by Derek L. Snook, M.D.

Nearly everyone has had or knows someone whom has had back pain in his or her life. Back pain is the number two reason to see a doctor next to the common cold. This is obviously a tremendous quality of life issue and common reason for lost work and productivity world-wide. Thankfully, most back pain is benign and self-limiting, meaning it tends to run a definite, limited course.

When personally faced with back or neck pain, many people have anxieties about the pain, and determining what to do can be a daunting task. Neighbors, friends, relatives and the popular press are quick to offer opinions. However, there are several reasons they may not know what's best for you.

First and foremost, back pain is not a diagnosis. It is a symptom, just as every cough doesn't mean someone has pneumonia. Common causes of back pain include disc herniations and spinal stenosis, or narrowing of the spinal canal. These are secondary to bone spurs and disc bulges. There are many doctors who have toiled for years to find the answers to back pain, often without satisfying resolution. There is, however, hope in the mounting body of "Evidence-Based Medicine."

Evidence-based medicine is an attempt to sort through the myriad studies regarding medical conditions and give weight to the best studies to improve physician-patient interactions, and therefore, patient health and satisfaction. One such study was recently performed by a subcommittee within the North American Spine Society, tasked with establishing guidelines to treat some of the most common spinal conditions that cause pain. This group was multi-specialty, comprised of surgeons and non-surgeons, alike, who treat spinal conditions.

Their guidelines for spinal stenosis (the most common reason for surgery in those older than 65) are summarized as follows:

  1. Non-operative treatment is best for symptoms lasting less than 12 weeks, provided there are no neurologic deficits.
  2. Non-operative treatment recommended is non-steroidal anti-inflammatory medications AND physical therapy. There was moderate strength to this guideline, meaning the studies to support these treatments are fair.
  3. Surgery is RECOMMENDED for symptoms recalcitrant, or non-responsive, to non-operative treatment. This guideline, again, has moderate strength.

Many myths exist regarding surgical treatment for spinal conditions. One is that spine surgery doesn't help. Second is that there is a high chance those undergoing surgery will be paralyzed. Third is that reoperation at a certain time will be necessary.

These myths are probably best debunked by the SPORT trial, an acronym for the spine outcomes research trial. This was perhaps the most important study in musculoskeletal medicine since joint replacements. This was a multi-center research trial comparing the outcomes of surgery and non-surgical treatment for lumbar disc herniations and lumbar stenosis. The results have been published in many peer-reviewed papers and show that surgically treated patients do better than non-surgically treated patients early on and later with regard to pain levels, disease-specific functional outcomes and health-related quality of life measures. The chance of having a neurologic decline after surgery was only 1 percent. Reoperation rates were higher, but still necessary less than 10 percent of the time.

Living with back pain may be a reality for many, but improving your quality of life is potentially possible and safe. Consult with your medical doctor or spine care specialist to learn your diagnosis and potential options to improve your quality of life.

Suggested Readings

  1. Weinstein, J.N. et al: Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med, 358(8): 794-810, 2008.
  2. North American Spine Society, Evidence-Based Guidelines for Degenerative Lumbar Spinal Stenosis.
  3. Tosteson, A.N.A. et al. Surgical treatment of spinal stenosis with and without degenerative spondylolisthesis: cost-effectiveness after 2 years. Ann Inter