Back Pain: Surgery Vs. Non-Surgical Options

Summary:  Just went through the literature again looking for back pain and long term outcomes for surgery vs. nonsurgical treatment.  Can we just say that the studies will never be done?  Just finding long term follow up on patients after back surgery means I need to look outside the U.S. The short answer is that around 15% of patients will need another back surgery in ten years (based on one small study).  But patients with larger areas of involvement are more than five times more likely to need another surgery.  Personally, I’ve never seen a back where the whole back wasn’t involved to some extent.  It may not show up on the scans, but when one area is in crisis, the rest of the back accommodates the wounded part. 

Spine J. 2008 Mar-Apr;8(2):397-403. Epub 2007 Jan 30.

Spontaneous resorption of intradural lumbar disc fragments.

Borota L, Jonasson P, Agolli A.

Department of Radiology, Section of Neuroradiology, University Hospital of Northern Sweden, 90185, Umeå, Sweden.


BACKGROUND CONTEXT: Intradural disc herniation is relatively rare complication of the spinal degenerative process that occurs most frequently in the lumbar part of the spine. Both myelographic and magnetic resonance features of this entity have been described, and the mechanism of intradural herniation has already been proposed and generally accepted. In this article, we present a case of spontaneous resorption of an intradural, fragmented intervertebral disc. Spontaneous resorption of intradural disc fragments has not been previously reported.

PURPOSE: To discuss a possible mechanism of spontaneous resorption of the subdural disc fragments.

STUDY DESIGN: Case report and literature review.

METHODS: Radiological follow-up of a 46-year-old man with the intradural herniation of disc fragments.

CONCLUSION: The reaction generated by the meninges might lead to the complete resorption of intrathecally localized disc fragments.

PMID: 18299107

Neurosurg Rev. 2004 Apr;27(2):75-80; discussion 81-2. Epub 2003 Oct 15.

Intradural lumbar disc herniations: the role of MRI in preoperative diagnosis and review of the literature.

D’Andrea G, Trillò G, Roperto R, Celli P, Orlando ER, Ferrante L.

Department of Neurological Sciences, “La Sapienza” University, Rome, Italy.


The goal of this article is to report our experience on intradural lumbar disc herniation, consider the causes of this pathology, and analyze it from clinical, diagnostic, and therapeutic perspectives with a particular emphasis on the role of MRI in preoperative diagnosis. We analyzed nine patients treated surgically for intradural lumbar disc hernia. All of them underwent surgery, and hemilaminectomy was performed. In six cases, the diagnosis of intradural herniation was definitive and, in the three remaining, it was confirmed at surgery. In five cases, CT (with no contrast medium) of the lumbar area revealed disc herniation, but none could it confirm its intradural location. Myelography was performed in two cases but also could not prove intradural extrusion. Magnetic resonance imaging study was used in four cases. In five, the postoperative outcome has been excellent. Patients 6 and 9 recovered anal function postoperatively; patient 6 suffered from occasional and mild micturition urgency. The three patients previously operated (1, 2, 7) showed good outcome. Presently, we believe that radiologic diagnosis of intradural herniation is possible in carefully selected patients, thanks to MRI with gadolinium.

PMID: 14564663

Pain Physician. 2009 May-Jun;12(3):561-72.

A systematic review of mechanical lumbar disc decompression with nucleoplasty.

Manchikanti L, Derby R, Benyamin RM, Helm S, Hirsch JA.

Pain Management Center of Paducah, Paducah, KY, USA.


BACKGROUND: Lumbar disc prolapse, protrusion, or extrusion account for less than 5% of all low back problems, but are the most common causes of nerve root pain and surgical interventions. The primary rationale for any form of surgery for disc prolapse is to relieve nerve root irritation or compression due to herniated disc material. The primary modality of treatment continues to be either open or microdiscectomy, but several alternative techniques including nucleoplasty, automated percutaneous discectomy, and laser discectomy have been described. There is a paucity of evidence for all decompression techniques, specifically alternative techniques including nucleoplasty.

STUDY DESIGN: A systematic review of the literature.

OBJECTIVE: To determine the effectiveness of mechanical lumbar disc decompression with nucleoplasty.

METHODS: A comprehensive evaluation of the literature relating to mechanical lumbar disc decompression with nucleoplasty was performed. The literature was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs), and Agency for Healthcare Research and Quality (AHRQ) criteria was utilized for observational studies. The level of evidence was classified as Level I, II, or III with 3 subcategories in Level II based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF). A literature search was conducted using only English language literature through PubMed, EMBASE, the Cochrane library, systematic reviews, and cross-references from reviews and systematic reviews.

OUTCOME MEASURES: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, opioid intake, and return to work. Short-term effectiveness was defined as one year or less, whereas, long-term effectiveness was defined as greater than one year.

RESULTS: Based on USPSTF criteria the level of evidence for nucleoplasty is Level II-3 in managing predominantly lower extremity pain due to contained disc herniation.

LIMITATIONS: Paucity of literature, both observational and randomized.

CONCLUSION: This systematic review illustrates Level II-3 evidence for mechanical lumbar percutaneous disc decompression with nucleoplasty in treatment of leg pain. However, there is no evidence available in managing axial low back pain.

PMID: 19461823

Pain Physician. 2009 Mar-Apr;12(2):361-78.

Systematic review of percutaneous adhesiolysis and management of chronic low back pain in post lumbar surgery syndrome.

Epter RS, Helm S 2nd, Hayek SM, Benyamin RM, Smith HS, Abdi S.

Augusta Pain Center, Augusta, GA 30917-1839, USA.


BACKGROUND: Post lumbar surgery syndrome or failed back surgery syndrome with persistent pain continues to increase over the years. The speculated causes of post lumbar laminectomy syndrome include acquired stenosis, epidural fibrosis, arachnoiditis, radiculopathy, and recurrent disc herniation. Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome. Percutaneous epidural adhesiolysis has been employed in interventional pain management in the treatment of chronic, refractory low back and lower extremity pain after back surgery.

STUDY DESIGN: A systematic review of randomized trials and observational studies.

OBJECTIVE: To evaluate the effectiveness of percutaneous adhesiolysis in managing chronic low back and lower extremity pain due to post lumbar surgery syndrome.


METHODS: A comprehensive literature search was conducted utilizing electronic databases, as well as systematic reviews and cross references from 1966 through December 2008. The quality of individual articles used in this analysis was assessed by modified Cochrane review criteria for randomized trials and the Agency for Healthcare Research and Quality (AHRQ) criteria for assessment of observational studies. Clinical relevance was evaluated using 5 questions according to the criteria recommended by the Cochrane Review Back Group. Analysis was conducted using 5 levels of evidence, ranging from Level I to III, with 3 subcategories in Level II. OUTCOME PARAMETERS: The primary outcome measure was pain relief (short-term relief of at least 6 months and long-term relief of more than 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and change in opioid intake.

RESULTS: Of the 13 studies considered for inclusion, 3 randomized trials and 4 observational studies met the inclusion criteria for methodologic quality assessment and evidence synthesis based on methodologic quality scores of 50 or more. Evidence of percutaneous adhesiolysis in the management of chronic low back pain in post-lumbar surgery syndrome is Level I to Level II-1, with evidence derived from 3 randomized trials.

LIMITATIONS: There is a paucity of efficacy and pragmatic trials. No trials have been published after 2006.

CONCLUSION: The indicated level of evidence for percutaneous adhesiolysis is Level I or II-1 based on the US Preventative Services Task Force (USPSTF) criteria.

PMID: 19305485

Pain Physician. 2009 Jul-Aug;12(4):E123-98.

Comprehensive review of therapeutic interventions in managing chronic spinal pain.

Manchikanti L, Boswell MV, Datta S, Fellows B, Abdi S, Singh V, Benyamin RM, Falco FJ, Helm S, Hayek SM, Smith HS; ASIPP.

Pain ManagementCenter of Paducah, Paducah, KY, USA.


BACKGROUND: Available evidence documents a wide degree of variance in the definition and practice of interventional pain management.

OBJECTIVE: To provide evidence-based clinical practice guidelines for interventional techniques in the treatment of chronic spinal pain.

DESIGN: Best evidence synthesis.

METHODS: Strength of evidence was assessed by the U.S. Preventive Services Task Force (USPSTF) criteria utilizing 5 levels of evidence ranging from Level I to III with 3 subcategories in Level II.

OUTCOMES: Short-term pain relief was defined as relief lasting 6 months or less and long-term relief as longer than 6 months, except < or = one year and > one year for intradiscal therapies, mechanical disc decompression, spinal cord stimulation, and intrathecal infusion systems.

RESULTS: The indicated evidence for therapeutic interventions is Level I for caudal epidural steroid injections in managing disc herniation or radiculitis, and discogenic pain without disc herniation or radiculitis. The evidence is Level I to II-1 for percutaneous adhesiolysis in management of pain secondary to post-lumbar surgery syndrome. The evidence is Level II-1 or II-2 for therapeutic cervical, thoracic, and lumbar facet joint nerve blocks; for caudal epidural injections in managing pain of post-lumbar surgery syndrome, and lumbar spinal stenosis, for cervical interlaminar epidural injections in managing cervical pain (Level II-1); for lumbar transforaminal epidural injections; and spinal cord stimulation for post-lumbar surgery syndrome.

LIMITATIONS: The limitations of this guideline preparation included a paucity of literature, lack of updates, and lack of conflicts in preparation of systematic reviews and guidelines by various organizations.

CONCLUSION: The indicated evidence for therapeutic interventions is variable from Level I to III. This comprehensive review includes the evaluation of evidence for therapeutic procedures in managing chronic spinal pain and recommendations. However, this review and recommendations do not constitute inflexible treatment recommendations or “standard of care.”

PMID: 19668281

Rev Chir Orthop Reparatrice Appar Mot. 2008 Sep;94(5):464-71. Epub 2008 May 2.

[Long-term survival analysis after surgical management for degenerative lumbar stenosis]

[Article in French]

Lenoir T, Dauzac C, Rillardon L, Guigui P.

Service de Chirurgie Orthopédique, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy Cedex, France.


PURPOSE OF THE STUDY: The short- and mid-term symptom-relief of surgical treatment for lumbar stenosis is generally acknowledged, but the probability of a long-term reoperation remains to be studied. The purpose of this work was to determine the long-term risk of reoperation after surgical treatment of degenerative lumbar stenosis and to search for factors influencing this probability.

MATERIAL AND METHODS: All patients who underwent from 1989 to 1992 surgical treatment for degenerative lumbar spine stenosis were included in this work. At last follow-up, we noted functional outcome using a specific self-administered questionnaire, patient satisfaction, lumbalgia and radiculalgia using a visual analog scale, SF36 quality-of-life, reoperation or not with time since first operation if performed and the reasons and modalities of the reoperation. The probability of reoperation was determined with the acturarial method. A Cox model was used to search for factors linked with the probability of reoperation; variables studied were: age, comorbid factors, extent of the release, posterolateral arthrodesis or not, extent of the potential fusion, use or not of instrumentation for arthrodesis.

RESULTS AND DISCUSSION: The study included 262 patients. At last follow-up, 61 patients had died a mean 3.7+/-3 years after the operation; only one of these patients had a second operation 22 months after the first. Forty-four patients were lost to follow-up at mean 6.6+/-3 years. Among these 44 patients, four had a second operation during their initial follow-up at mean 47 months. One hundred fifty-seven patients were retained for this analysis at mean 15+/-1 years follow-up. Among these 157 patients, 29 had a second operation a mean 75 months after the first. There were four reasons for reoperating: insufficient release, destabilization within or above the zone of release, development or renewed zone of stenosis, development or renewed discal herniation. The risk of a second operation was 7.4% [95% CI 4.8-11.6], 15.4% [95% CI 10.7-21.1] and 16.5% [95% CI 11.7-219] at five, 10 and 15 years respectively after the first operation. Among the risk factors studied, only one had a significant impact on reoperation: extent of the zone of release (p=0.003). Compared with a release limited to one level, the risk of reoperation after release of three levels or more was five times greater [95% CI 1.8-12.7].

PMID: 18774021


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