So...
SPINE SURGERY
Worth it?
Short answer: In most cases, NO.
Of course, there's a time and place. And thank goodness for the newer technologies to help as a last resort when needed. But for most people, resorting to surgery should NOT be the first, or second, or third... etc.. option.
Which, is supported by the research,
and, as I've found out from talking with hundreds of people in this position...
also aligns with your intuition.
You've checked off the list:
Chronic pain
Hasn't gotten better over time
Ibuprofen just wasn't doing the trick anymore
Those stretches the PT gave you aren't working
Your family doc referred you over to get Xrays
'Nothings wrong! A little degeneration. So we should get an MRI, just to make sure'
MRI shows some disc issues.
Let's start with an injection. This should numb things up. Come back in 3 months.
3 sets of injections, and the pain is still there.
Let's get some more imaging
And talk about surgery.
Typical story.
I've heard it, countless times from people I've met out in the community, as well as those who have come into my office.
For good reason, as 80+% of the population will experience chronic back pain at some point in life, and is the #1 reason for occupational injury and disability.
Unfortunately, this is the process that so many go through. Not only do these measly processes rarely produce positive results at the beginning to get an individual better... but it prolongs the actual healing process and people are left in no better condition than when they started seeking 'treatment'. From a conventional standpoint, there's no true direction to help a person understand what's causing the issues, and more importantly, what can be done to correct them without drugs or surgery.
No clear answers.
No direction.
No hope.
Yes, they may receive 'treatment', but they don't receive CORRECTION, HEALING, AND RESOLUTION.
-Dr. Justin Lee D.C
There is a vast difference between treating symptoms... and correcting CAUSES.
By treating the cause of any issue, the underlying issue can be corrected, and the body will function better, and ultimately heal. Simply put, this is how you actually get healthy.
Of course, there is a time and place for surgery and other procedures (yes, it had to be repeated). In a life saving emergency, and when there is considerable damage and ALL other options have been exhausted. These are the moments where, thank God, we do have emergency medicine and the best specialists on the planet, with the best technology. I have friends and colleagues that work in this industry, and I'm so grateful for many of the amazing things they do.
But, drugs and surgery are not the first and only option for most. And it should not be touted as the gold standard in addressing spine dysfunction and pain.
Spine Fusion Surgery: The Verdict
According to Dr. Ian Harris, a world renowned orthopedic surgeon, professor, and researcher; "There is very little evidence that spine fusion surgery for back pain is effective. It is quite expensive, often leads to complications, often requires further surgery, is associated with increased mortality, and often does not even result in the spine being fused."
"Millions of people have had spine fusions for back pain, and I am not at all convinced that the benefits of this surgery outweighs the considerable harm."
"Somebody is winning here, and it isn't the patients."
-Dr. Ian Harris
650,000-700,000 Spine surgeries per year.
From 2004-2015, Volume of elective lumbar fusion increased 62.3%.
In the same period, Aggregate hospital costs increased 177% during these 12 years, exceeding $10 billion in 2015, and averaging more than $50,000 per admission.
$40+Billion industry in treatment costs/year
Average cost of $100,000
Work loss, disability, indirect costs=$100-200 billion/year
149 million work days lost.
3 million people went to the emergency room in 2008=$9.5 billion (9th most expensive condition treated in U.S hospitals).
The U.S has the highest spinal surgery rate in the world; 200% higher than New Zealand, and 340% higher than the U.K. Rates are similar in Canada, Australia, Norway, and Finland. Neck and back pain rates are similar amongst these regions.
FDA: 50% of single level degenerative disc disease fuion and arthroplasty were a sucess
20% of lumbar spinal fuion patients underwent 2nd surgeries.
Other studies show 28%.
Most common cause of death after surgery? Opiod addiction/overdose.
Some research suggest as high as 90% of spine surgeries are unnecessary.
Numerous other studies, even within the orthopedic or neurological profession, support the glaring fact that spine surgery is not the best option for low back pain. In fact, most report that it should be used as a very last resort.
"The National Institute for Health and Care Excellence has issued guidelines that state fusion for non-specific low back pain should only be performed as part of a randomised controlled trial, and that lumbar disc replacement should not be performed. Thus, spinal fusion and disc replacement will no longer be routine forms of treatment for patients with low back pain. This annotation considers the evidence upon which these guidelines are based."
-PMID: 28768775
Comparison of spinal fusion and nonoperative treatment in patients with chronic low back pain: long-term follow-up of three randomized controlled trials
Conclusion: After an average of 11 years follow-up, there was no difference in patient self-rated outcomes between fusion and multidisciplinary cognitive-behavioral and exercise rehabilitation for cLBP. The results suggest that, given the increased risks of surgery and the lack of deterioration in nonoperative outcomes over time, the use of lumbar fusion in cLBP patients should not be favored in health care systems where multidisciplinary cognitive-behavioral and exercise rehabilitation programmes are available.
-The Spine Journal: Vol.13 Iss.11
Risks Associated with Spinal Surgery
Adverse events are NOT uncommon.
In fact, they're remarkably common.
Multiple independent medical research teams have shown that reoperation rates are greater than 22%.
Again, there is a time and place for medical intervention... but it's not every time. And any time it's in question, other options should be explored. It's important to get a full view perspective of all factors that could be affecting the situation. Chances are, your spine doesn't NEED surgical intervention... proper alignment, motion, and function is more than a likely place to start. It's a necessity for everyone.
Get to the CAUSE
To get to the cause, we start with:
Comprehensive Consultation
Functional Assessment
Specific Digital Xrays
I LOVE being able to provide this insight for people as it empowers people to not just understand what is going on with their health, but to take action and correct issues that have been plaguing them for years.
From a specific analysis of your spine, we will be able to determine how well your spine in functioning, the specific alignment of the spine from various viewpoints, and the best approach to improve, and even correct any underlying misalignments and dysfunctional areas that are causing you issues.
This typically requires a specific corrective plan for each individual, which would include both specific treatments and adjustments in the office, as well as corrective spinal exercises at home. Reassessments are done throughout the process, and most individuals will receive an updated set of Xrays to quantitatively assess structural improvements with their spine.
The outcome?
Improved spine function.
Which leads to better movement, range of motion, less restriction throughout the spine/hips/pelvis/extremities. These are the traditional benefits from a biomechanics standpoint.
Neurologically, there are many other benefits as well. Which, physiologically speaking, are more important than the improved biomechanics. Improving your nervous system function will inevitably improve the overall health of your body. Every system of your body in fact. Because every system is controlled directly, and/or indirectly by your nervous system.
These are the side effects.
Once your nervous system is able to properly communicate with the rest of your body, everything will come into better balance; allowing your system to heal more effectively.
We consistently hear about improved:
Stress response
Heart rate variability (HRV)
Organ function
Resolution of headaches/migraines
Sleep
Digestion
Allergies/Asthma improved or resolved
Better energy and focus
More robust immune system
Dizziness/vertigo
Ear infections
Recovery
ETC
The beauty about getting your spine checked, and corrected, is that you have nothing to lose. All medications, all surgeries, and the vast majority of medical interventions carry a risk. Chiropractic carries very little (and if done right, basically zero) risk. You only have things to gain. Like, improving your health from every angle!
Citations and Resources
Todd NV. The surgical treatment of non-specific low back pain. Bone Joint J. 2017 Aug;99-B(8):1003-1005. doi: 10.1302/0301-620X.99B8.BJJ-2017-0199.R1. PMID: 28768775.
One-year outcomes of surgical versus nonsurgical treatments for discogenic back pain: a community-based prospective cohort study
Spine J . 2013 Nov;13(11):1421-33.
doi: 10.1016/j.spinee.2013.05.047.Epub 2013 Jul 23.
You always have to be careful with where you're getting information... what type of treatment was given? What treatment was the 'control' group given? How did they measure outcomes? How was 'success' defined? There are a lot of considerations to be made, especially when making such an important health decision.
"Conclusions: The surgical group showed greater improvement at 1 year compared with the nonsurgical group, although the composite success rate for both treatment groups was only fair. The results should be interpreted cautiously because outcomes are short term, and treatment was not randomly assigned. Only 5% of nonsurgical patients received cognitive behavior therapy. Nonsurgical treatment that patients received was variable and mostly not compliant with major guidelines."
Acta Orthop Suppl . 2013 Feb;84(349):1-35. doi: 10.3109/17453674.2012.753565.
Decision making in surgical treatment of chronic low back pain: the performance of prognostic tests to select patients for lumbar spinal fusion
10 Things to know about spine surgery
. 2019 Mar 1;44(5):369-376. doi: 10.1097/BRS.0000000000002822.
Trends in Lumbar Fusion Procedure Rates and Associated Hospital Costs for Degenerative Spinal Diseases in the United States, 2004 to 2015
Needless treatments: spinal fusion surgery for lower back pain is costly and there’s little evidence it’ll work
"Back pain affects one in four Australians. It’s so common, nearly all of us (about 85%) will have at least one episode at some stage of our lives. It’s one of the most common reasons to visit a GPand the main health condition forcing older Australians to retire prematurely from the workforce.
Treatment costs for back pain in Australia total almost A$5 billion every year. A great proportion of this is spent on spinal surgical procedures. Recently, Choosing Wisely, the campaign to educate medical professionals and the public about tests, treatments and procedures that have little benefit, or lead to harm, added spinal fusion for lower back pain to its list."
Eur J Pain. 2021 Aug;25(7):1429-1448. doi: 10.1002/ejp.1773. Epub 2021 Apr 15.
Neurophysiological mechanisms of chiropractic spinal manipulation for spine pain
Lumbar fusion versus nonoperative management for treatment of discogenic low back pain: a systematic review and meta-analysis of randomized controlled trials
"Results: Five RCTs met our inclusion criteria. A total of 707 patients were divided into lumbar fusion (n=523) and conservative management (n=134). Although inclusion/exclusion criteria were relatively similar across studies, surgical techniques and conservative management protocols varied. The pooled mean difference in ODI (final ODI-initial ODI) between the nonoperative and lumbar fusion groups across all studies was -7.39 points (95% confidence interval: -20.26, 5.47) in favor of lumbar fusion, but this difference was not statistically significant (P=0.26).
Conclusions: Despite the significant improvement in ODI in the lumbar fusion groups in 3 studies, pooled data revealed no significant difference when compared with the nonoperative group. Although there was an overall improvement of 7.39 points in the ODI in favor of lumbar fusion, it is unclear that this change in ODI would lead to a clinically significant difference. Prospective randomized trials comparing a specific surgical technique versus a structured physical therapy program may improve evidence quality. Until then, either operative intervention by lumbar fusion or nonoperative management and physical therapy remain 2 acceptable treatment methods for intractable low back pain."
Spine J
. 2014 Jul 1;14(7):1237-46. doi: 10.1016/j.spinee.2013.08.018. Epub 2013 Nov 7.
How do coverage policies influence practice patterns, safety, and cost of initial lumbar fusion surgery? A population-based comparison of workers' compensation systems
"Results: Overall rate of lumbar fusion operations through WC programs was 47% higher in California than in Washington. California WC patients were more likely than those in Washington to undergo fusion for controversial indications, such as nonspecific back pain (28% versus 21%) and disc herniation (37% versus 21%), as opposed to spinal stenosis (6% versus 15%), and spondylolisthesis (25% versus 41%). A higher percentage of patients in California received circumferential procedures (26% versus 5%), fusion of three or more levels (10% versus 5%), and bone morphogenetic protein (50% versus 31%). California had higher adjusted risk for reoperation (relative risk [RR] 2.28; 95% confidence interval [CI], 2.27-2.29), wound problems (RR 2.64; 95% CI, 2.62-2.65), device complications (RR 2.49; 95% CI, 2.38-2.61), and life-threatening complications (RR 1.31; 95% CI, 1.31-1.31). Hospital costs for the index procedure were greater in California ($49,430) than in Washington ($40,114).
Conclusions: Broader lumbar fusion coverage policy was associated with greater use of lumbar fusion, use of more invasive operations, more reoperations, higher rates of complications, and greater inpatient costs."
Spine (Phila Pa 1976) . 1998 Apr 1;23(7):814-20. doi: 10.1097/00007632-199804010-00015.
5-year reoperation rates after different types of lumbar spine surgery
-Older study. But, worth looking into.
Review Neurosurgery . 2017 May 1;80(5):701-715. doi: 10.1093/neuros/nyw162.
Lumbar Fusion for Degenerative Disease: A Systematic Review and Meta-Analysis
"The literature search yielded 65 studies (19 randomized controlled trials, 16 prospective cohort studies, 15 retrospective cohort studies, and 15 registries) enrolling a total of 302 620 patients. "
" Relative to decompression-alone, the risk of reoperation following fusion was increased for spinal stenosis (relative risk [RR] 1.17, 95% confidence interval [CI] 1.06-1.28) and decreased for spondylolisthesis (RR 0.75, 95% CI 0.68-0.83). Among patients with spinal stenosis, complications were more frequent following fusion (RR 1.87, 95% CI 1.18-2.96). Mortality was not significantly associated with any treatment modality.
Conclusion: Positive clinical change was greatest in patients undergoing fusion for spondylolisthesis while complications and the risk of reoperation limited the benefit of fusion for spinal stenosis. The relative safety and efficacy of fusion for chronic low back pain suggests careful patient selection is required (PROSPERO International Prospective Register of Systematic Reviews number, CRD42015020153)."
The surgical treatment of non-specific low back pain.
"The National Institute for Health and Care Excellence has issued guidelines that state fusion for non-specific low back pain should only be performed as part of a randomised controlled trial, and that lumbar disc replacement should not be performed. Thus, spinal fusion and disc replacement will no longer be routine forms of treatment for patients with low back pain. This annotation considers the evidence upon which these guidelines are based."
Acta Orthop Suppl. 2013 Feb;84(349):1-35. doi: 10.3109/17453674.2012.753565.
Decision making in surgical treatment of chronic low back pain: the performance of prognostic tests to select patients for lumbar spinal fusion.
Why ‘Useless’ Surgery Is Still Popular
J Bone Joint Surg Am. 2006 Apr;88 Suppl 2:21-4. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences.
"The total costs of low-back pain in the United States exceed $100 billion per year. Two-thirds of these costs are indirect, due to lost wages and reduced productivity. Each year, the fewer than 5% of the patients who have an episode of low-back pain account for 75% of the total costs. Because indirect costs rely heavily on changes in work status, total costs are difficult to calculate for many women and students as well as elderly and disabled patients. "
No Drugs for Back Pain, New Guidelines Say The American College of Physicians says to use natural and alternative therapies first
National trends in the surgical treatment for lumbar degenerative disc disease: United States, 2000 to 2009
Overtreating Chronic Back Pain: Time to Back Off?
" over approximately a decade - a 629% increase in Medicare expenditures for epidural steroid injections; a 423% increase in expenditures for opioids for back pain; a 307% increase in the number of lumbar MRIs among Medicare beneficiaries; and a 220% increase in spinal fusion surgery rates. The limited studies available suggest that these increases have not been accompanied by population-level improvements in patient outcomes or disability rates."
"Pain complaints are a leading reason for medical visits.1 The most common pain complaints are musculoskeletal, and back pain is the most common of these. "
"The proportion of office visits attributed to back pain has changed little since 1990"
"National Medical Expenditure Panel Survey showed a 108% increase in opioid prescriptions from 1997 through 2004 (Figure 1b). The combination of increasing use and higher drug prices resulted in a 423% inflation-adjusted increase in expenditure"
"The Cochrane Collaboration review of opioids for chronic low back pain similarly concluded that “Despite concerns surrounding the use of opioids for long-term management for chronic LBP, there remain few high-quality trials assessing their efficacy…Based on our results, the benefit of opioids in clinical practice for the long-term management of chronic LBP remains questionable.”40 In population-based studies, many patients receiving opioids for non-cancer pain have persistent high levels of pain and poor quality of life.41Ironically, patients with major depression and other psychiatric disorders are more likely than others to initiate and to continue opioid therapy,42 yet they also are more likely to misuse medication,43,44 and may be less likely to experience analgesic benefit.45 Although depression and other psychiatric disorders are common among patients with chronic back pain,42,46-48 patients with such disorders are commonly excluded from trials of opioid therapy,42 raising questions about the generalizability of efficacy studies to routine practice."
"Some adverse effects of opioid use may be underappreciated, including hyperalgesia,49,50 which may result from changes in the brain, spinal cord, and peripheral nerves.51-53 In short, opioid use may paradoxically increase sensitivity to pain. Hypogonadism is another underappreciated consequence of chronic use, resulting in reduced testosterone levels, diminished libido, and erectile dysfunction."
"Despite no specific concurrent reports of clarified indications or improved efficacy, there was a 220% increase in the U.S. rate of lumbar spine fusion surgery from 1990 to 2001"
"In the state of Maine, the best surgical outcomes occurred where surgery rates were lowest; the worst results occurred in areas where rates were highest"
Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State
"Back injuries are the most prevalent occupational injury in the United States. Little is known about predictors of lumbar spine surgery following occupational back injury."
"42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor. The multivariate model’s AUC was 0.93 (95% CI 0.92–0.95), indicating excellent ability to discriminate between workers who would versus would not have surgery."
"Costs relating to occupational back pain increased over 65% from 1996 through 2002, after adjustment for medical and general inflation.3 Spine surgeries, including those after occupational back injury, represent a significant proportion of these costs and have faced increasing scrutiny regarding effectiveness and efficacy.4,5 Spine surgeries are associated with little evidence for improved population outcomes,4 yet rates have increased dramatically since the 1990s"
Comparison of spinal fusion and nonoperative treatment in patients with chronic low back pain: long-term follow-up of three randomized controlled trials
Results Of 473 enrolled patients, 261 (55%) completed LTFU, 140/242 patients randomized to receive surgery and 121/231 randomized to receive multidisciplinary cognitive-behavioral and exercise rehabilitation. The intention-to-treat analysis showed no statistically or clinically significant differences between treatment groups for ODI scores at LTFU (adjusted for baseline ODI, previous surgery, duration of LBP, sex, age, and smoking habit): the mean adjusted treatment effect of fusion was −0.7 points on the 0–100 ODI scale (95% confidence interval [CI], −5.5 to 4.2). An as-treated analysis similarly demonstrated no advantage of surgery (treatment effect, −0.8 points on the ODI (95% CI, −5.9 to 4.3). The results for the secondary outcomes were largely consistent with those of the ODI, showing no relevant group differences. Conclusions After an average of 11 years follow-up, there was no difference in patient self-rated outcomes between fusion and multidisciplinary cognitive-behavioral and exercise rehabilitation for cLBP. The results suggest that, given the increased risks of surgery and the lack of deterioration in nonoperative outcomes over time, the use of lumbar fusion in cLBP patients should not be favored in health care systems where multidisciplinary cognitive-behavioral and exercise rehabilitation programmes are available.
Use of Epidurals and steroid injections
FDA Drug Safety Communication: FDA requires label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections for pain
FDA Warns About Dangers of Epidural Steroid Injections for Back Pain. Must Read Before Taking These Steroid