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Back Surgery

Useless Surgery 

http://mobile.nytimes.com/2016/08/04/upshot/the-right-to-know-that-an-operation-is-next-to-useless.html?smid=tw-nytimes&smtyp=cur&_r=1&referer=https%3A%2F%2Ft.co%2FsQS0hcyeah

Look to the Brain, not the Back
https://aeon.co/essays/to-treat-back-pain-look-to-the-brain-not-the-spine

The surgical treatment of non-specific low back pain.

  • "The National Institute for Health and Care Excellence has issued guidelines that state fusion for non-specific low back pain should only be performed as part of a randomised controlled trial, and that lumbar disc replacement should not be performed. Thus, spinal fusion and disc replacement will no longer be routine forms of treatment for patients with low back pain. This annotation considers the evidence upon which these guidelines are based."
 2013 Feb;84(349):1-35. doi: 10.3109/17453674.2012.753565.

Decision making in surgical treatment of chronic low back pain: the performance of prognostic tests to select patients for lumbar spinal fusion.


https://www.ncbi.nlm.nih.gov/pubmed/23427903


http://www.nbcnews.com/id/39658423/ns/health-pain_center/t/back-surgery-may-backfire-patients-pain/

27 million adults with back problems A recent report by the Agency for Healthcare Research and Quality, a federal organization, found that in 2007, 27 million adults reported back problems with $30.3 billion spent on treatments to ease the pain. 600,000 Americans opt for back operations each year. But for many like Scatena, surgery is just an empty promise, say pain management experts and some surgeons.
A new study in the journal Spine shows that in many cases surgery can even backfire, leaving patients in more pain.
Researchers reviewed records from 1,450 patients in the Ohio Bureau of Workers’ Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses.
After two years, just 26 percent of those who had surgery returned to work. That’s compared to 67 percent of patients who didn’t have surgery. In what might be the most troubling study finding, researchers determined that there was a 41 percent increase in the use of painkillers, specifically opiates, in those who had surgery.

  • Same story with knee surgery:
    • About 400,000 middle-aged and older Americans a year have meniscus surgery. And here is where it gets interesting. Orthopedists wondered if the operation made sense because they realized there was not even a clear relationship between knee pain and meniscus tears. When they did M.R.I. scans on knees of middle-aged people, they often saw meniscus tears in people who had no pain. And those who said their knee hurt tended to have osteoarthritis, which could be the real reason for their pain. 
  • 85% of pop will develop
    • 2nd MC cause for disability
    • $200 billion /year in US
    • 149 million  Work days lost. 
  • More prone to 
    • Stress
    • Depression
    • Anxiety 
    • Job Dissatisfaction 
    • Self image issues
    • ETC
  • FDA:
    • 50% of single level degenerative disc disease fuion and arthroplasty were a sucess
    • 20% of lumbar spinal fuion patients underwent 2nd surgeries.  

http://mobile.nytimes.com/2016/08/04/upshot/the-right-to-know-that-an-operation-is-next-to-useless.html?smid=tw-nytimes&smtyp=cur&_r=1&referer=https%3A%2F%2Ft.co%2FsQS0hcyeah


Dismal Results for Spinal Fusion Among Patients With Workers' Compensation Claims





Comparison of spinal fusion and nonoperative treatment in patients with chronic low back pain: long-term follow-up of three randomized controlled trials



  • Results

    Of 473 enrolled patients, 261 (55%) completed LTFU, 140/242 patients randomized to receive surgery and 121/231 randomized to receive multidisciplinary cognitive-behavioral and exercise rehabilitation. The intention-to-treat analysis showed no statistically or clinically significant differences between treatment groups for ODI scores at LTFU (adjusted for baseline ODI, previous surgery, duration of LBP, sex, age, and smoking habit): the mean adjusted treatment effect of fusion was −0.7 points on the 0–100 ODI scale (95% confidence interval [CI], −5.5 to 4.2). An as-treated analysis similarly demonstrated no advantage of surgery (treatment effect, −0.8 points on the ODI (95% CI, −5.9 to 4.3). The results for the secondary outcomes were largely consistent with those of the ODI, showing no relevant group differences.

    Conclusions

    After an average of 11 years follow-up, there was no difference in patient self-rated outcomes between fusion and multidisciplinary cognitive-behavioral and exercise rehabilitation for cLBP. The results suggest that, given the increased risks of surgery and the lack of deterioration in nonoperative outcomes over time, the use of lumbar fusion in cLBP patients should not be favored in health care systems where multidisciplinary cognitive-behavioral and exercise rehabilitation programmes are available.

Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State

  • "Back injuries are the most prevalent occupational injury in the United States. Little is known about predictors of lumbar spine surgery following occupational back injury."
  • "42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor. The multivariate model’s AUC was 0.93 (95% CI 0.92–0.95), indicating excellent ability to discriminate between workers who would versus would not have surgery."
  • "Costs relating to occupational back pain increased over 65% from 1996 through 2002, after adjustment for medical and general inflation. Spine surgeries, including those after occupational back injury, represent a significant proportion of these costs and have faced increasing scrutiny regarding effectiveness and efficacy., Spine surgeries are associated with little evidence for improved population outcomes, yet rates have increased dramatically since the 1990s"
PMCID: PMC2729142
NIHMSID: NIHMS127391

Overtreating Chronic Back Pain: Time to Back Off?

  • " over approximately a decade - a 629% increase in Medicare expenditures for epidural steroid injections; a 423% increase in expenditures for opioids for back pain; a 307% increase in the number of lumbar MRIs among Medicare beneficiaries; and a 220% increase in spinal fusion surgery rates. The limited studies available suggest that these increases have not been accompanied by population-level improvements in patient outcomes or disability rates."
  • "Pain complaints are a leading reason for medical visits. The most common pain complaints are musculoskeletal, and back pain is the most common of these. " 
  • "The proportion of office visits attributed to back pain has changed little since 1990"
  • "Positive findings, including herniated disks, are common in asymptomatic people.- In a randomized trial, there was a trend toward more surgery and higher costs among patients receiving early spinal MR than those receiving plain films, but no better clinical outcomes."
  • "National Medical Expenditure Panel Survey showed a 108% increase in opioid prescriptions from 1997 through 2004 (Figure 1b). The combination of increasing use and higher drug prices resulted in a 423% inflation-adjusted increase in expenditure"
  • "The Cochrane Collaboration review of opioids for chronic low back pain similarly concluded that “Despite concerns surrounding the use of opioids for long-term management for chronic LBP, there remain few high-quality trials assessing their efficacy…Based on our results, the benefit of opioids in clinical practice for the long-term management of chronic LBP remains questionable.” In population-based studies, many patients receiving opioids for non-cancer pain have persistent high levels of pain and poor quality of life.
    Ironically, patients with major depression and other psychiatric disorders are more likely than others to initiate and to continue opioid therapy, yet they also are more likely to misuse medication,, and may be less likely to experience analgesic benefit. Although depression and other psychiatric disorders are common among patients with chronic back pain,,- patients with such disorders are commonly excluded from trials of opioid therapy, raising questions about the generalizability of efficacy studies to routine practice."
  • "Some adverse effects of opioid use may be underappreciated, including hyperalgesia,, which may result from changes in the brain, spinal cord, and peripheral nerves.- In short, opioid use may paradoxically increase sensitivity to pain. Hypogonadism is another underappreciated consequence of chronic use, resulting in reduced testosterone levels, diminished libido, and erectile dysfunction."
  • "Despite the limited benefit of epidural injections, Medicare claims showed a 271% increase during a recent seven-year interval (Figure 1c). Facet joint injections increased 231%"
  • "Despite no specific concurrent reports of clarified indications or improved efficacy, there was a 220% increase in the U.S. rate of lumbar spine fusion surgery from 1990 to 2001"
  • "In the state of Maine, the best surgical outcomes occurred where surgery rates were lowest; the worst results occurred in areas where rates were highest"

FDA Drug Safety Communication: FDA requires label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections for pain


https://www.fda.gov/Drugs/DrugSafety/ucm394280.htm


FDA Warns About Dangers of Epidural Steroid Injections for Back Pain. Must Read Before Taking These Steroid




From Dr. Oz! 
--Hey, he's got some good stuff.. 
An In-Depth Investigation: Epidural Steroid Injections


 2001 Dec;15(6):474-83.

[Relevance of nerve blocks in treating and diagnosing low back pain--is the quality decisive?].


 2001 Dec;15(6):418-24.

[Anatomical background of low back pain: variability and degeneration of the lumbar spinal canal and intervertebral disc].


 1993 Jun 15;18(8):1030-43.

Relationship of the dura, Hofmann's ligaments, Batson's plexus, and a fibrovascular membrane lying on the posterior surface of the vertebral bodies and attaching to the deep layer of the posterior longitudinal ligament. An anatomical, radiologic, and clinical study.

https://www.ncbi.nlm.nih.gov/pubmed/8367771

 2016 Apr;20(2):300-9. doi: 10.1016/j.jbmt.2015.06.003. Epub 2015 Jun 9.

Application of neuroplasticity theory through the use of the Feldenkrais Method(®) with a runner with scoliosis and hip and lumbar pain: A case report.

https://www.ncbi.nlm.nih.gov/pubmed/27210847


Back pain? Try some placebo surgery

http://www.smh.com.au/national/back-pain-try-some-placebo-surgery-20160223-gn1xna.html



NY Times 'Useless Surgery' 
http://mobile.nytimes.com/2016/08/04/upshot/the-right-to-know-that-an-operation-is-next-to-useless.html?smid=tw-nytimes&smtyp=cur&_r=1&referer=https%3A%2F%2Ft.co%2FsQS0hcyeah


No Drugs for Back Pain, New Guidelines Say

The American College of Physicians says to use natural and alternative therapies first

https://www.wsj.com/articles/no-drugs-for-back-pain-new-guidelines-say-1487024168


 2006 Apr;88 Suppl 2:21-4.

Lumbar disc disorders and low-back pain: socioeconomic factors and consequences.

  • https://www.ncbi.nlm.nih.gov/pubmed/16595438
  • "The total costs of low-back pain in the United States exceed $100 billion per year. Two-thirds of these costs are indirect, due to lost wages and reduced productivity. Each year, the fewer than 5% of the patients who have an episode of low-back pain account for 75% of the total costs. Because indirect costs rely heavily on changes in work status, total costs are difficult to calculate for many women and students as well as elderly and disabled patients. "

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