• Dr. J

Is Spine Surgery your Best Option?

Updated: Dec 2, 2021





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

https://www.ncbi.nlm.nih.gov/pubmed/23427903


10 Things to know about spine surgery

https://www.beckersasc.com/outpatient-spine/10-things-to-know-about-spine-surgery-in-ascs.html


. 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

https://pubmed.ncbi.nlm.nih.gov/30074971/


Needless treatments: spinal fusion surgery for lower back pain is costly and there’s little evidence it’ll work

https://theconversation.com/needless-treatments-spinal-fusion-surgery-for-lower-back-pain-is-costly-and-theres-little-evidence-itll-work-91829


"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


https://pubmed.ncbi.nlm.nih.gov/33786932/



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."

https://pubmed.ncbi.nlm.nih.gov/24210578/




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

https://pubmed.ncbi.nlm.nih.gov/9563113/

-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)."

https://pubmed.ncbi.nlm.nih.gov/28327997/


The surgical treatment of non-specific low back pain.

https://www.ncbi.nlm.nih.gov/pubmed/28768775


  • "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.

https://www.ncbi.nlm.nih.gov/pubmed/23427903


Why ‘Useless’ Surgery Is Still Popular

https://www.nytimes.com/2016/08/04/upshot/the-right-to-know-that-an-operation-is-next-to-useless.html?smid=tw-nytimes&smtyp=cur&_r=1&referer=https%253A%252F%252Ft.co%252FsQS0hcyeah



J Bone Joint Surg Am. 2006 Apr;88 Suppl 2:21-4. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences.


https://www.ncbi.nlm.nih.gov/pubmed/16595438

  • "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

https://www.wsj.com/articles/no-drugs-for-back-pain-new-guidelines-say-1487024168


National trends in the surgical treatment for lumbar degenerative disc disease: United States, 2000 to 2009

https://www.thespinejournalonline.com/article/S1529-9430(14)01544-7/abstract


Overtreating Chronic Back Pain: Time to Back Off?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729142/

  • " 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. "