Surgery better than therapy for back problem, study says

Surgery is twice as effective as physical therapy and drugs for relieving pain and improving mobility in one of the most common back problems, researchers report today.

The study, published in the New England Journal of Medicine, gives “us more confidence in recommending surgery to our patients,” said Dr. Mark J. Spoonamore of the University of Southern California’s Keck School of Medicine. The recommendation is “not just our gut feeling, but based on a strong scientific foundation.”

Dr. Arya Shamie of the University of California, Los Angeles’ Geffen School of Medicine added, “This is a great study … confirming what doctors have believed all along.”

The condition, called degenerative spondylolisthesis with spinal stenosis, occurs when one lumbar vertebra in the back slips forward relative to the one next to it, pinching the spinal cord and producing severe pain in the legs.

The condition affects as many as 600,000 Americans, although only about half of those seek medical treatment and perhaps only a quarter of them now undergo surgery, according to Dr. James W. Weinstein of the Dartmouth-Hitchcock Medical Center in Hanover, N.H., who led the study.

The bulk of the patients are over 50, and women are six times as likely as men to suffer from it, with black women at greatest risk.

Conventional treatment involves physical therapy, steroids to reduce swelling and anti-inflammatory drugs. But only about 20 percent of patients get better and 20 percent stay the same without surgery, according to Shamie, who was not involved in the study.

Surgery relieves pain by removal of bone and soft tissue in a procedure called a decompressive laminectomy. Because of the aging American population, back surgeries are one of the fastest-growing areas of medical care, with hospital costs alone totaling more than $21 billion per year, according to Dr. Richard A. Deyo of the University of Washington.

The federally funded study included 601 patients at 13 medical centers in 11 states. Of those, 372 underwent surgery and 235 did not.

Two years after their enrollment in the study, the patients who did not undergo surgery reported only modest improvements in their condition.

Those who had surgery reported significantly reduced pain and improved functionality. Major improvements were seen as soon as six weeks after the surgery.

The most common complication of the more than three-hour surgery was a tear in the dura, the lining of the spinal cord.

In a second study in the journal, a Dutch team led by Dr. Wilco C. Peul of the Leiden University Medical Center studied 283 patients with severe sciatica, which produces a burning pain in the sciatic nerve that runs down the outside of the leg. The pain is caused by herniated disks in the spine that put pressure on the sciatic nerve.

Peul and his colleagues reported that sciatica patients undergoing surgery got much faster relief from the pain than those receiving only physical therapy and drugs but that at the end of a year, 95 percent of patients in both groups were largely free of pain.

Those results were similar to findings reported by Weinstein and his colleagues last year in a much larger study – although Weinstein found a small but persistent benefit from surgery.

In a third arm of the U.S. study, Weinstein and colleagues will report later this year on the benefits of surgery for patients with spinal stenosis – a narrowing of the spinal column – caused by degenerative arthritis.