Article by Simon Bell (osteopath)
When it comes to back pain - long term back pain in particular - the use of surgery as a method of relief has become increasingly popular. However, evidence for the effectiveness of such interventions is far from concrete. So, when and for whom is surgery a useful option? Is your back pain a candidate for the operating table?
Which Type of Surgery?
First, let’s have a look at the type of operations available. Two are commonly used when dealing with back pain: spinal fusion and a type of discectomy/laminectomy. They're fancy words but, essentially, the former involves the fusion of two vertebrae and the latter includes the removal of an affected disc or any bone tissue that may be impacting on nerves. In theory, this relieves the pressure on said nerves and, as a result, removes the source of the pain. Simple! However, this mechanistic approach makes a big assumption; it's an assumption recent evidence is helping us to better understand. Pain may not be the result of tissue damage or a pinched nerve.
The Evidence for Surgery:
Several studies have investigated the effects of surgery on lower back pain. The Spine Patient Outcomes, Research, Trial (SPORT) for example, examined 4 year follow ups of patients who underwent surgery vs those that elected for non operative treatment with diagnosed disc herniations. The researchers actually did find significant differences in subjective pain scores on a 100 point score system, up to 11 points lower (less pain) for patients who underwent surgery. Surgery also demonstrated better relief of symptoms for patients suffering other disc related symptoms such as sciatica and numbness.
Pretty compelling stuff! It seems a surgical procedure such as a discectomy or fusion can be useful for providing sciatic relief and other reducing other types of low back pain. Yet, the question remains: what about other non-invasive treatment options like back physio prescribed exercises for lower back pain or manual therapy? Is surgery always a better option? Well, not exactly.
Some Criticisms:
There are a few issues with the idea of using surgery. Firstly, patients/subjects in the SPORT study were confirmed as having ‘symptomatic’ disc herniations which isn’t the case for the vast majority of back pain sufferers. In some studies, it’s been estimated up to 90% of lower back pain isn’t directly attributable to a disc issue/damage. In addition, the study also confirmed substantial improvements over time in non-surgery patients and an increased likelihood of reporting a negative reaction if the patient ‘crossed over’ from the non-operative group to the operative one (i.e. they chose to have an operation half way through the study). In a separate study, the authors looked at 4 year follow up symptom relief and how likely the patients were to return to work. This study found no real difference whether patients underwent surgery or not!
A 2014 study in the BMJ that looks more generally at back pain as a whole is strongly against the use of surgery as a first line of defence against back pain. It reports a rise in surgery related complications and suggests the use of surgery as a whole for back pain relief has risen dramatically without sufficient evidence for its effectiveness over methods like exercise and manual therapy.
So, What to Make of All This:
Simply put, a lot of positivity! There are loads of studies out there that show improvements for patients with lower back pain with or without the use of surgery. In cases of significant radiculopathy (i.e the numbness, pins and needles & bowel and bladder change symptoms), surgery seems to have an overall better outcome. So, it's still a really useful tool in the management of lower back pain and any good therapist can point their patients in the direction of surgery when needed. But in the vast majority of cases, there are many non-operative options with plenty of evidence as to their ability to help!
Just sticking to exercise is a good recommendation. Recent evidence suggests patients almost always see positive results simply from doing some exercise (no matter what the exercise is) which implies having the will to move is one of the most important factors in pain reduction and regaining pain free movement. In addition to this, several papers have also shown exercise is unlikely to wear out and damage tissue, meaning that it won’t make an injury worse. To the contrary, studies as far back as the 90s have shown less mechanical abnormality in runners vs those who don’t run at all! Perhaps even more supportive of the case for exercise in back pain recovery is the fact the health of your back is actually improved by doing back pain exercise (disc health and size are improved through loading).
Adding even more substance to the case for avoiding the knife are things like manual therapy and psychological management like meditation and sleep quality. All of which have long standing scientific merits for their effectiveness in reducing pain.
When you use Easy Physio, you are choosing to link up with an expert group of specialists who have designed a system tailored to maximise your chances of recovering from pain fast. Our questionnaire, self-assessment process and back pain exercises are all designed as valuable tools to help you! It’s perfectly normal to question your suitability for surgery, I see it all the time when working with patients, but you can take comfort in knowing you’re in safe hands and our experts are available for one-to one-sessions should you require their services.
Visit our website to book a session!
References:
- Belavy DL, Quittner MJ, Ridgers N et al: ‘Running exercise strengthens the intervertebral disc’ Scientific Reports 2017:Vol 7 45975
- Brox JI, Nygaard OP, Holm I et al: ‘Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain’ Ann Rheum Dis 2010;69:1643–1648.
- Gordon R, Bloxham S. A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain. Healthcare (Basel). 2016;4(2):22.
- Keener JD, Skelley NW, Stubbs-Cucchi G et al: ‘Shoulder activity level and progression of degenerative cuff disease.’ J Shoulder & Elbow Surg. 26(9):1500-1507.
- Peul WC, Brendenoord AL, Jacobs WCH ‘Avoid surgery as first line treatment for non-specific low back pain’ BMJ 2014:1-4.
- Shellock FG, Deutsch AL, Mink JH ‘Do asymptomatic marathon runners have an increased prevelance of meniscal abnormalities? An MR study of the knee in 23 volunteers’ AJR AM J 1991 Dec;157(6):1239-41.
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