatment Directory and the author of The Truth About Chronic Pain Treatments: The Best and Worst Strategies for Becoming Pain Free. She’s located in the Albany, NY area, where she has been helping people improve their health and emotional well-being for over 27 years. See her provider profile HERE.

Related Articles:

Effectiveness of Surgery for Back Pain, Knee Pain and More

Low Back Pain Treatment: What Works?

Back Pain Relief Without Drugs

Reduce Back, Neck and Shoulder Pain With These Stretches

This article originally appeared at https://www.paintreatmentdirectory.com/posts/the-faulty-rationale-for-most-surgery-for-back-pain and is being reprinted with the permission of its author, Cindy Perlin, LCSW. Find out more about Cindy and his work at https://www.paintreatmentdirectory.com/about-us.

References

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[2] Cherkin, D. C., Deyo, R. A., Loeser, J. D., Bush, T., & Waddell, G. (1994). An international comparison of back surgery rates. Spine, 19, 1201–6.

[3] Nachemson, A. (1993). Evaluation of results in lumbar spine surgery. Acta Orthop Scand, 251, 130–3.

[4] Chan, C. & Peng, P. (2011). Failed Back Surgery Syndrome. Pain Medicine, 12, 578.

[5] Burton CV. (2006). Failed back surgery patients: The alarm bells are ringing. Surgical Neurology, 65, 5–6.

[6] Peul, W. C., van Houwelingen, H. C., van den Hout, W. B., et al.; Leiden-The Hague Spine Intervention Prognostic Study Group. (2007). Surgery versus prolonged conservative treatment for sciatica. New England Journal of Medicine, 356, 2245–56.

[7] Peul, W. C., van den Hout, W. B., Brand, R., Thomeer, R. T. W. M., & Koes, B. W. (2008). Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: Two year results of a randomized control trial. British Medical Journal, 336,1355–8.

[8] deKleuver, M., Oner, F. C., & Jacobs, W. C. (2003). Total disc replacement for chronic low-back pain: background and a systematic review of the literature. European Spine Journal, 12(2),108-16.

[9] Wilkinson, H. A. (1992). The Failed Back Syndrome (2nd ed.). New York: Springer-Verlag.

[10] Boden, S. D., Davis, D. O., Dina, T. S., Patronas, N. J., & Wiesel, S. W. (1990). Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. Journal of Bone and Joint Surgery AM, 72, 403-8.

[11] Jensen, M., Brant-Zawadzki, M., Obuchowski, N., Modic, M., Malkasian. D., & Ross, J. (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine, 331(2), 69-72.

[12] Zimmerman, Robert D. (1997). A Review of Utilization of Diagnostic Imaging in the Evaluation of Patients with Back Pain: The When and What of Back Pain Imaging. Journal of Back and Musculoskeletal Rehabilitation, 8, 125-33.

[13] Borenstein, G., Boden, S. D., Wiesel, S. W., et al. (2001). The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic individuals: A 7-year follow-up study. Journal of Bone and Joint Surgery AM, 83, 320-34

[14] Marcus, Norman, M. D. (2012). End Back Pain Forever: A Groundbreaking Approach to Eliminate Your Suffering. New York, Atria Books, 45.

[15] Marcus. End of Back Pain Forever. Atria.

[16] Marcus. End of Back Pain Forever. Atria.

[17] Carragee, E. J., Alamin, T., Miller, J. L., & Carragee, J. M. (2005) Discographic, MRI and psychosocial determinants of low-back pain disability and remission: A prospective study in patients with benign back pain. Spine Journal, 5, 24–35.

[18] Celestin, J., Edwards, R. R., & Jamison, R. N. (2009). Pretreatment psychosocial variables as predictors of outcomes following lumbar surgery and spinal cord stimulation: A systematic review and literature synthesis. Pain Medicine, 10, 639–53.

[19] Mannion, A. F. & Elfering, A. (2006). Predictors of surgical outcome and their assessment. European Spine Journal, 15, S93–108.

[20] Bosacco, S. J., Berman, A. T., Bosacco, D. N., & Levenberg, R. J. (1995). Results of lumbar disc surgery in a city compensation population. Orthopedics, 18, 351–5.

[21] Klekamp, J., Mccarty, E., & Spengler, D. M. (1998). Results of elective lumbar discectomy for patients involved in the workers’ compensation system. Journal of Spinal Disorders, 11, 277–82.

[22] Taylor, V. M., Deyo, R. A., & Ciol, M, et al. (2000). Patient-orientated outcomes from low back surgery: A communitybased study. Spine, 25, 2445–52.

[23] Waddell, G., Main, C. J., Morris, E. W., Di Paola, M., & Gray, I. C. M. (1984). Chronic low-back pain, psychologic distress, and illness behaviour. Spine, 9, 209–13.

[24] Schofferman, J., Anderson, D., Hines, R., Smith, G., & White, A. (1992). Childhood Psychological Trauma Correlates with Unsuccessful Lumbar Spine Surgery. Spine, 17(6), S138-144.

[25] Grevitt, M., Pande, K., O’Dowd, J., & Webb, J.(1998). Do first impressions count? A comparison of subjective and psychological assessment of spinal patients. European Spine, 7, 218-223.

[26] Block, A., Ohnmeiss, D., Guyer, R., Rashbaum, R., & Hochschuler, S. (2001). The use of presurgical psychological screening to predict the outcome of spine surgery. The Spine Journal, 1(4), 274-282.

[27] Amaral V, Marchi L, Martim H, Amaral R, Nogueira-Neto J, Pierro, Oliveira L, Coutinho E, Marcelino F, Faulhaber N, Jensen R, Pimenta L. (2017) Influence of psychosocial distress in the results of elective lumbar spine surgery. Journal of Spine Surgery, Sep 3(3):371-378.

[28] Young, A. K.., Young, B. K., & Riley, L. H. 3rd. (2012). Skolasky Assessment of Psychological Screening in Patients Undergoing Spine Surgery, Journal of Spinal Disorders and Techniques.