Published May 31, 2007
For two specific kinds of back and leg pain, back surgery offers the fastest relief — but those who choose nonsurgical treatments get better, too.
Two separate studies reported in this week's New England Journal of Medicine show that surgery is the fastest route to pain relief for two very different conditions: severe sciatica and degenerative spondylolisthesis.
But the studies also show that these conditions do not worsen if surgery is delayed — and that nonsurgical treatments can relieve at least some of the pain.
An editorial titled "Back Surgery: Who Needs It?" accompanies the studies. Editorialist and back pain researcher Richard A. Deyo, MD, MPH, is professor of medicine and director of the center for cost and outcomes research at the University of Washington in Seattle.
"The people who truly need back surgery are those who need it to preserve their ability to function," Deyo tells WebMD. "But short of that, most back surgery is an elective procedure. It is not urgent. Patients face real choices that are quite reasonable: either surgical or no surgery."
Sciatica: Surgery vs. No Surgery
Sciatica is pain or tingling that begins in the back or buttocks and runs down the leg. The most common cause is a bulging disk in the spine. The bulge presses against a nerve root, causing problems all along the nerves that branch from that root.
Surgical treatment of sciatica relieves pressure on the nerve root by removing a portion of the affected spinal disk. But sciatica often gets better over time. Is surgery really the best choice? How long should a patient wait before opting for surgery?
To answer these questions, neurosurgeon Wilco C. Peul, MD, head of the spine intervention study group at Leiden University Medical Center in the Netherlands, led a study of 283 patients with confirmed cases of severe sciatica.
All of these patients' symptoms had lasted for six to 12 weeks. Even with pain medication, they could barely walk and were not able to work around the house or at their normal jobs.
Half the patients underwent early surgery, most within two weeks of study entry. The other patients were assigned to "conservative treatment," which included pain management and physical therapy.
As expected, early surgery meant quicker recovery. But Peul and colleagues were surprised by what happened in the conservative-treatment group.
"The most important result is that what we did not expect — that in the conservative-treatment group, most of them also had a quick recovery," Peul tells WebMD. "It was slower than the early-surgery group. And 39 percent had longer-lasting leg pain and needed surgery. But at one year, the results for the two groups are nearly equal. Even at three and six months, the outcomes were not that much different."
Patients whose surgery was delayed got just as good results as those who had surgery right away.
"So for leg pain, if you cannot cope with the pain, there is a quite good reason to have surgery early," Peul says. "But if you can stand the leg pain and have enough medication and cortisone shots, you can postpone and even evade surgery. And patients have to be informed that whether surgery is done now or later, they will have the same outcomes."
Current recommendations are for patients to wait six weeks to see whether their sciatica gets better.
"I think we should wait at least two extra months to see if the patient is recovering. If not, or if the pain is worsening, surgery should be done early if the patient is asking for it," Peul says. "If the patient can sustain the pain, waiting is the best strategy. But if the patient very badly wants to do it, early surgery is a good choice."
Surgery does not always work. Peul says that one in 20 patients with severe sciatica has continued pain even after back surgery.
Spondylolisthesis: Surgery vs. No Surgery
Degenerative spondylolisthesis sounds bad — and it can, indeed, be a very painful condition. It's a disease of aging, occurring six times more often in women than in men and affects black women in particular.
The condition occurs when one of the vertebrae in the lower spine slips forward across another. This may cause spinal stenosis — a narrowing of the spinal canal that causes bone and soft tissue to press against a nerve. The result is pain in the buttocks or legs while walking or standing.
Surgery involves laminectomy, an operation that removes part of the spinal bone to relieve the pressure on the nerve. The procedure often includes fusing the affected vertebrae with a bone graft.
Patients tend to be elderly, so surgery carries a risk. Is the risk worth it?
The answer is a qualified "yes," find James N. Weinstein, DO, of Dartmouth Medical School in Lebanon, N.H., and colleagues. Weinstein and colleagues report the two-year outcomes for more than 600 patients with at least 12 weeks of symptoms from degenerative spondylolisthesis with spinal stenosis.
Patients who underwent surgery had better symptom relief and better daily function starting six weeks after the operation and persisting for at least two years.
But that doesn't mean surgery is for every patient.
"In this study, we see a greater benefit to surgical than nonsurgical treatment," Weinstein tells WebMD. "But what has never been shown before is the nonoperation patients do get better. So now there is a basis for giving patients an informed choice about treatment options for this condition."
Weinstein says that patients with spondylolisthesis should know that back surgery is very likely to relieve their pain. But they should also know that it won't bring them all the way back to normal levels of function. And it's also important for them to know that if they don't want to undergo surgery, they can still expect significant recovery.
So what should patients do?
"Go to a doctor who will share this information with you, who can understand your preferences, and help you make the choice that is best for you," Weinstein says. "This study shows surgery works a little better than nonsurgical treatment. But there are patients who choose not to have surgery. And that is a good choice, too."
This article was reviewed by Louise Chang, MD.
SOURCES: Weinstein, J.N. The New England Journal of Medicine, May 31, 2007; vol 356: pp 2257-2270. Peul, W.C. The New England Journal of Medicine, May 31, 2007; vol 356: pp 2245-2256. Deyo, R.A. The New England Journal of Medicine, May 31, 2007; vol 356: pp 2239-2243. James N. Weinstein, DO, Dartmouth Medical School, Lebanon, N.H. Wilco C. Peul MD, Leiden University Medical Center, Leiden; and Medical Center Haaglanden, The Hague, Netherlands. Richard A. Deyo MD, MPH, professor of medicine and director of the center for cost and outcomes research, University of Washington, Seattle.