We have received a lot of question at the clinic regarding a news highlight that aired last week on lumbar spine surgery. While the segment was a powerful testimonial to the potential success of spinal surgery, it is important to understand the clinical decision making process that is used to ensure those who are appropriate for surgical intervention have similar results.
Historically, the care and prevention of spinal injuries has been quite poor in the medical community. Despite the vast number of treatment options available: surgery, physiotherapy, massage therapy, acupuncture, chiropractic care, etc.; it would appear that we still have not mastered managing spinal pain. In the United States alone there are 44 million prescriptions written for back and neck pain every year, and to a lesser degree, this statistic is echoed in Canada (likely due to population discrepancies). Spinal injuries rival diabetes and cancer for top spot in overall health care costs. Unfortunately, approximately 80% of the population will experience a significant bout of lumbar spine pain at least once in their lives, and 60% will experience neck pain at least once over a 6-month period. Although these are some sobering statistics – don’t worry – it is not all bad news!
If we take another look at the research, we find that 95-98% of spinal injuries do not require surgical intervention to achieve long lasting relief. And 30-45% of individuals, who never experience back pain at all, will still present with abnormal findings on MRI scan or X-rays. These findings could include: herniations, “degenerative disk disease”, or vertebral slippages (spondylolythesis). This demonstrates that it is difficult to imply that there is direct relationship between findings on imaging and spinal pain. This misinterpretation of findings likely contributes to the current epidemic of spinal injury that we see today. So if spinal pain is common and we cannot always rely on medical imaging to accurately diagnose “the cause” of back pain, how do we know how to treat it?
Over the past 20+ years, we have been trying to answer that very question and the answers are starting to stream in with exciting results. If we stop looking at patients as a sum of their parts and begin looking at them as human beings, we can identify key symptoms that will predict, with reliable accuracy, likelihoods of success with certain treatments. So instead of relying on structural diagnoses, which are generally misleading, we can look at the spine through a different lens called a treatment based classification system. This system rules out potentially dangerous pathologies while attempting to identify key symptoms to help direct the practitioners to the safest and most effective treatment options for that particular patient. Two of the four streams under this classification system look at identifying neural compromise and how to accurately direct care whether it is surgical or conservative.
The first stream focuses on the lumbar radiculopathies (sciatica). The clinical presentation of true sciatica is constant, leg dominant pain. In this case, constant is defined by pain that despite your best day and most comfortable position cannot be abolished for even one second. While leg dominant pain is identified as your worst pain being located below the line in the skin where the glute meets the leg. This typically worsens with flexion and there are objective signs of neural compromise as identified by your GP, specialist or therapist. Generally speaking these injuries are caused by a structural injury to the disk called a herniation (much different than a disk bulge) and will generally resolve with conservative care in 3-6 months. If this symptom presentation does not match your symptoms and/or findings on imaging – this is good news and you do not need surgery! It is important to note that if you underwent surgery with out this presentation the likelihood of being symptomatically worse post surgery is significantly greater. If this does match your presentation – this is also good news and you have roughly a 95-98% chance of recovering without surgery! The general rule of thumb with respect to surgical intervention is failure of improvement within the first 3 months tends to increase the likelihood that surgery will be a meaningful intervention. The usual response I get to this statement is that the patient wants long lasting relief now! This is entirely understandable as no one likes to be in constant pain; however, research suggests that although surgery for the right candidate does have the potential for superior short-term relief when compared with conservative care, the long-term outcomes at 1-2 years are roughly equal – which is food for thought.
The second stream aims to identify patients suffering from spinal stenosis. This is a condition where the spinal foramena (holes in the spine where nerves exit) are being narrowed by degeneration and compressing nerve roots (think kink in a hose). Symptoms present as bilateral or at times unilateral leg aching and weakness with prolonged walking (roughly 1-2 blocks) that is immediately relieved by sitting within a few minutes. The pain may or may not extend into the back, and standing or extension is the primary aggravating position. Research continues to surface and promotes a conservative approach consisting of: regaining hip extension, spinal decompression and general conditioning. However, this is a progressive condition of the bones and does have a tendency to require surgery at some point. If you have this presentation – good news – this surgery has one of the higher success rates between 85-95%, when compared to other spinal surgeries!
My hope is that this information helps shed some light on how current trends in back care are progressing. It is an exciting time to be in the healthcare field as new discoveries are being made. If you think your symptoms match one of the above descriptions and you still have questions our team of Phyisioterapists in Victoria are always here to help. If not, rest assured your back pain will improve and with the right interventions, faster than you might think.
Colin Beattie is a physical therapist at Synergy Health Center. He has been working in the field of chronic non-surgical spinal care for the past 5 years. Prior to this he spent time in neurology at Surrey Hospital and GF Strong Hospital in Vancouver working with Spinal cord injuries and Stroke rehabilitation. Colin believes strongly in keeping up with the most current evidence on surgical care, conservative care and pain science in order to inform and empower patients to make sound decisions in the care of their spinal injuries. Colin can be reached by phone or appointment at Synergy Health Center at 250-727-3737 ext. 2.