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| Text of article from “The Medical Post” December 2003 MONTREAL - Doctors should take a more dynamic approach with slipped disc patients who have traditionally been considered only marginal candidates for surgery, say the results of a new randomized clinical trial. The trial found that patients whose condition was not severe enough to make them clear candidates for surgery but who underwent microdiscectomy surgery improved markedly over those who were treated with only exercise and back pain education. The results of the study were presented at the North American Spine Society's annual meeting held here last month. The society considered the results to be so significant that the paper was chosen as the opening presentation of the five-day conference. The findings are the first clear assessment of the benefits of surgery to mildly disabled patients since a 1983 study that evaluated procedures performed as far back as the 1960s and 70s. The trial's results imply that more patients can benefit from surgery than are currently treated and that back pain as well as sciatica (leg pain)can improve, a departure from traditional practice, said Keith Greenfield, clinical research associate at Frenchay Hospital, UK, who presented the results. Dr. Greenfield and his team from the University of Bristol and the Walton Neurosurgery Centre in Liverpool, found that the group of patients who had the microdiscectomy surgery did better in all outcomes, including disability, leg pain and, surprisingly, back pain than those who did not. The researchers say that it is the first time that such patients have been shown to get relief from back pain, as well as leg pain and that more of them should be offered the surgery. "Our study looked at the type of patient with a slipped disc but who is in the grey area between those who obviously need an operation and those who don't," said Dr. Greenfield, who works with a team of neurosurgeons at Frenchay Hospital, one of the busiest neurosurgery departments in Europe. Many of these people have a lot of clinical uncertainty about whether to have surgery or avoid it. They suffer moderate levels of pain, moderate disability in normal activities, such as walking, sitting, travelling, standing and probably have to take a lot of time off work, he said. "This is a group of patients that risks toppling over into long-term disability with all the economic consequences that that implies," said Dr. Greenfield in an interview. The UK study showed that not only did this type of patient do much better overall when they had surgery, but that they also unexpectedly found significant relief from back pain. "We were not surprised about the improvement in leg pain because the surgery was to take the pressure off one of the nerves in the spinal canal. "But what was most interesting was that the back pain improved as well-and that's not normally expected," said Dr Greenfield. "We know that pressure on nerves causes leg pain, not back pain so the reduction in back pain in this group of patients was a bonus. "That's an exciting finding because it means that more people might be appropriate candidates for the surgery than is realized at present." The trial took 88 patients with low back pain and sciatica, whose MRI scans showed small to moderate lumbar disc herniation. Half were randomly allocated to microdiscectomy, the rest to proactive exercise and education. Patients with obvious indications for surgery, such as major neurological symptoms or severe sciatica, spinal stenosis or previous surgery were excluded. "We took the type of patient with a slipped disc but who is in the grey area between those who obviously need an operation and those who do not need invasive treatment". "An obvious candidate for surgery has severe leg pain or marked weakness in the affected leg, and a scan demonstrating a prolapsed intervertebral disc with significant pressure on a related spinal nerve. "If, on the other hand, the patient's problem is essentially pain in the lower back and the scan reveals no compression of the spinal nerves, then they are not good candidates and should avoid disc surgery. "Patients in this study had a mixture of back and leg pain, with scans showing mild or moderate disc prolapses. There are very significant international and even regional variations in the threshold for embarking on disc surgery, for instance the rate in the USA is more than 10 times that in the UK. Many sufferers don't even get referred to the specialist clinics, but are left alone in the primary care setting," said Dr. Greenfield. All the patients in the study showed improvement but those who had the surgery improved faster and better than those who did not, especially in the first three months, the trial found. "In the study, both groups of people had similar levels of pain and disability at the outset, but the people who had the surgery saw a big drop in their scores of pain and disability in the first three months. From then until 12 months, both groups improved at a slow rate. "Our statistically significant 12-month results suggest that the traditional view that the more the pain is in the back, the less likely surgery will help should be revised." Dr. Greenfield believes that the finding that these 'grey-area patients' do better with back surgery has important health-economic implications for industrialized countries where back pain related disability has increased enormously over the last thirty or so years and is the fastest-growing type of musculo-skeletal disability. "The economic cost in loss of productivity as well as state benefits for back pain patients is enormous. Once a back pain sufferer has been off work for six months, they statistically only stand a 50 per cent chance of ever getting back to paid work. So if nothing is done about it there is a significant chance that that individual will become a financial liability to the state for the rest of their life. Governments are now just coming round to realizing that treating people more quickly will save the country money, he said. "About 80 per cent of costs to the state occurring because of back pain are due to a small percentage of sufferers, about 7 per cent, who become chronically disabled and then require life-long state support. Dr Greenfield and his team now plans to release 2-year results at the International Society for the study of the Lumbar Spine in Vancouver in May. | The above image shows a lumbar spine disc prolapse, the so-called "slipped disc", at the second lowest disc level. Sciatica results from any resulting compression or irritaion of spinal nerves. In about 95% of cases, symptoms of back pain and/or sciatica will resolve satisfactorily with the passage of time. ------------------------------ It is notoriously difficult to predict which patients will improve and which will have pain for an unacceptable length of time without invasive treatment. In the article reproduced opposite, which discussed the results of a research trial of disc surgery, our conclusions that more people (than currently receiving such treatment) may benefit from disc surgery, were reported. One year following treatment, the patients who had received surgery had less residual pain than those who did not have the operation. We subsequently found that the difference reduced with the passage of time and that when assessed 2 years following their treatment, there was no difference in the average pain in the surgery and non-surgery patients. We also assessed other important factors such as disabililty (the ability to perform normal daily activities such as sitting and travelling) and emotional state, and found that results displayed the same converging pattern. -------------------------- These findings, presented at the North American Spine Society and Eurospine conferences, illustrate the importance of providing patients with high quality information about backpain related conditions, options for treatment, and likely outcome, before treatment decisions are made. This is the concept of "informed patient choice" sometimes referred to as "informed consent". This approach is important when dealing with spinal problems. ------------------------------ RECOMMENDATIONS FOR FURTHER READING For further information of academic interest I would recommend a visit to the homepage of "Spine", the leading journal in the field, at www.spinejournal.com which has a search engine and access to abstracts. For patient information I suggest the NORTH AMERICAN SPINE SOCIETY at www.spine.org which has a section aimed at sufferers. It is interesting and relevant that USA treatment protocols are far more dynamic and interventionist than in our NHS, and more equivalent to UK private practice. For high quality and very readable information on evidence based healthcare I strongly recommend BANDOLIER at www.jr2.ox.ac.uk/bandolier which is increasingly read by medical professionals. Finally, on a more lighthearted note, but still heartily recommende for information on some of the perils of healthcare, ckeckout the excellent QUACKWATCH at www.quackwatch.org | |||||
| Keith Greenfield PhD MCSP SRP SpineOnline Bristol Email:kg@spineonline.co.uk Copyright © Keith Greenfield PhD MCSP SRP 2010 | ||||||
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