STAYING HEALTHY
Surgery to relieve back pain is often unnecessary and
unsuccessful.
Below, some questions to ask and some alternatives to the surgeon's knife.
"Doc, do something--fast!"
By Katarzyna Wandycz
SOME 200 million Americans suffer from back pain at some point in their lives; every year almost half a million of them undergo surgery to relieve the pain. Yet several recent medical studies have concluded that many patients who elect back surgeries don't need them.
For example, an article in the medical journal Spine stated that as many as 70% of those who underwent back surgery still suffered from back pain for up to 17 years after the surgery.
How does one know if one needs surgery? If you are in such excruciating pain that you cannot tolerate it, then you probably need surgery. This is especially true if the pain extends from your back down into your legs. This means there is pressure on the root of the nerve going out of your spine into the legs. There are drugs to alleviate such pain; Upjohn's Ansaid helps reduce inflammation and pain in the spine. Exercise, too, often helps. But if so-called conservative care--drugs or physical therapy--hasn't brought relief within six weeks, doctors will usually recommend surgery.
How successful the surgery will be depends on what's causing the pain. The most frequent reason for back surgery is a ruptured, or herniated, disk. A disk is an oval-shaped shock absorber that's situated between the bones that make up the vertebrae. The disk has a nucleus made of a thick, jelly-like substance; ligaments wrap around and contain the nucleus. But when these ligaments tear, part of the nucleus bursts out and flows into the spine, putting pressure on the nerves in the spinal column and causing pain.
The disk may rupture simply as a function of age. But disks can also be ruptured by a sudden trauma--yanking on a stubborn lawnmower engine cord, say--or by repeated twists and turns of the body-playing tennis, for example, or skiing moguls.
Of the half million back surgeries performed every year in the U.S., over 300,000 are to remove parts of ruptured disks or whole disks. These are the most straightforward back operations; about 90% of them are successful, says Garth Russell senior surgeon at the Columbia Spine Center in Columbia, Mo. The patient stays in the hospital for three days and goes home pain-free. The cost of such an operation ranges from $5,000 to $12,000, including the hospital stay.
But Russell says that as many as 90% of people who suffer herniated disks would be cured equally well with physical exercise or medication. Why then do so many elect surgery? Because the exercise and medication relief take weeks or months, and people with back pain want immediate relief. Says Russell: "Patients come in and say: ‘Doc, do something-fast! I want to get back to work, I have payments on my house, I want surgery.' "
Adds Joel Press, an assistant professor of physical medicine and rehabilitation at Northwestern University's medical school: "I was treating eight cardiologists with ruptured disks, and seven of them chose to undergo surgery." At the $1,000 a day the average U.S. cardiologist earns, it makes economic sense to get back to work as fast as possible.
Much less straightforward than ruptured, or herniated, disk problems are cases where patients suffer chronic back pain caused by degenerative disk disease. In such cases the patient may not feel any pain in his or her legs, but may experience excruciating pain in the back. What happens is that as the disk degenerates--that is, grows old--it releases a substance that irritates the nerve roots, causing pain. Surgeons can correct the problem by fusing two or more vertebral bones together; the joint doesn't move, the disk becomes inactive and stops producing the irritating substance that was causing pain.
Sounds simple enough, but it isn't. Columbia Spine's Russell estimates that of the 150,000 operations performed every year in the U.S. to fuse vertebrae, fully one-third will fail to ease the patients' pain.
A herniated disk can cause excruciating pain.
Your disk can rupture by itself as you age. But it can also rupture from
sudden trauma--say, when you yank on a stubborn lawnmower engine cord.
The problem with degenerative disks is that doctors cannot be sure what is actually causing the pain. A herniated disk shows up on X rays and CAT scans and gives doctors something to go after; hence the 90% success rate for ruptured disk removal operations. But with degenerated disks there are no good tests to determine that pain is actually coming from the disk-X rays or CAT scans don't show them. And if it turns out that a degenerated disk isn't the cause, then fusing the vertebrae does nothing.
“It's extremely frustrating," says Russell. "The same operation may work on one patient, and be a complete failure with another."
For patients who have tried surgery, drugs or physical therapy without success, there are numerous other treatments, including the relatively new prolotherapy (see box) offered by pain clinics around the country. If you want to work on preventing back pain by living a healthy lifestyle and doing the right exercises, call 1-800-824-BONES. The service is run by the American Academy of Orthopaedic Surgeons, in Rosemont, Ill. The Academy will send you a free "Lift It Safe" brochure.
Here are some of the Academy's recommendations:
PENNY SWEEZEY, the 42-year-old president of Dallas' Accurate Research Inc., suffered from lower back pain for six years. She underwent five painful--but unsuccessful—back surgeries, costing $575,000 (including medication, physical therapy and back braces): Insurance covercd $500,000. "I was at my wit's end," she says.
Then one of Sweeney's employees told her about a treatment for lower back pain called "prolotherapy." Sweezey went through the treatments, spent a total of $20,000 (including travel expenses for several trips between Dallas and Houston) and is now back at work full time. She still feels some pain occasionally but is able to climb stairs and drive a car.
Back pain is often the result of damaged ligaments that can't keep vertebrae tightly in place. When a person moves and spinal bones move out of alignment, they irritate the nerves and create pain.
Pioneered in the early 19th century by French physician Alfred Velpeau to treat hernias, prolotherapy has lately been used to treat back pain. It involves injecting an irritating, natural substance into the ligaments. The body responds by sending healing cells--like sending in a maintenance crew to reinforce the under-girders on a bridge. As healing cells arrive, more tissue is produced, strengthening ligaments that serve as support for the joints. Prolotherapy treatment requires 12 to 30 sessions, involving between 10 and 30 injections.
How effective is prolotherapy? In 1987 the Lancet, a respected British medical publication, reported that 35 out of 40 patients in an experimental prolotherapy group showed greater than 50% improvement. Another study published in the U.S.' Journal of Spinal Disorders this February found similar results.
But prolotherapy is relatively untested and therefore controversial. Only about 250 doctors in the U.S. perform the treatment. "I don't think it's fair to use that type of treatment on patients," says Carol Warfield, assistant professor of anesthesia at Harvard Medical School.
Warfield and other back pain specialists with whom FORBES discussed prolotherapy questioned how prolotherapists know where to inject the substance, since the weakening in the ligaments doesn't show on X rays. The skeptics fear that if the prolotherapy irritant is injected too closely to the nerves, it may damage the nervous system. In fact, Lancet reported that in the 1950s there had been three cases of paralysis and two deaths of patients undergoing the treatment.
Doctors who have been successfully treating patients with prolotherapy say the injected solution has been altered over the years, and they haven't seen damage from it over the last 30 years.
Should you or shouldn't you? It's a tough call, but we'll note this: In researching this article, FORBES spoke to ten people who had undergone prolotherapy. They all said they felt better. If you suffer from chronic back pain, you may want to talk to your physician about prolotherapy.
- SUZANNE JENNINGS
Originally printed in Forbes - December 6,1993