SPINAL fusion surgeries for chronic low back pain are on the rise, despite the lack of research to back their efficacy, and experts are now calling for tighter guidelines, including a waiting period.
Dr Richard Williams, orthopaedic surgeon and spokesperson for the Royal Australasian College of Surgeons, told MJA InSight that a key regulation should be that patients must wait a period of 12 months before a spinal fusion surgery was performed.
During this time, the patient must undergo aggressive rehabilitation to try to lose weight and reduce their back pain.
“Most patients will recover after these 12 months,” he said. “It’s also the duty of the doctor to set realistic expectations for the patient, and explain that spinal fusion rarely results in having no pain at all. The surgery works for a proportion of patients, not all.”
Dr Williams was commenting on an article published online by the MJA which discussed the controversy around spinal surgery for chronic low back pain. The authors wrote that there was a continued lack of evidence when it came to the benefit of spinal fusion for low back pain.
In 1999, a Cochrane review found there were no published randomised controlled trials which established effectiveness of fusions for chronic pain. A 2005 review was critical of the outcomes measured, saying that the limited evidence on the long-term effects of either surgical decompression or fusion remained a matter of concern, given the numbers and the costs of the surgical procedures being performed.
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The authors wrote that patients were presenting with high expectations of modern medicine, and in many cases there were additional entitlements to monetary gains from workplace injury compensation and third-party incidents.
“There has been a lack of patient-oriented surgical outcomes, and there is a lack of outcomes for most things that we do for chronic low back pain,” they wrote.
While the spinal fusion procedure remains controversial, it would be valuable for spinal surgeons to undertake a national audit of patient-centred outcomes for the procedure, the authors concluded.
Professor Jeffrey Rosenfeld, senior neurosurgeon at the Alfred Hospital and director of the Monash Institute of Medical Engineering, told MJA InSight that there were two main reasons for the increasing rates of spinal fusion surgeries in Australia.
The first was that patient expectations of surgery can often be high, meaning they “lap up” the positive side of the story and don’t hear the negative side, he said.
Should some patients be given a choice between committing to several sessions of physiotherapy, seeing a psychologist and undertaking an exercise regimen to manage their pain, and undergoing a surgical procedure, many will choose the surgery because it feels like the easier option.
“Surgeons can also overemphasise the positives, and this gives the patient the wrong perspective about the surgery,” Professor Rosenfeld said.
Ian Harris, an orthopaedic surgeon at Liverpool and St George hospitals and professor of orthopaedic surgery at the University of NSW, told MJA InSight that the medical community found itself in a difficult position.
Randomised controlled trials were crucial, he said, and should always take place before any treatment became so frequently used. However, as this was never done with spinal fusions, researchers must now attempt to work in reverse and undertake these studies.
“Once a surgery is common place, it becomes a standard of care, and this is not questioned,” Professor Harris said.
He added there was a basic reason for why surgeons persisted in performing spinal fusion surgeries in the absence of evidence.
“Surgeons believe that it’s effective, and this belief comes from their own direct observation of patients.” However, relying on patient observations was inherently risky. “As with any other operation or treatment, we’ll always see that around two-thirds of patients seem to get better. But when there is such a poor evidence base, we can’t assume the surgery is effective,” Professor Harris said.
Professor Rosenfeld said that “the careful and considered selection of patients who may benefit from spinal surgery is the key issue here”.
Professor Harris said that when it came to clear indicators for spinal fusion surgeries to treat chronic back pain, “I don’t know of any”.
“Yes, if a patient has low back pain because they have a tumour or have been in an accident and have a dislocation, these are indicators.” However, if the patient had non-specific, chronic back pain, spinal fusion surgery was not warranted. “There are some invalidated constructs which are being used to justify intervention. The classic one is spinal instability,” he said.
Professor Rosenfeld said that for patients who do not have clear indicators for spinal fusion surgery, a multidisciplinary approach is preferable, which includes managing the psychosocial issues of chronic pain. This involves input from specialists, physiotherapists, chiropractors, clinicians, psychologists and other allied health professionals.
“We need to develop more structured, multidisciplinary pain management and raise the profile and reach of these services. This will often give people better long-term pain outcomes than having multiple spinal surgeries.”