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Debate explores appropriateness of surgery for axial lumbar pain

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The treatment options for a patient with axial lumbar pain are many and benefits for a surgical intervention and nonsurgical intervention depend on the individual, according to two surgeons.

At a meeting, R. Douglas Orr, MD, of the Cleveland Clinic, and Michael J. Vives, MD, of Rutgers New Jersey Medical School, in Newark, N.J., presented opposing positions on surgical and nonsurgical treatment of patients with axial lumbar back pain, particularly when the patient has reasonable range of motion and lacks neurological deficits.

Orr discussed the surgical options and said patients with true mechanical back pain are indicated for surgery and can experience relief at a single level.

“I think you have to have a collapsed disc, as well. I think you have to have normal psychometrics,” Orr said.

The bulk of Vives’ argument against surgery rested on the fact that the best available literature does not clearly demonstrate clinically meaningful improvement over a nonoperative option.

Support for surgery

Orr discussed results of a 2001 study by Fritzell and colleagues, a 2003 study by Brox and colleagues and one study on the topic by Fairbanks and colleagues published in 2005. He also cited a 2013 publication by Mannion and colleagues — a combination study that analyzed patients from the Brox and Fairbanks studies 11 years later.

In the Fritzell study, the patients in the surgery group had better outcomes than the controls and in the Brox study there was no difference between the patients who had surgery and patients who had cognitive behavioral therapy (CBT), Orr noted. The only significant difference in that study, he said, was in the fear avoidance belief questionnaire results. Patients who underwent surgery in the Fairbanks study had better Oswestry Disability Index (ODI) scores, he said, but all the other outcomes were no different than for the patients who had intensive physical therapy.

Vives said in his presentation that surgery was not proven to clinically benefit those with axial pain in European trails comparing it to a very intensive and structured CBT program. Furthermore, in trials comparing surgery to physical therapy, the patients had often previously undergone physical therapy. When such patients end up randomized to “more of the same,” it may influence their self-reported outcomes, he said.

Changes in ODI scores

In the combination study by Mannion and colleagues cited by Orr, there was no significant fall off in results for patients who underwent surgery in the results 11 years later. That puts to rest the concerns about adjacent level degeneration, Orr said.

Also, he said many published studies point to the greater improvement in ODI scores in surgical management groups of patients compared to groups of patients who underwent CBT or physical therapy.

However, Vives said that on close examination, while a clinically meaningful difference between ODI scores is considered to be 15 points, these trials demonstrated that the difference between the surgical groups and the CBT groups tended to just approximate double digits.

“The minimum clinically important difference or change (MCID) is not a lofty goal. It is really the point where a patient can discriminate between being unchanged and being somewhat better,” Vives said.

Based on these data, he counsels patients that are considering lumbar fusion surgery for this indication to have realistic expectations for some, but not overwhelming improvement.

Results cannot be generalized

Vives explained that generalizing the results of these trials is problematic in that the surgical techniques utilized in the studies varied and some included techniques infrequently used today for this indication. He said he would typically recommend a CBT program for a patient with axial lumbar pain who has no neurological deficits and good range of motion to see if his or her condition would improve before considering any kind of surgery.

Vives acknowledged, however, that such highly intensive CBT programs are not widely available or even covered in this country, and he is aware of none that are structured similar to those described in the European trials.

“This is more an academic debate than a practical one,” he told Spine Surgery Today. “Insurance carriers should not use the results of these trials as grounds for non-coverage policies because the comparator treatment utilized is not even generally available to our patients.” – by Robert Linnehan