Who May Benefit From Spinal Surgery

Patients with CLBP and their treating physicians need to approach the issue of spinal surgery with caution. It is important to understand that the spine surgical community is indeed split as to whether they believe spinal surgery is an option for the patient with CLBP. This is a controversial area of medicine highlighted by recent published expert opinion statements critical of spinal fusion surgery146[V] and in response, supportive of surgery.147[V]

Part of the controversy is centered around the assumption that CLBP is caused by a painful disk and therefore removing the disk surgically should alleviate the pain. This view fits well with the orthopedic model of CLBP which is arguably bioanatomically based. History, examination, and imaging or provocative discography studies do a poor job at differentiating patients with truly discogenic pain from others.

On the other hand, recent clinical trials using a bio-psychosocial model of CLBP have shown evidence supporting conservative care for these patients. The first randomized trials comparing spinal fusion to an aggressive exercise therapy treatment approach within a CBT program have shown virtually identical results. Both groups showed improvement in pain and disability, but the surgical group had more morbidity in the interoperative and postoperative periods.133,148 [II] Another similarly designed comparison published earlier showed an advantage to spinal fusion surgery. However, the conservative treatment group in that study was poorly defined and treatment was variable with little attempt at a formal therapy component.149[II]

Probably the best candidate for spinal fusion surgery for CLBP is one in whom the imaging studies and dis-cography define a single discogenic pain generator in a patient who is otherwise fit, motivated to get better, and continues to have disabling CLBP, despite all the reasonable medical treatments previously discussed. In addition, they need to have realistic expectations for and understand the risks of the surgery itself.

Radiculopathy patients are surgical candidates if they have predominantly leg pain, a clear corroborative disk on imaging studies, and have failed with aggressive medical management for at least six weeks. About 70 percent of patients will realize significant improvement within six weeks of symptom onset150 without the need for surgery. Rarely, progressive neurological deficit (2-4 percent) or cauda equine syndrome (1-2 percent) will prompt urgent or emergency surgery, respectively. Otherwise, it does not appear that mild static weakness is an indication for surgery as patients will recover strength to the same extent and at the same rate, whether they are treated surgically or medically.150,151

Spinal stenosis surgery is similar to radiculopathy as it is an elective procedure driven by patient function/disability. The natural history of typical degenerative central spinal canal stenosis is one of very little change over many months with 15 percent actually improving over time.152

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