SPINAL surgery, specifically spine fusion, to help with the treatment of lower back pain is increasing in Australia despite the absence of evidence that proves its effectiveness in every single one of patients, claim researchers of a brand new report.
The review was conducted by professor Kate Drummond, the authors of the review, which was published in the MJA and expressed their concern that, since the procedure is performed disproportionately among those who are insured privately, “the contribution of industry and third-party payers to this rise as well as their participation in research published, needs attention to detail”.
Associate Professor Andrew Morokoff, a neurosurgeon at the Royal Melbourne Hospital and a co-author on the review and a co-author of the review, stated that there were many reasons for the rise in spinal surgery for lower back pain.
“One of the main reasons people believe doctors are untrustworthy and performing these procedures without a reason,” he told InSight+in an exclusive podcast.
“But there are other causes for this growth also. One reason is that we are growing older. People are getting back problems.
“And the second reason is that the majority of these procedures rely on modern technologies that only been developed in the last decade or so. Most of them use minimally invasive or keyhole technology, which makes it more secure and feasible to perform these procedures far more securely, especially when older people are involved.
“When I began neurosurgery, 20 years ago, these procedures weren’t possible – there simply wasn’t the technology. The procedure involved a large cut, a large blood loss, lots of pain, and a slow recovery.
“The modern methods to do it mean that we’ve turned the four-hour procedure into a thirty-minute procedure with no loss of blood. It’s actually easier to carry out for those who have an elderly patient with multiple comorbidities.”
However it is true that it is worth noting that MJA report suggested the chronic lower back pain can be treated using “a holistic biopsychosocial strategy that includes generally non-surgical treatments”.
“Spinal surgery plays a key role in relieving radicular pain as well as disabilities due to neural compression or in cases where back pain is related to infections, cancer or even a gross instabilities,” wrote Drummond and colleagues.
“Spinal surgery for any other type of back pain is not supported by evidence from clinical studies, and the evidence foundation for spinal surgery for the treatment of lower back pain is weak and suggests that it is not effective.”
The selection of patients was crucial in the process, Associate Professor Morokoff said to the magazine InSight+.
“It is all about the selection of the patient, doing the surgery with the appropriate indications, and making sure you get the proper diagnosis.
“That’s another thing we’ve become much better at. When I first started my training, there weren’t any MRIs but now we have an MRI at every corner, and they’re significantly more effective. This is the most amazing improvement in the way we can see the root of the issue.
“Most of the reason for procedure from our point of viewpoint, is for patients who have serious nerve problems – that is, severe sciatica or severe nerve pain, which persists for more than six months and does not respond to medications.
“And frequently, they’ll suffer from a neurological problem such as the weak foot drop or a weak leg.”
To conclude of the time, he states, the management and treatment of lower back discomfort must be a multidisciplinary long-term plan.
“The solution is the training and education of surgeons and physicians as well as all health professionals dealing with issues related to low back discomfort, such as psychologists, nurses, and physiotherapists,” said Associate Professor Morokoff.
“It’s an extremely complicated problem.
“A surgeon usually plays an insignificant role in the life of a patient over one year, and they could choose or decide not to undergo surgery.
“But the reality is spread over many, many years . it’s a long-term condition.
“What’s the most effective mix? The conservative management of several years, and after which they might get better with one company, and after that perhaps the management is more moderate?
“It’s not about saying, would I like just one operation or one week of physiotherapy – it’s about what’s the most effective strategy for the rest of their lives.”
Drummond and coworkers concluded that the rising weight of lower back pain poses an “significant threat to health care systems around in the entire world”.
“Its treatment should be supervised by primary health care doctors and centered on a holistic biopsychosocial strategy that generally does not require surgery,” they wrote.
“Even although spinal surgery can play an impact on the relief of neurogenic claudication or radiculopathy or when back pain is due to an infection, cancer, or instability, its significance in managing chronic low back pain isn’t supported by current research studies.
“Despite this, the use of surgery to treat low back pain has risen significantly in Australian people, but in a significant way when compared to those who have the option of private insurance. Industry’s contribution to this growth, as well as their role in the conducting of research published, warrants more examination.”
Associate Professor Morokoff was skeptical about the possibilities of further research in this area.
“We have identified five randomised control trials within this field. They were all published a minimum of 10 years ago or more than 10 years in the past. There hasn’t been any published since then,” he said.
“We concentrated on studies which compared surgical and non-operative treatment. None of them was top-quality. The problem is that it’s difficult to gather solid evidence.
“The problem is measuring correct results in a highly reliable method.
“You need to monitor those patients for an long period of time to observe how they progress. You must conduct many very accurate assessments of disability and pain scores, and this is expensive. It is also necessary to conduct it in a manner that’s non-biased. We would prefer trials that aren’t sponsored.
“In terms of obtaining the right patient population , and an appropriate diagnosis that will yield the desired results It’s a huge challenge. I don’t think it’s straightforward for anyone to run a successful trial.”
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