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Back Pain & Osteoporosis

From the Current Issue

Are You a Good Candidate for Spinal Fusion?
Though increasingly used for the treatment of back pain, spinal-fusion surgery benefits only a small subset of patients.

The use of spinal-fusion surgery has increased drastically in recent years, from 150,000 procedures in 1993 to 300,000 in 2001. Although many long-established uses exist for spinal fusion—for the treatment of severe scoliosis, spinal tuberculosis, and vertebral fractures—doctors are increasingly using it to treat back pain resulting from degenerative changes in the spine, disk disorders such as herniated disks, and spinal stenosis. However, there is no convincing evidence that spinal fusion works for most patients with back pain from these conditions.

So Many Fusions, So Little Evidence

Why, despite little evidence to support it, do doctors consistently recommend spinal fusion surgery to their patients? The answer may lie in part with what some have called a “triumph of technology over reason.” Because the technology of spinal fusion has advanced enough that the surgery can be done relatively safely, surgeons may be quicker to suggest fusion than they were in the past, even if the patient is not an excellent candidate for the procedure. The attitude may be that “it can’t hurt to try.”

There is some evidence, however, that spinal fusion may help a very select group of patients. According to a 2001 study published in Spine of 294 patients with chronic low back pain, back pain was reduced by 33% in patients randomized to receive spinal fusion compared with 7% in those undergoing physical therapy. However, to achieve success, the authors of this study point out that patients must be carefully selected for surgery (see the section below) and well informed about its potential outcomes.

Not For Everyone With Back Pain

If your doctor recommends spinal fusion for treatment of degenerative changes, a herniated disk, or spinal stenosis, how do you know if you’re actually a good candidate? First, you should have severe disability from your back pain—for example, being unable to perform activities of daily living (such as dressing or bathing yourself) or to do your job. Second, you already should have tried conservative care—such as self-treatment, pain relievers, and exercise—at least for six months without success. Third, the back problem should be localized, that is, confined to a small area (one to two levels) of the spine, with no associated deformity.

In addition, potential candidates for spinal fusion should have no significant psychosocial problems. Research has consistently shown that people with back pain who have problems such as depression, large debts, an unhappy marriage, or jobs that involve repetitive manual labor do not experience improvement in pain after a fusion. Their pain tends to be magnified because of their psychological issues, and fixing the physical problem has little benefit. These patients should instead seek psychological counseling.

Patients who choose spinal fusion also should have realistic goals regarding the outcomes of the procedure. They should anticipate a hospital stay of two to six days and be prepared for a long recovery time. Although some patients are able to return to work in as little as six weeks, others may need as much as six months to a year. The amount of time depends in part on the person’s previous lifestyle and job. Someone with a desk job likely will have a shorter recovery time than someone who engages in physically demanding work. In addition, people who undergo spinal fusion should not expect to fully recover their former physical abilities. For example, a 50-year-old tennis player who has played only doubles because of discomfort will likely not go back to playing singles like he or she did at age 25.

Also, people with nerve problems, such as sciatica, associated with the back pain (with the leg pain being greater than the back pain) are not good candidates for spinal fusion; they do best with decompression surgery (see page 33). However, if the person has a long history of back pain or evidence of abnormal motion on imaging studies, decompression might be combined with a fusion.

The Bottom Line

Although studies have not clearly shown that spinal fusion is effective for spinal degenerative changes, herniated disks, or spinal stenosis, some people with these conditions report pain relief from the procedure. Deciding who will benefit most from the procedure requires a careful analysis of the patient’s particular situation—both physical and psychological. To reduce your odds of undergoing a surgical procedure that will provide no benefit, get a second opinion before yielding to the knife. Also, many doctors now increasingly consider disk replacement as an alternative to spinal fusion.



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Back Pain & Osteoporosis

The Back Pain and Osteoporosis White Paper from The Johns Hopkins White Papers series is an annual, in-depth report written by Hopkins physicians.



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