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Spinal Fusion Surgery May Leave Some Back Pain Patients Worse Off: Study

By Maureen Salamon
HealthDay Reporter

WEDNESDAY, Feb. 23 (HealthDay News) -- Spinal fusion surgery for chronic low back pain -- an increasingly controversial treatment that has exploded in use over the last 20 years -- leads to higher rates of permanent disability for worker's compensation patients compared to those treated non-surgically, a new study finds.

Researchers randomly selected 725 people with low back pain treated with fusion surgery and 725 whose more conservative treatment included exercise and physical therapy. Participants were chosen from a pool of worker's compensation patients in Ohio whose on-the-job injuries between 1999 and 2001 resulted in chronic low back pain.

When the study ended in 2006, nearly all outcome categories were worse in the surgical group. Only about a quarter had returned to work after two years, compared with two-thirds of non-surgical patients. Eleven percent were permanently disabled compared with 2 percent of those without surgery.

And nearly 85 percent of the spinal fusion patients continued using opioid painkillers vs. 49 percent of non-surgical patients, with those who had had the surgery upping their daily opioid use by 41 percent.

In addition, 36 percent of the spinal fusion group had complications from the surgery, including meningitis, kidney failure and death. The re-operation rate was also 27 percent in the surgery group, and included three people who underwent four re-operations. And total days off work was also greater in the spinal fusion group (1140 days vs. 316 days).

"I'm not saying don't have lumbar fusion surgery . . . but it should be carefully evaluated before it's done," said lead study author Dr. Trang H. Nguyen, who practices occupational medicine in Cincinnati and conducted the research while a doctoral candidate at the University of Cincinnati College of Medicine. "The chances are it will have a poor outcome."

The study was published in the Feb. 15 issue of Spine.

Spinal fusion surgery, which fuses adjacent vertebrae together to treat degenerative back conditions, has increased 220 percent since 1990, the study authors said.

Research published in the Journal of American Medical Association in April 2010, for example, indicated that the use of complex surgical procedures such as spinal fusion to treat back pain had risen 15-fold over the prior six years despite the fact that the operations are riskier and not necessarily more effective.

Few studies, however, have focused solely on spinal fusion outcomes in worker's compensation patients, Nguyen said.

The findings, Nguyen added, are "very consistent with previous studies. The result we've provided is nothing new."

Most of the patients in Nguyen's study had degenerative disc disease, herniated discs or nerve root disease.

But the surgery may work well for those with other conditions, such as unstable spines, severe vertebral fractures, cancer or extremely herniated discs, Nguyen said.

Dr. Leah Y. Carreon, clinical research director of the Norton Leatherman Spine Center in Louisville, Ky., questioned whether the surgical group could be compared fairly to the non-surgical group since certain back conditions are more likely to respond to surgery than others.

"They're looking at the nebulous diagnosis of chronic low back pain, which is what we're trying to veer away from," Carreon said.

Carreon said she doesn't believe the two worker's compensation groups in the study are comparable.

"I'm not sure the amount of disability is the same for the non-surgical group as the surgical group," she said. "Despite the numbers [of participants], you'd think they would come up with a homogenous group, but I don't have any proof of that. They still did not come up with an apples-to-apples comparison."

Dr. E. Kano Mayer, a staff physician and physiatrist (rehabilitation physician) at the Cleveland Clinic for Spine Health, said he agrees with the study's conclusions and doesn't think the surgical patients had worse underlying disease or any other factors that led to their poorer outcomes.

The best treatment, he noted, would focus on physical therapy to increase flexibility and strength.

"Just like an injured athlete, the goal is to get them back to where they can do their job," Mayer said. "It's bad advice to rest afterward, so early activity and doing normal things seems to be how you get started and not let people go off the rails."

More information

Learn more about spinal fusion surgery from the U.S. National Library of Health.

SOURCES: Trang H. Nguyen, M.D., Ph.D., occupational medicine specialist, Cincinnati, Ohio; E. Kano Mayer, M.D., staff physician and physiatrist, Cleveland Clinic for Spine Health; Leah Y. Carreon, M.D., clinical research director, Norton Leatherman Spine Center, Louisville, Ky.; Feb. 15, 2011, Spine.

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