Last resort, not a first choice
Lumbar spinal stenosis — a back condition affecting many older adults — can mean persistent bouts of back pain and a gradual loss of mobility. Patients are increasingly opting for a type of back surgery called spinal fusion. However, recent studies suggest spinal fusion is no more effective than less-drastic treatments for moderate stenosis cases. Before taking the surgical route, experts suggest trying more conservative approaches — like physical therapy — and making sure spinal fusion is really right for you. Here are some things to consider.
Pressure on your spinal cord causes pain.
Spinal stenosis involves a narrowing of the space between the backbones — the spinal canal — leading to increased pressure on the spinal cord and nerves. Lumbar spinal stenosis, which usually results from normal wear and tear on the spine, often shows up in people in their 60s and older.
Come-and-go pain can improve.
Leg weakness, numbness and pain that worsens when you walk or stand, and eases when you sit, are hallmarks of spinal stenosis. “If your exam shows you have no neurologic deficits — your legs are functioning fine; your toes are functioning fine — I would not recommend [surgery],” Dr. Trang Nguyen, a family physician in Milford, Ohio, said in a 2015 interview with U.S. News. “You might have low back pain from time to time. You might have good days or bad days. I would recommend conservative care — physical activity, diet and exercise — things that would improve it over time.” Losing weight can help you feel better, she said.
Older adults are opting for spinal fusion.
More patients are having spinal fusion than in decades past. An in-depth 2014 report on spinal stenosis treatment by the Dartmouth Institute for Health Policy and Clinical Practice revealed that of Medicare beneficiaries age 65 and over, these operations increased 67 percent between 2001 and 2011.
‘Welding’ the spine can make it more stable.
Spinal fusion surgery is a sort of “welding” procedure to fix problems affecting the small bones of the spine, the vertebrae, by fusing them together so they can heal into one solid bone, according to the American Academy of Orthopaedic Surgeons. That stabilization eliminates movement between the problem bones, potentially relieving back pain caused by movement.
Spinal fusion is overused.
Among U.S. older adults, Florida seniors were most likely to get a spinal fusion while Maine seniors were least likely to undergo the surgery, according to the Dartmouth report. Spinal fusion is performed too frequently, experts say. “Back pain is pretty common,” Dr. James Weinstein, a renowned spine surgeon and former director of the Dartmouth Institute for Health Policy and Clinical Practice, said in a 2015 U.S. News interview. “Eighty percent of people get back pain at some time in their lives; 30 percent of people on any given day. Doing fusions for back pain is over-utilized.”
Disability may continue after surgery.
Nguyen led a 2011 study comparing workers’ compensation patients who either had spinal fusion surgery or more conservative treatment — such as exercise and physical therapy — for their low back pain. She found that patients who didn’t have surgery were more likely to return to work after two years, and less likely to keep taking opioid painkillers.
Surgery can be quite complex.
Spinal fusion can take a couple of hours or much longer, Weinstein said, depending on complexity. Bone grafting is the basis of the surgery. Some surgeries may involve artificial bone grafting materials to promote fusion and healing. Instrumentation — think: metal rods, plates and screws — is sometimes used to stabilize the spine when indicated. Potential complications include infection, bleeding, graft site pain, nerve damage and blood clots. The risk of eventual reoperation is significant, Weinstein said: up to 20 percent over time.
Recent studies back less-invasive surgery.
In April 2016, findings in the New England Journal of Medicine questioned the effectiveness of spinal fusion. Two studies looked at patients with moderate spinal stenosis. They found the surgery was no better than a less-invasive, less-costly procedure called laminectomy at reducing patients’ walking-related disability or allowing them to go about their daily lives.
Other procedures might be better.
Another less-invasive surgery like spinal decompression (or no surgery at all) may be a better choice, depending on your condition. Laminectomy and discectomy are both decompression procedures. Always ask for a second opinion when exploring surgical options. Get all the facts before making this big decision. Ask about risks and benefits; how long you’ll be in the hospital; what recovery will entail; and whether you really need a fusion. And if you want to avoid surgery altogether — what are your options?
Clear indications for spinal fusion exist.
Patients who’ve experienced severe spinal trauma, or who’ve had surgery to remove tumors from their spine may be more appropriate candidates for spinal surgery. People with scoliosis involving severe spinal curvature can benefit. Others with a condition called “degenerative spondylolisthesis,” which can occur with stenosis, have done well after fusion, according to Weinstein.
Surgery can ease pain.
Spinal fusion can help reduce pain (but you probably won’t be pain-free). Weinstein was a researcher on the multicenter, long-term SPORT study, a landmark series comparing treatment outcomes for patients with spine conditions. Of stenosis patients randomly assigned to either have surgery or conservative care, surgical patients — most of whom underwent laminectomy combined with fusion — showed greater improvement in pain and function shortly afterward and several years later.
Experience counts.
As with any major surgery, seek surgical centers and surgeons who routinely perform spinal fusion. “Go to a doctor who sees lots of patients like this and has the results of their procedures,” Weinstein advised, adding: “Somebody who can share their outcomes with you.” Asking if you can see data on outcomes and even talking to former patients who’ve had the procedure could be helpful.
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Spinal Fusion for Lower Back Pain: Weighing the Pros and Cons originally appeared on usnews.com
Update: This article was originally published on May 29, 2015.
