Surgical Treatment

Surgical procedures utilizing conventional approaches have established the merits of decompression of intervertebral disc spaces in the management of LBP syndrome. Surgery will continue to play an important role in the treatment of LBP and sciatica associated with herniated discs and degenerative disc disease.

Surgical treatment may be appropriate for patients with radicular or other neurological conditions in the following circumstances: 1) Their clinical exam demonstrates persistent symptoms and examination findings that prevent resumption of normal activities, and are unresponsive to an appropriate course of active non-surgical treatment; and 2) Diagnostic test findings objectively verify a surgically remediable condition that correlates with the clinical examination; and 3) There is no significant physical and/or psychological co-morbidity that is likely to lead to a poor surgical outcome for the injured worker.

Spinal fusion
Spinal fusion for low back problems such as herniated or painful discs is not recommended unless a specific anatomic site of lumbar instability has been identified. Potential sources of instability include degenerative spondylolisthesis, unstable fracture, and surgically induced instability. Surgical treatment for mechanical low back problems is rarely indicated.

A large study by Dvorak J. et al. reviewed the long-term results of patients that had received surgery for lumbar disc herniations 23. They reported that of the 575 patients studied, 70% still complained of back pain; 83% complained of constant heavy pain; 45% have a residual sciatica; 35% are still under some kind of treatment; 47% are receiving a disability pension and 17% required repeat surgeries.

The authors stated "Based upon the criteria given by Spine as related to justified or unjustified indication, there was no statistical difference in long-term results for surgery as compared to conservative care". "The so-called justified indication for disc herniation neurosurgery does not necessarily imply a good long term result."

The overuse of surgery has been perhaps the single most damaging medical intervention for back pain sufferers. Bigos and Battie reported, "Surgery seems helpful for at most 2% of patients with back problems, and its inappropriate use can have a great impact on increasing the chance of chronic back pain disability. 24"

In a Volvo award winning paper, Waddell reports, "Dramatic surgical success unfortunately only applies to approximately 1% of patients with low back disorders. Our failure involves the remaining 99% . . . for whom the problem has become progressively worse." 25

Saal and Saal supervised care for a group of patients referred by neurologists for surgery. They attempted rehabilitation for these patients and made the following observations: "Surgery should be reserved for those patients for whom function cannot be satisfactorily improved by a physical rehabilitation program . . . Failure of passive non-operative treatment is not sufficient for the
decision to operate." 26 They also reported that, "the premise that operative patients fare better in the first year is contrary to our results, and the notion that surgery is necessary in a patient with a large disk extrusion is not supported in the literature. The presence of a disk extrusion does not adversely effect the outcome of non-operative treatment and should not be used as overwhelming evidence that surgery is necessary.

In 1983, Weber reported that, even in properly selected patients, there is no difference in outcome between surgically and conservatively treated patients at two years. 27

In 1992, Bush et al 28 stated that, "86% of patients with clinical sciatica and radiologic evidence of nerve root entrapment were treated successfully by aggressive conservative management." They reported that, "the intervertebral disc pathomorphology that might seem best suited to surgical resection is in fact that which shows the most significant incidence of natural regression... these results confirm that if the pain can be controlled, nature can be allowed to run its course with the partial or complete resolution of the mechanical factor... lumbar herniated nucleus pulposus can be treated non-operatively with a high degree of success."

Bush et al also stated that ‘Surgery clearly has its place in the treatment of lumbar spine disorders. Conservative care practitioners must be able to select the patients who satisfy the criteria for surgical intervention. These criteria are more strict than previously believed."

::Continued::

in VAX-D Guidelines section of Physicians Forum