But Spinal Fusion Isn't Needed, Researcher Says
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Reviewed By Louise Chang, MD
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Feb. 20, 2008 -- Surgery is more effective than other treatments for one of the most common causes of serious back pain in older adults, new research shows.
About 400,000 Americans over the age of 60 suffer from spinal stenosis, a condition where the spinal canal narrows, pinching the nerves within the spine.
Symptoms of spinal stenosis of the lower spine can include lower-back pain with radiation to the buttocks and legs, numbness and weakness in the lower extremities, and problems with bladder, bowel, or leg function.
Treatments range from drugs to reduce inflammation and relieve pain to physical therapy to spinal surgery with or without fusion.
Spine Surgery Without Fusion
The newly reported findings, published in the Feb. 21 issue of The New England Journal of Medicine, are part of the Spine Patient Outcomes Research Trial (SPORT), a five-year-long study funded by the National Institutes of Health (NIH) designed to examine surgical and nonsurgical treatments for the most common back conditions.
Researchers compared outcomes among more than 650 surgically and nonsurgically treated patients with spinal stenosis.
Nine out of 10 surgically treated patients had a decompression procedure without fusion, in which bone and soft tissue are removed to relieve pressure on compressed nerves.
Three months after treatment, surgically treated patients reported less pain and greater physical function than the patients who did not have surgery, and they continued to report better outcomes over two years of follow-up.
The findings show that minimally invasive spinal surgery can be a highly effective treatment for patients with spinal stenosis, lead researcher James N. Weinstein, DO, of Dartmouth Medical School, tells WebMD.
"Spinal stenosis is the most common reason for spinal surgery in people over 60, and this study tells us that most of them will do quite well by relieving the pressure with decompression alone," he says.
But patients are increasingly getting more expensive and invasive fusion surgeries, which take longer to recover from and have a higher rate of complications, Weinstein says.
His research, published in 2006, showed that Medicare spending for lower spine fusion surgery increased by 500% in just over a decade, from $75 million in 1992 to $482 million in 2003.
By 2003, spending for fusion surgery accounted for 47% of all Medicare dollars spent for back surgery, compared with 14% in 1992.
Surgery Not the Only Option
In part of the study, 289 patients were randomly assignedto have surgery or nonsurgical treatments, including physical therapy and pain management.
But after two years, only 67% of the patients assigned to surgery had had the decompression procedure, and 43% of patients assigned to nonsurgical care had opted for surgery.
Another part of the study included 365 patients for whom no specific treatment was assigned. These patients were followed on their choices of surgical or nonsurgical treatment.
Though the surgically treated patients fared better in terms of pain and function in the combined analysis of both study parts, the researchers reported little evidence of harm from either treatment.
Surgery-related complications were uncommon, and patients treated without surgery showed some improvement over the two-year follow-up.
"Often patients fear they will get worse without surgery, but this was not the case for the majority of patients in the non-surgical group, who, on average, showed small improvements in all outcomes," the researchers write.
The message is clear, Weinstein says: Patients need to understand that surgery is not the only treatment option for spinal stenosis.
"Surgery is an elective procedure for this condition," he says. "Some patients find that they can live with their symptoms, and others find they can't. It is up to the physician to provide the information the patient needs to make an informed choice."
Clinician and back pain researcher Richard Deyo, MD, agrees.
Deyo is the Kaiser Permanente professor of evidence-based family medicine at the Oregon Health and Science University in Portland.
"The key is for patients to understand their choices and to understand what to expect from those choices," he says. "If they are well informed and clearly have a preference, this study finds that either surgical or nonsurgical treatment is a reasonable choice."
SOURCES: Weinstein, J.N., The New England Journal of Medicine, Feb. 21, 2008; vol 358: pp 794-810. James N. Weinstein, DO, department of orthopedics, Dartmouth Medical School, Hanover, N.H. Richard Deyo, MD, MPH, Kaiser Permanente Professor of Evidence-Based Family Medicine, Oregon Health and Science University, Portland. American Association of Neurological Surgeons web site. Weinstein, J.N., Spine, Nov. 1, 2006; vol 31: pp 2707-2714.
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