Bad Back, Bad Treatment
June 07, 2016

Bad Back, Bad Treatment

Imagine you suffer from chronic pain. I hope you only have to imagine, because the pain I am describing interferes with your life. You’ve tried just about every treatment you can, without much benefit. Now, what if I offered surgery for your pain? It has some risks, the recovery is long, and you will require months of rehab. At the end we will flip a coin to see if you get better or not.

If you are only imagining this situation, this scenario probably sounds crazy to you, no way are you having surgery with those odds! But if you have lived or are living with chronic back pain (back pain lasting for at least 12 weeks), it might not seem so out-there. You may have even opted for the coin toss and had spinal surgery.

Spinal surgery for chronic back pain is seen as the last hope for many people. After trying physical therapy, medications, and even seeking out alternative methods of care, they find themselves desperate for relief.

This is no small problem. More than 26 million adults aged 20 to 64 experience frequent back pain. And we spend 86 billion dollars a year on bad backs – about the same as we spend on cancer treatment.

But the sad truth is surgery for back pain often fails to provide relief.

Consider spinal fusion. This surgery is appropriate when one vertebra has slipped over the one below it. The surgeon fuses the two vertebrae together to keep them in place. When used in this situation it is successful 80 percent of the time. However, it is becoming more common to perform this surgery for a degenerated disc. After months of rehab and considerable financial cost, a great many find themselves back where they started.

So why doesn’t it work all, or even most, of the time? Usually because the diagnosis never precisely pinpointed the source of the pain. About a third of us have an abnormality in our back that would show up on an x-ray or MRI – but many of the people with the abnormality have no pain whatsoever. This leaves us asking: when surgery is performed for, say, a bulging disc, to reduce back pain – is that disc really the culprit?

Surgeons have incentive to operate. The median salary for an orthopedic spine surgeon is about $736,000 per year. They don’t make bank like that by recommending yoga and regular doses of ibuprofen.

Worse, inappropriate relationships between physicians and medical product firms incentivize surgery. High profile physicians have been fired from various positions for not disclosing their financial arrangements with medical equipment companies. In 2006, Medtronic paid a 40 million dollar settlement to the Department of Justice for paying doctors to use their spinal products. The company admits no wrong-doing. However, Medtronic reported a net income of over one billion dollars in the last quarter of 2015. Forty million dollars isn’t much of an incentive for Medtronic to change anything. It’s just a cost of doing business.

But whatever the financial circumstances, it’s right for a surgeon to operate if surgery is truly indicated and has a good chance of success. Back pain is the number one cause of disability in adults under age 45. Anyone who has lived with it understands it is a miserable experience. A surgery to get them back to normal, or even someplace in normal’s neighborhood, is a godsend.

But if you are a surgeon who truly wants to help a hurting patient or, more nefariously, just wants to fill up your operating schedule, you might be tempted to go ahead and operate even though you don’t have reason to believe it will help all that much. Add a patient who has been hurting for so long he is desperate and it pretty much guarantees a surgery.

This means that a hurting patient must work hard to be sure they know what they are getting.

Before considering surgery, explore all of your options. Keep your primary doctor on board to monitor your status. Rule out some of the big, scary causes of back pain. Anti-inflammatories have been shown to provide some relief for back pain. Avoid narcotics. They are not appropriate for the management of chronic pain. They can quickly lead to their own set of issues - physical dependence and addiction.

Exercise, not rest, is a key component to improving back pain. A licensed physical therapist can help develop a regimen that you can manage.

Research shows mixed results with chiropractic and acupuncture. But the risks are low, so they may be worth a try. Avoid chiropractic manipulation of the neck, however, because it does carry a small risk of stroke.

Finally, a recent study in the Journal of the American Medical Association found that patients who received Bognitive Behavioral Therapy (CBT) or Mindfulness Based Stress Reduction (MBSR) with Yoga had twice as much improvement in back pain as those who sought whatever medical care they would normally receive. Seek out a practitioner skilled in these areas to find a program with the best chance of providing benefit.

If you decide to consider a surgical option the first step is to get two opinions and ask for the research-based evidence that their opinion is right. Get a third opinion if the first two conflict. Choose busy surgeons who specialize in spine surgery. You don’t want a surgeon who needs to fill his operating schedule. You may have to wait longer, but an extra month is a small price to pay for the peace of mind of a good choice.

Sadly, we don’t have all the answers to the chronic back pain issue. This leaves the patient, as in other healthcare situations, making big decisions with incomplete information.

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