Spinal surgery, particularly spinal fusion, for the treatment of back pain has been increasing in Australia, despite a lack of good quality evidence for its effectiveness in all but one patient population. small number, say the authors of a new narrative review.
Led by Professor Kate Drummond, the authors of the review, published in the MJA, expressed concern that because the surgery is disproportionately performed among patients with private insurance, “the contribution of industry and third-party payers to this increase, and its implication in published research, requires careful consideration”.
Associate Professor Andrew Morokoff, a neurosurgeon at the Royal Melbourne Hospital and co-author of the review, said there were multiple reasons for the rise in spine surgery for back pain.
“One of the reasons people suggest is that surgeons are unscrupulous and do these surgeries for no reason,” he told InSight+ in an exclusive podcast.
“But there are also some other reasons for this increase. One of them is that our population is getting older. There are more people with back problems.
“And the other reason is that a lot of these operations are based on newer technologies that have become available in the last 10 to 15 years. A lot of them are minimally invasive or lock technologies, which make it safer and more possible to do these operations much more safely, especially in elderly people.
“When I started in neurosurgery 20 years ago, this type of surgery wasn’t done, the technology just wasn’t there. It involved a big cut, a lot of blood loss, a lot of pain and a slow recovery.
“The newer ways of doing it mean we’ve turned a four-hour operation into a 30-minute operation with no blood loss. That makes it more viable if you have an 80-year-old with co-morbidities.”
However, the MJA narrative review found that chronic low back pain should be managed with “a holistic biopsychosocial approach of generally non-surgical interventions”.
“Spine surgery has a role in the relief of radicular pain and disability resulting from neural compression, or when back pain is related to cancer, infection, or severe instability,” wrote Drummond and colleagues. leagues
“Spine surgery for all other forms of back pain is not supported by clinical data, and the broadest evidence base for spine surgery in the treatment of back pain is deficient and suggests that it is ineffective.”
Patient selection was key, Associate Professor Morokoff told InSight+.
“It’s absolutely about patient selection, doing [the surgery] for the right indications and get the right diagnosis.
“That’s another thing we’ve done a lot better. When I started training, we didn’t have MRIs; now there’s an MRI on every corner and they’re so much better. It’s the coolest advancement in seeing what is the problem
“Most of the indication for surgery, from our point of view, is for people who have severe nerve problems, so severe sciatica, severe nerve pain, which is persistent for more than six months and is unresponsive to medication
“And often they’ll also have a neurological compromise — a weak foot drop or a weak leg.”
For the rest, he says, the treatment and treatment of low back pain must be a multidisciplinary and long-term plan.
“The answer involves the training and education of surgeons and practitioners and all health-related people who deal with the problem of back pain, including physiotherapists, nurses and psychologists,” said Associate Professor Morokoff.
“It is a very complex problem.
“A surgeon often plays a small role in a patient’s life for a year and may or may not decide to operate.
“But the real situation has been many, many years: this is a chronic disease.
“What is the best mix? Conservative management for a few years, then maybe they’ll improve a bit with an operation, and maybe more conservative management?
“It’s not just saying, I want an operation or a week of physical therapy, it’s the best plan for the rest of your life.”
Drummond and colleagues concluded that the growing burden of back pain presents a “significant challenge to health systems worldwide.”
“Its management should be supervised by primary care physicians and focused on a holistic biopsychosocial approach to generally non-surgical interventions,” they wrote.
“While spine surgery has a role in relieving the symptoms of radiculopathy or neurogenic claudication, or in circumstances where back pain is related to cancer, infection or severe instability, its role in management of degenerative low back pain is not currently supported by studies.
“Despite this, surgery for back pain has increased substantially among Australian patients and disproportionately among those with private health insurance. Industry’s contribution to this increase, and its role in making published research, requires further scrutiny.”
Associate Professor Morokoff is skeptical about the possibility of future research in this field.
“We identified five randomized control trials in this area. All of them were published, basically ten years ago, or more than ten years ago. Nothing has been done recently,” he said.
“We focused on trials that compared surgery with non-surgical management. None of them were of extremely high quality. But the problem is that it’s very difficult to get strong evidence.
“The barrier is really measuring the right outcomes in a very robust way.
“You have to follow these patients for a long time to see how they’re doing. You have to do a lot of very appropriate surveys of disability and pain scores and that kind of thing gets expensive. Then you have to do it in a way that’s not bias We prefer trials that are not industry funded.
“In terms of getting the right patient population and the right indication with the right outcome, it’s very difficult. I don’t see it being easy for anyone to ever do a proper trial.”
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