You’ve been hurting for months. You can’t stay on your feet for more than a few minutes. It hurts to sit for too long. Recently you can’t get a good night’s sleep because you just can’t get comfortable. The painkillers aren’t working, and you’re starting to think seriously about back surgery. But after all the expense, rehabilitation and risk, will you bet better off? There are alternatives to surgery, and they just might work for you.
Back pain that leads to surgery is often associated with a damaged intervertebral disc or spinal stenosis. The discs are the tough, flat cushions between the vertebrae. Imagine a disc as the warm toasted marshmallow sandwiched between two graham crackers in a s’more. If the crackers are pressed together evenly, the marshmallow will spread out evenly as well. If you squeeze just one side of the sandwich together, the marshmallow (or disc) will ooze out to the opposite side. That’s what happens with a “slipped” disc. The protruding part can irritate a nearby nerve. If it ruptures, there can be chemical irritation of the nerve as well. The discs also tend to degenerate, flatten and become less resilient over the years, so there is less space for the nerves where they come out of the spinal column.
Sciatica is an irritation of the sciatic nerve. It can cause radiating pain, burning sensations or cramping in the buttocks and down the leg. This may be caused by a nerve root problem in the lower part of the spine, but it can also be caused by impingement further down in the area of the buttocks. The piriformis muscle runs across the back of each hip joint, deep in the buttock, where it crosses paths with the sciatic nerve. Pressure from an overly tight piriformis muscle is believed to irritate the sciatic nerve causing buttock and/or radiating leg pain. This is known as piriformis syndrome. It can be addressed by releasing excess tension and any “trigger points” (knotted areas) in the piriformis and associated muscle groups.
Stenosis is a narrowing of the spinal canal that leads to compression of the enclosed spinal cord and nerves. Fractures of the spine can also result in unstable vertebral joints and irritation to the spinal nerves.
Treatment Options Common surgical procedures for these conditions include discectomy, laminectomy, and fusion. In a discectomy, the part of the disc that is stressing the spinal cord or a nerve is removed. Removing or trimming part of the bony structure around the spinal cord (the lamina) is called a laminectomy. This may be done to widen the spinal canal when it has been restricted by stenosis, or to provide access for a discectomy. Spinal fusion fixes vertebrae together using bone grafts and screws or other hardware to prevent any movement between them.
Determining when surgery is appropriate is not always easy. Most incidents of back pain resolve themselves over several weeks. Even cases of severe chronic back pain or sciatica may respond very well to more conservative treatments. Individuals with substantial disc degeneration and/or stenosis can return to an active pain-free life without surgery. Surgeons may have a skewed perspective because their patients who are diagnosed as needing surgery, but who go on to rehabilitate themselves through non-surgical means, are unlikely to report back to the surgeon.
Even when there is clear disc impingement upon a nerve, non-surgical remedies are possible. Experiments have shown that a healthy nerve root (where the nerve exits the spinal cord) can withstand substantial pressure without pain or paresthesia (tingling or burning). When a nerve root is injured, pressure on it can cause loss of feeling, reduced reflexes and eventually reduced strength and motor reflex. However, when a nerve root has a poor blood supply (ischemia), it becomes very sensitive to pressure. So, a healthy nerve root with a good blood supply can tolerate a fair amount of mechanical abuse. But once it has become irritated, swollen, inflamed or otherwise suffered decreased blood flow, it will be much more easily irritated. Therapy should therefore be aimed at reducing mechanical irritation, reducing inflammation, and improving blood perfusion.
“Conservative treatment” is a term that can be applied to anything from pain pills and bed rest to much more aggressive therapy that involves substantial patient participation. The latter requires more commitment but is likely to give better results. The patient can also learn some useful self-care techniques during treatment. Analgesics, muscle-relaxers and anti-inflammatory drugs (or herbal formulas) may also have their place in the therapy.
Seeing the Bigger Picture The muscular, skeletal, neural, vascular and lymph systems of the body all affect one another. A good treatment plan works toward optimizing all of them. When there is pain, as from nerve impingement, a common protective reaction of the body is to tighten up and stabilize the area. Unfortunately, this tightening can exacerbate the problem by putting more pressure on the damaged structures. Also, chronic spasm of the muscles leads to decreased blood infusion (ischemia) and poor lymph movement. The muscles become poorly nourished, and the tissues are not properly cleansed of cellular waste products. A large component of patient’s pain can be from this muscular dysfunction, rather than from the direct nerve impingement itself.
Tight muscles, especially when their forces are not well balanced, are intimately involved with skeletal joint dysfunction. The skeletal system, after all, is aligned and controlled by the soft tissues around it (with limits set by the bony structures themselves and by the ligaments that surround the joints). When muscular action on one side of the spine is stronger and tighter than the other, it can significantly change the alignment between the vertebrae, and inhibit the natural smooth gliding at the joint surfaces. Besides nerve irritation (remember that squeezed marshmallow), this can accelerate arthritic changes in the joints.
Nerves are responsible not only for sending pain signals back to the brain, but also for sending motor control signals out to the muscles. Therapy should address the neural components of the problem. Neuromuscular reeducation refers to therapy that aims at normalizing the interaction between muscles and their nerve signals.
Many types of non-surgical therapies are available, and each has its strengths. Chiropractic adjustments can restore normal joint function, and thus release tension and inflammation in surrounding soft tissues. Unfortunately, some people do not respond well to this high-velocity approach, and normal muscular function often does not follow. Skilled massage, physical therapy, yoga, stretching, strengthening and other manual therapies can address the muscular components. Functional and postural habits that exacerbate the condition may need to be relearned. Acupuncture works via several pathways: it can release and balance muscle tensions, moderate nerve signals, decrease inflammation and increase local blood flow to the tissues.
The Benefits of Avoiding Surgery Results from conservative therapy can be dramatic, but it typically takes weeks or months to effect lasting changes, and a combination of techniques may be needed. The reward for this effort is a reduction or elimination of pain, a better functioning body and more information about how to keep it that way, not to mention the avoidance of surgery, anesthesia, and post-surgical rehabilitation. This can save tens of thousands of dollars, and greatly decreases one’s exposure to pharmaceuticals. Even with a course of anti-inflammatory drugs, a patient will be subjected to a much lower pharmaceutical load that when undergoing surgery.
Besides, surgery often fails. The U.S. Agency for Healthcare Research and Quality states that “Patients considering lumbar spine surgery should be informed that the likelihood of having another spine operation later is substantial.” A study of 24,882 adults who had low back surgery for degenerative spinal problems in the early 1990’s found that about one out of five had another back surgery within 11 years. That’s about double the rate for hip or knee replacement. And one should not assume that the rest were living pain free.
Is Good Medicine Driving High Back Surgery Rates? A study by the University of Washington’s Center for Cost and Outcomes Research looked at spinal surgeries in the U.S. and confirmed some disturbing trends. In 2001, approximately 122,000 lumbar fusions were performed, representing a 220% increase from 1990. Were those surgeries more successful than in the past? It seems not. Reoperation rates actually increased during the 1990’s, with a cumulative rate of about 12% just three years after the initial surgery.
The Department of Health Services at the University of Washington has noted that there are large variations in back surgery rates across different parts of the country. The Department also found that “The rate of back surgery in the United States was at least 40% higher than in any other country and was more than five times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopaedic and neurosurgeons in the country.” That sounds more like supply-side economics than evidence-based medicine.
Meanwhile, the New England Journal of Medicine has published a new study of 283 patients with severe sciatica. The participants were randomly selected to have surgery early on, or to have extended conservative treatment and undergo surgery at a later time, if needed. Only 39% of this second group actually ended up having surgery. After one year, the outcomes were similar for those with early surgery and the conservatively treated group, although those receiving early surgery had somewhat faster pain relief and self-perceived recovery rates.
The decision to have surgery for back pain or sciatica due to degenerative conditions will usually be left to the patient. Trauma resulting in fractures, cancer, and other conditions causing back pain may permit fewer options. But for patients who are willing to participate in their own recovery, conservative treatment holds a lot of promise with very low risk. Surgery, after all, will remain an option. They may need to be more proactive in seeking out treatment. Learning stretches and other exercises from a skilled therapist will give them some control over their recovery. A willingness to try appropriate therapies and actively engage in the treatment process can lead to much greater success than simpler treatments involving only rest and drugs. Those who choose such a treatment plan may well be rewarded with a strong, pain-free body, and new knowledge that can help keep it that way.