One of the biggest questions I get asked in the clinic is whether surgery would be a good idea or not. This can be a difficult question to answer. So, I am going to try to gather up a little bit of information to help people decide whether to elect for surgery, try conservative management, or try conservative measures before going for surgery. This is a large subject, so I figure I would limit it to one area of the body today, the lumbar spine.1
Low back pain affects approximately 60-85% of adults during some point in their lives.2 The good news is the majority of these cases have mild and transient symptoms which subside in six weeks or less with taking proper measures.
However, in some cases these symptoms can become chronic and become quite debilitating for patients. Pain in the low back can come from a variety of sources described by a number of confusing medical terms.
Managing low back pain through conservative management first eliminates the risk of side affects from surgery, improves mobility, strength and knowledge on the condition itself, provides strategies on how to manage the pain, and tends to produce more active living, longer.
We commonly hear things like lumbar osteoarthritis, disk degeneration, degenerative disk disease, and spondylosis. All of these conditions essentially describe anatomical changes to the vertebral bodies, the space between the joints in the spine, or the intervertebral disk itself. Changes to these areas can be associated with pain in the back, into the hip and potentially into the legs and toes.
These age-related changes in the back can result in narrowing within the spinal canal through disk bulges or tissue build up, which can also cause compression on nerve roots and cause pain or other symptoms of sciatica. Sciatica is an umbrella term thrown out whenever people get pain from their back into their hip or leg. So what is it actually? It is a disorder caused by pressure on a nerve root in the low back with symptoms including unilateral leg pain, pain radiating beyond the knee, decreased muscle strength and changes in sensation.3 All of these can sound scary if you have never heard of them before; or you can get the wrong impression if you start asking Dr. Google. Many of these conditions become more common as we get older, but there are lots of things we can do to try to limit the pain from them, and make the pain more manageable.
So you’ve been told that you have arthritis, stenosis, sciatica, or degeneration
Some of the surgical options for these conditions can include laminectomy, fusion, or spinal devices and prostheses. Laminectomy is removal of bone from the vertebra to create more space. Fusion is the fusing of two or more vertebrae to limit movement and improve stability.4
Whereas some of the conservative treatment available includes exercise, manipulation, mobilization, physiotherapy, medication, acupuncture, bracing, and education.
The idea behind surgery is to increase the space between the joints by taking out some of the structures to allow for decompression of those neural or vascular structures. The issue with this and other surgeries on the low back, is with the removal of some of these structures we can actually be decreasing the stability in the area, while also having to limit movement and activation of the core which will reduce the musculature in the area as well.
Other complications of surgery include needing further operative treatment which occurs around 17% of the time, as well as medical complications such as cardiopulmonary complications or stroke, especially in those with comorbidities like diabetes, high blood pressure, COPD, obesity, high cholesterol, and more.
Conservative treatments are nonsurgical and include physiotherapy, pharmacological treatment, and infiltrations. These are in many cases sound alternative approaches for symptomatic patients. For example, 90% of sciatica cases due to lumbar disc herniation resolve with conservative measures. And nonsurgical treatment of lumbar disc herniation has a lower risk of complications than surgery and is preferred by the vast majority of patients. Physiotherapy acts to improve the mobility, strength and control of the movement in the low back. Physiotherapists will also work to promote healthy behaviours and increase your knowledge on the condition and strategies to help with the pain.5
Evidence for nonsurgical treatments
This decision can be a difficult one to make. Here are a couple examples of studies looking at surgery vs non surgery in people with sciatica and stenosis.
In a study following 370 people over 104 weeks they tried to determine whether surgery or conservative therapy is best for sciatica due to disk herniations. Ultimately, it was found that there was no evidence that surgical treatment reduces the severity or improved quality of life of patients with lumbar herniations compared to conservative therapy past the 6 week mark. It was determined however that pain was relieved more quickly in the first three weeks with the surgical group, however at the mid term and long-term follow ups the conservative groups scored just as good as the surgical group. So, what this means is surgery relieved the back pain faster, but there were no clinical differences after three months (Gugliotta et al., 2016).
A second study by Lindbäck et al., 2018, is a study looking at whether pre surgery physiotherapy improves function, pain and health in patients with degenerative lumbar spine disorders scheduled for surgery. In the study there were 2 different groups of 191 people. The first group was told to stay active by the surgeon, while the second group received pre-surgery physiotherapy interventions 2x/week for 9 weeks. The physio group was given individualized exercise programs, had manual therapy done in the clinic and were given behavioural education on fear avoidance behaviours. The study showed that after 9 weeks the physio group showed improvement in back and leg pain, as well as being less fearful of movement and improved quality of life. At 1 year follow up the benefits were similar in each group, however it was shown that the physio group remained more active and was in better health.6
A review by Zaina et al., (2016) similarly looked at the evidence for the difference in function between surgery vs conservative management for lumbar stenosis, however the evidence was low regarding which treatment was better they did ultimately suggest that due to the high rates of side effects associated with surgery it is always suggested to try conservative management first, as this method will improve mobility, strength and knowledge on the condition itself, as well as provide strategies on how to manage the pain (Zaina et al., 2016).
Navigating these decisions is personal and contextual
With wait times as high as 40 weeks for some orthopedic surgeries, all of the evidence in this post suggests that conservative management should be exhausted prior to decision making about surgery for spinal stenosis, disk herniations, spondylosis or any changes in the back. If there is no improvement in pain or function after trying non-surgical measures then you can later pursue other interventions, such as surgery.
Always remember, the stronger you are going into surgery the stronger you are coming out of surgery.
- Check back in future articles for information on other areas of the body. ↩
- See Middleton & Fish, 2009: Middleton K, Fish DE. Lumbar spondylosis: clinical presentation and treatment approaches. Current reviews in musculoskeletal medicine. 2009 Jun 1;2(2):94-104. ↩
- See Gugliotta et al., 2016: Gugliotta M, da Costa BR, Dabis E, Theiler R, Jüni P, Reichenbach S, Landolt H, Hasler P. Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ open. 2016 Dec 1;6(12):e012938.. ↩
- Zaina F, Tomkins‐Lane C, Carragee E, Negrini S. Surgical versus non‐surgical treatment for lumbar spinal stenosis. Cochrane Database of Systematic Reviews. 2016(1). ↩
- This article was from the British Medical Journal and was conducted as a prospective cohort study, taking 370 patients and comparing an open discectomy vs conservative interventions and looking at changes at 6, 12, 52 and 104 weeks. With the main result showing at the six week point there was less pain and more function in the surgical group, but at every point after three months there were little differences between the groups. ↩
- Lindbäck Y, Tropp H, Enthoven P, Abbott A, Öberg B. PREPARE: presurgery physiotherapy for patients with degenerative lumbar spine disorder: a randomized controlled trial. The Spine Journal. 2018 Aug 1;18(8):1347-55. ↩