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Spinal operations

Written By, On March 2, 2014

Back pain has become something of a modern epidemic in our desk-bound, sedentary society, with 80 per cent of adults experiencing it at some time or another, and a third of the population suffering from it regularly.

Many GPs can offer sufferers little more than pain relief, which has led to great demand for chiropractors. Easing yourself into normal activities with the help of painkillers and anti-inflammatories is what most GPs recommend and, for most people, this will curb the pain however without identifying the cause. If the pain doesn’t go you need expert help, increasingly patients are turning to chiropractors who have become the experts of choice in such cases as patients realise that they cannot just take painkiller repeatedly without suffering the consequences in the future.

” Chiropractors offer treatment as part of a whole spectrum of treatments that are effective for musculoskeletal conditions.  Chiropractors in this country undergo an extensive five university degree based on medical training in musculoskeletal conditions and are a closely regulated profession with very high standards.  After university they  must also complete a programme of further education every year in order to be allowed to stay on the register of the General Chiropractic Council. Any chiropractor who is not on the register is practising illegally.

Chiropractic treatment combining manipulation with the latest rehabilitation techniques has a proven track record, so why doesn’t everyone with back pain just go to their local chiropractor. Back pain is incorrectly perceived as a transient injury that will heal itself after taking a course of painkillers, wrong. With back pain at epidemic levels this can simply not be true. Many people do not understand what chiropractors actually do, most people still believing that they manipulate bones into place.  Whatever the real or perceived risks, for many people with back problems,  chiropractic is  a proven way of alleviating and managing debilitating pain. So why don’t studies reflect this?

Because osteopaths and chiropractors tailor their treatment to individual patients, it is difficult to conduct accurate clinical trials, as no two individuals are the same, says Robert Lever, professor at the European School of Osteopathy in Kent.

People often come to chiropractors on personal recommendation and word of mouth, not because of reviews in medical journals. The bottom line is that they are interested in results.

People often don’t appreciate their medical training and that they are qualified to use X-rays and other special imaging, just as spinal surgeons can. In some cases, as you see with spinal surgeons, chiropractors will use similar X-ray and MRI images to diagnose why patients are in pain.

Unfortunately MRI and CT scans – usually the first step in trying to identify the source of back pain – are notoriously unreliable in providing useful answers. For many decades now the use of MRI scans and X-rays have been shown to present an inaccurate picture for back pain. Because the majority of back pain is due to functional dysfunction and not related directly to structural abnormalities of the kind shown with spinal images.

It should only be once  these conservative measures fail that a spinal surgeon should be considered as a last resort. Even then, it’s seldom the quick fix that patients pin their hopes on, and some surgeons warn that over-treatment, particularly in private practice, is all too common. Research studies have often suggested surgery is over used and has more outcome too often.

‘A lot of people without back pain have a bulging disc on an MRI scan — so you can’t automatically link this to the patient’s pain,’ says Paul Thorpe, spinal surgeon at Musgrove Park Hospital in Taunton.  ‘Also, painful muscles and ligaments look perfectly normal on a scan  and yet this may be the root of the problem”.

It is very difficult to take a picture of a spine that simply is out of condition and weak, only a physical assessment can achieve this and this is where the skill of a good chiropractor can come into play.

Spinal surgeons are drawn from two specialty areas – neurosurgery and orthopaedics. ‘The margins between them have now blurred,’ says Mike Hutton, a spinal surgeon at Royal Devon & Exeter Hospital in Wonford. ‘But those from orthopaedics are the carpenters. They deal with deformity in the spine, such as scoliosis (curvature of the spine). ‘Those from a neurosurgical background are the electricians, they deal with more specialised surgery involving the nerves of the spine.’

Both operate on some of the most common back complaints, such as a  ruptured disc where  fragments of the disc are removed to stop it pressing on the nerves.

Another common back operation is spinal fusion where two segments of the vertebrae are effectively welded together (for instance to reduce the pain of arthritis), and decompression surgery where the overgrowth of bone in the spine is removed to stop it squeezing nerves.

Surgery is only used in 1-2% of all back pain cases, 99%  of back pain sufferers as a whole need other solutions to their back pain.

Back pain is a common affliction, frequently blamed on degenerative change even though this develops inexorably during life so that nobody by middle age has escaped it; yet for many, pain is an infrequent visiter. Any spinal expert will admit that they cannot predict why you are pain with 100% confidence, it simply is not possible even with all the advances made in modern medicine.

Interfering with a structure about whose function we are so profoundly ignorant, is surely not sensible but to date no specific treatment has proved to be the best.

Here are some patients reports.

I had a fusion about 21 years ago, because one of my vertebra crumbled – I was very lucky that at the time, they used some of my hip bone to do the fusion so no screws or metal work – my back is now stronger than ever and I Zumba 4 times a week and keep myself at my proper weight – I must admit, its not for the faint hearted, but if you are truly suffering with back pain, go and see someone. I lived on pain killers and anti-inflammatories for about 3 yrs before the surgery had to be done and I have stomach ulcers now because the pills were so strong.

Try and find out the cause of the pain seek out a good chiropractor and stick with them as they will try and identify the cause and try exercise, combined with manipulation to improve  muscles that  can support your back. Be realistic don’t expect miracles they don’t exist. Back pain has to be managed not cured if you can accept that you won’t be disappointed.

Having suffered with Degenerative Disc Disease of the neck and lumbar spine since the age of 22 (I worked on construction sites levelling and setting out) I finally underwent a C5/6 prestige disc replacement in August 2007 (Aged 36). Pain is still horrendous, movement of the neck to the left is severely limited, Peripheral nerve damage has since been identified. Am unable to drive, unable to walk, and have had to give up my precious job. Think VERY CAREFULLY before you undergo any surgery of this type. You may, like me, end up with a very poor quality of life, post surgery.

Spine Surgery Found No Better Than Placebo

In the past decade, a low-risk technique for repairing fractured bones in the spine has surged in popularity, to an estimated 100,000 operations last year in the U.S. But in the first two studies to rigorously examine the effect of the procedure, known as vertebroplasty, researchers found no detectable benefit when compared with a placebo group of patients who received a sham procedure that only mimicked the real thing.

It was the latest of several cases in which a popular medical procedure has been called into question by independent studies.

The results are likely to stir further debate about assertions—heard often in the Washington debate over health-care legislation—that unnecessary or relatively ineffective medical procedures are contributing to soaring costs. The American healthcare system different to UK but concerns exist.

“Vertebroplasty should not be done any longer, unless it’s in the setting of a study,” said Jeffrey Jarvik, of the University of Washington, who served as the senior author on one of the studies, which was funded by the National Institutes of Health.

The results, published in the New England Journal of Medicine, will also focus more attention on “comparative-effectiveness” research studies that aim to assess the benefits of different treatments already on the market.

“If we’re going to institute health-care reform, there’s rigorous evidence that [vertebroplasty] doesn’t work any better than a control intervention, and we should stop paying for it.”

The federally funded study signed up 131 patients in the U.S., Britain and Australia. Half of them received a vertebroplasty, in which the back is numbed, an injection is made into the vertebra, and bone cement is injected by a radiologist or spine surgeon to shore up a fracture. The other group of patients received a sham procedure, including the numbing, but no injection. The doctor opened the container of bone cement so its scent would fill the operating room to disguise whether these patients were receiving a real surgery or not.

After a month, both groups saw a substantial reduction in various measures of disability and pain, assessed by a questionnaire. But the reductions were a statistical tie—the actual procedure yielded no gain beyond the placebo effect of the sham surgery.

A separate study, including 78 patients and conducted similarly, was funded by the Australian government and Cook Medical Inc., a U.S. manufacturer of bone cement. It reached a similar conclusion: Vertebroplasty didn’t relieve pain any more than the sham surgery, measured three months later.

The results follow a 1999 loosening of regulations concerning the marketing of bone cement. In that year, orthopedic makers persuaded the Food and Drug Administration to downgrade the classification of bone cement to a low-risk regulatory category that doesn’t necessarily require clinical trials to show a product is effective at what it claims to do. At that time, the cement was sold to attach prosthetic joints to the bone, such as in the knee or hip.

Five years later, the FDA allowed makers of bone cement, including Stryker Corp., Johnson & Johnson and Cook, to market their products for use in a vertebroplasty—without a prosthetic, and without needing a controlled clinical trial that vertebroplasties are effective.

An FDA official said the agency’s decision was based on previous use of bone cements to fill in fractured bones. “We determine it’s not so extremely different that it’s outside the box,” said Heather Rosecrans, who directs the agency’s review of such devices.

Stryker and J&J declined to comment. Cook pointed to the small number of patients in each of the latest trials. “Bottom line is that more data, more research needs to be done here,” said Daniel Sirota, global business unit leader at Cook.

Other findings that have questioned established treatments included a large 2002 study that found no benefit to two popular knee surgeries, compared with a sham treatment.

Is back fusion surgery just a placebo?

It is possible that spine fusion surgery for back pain achieves its effectiveness through the placebo effect. The case that it is not only possible, but also probable has been discussed.


Spine fusion can be done for many reasons, but the most common reason is degenerative conditions in the lumbar spine. Yet there is very little evidence that spine fusion surgery for back pain is effective. It is very expensive (the implants alone are often in the tens of thousands per case), often leads to complications, often requires further surgery, is associated with increased mortality and often does not even result in the spine being fused. That last one is not a big deal, because the results of the surgery are not well correlated with whether or not the spine fuses. Nor are the results related to how you fuse the spine, or whether or not you use implants (screws, rods and cages), except that “instrumented” fusions (using implants, which is now routine) are associated with more complications.

The rates

The rate of spine fusion surgery is increasing and has been increasing for many years. Data shows that in the USA, the rate has gone a long way past the rate of 1 spine fusion per 1,000 population per year. The rate has already overtaken hip replacement surgery and continues to rise. The rates of surgery vary widely across the USA, where back fusion is associated with the highest degree of practice variation. The US rates are far higher than most other countries, but the rates in many of those countries are increasing too.

The evidence

Three randomised clinical trials have been published comparing surgery to non-operative treatment for back pain. There have been no sham surgery trials, but the evidence from these three trials indicate that this surgery might achieve its results through the placebo effect.

Two of the studies put spine fusion surgery up against structured non-operative treatment alternatives: cognitive behavioural therapy and intensive rehabilitation in another. These studies found no significant differences in the outcomes between the operative and non-operative groups (except that the complication rate in the surgical group was higher).

The third study concluded that the surgical group did better. Interestingly, the surgical group didn’t do any better than in the other studies; the difference was that the non-operative group didn’t get better at all. This is because the non-operative treatment was not dressed up as something that might work (i.e., it wasn’t a good placebo). The authors state that the non-operative treatment “could vary within broad but commonly used limits reflecting the nonsurgical treatment policy in the society”. Patients were basically given more of the treatment that they had received before (the treatment that had previously failed and that led them into the study). Faced with more of the treatment that had already failed, this group was never going to get better – there is no placebo effect in doing nothing.

Spine surgery is not just a sugar pill; it is a much more elaborate placebo than that, and it is much more dangerous. The onus is on doctors to prove that spine fusion surgery for back pain is better than placebo before subjecting so many people to the risks of such major surgery.




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