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Arkansas Neurosurgery, Brain & Spine Clinic |
Newsletter Library: ANC June NewsletterClinical Neurosciences Grand Rounds #1; May 07. Spine Surgery: A Case for Restraint.There has been an explosion in the number of spinal surgeries and invasive procedures in the last several years across the world. This has paralleled the enormous investment, development and marketing of new and expensive spinal technologies by spine implant companies. These technological developments, when used for the correct indications, have been of unquestionable benefit to a multitude of patients. Unfortunately, much of this explosion has been fueled by the use of these technologically amazing products without adequate indications. Much has been justified by the spine implant companies and many surgeons based on biased studies that are on “very shaky scientific grounds”. Much has been written very critical of many of these procedures not only regarding the tremendous costs but also the risks of adversity both short and long term to the patient while pointing out the lack of clinical efficacy. I have included some of these articles regarding procedures that I feel have been the most controversial. You will have many patients who have questions regarding these procedures and I want to share with you my thoughts and concerns. Our philosophy has always been and will always be to be as conservative as possible and use our surgical skills only when the benefits far outweigh the risks. The largest area of concern is the concept of degenerative disc changes being called and treated as a surgically curable disease. It is not a disease but rather a universal radiological normal finding to some degree in all of us. We do not feel that any form of surgery is indicated for most patients for the diagnosis of “degenerative disc disease”. In fact we wish that no one had ever coined the term degenerative disc “disease”. Disc and facet joint degeneration is a normal aging process just as is graying of our hair. We all have it and in all of us it increases in degree with each and every year. Because there is no good scientific correlation between the radiological presence of disc and facet degeneration and pain there is no way to reliably predict that a patient will benefit from any form of invasive treatment for the spinal degeneration. We respectfully disagree with those who use surgery of any kind as a treatment for patients with back or neck pain and degenerative disc “disease”. There is absolutely no evidence in the literature to support the procedures of spinal fusions, percutaneous discectomy, IDET’s, nor lumbar artificial disc replacements for degenerative disc “disease”. Reports that appear in the literature that claim good results from these procedures for disc degeneration are biased studies that lack proper controls that are required of evidence based medicine. Empirically, these procedures when performed for the indication of degenerative disc disease seem to lead to a never ending spiral of surgeries and more surgeries and chronic pain disorders with major ramifications to the patient, their families, and to society. These patients often end up being put on chronic narcotics by the physicians who have this aggressive philosophy and who continue to recommend further procedures be performed next. The direct and indirect economic costs are staggering in these “failed back” cases. You have undoubtedly had numerous patients ask you about getting an artificial lumbar disc (disc arthroplasty or disc replacement surgery). Due to the aggressive marketing efforts of the spinal implant companies, many patients and health professionals alike have been falsely led to believe that FDA approval means that this surgery has been proven to be beneficial to patients with back pain due to degenerative disc “disease”. Nothing could be further from the truth. Included are some critical assessments that certainly dispel such a myth. In fact the FDA approval came from a study that showed that artificial lumbar disc surgery was no worse than fusion for degenerative disc “disease”. As no there is no evidence based medicine study nor empiric experience to suggest that fusions have any statistical likelihood of benefit to patients with back pain secondary to degenerative disc “disease” it is in our opinion illogical to extrapolate any support for the disc replacement surgery. The proposed benefit to lumbar disc replacement surgery over fusion is that there is an alleged decreased incidence of adjacent segment degeneration. This alleged benefit has not been demonstrated. The risks of the lumbar artificial disc procedure are far greater than the risks for lumbar fusion. Re-operations for artificial discs have been far too frequently needed and fraught with significant morbidity and mortality. Therefore, if one did believe in surgical treatment for degenerative disc disease, which we do not, then there is no evidence that the more dangerous procedure of disc replacement surgery should be used in lieu of fusions. We feel that there are no proven clinical indications for the use of artificial disc surgery at this time. Again we do not support the use of fusions, IDETs, percutaneous discetomies, open discectomies, nor disc replacement surgery for the diagnosis of lumbar degenerative disc “disease” nor disc herniations associated with back pain. There are very good indications to be discussed below for fusions and open/percutanous procedures for sciatica/back pain conditions. There also seems to be a high incidence of lumbar fusions being performed on patients with disc herniations for the treatment of LBP and sciatica when a simple microdiscectomy/decompression would be the treatment of choice if surgery was needed. We would always recommend that the least invasive treatment option be used to treat any spinal condition when possible. Lumbar fusion surgery is however very useful in very specific conditions when conservative options have failed or when the spine is grossly unstable. Lumbar fusion indications include:
There is good evidence based medicine support for the use of spinal fusion surgery in the treatment of the conditions listed above. The outcome from spinal decompression and fusion when used for the above indications in my practice has been extremely good with good outcomes in greater than 95% of patients. These conditions however are far less common than the omnipresent disc degeneration that is so commonly called a “disease” and is associated with a very poor response to any invasive treatment modality. Undoubtedly there is the rare patient that we see maybe once or twice a year that might benefit from some form of procedure for their degenerated disc but the lack of any proven diagnostic method to successfully predict a good response to treatment leads us to the opinion that no surgery at all is far better than failed surgery in so many. The provocative discogram is the most commonly used diagnostic tool by those that believe in degenerative disc changes as a surgically treatable disorder. Unfortunately this test has no proven efficacy in predicting good response to either invasive surgery or minimally invasive percutaneous procedures as there is an understandably high incidence of false positive results i.e. pain experienced in the injection of degenerative discs in normal subjects without any pre-injection spine pain whatsoever. We rarely if ever order such tests as the information obtained is really of no clinical use in most patients. What can be done for these patients with refractory LBP and degenerative changes on MRI? There is only one reasonable option-conservative care. Aggressive spine rehab programs with extensive patient controlled core fitness have been shown to be just as effective as spinal fusions for disc degeneration. Interaction with an experienced physical therapist and/or chiropractor is often helpful. NSAIDS and spinal injections should be tried. Narcotics should be avoided. Other conservative treatment modalities such as acupuncture, tens units etc can be considered. Surgery of any kind including IDETs, open or percutaneous disc surgery, fusion or disc replacement surgery just doesn’t have a role in the vast majority of these patients. Certainly, there will be patients that demand to be treated for whatever reason with surgery. I simply tell them that I can not and will not perform nor recommend a procedure for them that I would not want for myself or my family. In ConclusionSurgery is not indicated for the treatment of LBP and neck pain secondary to degenerative disc “disease” and non-radicular spine pain with disc hernaitions. This includes any surgery-discectomy-open or percutaneously, IDET, laminectomy, fusions or artificial disc replacement. Surgery may be indicated for the treatment of selected cases of spine pain with radiculopathy or myelopathy with spinal stenosis/disc herniations, spondylolisthesis, spine tumors and trauma etc. Additional Resources to Review
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