My Aching Back: Stats and Sense
Itís hard to say whether the word "stats" (for "statistics") or the phrase "mathematical analysis" is the bigger turn-off. But statistics and analysis are important, if properly used. Clinical decisions about diagnosis and treatment should whenever possible, be based on information already collected from large numbers of patients sharing similar complaints. Otherwise we tend to treat everyone as unique, a candidate to be "plugged into the laboratory," an MRI machine - or worse still, to be sent for unnecessary surgery. Letís look at back pain and see what we can learn by playing the numbers game.
Back pain, after cough and throat complaints, is the most common symptom reported by patients, and costs Americans over $26 billion a year. Low back pain (LBP) affects up to 75% of us at some time during lives, and as many as 30% of adults at any given moment. It is largely a self-limiting problem, with 9 out of 10 patients recovering within six weeks, and nearly 3 out of 5 patients returning to work within one week. Sciatic symptoms, characterized by one-sided pain, numbness, or tingling radiating to the buttock, sometimes down the back of the leg or into the ankle and foot, may occur in 30% of cases of acute low back syndrome. The likelihood of a herniated (ruptured) lumbosacral disc is increased when acute or recurrent episodes of low back pain persist for more than 4-6 weeks and when sciatica is severe.
In a study of 98 normal patients without back complaints, two thirds had protruding, degenerating, or bulging disks on MRI, and a third had more than one abnormality. Even when patients with back pain have an abnormal MRI the pain often goes away. Similarly, abnormalities are seen in a large number of CT scans in patients without back pain, and X-ray findings of "degenerative changes" are reported in a high percentage of patients without back complaints.
Since LBP is self-limiting but recurrent about 90% of the time, it is important for you to learn how to self-treat and avoid attacks by proper care of the back. The condition has been treated with almost every known modality including, but not limited to bed rest, narcotics, exercise, immobilization, traction, massage, muscle relaxants, epidural injections, surgery, etc. Yet for all the hours and money spent on acupuncture, massage, manipulation, doctor visits, let alone surgery, in study after study, leading medical experts continue to ask what, if anything is doing any good.
Back pain has always been around, like heartburn and headache, but there is no evidence of any explosion of new cases. Rather, the cost per case is increasing without any convincing proof that patients are better off. What have changed are peopleís expectations. According to Dr. Richard Deyo, a Professor at the University of Washington, "People say they are not going to put up with it, and we in the medical profession have turned to ever more aggressive treatments, more surgery and more invasive surgery." This includes many of the newer, controversial techniques of spinal fusion using surgical implants, intervertebral cages, pedicle screws, etc.
Almost everyone has a friend or relative who has had low back surgery, and after the operation, has never been "quite the same." This is not to deny that back surgery can be the only effective treatment in a certain limited group of patients. However, according to the American Academy of Orthopedic Surgeons, there are approximately 200,000 laminectomies performed every year. An estimated 20% -30% are reported to be unsuccessful, with a reoperation rate of 10%-25%. It is easy to see that the problems of "failed back surgery" are enormous. This high rate of failure is related in most cases to the choice of surgical treatment over conventional "watch and wait" strategies, and often driven by patient demands to be "fixed ASAP," as observed by Dr. Deyo.
One of the most enlightening discussions on current thinking about surgical treatment and management of spine and back problem is by Dr. Thomas J. Errico, President of the North American Spine Society. In his letter to the Editor of the New York Times, Dr. Errico, in commenting on an article by Abelson and Peterson (Dec. 31, 2003) says "Treatment of the patient with spine problems is an art based in science. It is vital to note that back pain can have a wide variety of causes. A survey of our members indicates that 90% of the care they provide is nonoperative. Surgery is usually the last resort (absent clear neurologic indications or acute incapacitating pain). Still controversies do exist - what one doctor might think is appropriate treatment another doctor might think is inappropriate. Often what they disagree on is the timing of an intervention."
An excellent information source for back patients is the site of the North American Spine Society which gives extensive information on care of the back, back exercises, high risk back pain, treatment options, and a host of other aspects of back problems.
Martin F. Sturman, MD, FACP
Copyright 2004, Mathemedics, Inc.
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