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Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain

happyHBmomhhappyHBmom Posts: 2,070
edited 06/11/2012 - 8:48 AM in Lower Back Pain
This article should be available to everyone. I am not sure if you have to register with pubmed to see it, but it's the first I've seen that actually randomly assigned people to either get fusion or rehabilitation and then followed people for 4 years!

Outcome was no significant difference in pain or disability after 4 years between the two groups. 25% of those who started in the rehab group went on to get surgery, but 25% of those in the surgical group went on to get a second surgery so even that was no benefit.


Details are in the extended report.


  • HB,

    I just made a Word document out of it for my files. It's kind of a bummer in that I put off my first cervical and did all the 'conservative' methods, for what? 2 more years of ridiculous pain? Argh! Hindsight is 20-20 I guess. (G) I of course know now that spine surgery (especially in fusions) will never 'fix' you, but hopefully the outcome is to improve how bad we've become. :)

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • Studies don't apply very well to individuals in hindsight, because you're trying to apply the general to the specific.

    This study says that in general, there isn't any benefit to fusion over cognitive behavioral therapy for lumbar back pain. Even the interim studies didn't show much benefit, although I think the surgery group might have had slightly less pain at one year.

    It doesn't study cervical surgery. And it doesn't address the other reasons people get back surgery, although there are other studies that do- and most of them say that surgery is unlikely to reduce your back pain much, no matter what is wrong with your back.

    Don't you think that's kind of sad? What is it, 80% of people will have back pain at some point in their life? And after all this time, the surgical procedures they've been using don't really help :(

    I am glad many doctors are now telling their patients this, but I think there are too many who are not.

  • All of those who suffer back pain, (both those in the early acute phase and those in the later chronic phase) do you really think they will be willing to accept a treatment diagnosis that says no surgery? How many have you seen on boards like these who practically beg their docs to send them to a surgeon and then practically beg the surgeon to do "whatever it takes" to fix them. Television has been great for creating the illusion that surgery is a "magic cure" for even the most horrific injuries. How many have you seen on this board and others, who go from doctor to doctor until they find one who will do surgery to "fix them". Of course many find that their magic fix did nothing for the pain which was most likely their main concern.

    Studies are okay to a certain point. However, they are relying on the feedback given by the patients in the study. From day to day things change in the life of a chronic pain patient. How they go about recording the information that is then translated to the study through the doctor or the doctors appointed recorder, can significantly skew the study "results".

    It's kind of like asking 3 fusion patients if they feel their surgery was a success. One will say no, because I still hurt as much. Another will say no, because I have lost the ability to run or lost so much range of motion. A third will say yes, because although I still hurt and have lost some range of motion, my spine is stable and could be a lot worse.

    A patient with cervical myelopathy is a real good one to ask. They may still hurt or may even feel worse, but they are happy because the myelopathy has been kept from getting worse or progressing.

    Anyway, just some random thoughts.

  • Regarding back pain studies, I think you raise some valuable points. There are some newer validity standards for back pain research that I did not really understand, but they do try to control for the challenges to the research validity. But as you said, applying research (general) to an individual is sometimes difficult.

    Regarding your other comment, I know. It's the same as the issue with antibiotics and viral diseases- you can tell people they won't help, but people want someone to fix it, and they want it NOW!
  • to re-iterate this study only included patients with lower back pain from disc patholgy, not any other co-morbid patholgy.

    i think its really important for surgeons to think what benefit is fusion going to have for THIS particulat patient probs.

    i think some fusions were done without a good patient selection, and now they are starting to focus more on the individual" s prob

    yes, lets get realistic outcomes spoken about, far better for all
  • I have looked at so many of those studies and have yet to see one that lends much evidence in my opinion. This studies whole theory stands behind using the oswestry disability index, which is very subjective. For example one of the questions in that survey is sleeping and goes as follows:

    Section 7: Sleeping
    I get no pain in bed.
    I get pain in bed, but it does not prevent me from
    sleeping well.
    Because of pain, my normal night’s sleep is reduced
    by less than 1/4.
    Because of pain, my normal night’s sleep is reduced
    by less than 1/2.
    Because of pain, my normal night’s sleep is reduced
    by less than 3/4.
    Pain prevents me from sleeping at all.
    This question I like the best as with all the stressors of todays busy lives how many people sleep like they would like, with no back injury? I wonder how truthful this answer could be that it is all back pain that is causing patients to loose sleep and how literally patients taking this test read the question?

    That tool was originally designed to help patients in physical rehab and to help the therapist lead their therapy for more successful outcomes. In my personal experience I never seen the chart till I had to have a FCE completed. Also I might add what is the patient comparing it to? I asked a few of my friends those very same questions whom are not injured to see what type of responses I would get, and they certainly didn't score perfect either. One was a busy mom who scored being somewhat disabled. So I guess from my perspective I have issues with those questions to begin with and the mere subjective nature of them.

    I further think a important note is what type of employment did these patients in this study do? Was their job physically demanding, and what was the expectations of surgery to begin with.

    C, brings up a great point on myelopathy the goal of surgery is not to reduce pain, but rather to keep the symptoms from getting worse. Anyone whom has those symptoms knows they don't want them to progress. I think when you look at patients having spinal surgery, you need to look at what is the patients expected outcome of the surgery? You will see some that say to get my old life back, which in all reality what does that mean? Their life when they were 20 or the life they were living prior to surgery? To many patients think that surgery is going to restore them to some unrealistic place they were not able to achieve prior to surgery. But I would question the baseline of the person to begin with? Was it someone who sits and thinks about doing things and not motivated to do things or was it someone whom was a go getter and out doing things?

    For myself I think surgery is all in the eyes of the beholder and their realistic expected outcomes of proceeding with a surgery. I am just not comfortable with any study being able to wrap it up in some nice package and find the variables consistent across the boards. Taking into effect ones mental/emotional state, physical demands prior to surgery and levels of performance prior to what got them in the situation to be needing help for back pain.

    I also except the notion that to many patients want the fast fix as we do in every form of life and with surgery or any treatment modality that wether or not that exist. AS we see on these forums members posting how poorly they are doing post surgery, then you see them gradually stop posting and more than likely they are gradually taking back their life and moving on. So did they get better and what is the comparative to that? Years ago if you had a pinched nerve they would put you in a hospital for a few weeks on bed rest before attempting any surgery, then a surgery might be a two week stay to recover from. While I don't think most of the approaches have changed in the treatment lengths of stay have most certainly. A good example of that can be seen in women bearing children and the old lengths of stay versus now what is the norm. But certainly the means by which babies are delivered still hasn't changed. We just moved the clocks up and expect more now days.

    I do believe we have many whom believe they follow conservative treatment and treatments fails that they will still have to have surgery, and think why waste all that time and resources if the means will still be the same in the end. Now is that right or wrong thinking, not sure I am not living in their shoes or no the pressures they are under in life. But one thing for sure this is "a hurry up world and things are expected so fast". Be it your internet, getting into a doctors, recovering from a surgery or your productive at work or in life.

  • It didn't just use the owetry disability index, that was just the main outcome measure though. And not all studies use that index. And yet, the result turn out the same.

    The question is, is fusion a solution to back pain? And the answer seems to be no, no matter how they measure it.

    Remember that this study compared fusion to a cognitive rehabilitation program geared at increasing function, not to no treatment. So although there is a mental benefit to fusion, the people in the control group also received a benefit. Is fusion really worth it for the mental benefit?
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