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SPINAL surgery, particularly spine fusion, for the treatment of low back pain has been on the rise in Australia, despite a lack of quality evidence for its efficacy in all but a small number of patients, 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 done disproportionately among privately insured patients, “the contribution of industry and third-party payers to this increase, and their involvement in published research, requires careful consideration”.
Associate Professor Andrew Morokoff, a neurosurgeon at the Royal Melbourne Hospital and a co-author of the review, said there were multiple reasons for the increase in spinal surgery for low back pain.
“One of the reasons people suggest is that surgeons are being unscrupulous and doing these surgeries without reason,” he told InSight+ in an exclusive podcast.
“But there are a few other reasons for that increase as well. One of them one is that our population is getting older. There are more people getting back issues.
“And the other reason is that a lot of these operations rely on newer technologies that have become available in the last 10 or 15 years. A lot of them are minimally invasive or keyhole technologies, that make it safer and more possible to do these operations much more safely, particularly in older people.
“When I started neurosurgery 20 years ago these kinds of operations weren’t done – there just wasn’t the technology. 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 that we’ve converted a four-hour operation into a 30-minute operation with no blood loss. That does actually make it more viable to do if you’ve got an 80-year-old with comorbidities.”
Nevertheless, the MJA narrative review found that chronic low back pain should be managed with “a holistic biopsychosocial approach of generally non-surgical interventions”.
“Spinal surgery has a role in alleviating radicular pain and disability resulting from neural compression, or where back pain relates to cancer, infection, or gross instability,” wrote Drummond and colleagues.
“Spinal surgery for all other forms of back pain is unsupported by clinical data, and the broader evidence base for spinal surgery in the management of low back pain is poor and suggests it is ineffective.”
Patient selection was key, Associate Professor Morokoff told InSight+.
“It is absolutely about patient selection, doing [the surgery] for the right indications, and getting the correct diagnosis.
“That’s another thing that we’ve got a lot better at doing. When I started training, we didn’t have MRIs – now there’s an MRI on every street corner, and they are a lot better. It is the most fantastic advance in terms of seeing what the problem is.
“Most of the indication for the surgery, from our point of view, is for people that have severe nerve issues – so, severe sciatica, severe nerve pain, that is persistent usually for more than six months, and is not responding to medication.
“And often they will also have a neurological compromise – a weak foot drop or weak leg.”
For the rest, he says, management and treatment of low back pain must be a multidisciplinary and long term plan.
“The answer involves training and education of surgeons and practitioners and all related health people that deal with the issue of low back pain, including physiotherapists, nurses and psychologists,” said Associate Professor Morokoff.
“It’s a very complex problem.
“A surgeon often plays a small part in a patient’s life over a year and they may decide or not decide to operate.
“But the real situation is over many, many years – this is a chronic condition.
“What’s the best mix? Conservative management for a few years, then maybe they’ll get a bit better with one operation, and then maybe more conservative management?
“It’s not just saying, do I want one operation or one week of physio – it’s what is the best plan for the rest of their life.”
Drummond and colleagues concluded that the increasing burden of low back pain presents a “significant challenge to health care systems throughout the world”.
“Its management should be overseen by primary care physicians and centred upon a holistic biopsychosocial approach of generally non-surgical interventions,” they wrote.
“Even though spinal surgery does have a role in alleviating symptoms of radiculopathy or neurogenic claudication, or in circumstances where back pain is related to cancer, infection or gross instability, its role in the management of degenerative low back pain is not supported by the studies currently available.
“Despite this, surgical intervention for low back pain has increased substantially among Australian patients, and disproportionately among those with private health insurance. The contribution of industry toward this increase, and their role in the conduct of published research, requires further scrutiny.”
Associate Professor Morokoff was sceptical about the possibility of future research in this field.
“We identified five randomised control trials in this area. All of them were published, basically ten years ago, or more than ten years ago. There haven’t been any done recently,” he said.
“We focused on trials that compared surgery with non-operative management. None of them were extremely high quality. But the problem is it’s very difficult to get strong evidence.
“The barrier is actually measuring the right outcomes in a really robust way.
“You have to follow these patients for a long time to see how they go. You have to do a lot of very appropriate surveys of disability and pain scores and that kind of thing becomes expensive. Then you have to do it in a way that’s not biased. 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 that it’s easy for anyone to really do a proper trial ever.”
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The view of chronic pain genesis has changed in recent years. It is a disease of the central nervous system where the brain’s neural pathways change over time- Nociplastic pain. Most low back pain falls into this category. Psychosocial factors are the most predictive of chronic pain, not imaging findings. It intrigues me that the vast majority of operating for nonspecific low back pain occurs in the private sector whereas there is virtually nothing done in public medicine for this indication. The evidence for surgery for these conditions is poor. To the surgeons who believe their treatment is efficacious, you should provide evidence of this with well designed research, to your patients and the tax payers who are paying for it. A primary care and public health approach to chronic low back pain would be best promoting things we know work- maintaining a healthy weight, exercise, cessation of smoking, CBT/addressing mental health issues, sleep regulation, and a healthy diet. To the primary care physicians, I recommend painHealth website produced by the University of Western Australia for patients as a resource.
The educational video on herniated discs (below) shows that herniated discs disappear on their own in most cases. Surgery is rarely necessary. It is better to restrict it to the right indications. The risk of this surgery is among other things to generate neuropathic pain. This does not depend on the quality of the surgeon. They can occur in +/- 20% of back surgeries.
Video on herniated discs: https://youtu.be/pUMtCzvBUMU
These authors subscribe to the outdated neurocrompressive theory of spine surgery. A review of the references used in the article published in the MJA is telling. Most of the sources are 10-15+ old. Only 6 out 84 references were post 2018 and included opinion pieces. This is a cherry picked review where the authors wrote the conclusion and then went looking for sources to support their bias. As noted by anonymous rubbish in rubbish out. Let’s see some published articles in the MJA from Australian Spine Surgeons who have been published in the last 5 years in the international peer reviewed journals on spine surgery. Let’s see an MJA with a balanced approach to spine surgery please. It is becoming apparent that only one voice, one way to see the world of the care of the spine, makes its way through the editorial channels of the MJA..
It’s good to see this quote on the recent MJA article on low back pain and nuclear medicine bone scans.
Reinforces that bone scans aren’t not identifiers of nociception, they are purely for assisting in identification of red flag pathology.
” a Korean study observed no significant difference between patients receiving targeted pain interventions who did (n = 110, 73.83%) and did not (n = 17, 65.38%) have changes on SPECT‐CT (P = 0.37)”
Persistent nociceptive LBP requires a multidisciplinary approach, but not surgery. The article notes that surgery is only considered in 1) red flag pathology 2) radicular pain, radiculopathy, neurogenic pain
Not for nociceptive (somatic) pain, even if persisting.
After reading the article, i am bewildered this was published. The authors display a clear bias and set their agenda to discredit spine surgery. Rubbish in, rubbish out. There are so many flaws in the authors arguments. Firstly, low back pain is a symptom and not a diagnosis.
Precision diagnosis and targeted treatments for recalcitrant degenerative disc disease have been shown to be of substantial clinical benefit.