A knife in the back; is surgery the best approach to chronic back pain?(Annals of Medicine)

Surgeons have often touted procedures that ultimately proved to be disappointing. In the nineteen-fifties, many patients with angina and coronary-artery disease had an operation that involved tying off an artery that runs under the sternum. The idea was that it would increase the flow of blood to a heart that was being starved of its normal supply. Then, at the end of the decade, a clinical trial demonstrated that patients who underwent a sham operation did just as well as those who had the real one; the placebo effect apparently accounted for the fact that so many patients felt better afterward.

The radical mastectomy, pioneered a century ago, used to be routinely performed, too. Physicians believed that breast cancer spread in a contiguous, stepwise fashion from the primary tumor, and that the only way to eradicate the disease was to remove the entire breast and the underlying muscles. By the nineteen-eighties, it had become clear that tumor cells could spread throughout the body early in the disease, through lymph channels and blood vessels. A lumpectomy, followed by local radiation, proved as effective as a radical mastectomy in treating the cancer, and was far less traumatic to the patient.

Last year, approximately a hundred and fifty thousand lower-lumbar spinal fusions were performed in the United States. The operation, which involves removing lumbar disks and mechanically bracing the vertebrae, is of tremendous benefit to patients with fractured spines or spinal cancers; more frequently, however, it is performed to alleviate chronic lower-back pain. But how effective is it? That's a question that many of the doctors who perform the fusions, and the insurers who pay for them, appear reluctant to ask.

Roughly two-thirds of all Americans will experience significant lower-back pain at least once during their lives; some will also have sciatica, a pain that follows the nerve running from the lower back down the leg. In the United States, current estimates of the cost of medical care for those who have been disabled by severe back pain range from thirty to seventy billion dollars annually. Back pain is most likely to occur between the ages of forty-five and sixty-four, and, over all, nearly one in four Americans claims to suffer chronically from the problem. Many of these people are being told that fusion surgery is the solution.

Trisha Bryant (her name has been changed) is a former marketing executive in her mid-thirties. Two years ago, while working in a home-furnishings store, she helped a floor manager move some inventory and developed sciatica in her right leg. She continued to work but the pain persisted, and she eventually went to the emergency room for an MRI scan, which showed a small rupture of the disk below the fifth lumbar vertebra. Disks -- the spine's shock absorbers -- are sheathed in a fibrous casing called the annulus, which protects their gelatinous core, and when a disk ruptures bits of it break through the casing. The MRI scan showed that the protruding edge of Trisha's ruptured disk was just touching the right nerve root as it exited the spine. It also showed some narrowing of the disk immediately above -- an early sign of the wear and tear of aging, or "degeneration."

Trisha was given Percocet and told to stop working. For several months, she also received epidural steroid injections, but her discomfort persisted. About nine months after Trisha injured herself, an orthopedic surgeon performed a relatively simple procedure called a discectomy, in which a fragment of the ruptured disk is removed. For more than three-quarters of patients with sciatica who undergo discectomy, the procedure helps relieve pain. Trisha's sciatica went away, but the pain in her lower back increased. Another MRI showed that the disk the surgeon had operated on was protruding again, this time toward both the right and the left nerve roots. The surgeon told Trisha that the next step would be to fuse her lower spine, which had become "unstable." He planned to remove the degenerated disk or disks that were causing the pain and mechanically brace the spine with metal rods and bone grafts. First, however, he wanted Trisha to undergo discography, a procedure that was supposed to determine how much of her pain was coming from the lower protruding disk and how much from the upper, narrowed one. This information would help him decide whether one or two disks should be removed.

Trisha Bryant assumed that the procedures her surgeon recommended were necessary and had been validated by research. I, too, made that assumption when I suffered from recurrent lower-back pain twenty years ago and elected to have a fusion. If Trisha had explored the medical literature, however, she would have discovered that every aspect of her case -- the ...