The Truth About Back Surgery

Of the 56 million Americans who have back pain, only 5 percent need surgery. Here's how to protect yourself and find relief that really works.

There's an old joke in medicine: A man goes to the doctor because he has a miserable cold. His doctor prescribes some pills, but they don't help. On his next visit, the doctor gives him a shot, but that doesn't do any good, either. On the third visit, the doctor advises, "Go home and take a hot bath. As soon as you finish bathing, throw open all the windows and stand in the draft."
"But Doc," protests the patient, "if I do that, I'll get pneumonia."
"I know," says the doctor. "I can cure that."
If you have back pain, you may feel like the guy with the cold. Your doctor gives you one pill, then another kind, then a third. Maybe he sends you for a shot. Or he advises cold, or heat, or alternating cold and heat. And then it may be on to X-rays or scans. It's a scattershot approach based on often thin, even contradictory, evidence of what actually helps.
And it has made bad backs big business. Americans spend nearly $86 billion a year on their aching backs, which is just about on par with the outlay for cancer treatment. Yet for all those dollars — doled out at doctors' offices and hospitals, and for medications, manipulations, and pain-relief products to use at home — there has been no improvement in how patients fare overall, say researchers in a University of Washington study that compared reports from 1997 through 2005. In fact, today a larger proportion remain impaired by their back troubles. "The truth is, we may have oversold what we have to offer," says Richard A. Deyo, M.D., professor of evidence-based family medicine at Oregon Health & Science University. "We're using tests and treatments more widely than the science really supports."
A pill or heat belt that doesn't relieve pain is one thing. But what if you undergo surgery, spend months in rehabilitation, and still feel no better? That's what happened to Catherine Johnson, 50, a onetime competitive figure skater who is "not the sedentary type," she says. Johnson, the mom of an 18-year-old daughter, has owned four businesses and was active in her New Hampshire community. But for seven years, her life revolved largely around pain from a slipped disc in her back. She'd tried just about everything, but was still miserable: "My friends were sick of hearing me say, 'I can't do that because of my back.' And I was sick of saying it."
So in 2004, Johnson underwent surgery to repair the disc. She'd had a similar operation 10 years before and thought this one would be just as helpful. It wasn't. She was still in a lot of pain, still telling friends she couldn't do things. Three years later, in 2007, Johnson was injured further when a drunk driver slammed into her car. Afterward, she suffered muscle spasms and flares of pain so intense she often had to go to the emergency room for heavy-duty drugs. Finally, a new doctor referred her to the Spine Center at Dartmouth-Hitchcock Medical Center in Lebanon, NH. After 14 full days in the functional restoration program, doing intensive physical therapy and learning psychological techniques for managing pain, she found relief. In fact, the turnaround was so great that in September Johnson moved to California, where she hopes to get back to coaching skaters. "It's what I love most," she says.

Johnson's story wouldn't surprise Charles Rosen, M.D., clinical professor of orthopedic surgery at the University of California, Irvine, School of Medicine. "An enormous number of back surgeries don't give patients long-term relief," he says. There's even a term for what happens when an operation doesn't improve a patient's condition — "failed back surgery syndrome," said to be the only diagnosis named for a treatment that hasn't worked.
It gets worse. This is an area of medicine that's been tainted by suspiciously cozy relationships between industry and doctors. In July, for example, Jeffrey Wang, M.D., was dismissed from his post as executive codirector of the UCLA Comprehensive Spine Center for not disclosing about half a million dollars in payments he'd received from companies whose surgical products he was researching. (The David Geffen School of Medicine at UCLA, where Dr. Wang is still on the faculty, is looking into the matter.) And in a 2006 settlement with the Department of Justice, medical-device manufacturer Medtronic agreed to pay $40 million to settle allegations that one of the company's divisions had paid kickbacks to doctors to induce them to use the division's spinal products. The company, which also entered into a five-year Corporate Integrity Agreement (to ensure that relationships with physicians are appropriate), has denied any wrongdoing or illegal activity.
Such activities affect the treatment you receive. "Kickbacks...corrupt physicians' medical judgment," said Peter Keisler, assistant attorney general for the Department of Justice's civil division, in announcing the Medtronic settlement. And these physicians can, in turn, sway other doctors' decision-making. "These are often prominent surgeons, the ones in leadership positions in medical societies and on the boards of major journals," says Dr. Rosen, who is also founder and president of the Association for Medical Ethics. They write the articles that drive treatment methods and device acceptance — influence that undoubtedly contributes to a vast number of unnecessary operations. In the U.S., more than 1,150,000 people go under the knife for spinal problems every year, a rate double that of most developed countries and five times that of the United Kingdom, says Dr. Deyo. Yet the outcomes have been no better. "Maybe 5 percent of patients with back pain need surgery," says Dr. Rosen.
So whom can you believe, and what does help? There's little consensus. Indeed, last June, when the prestigious Institute of Medicine announced it would evaluate the effectiveness of approaches for 100 health issues, lower-back pain was placed in the "highest priority" group.
There is no one best way to treat everyone. But the chance of finding relief for ongoing pain unquestionably lies in understanding what has gone wrong — often not an easy task — and then seeing the most appropriate specialist for your problem and asking the right questions. With back problems, perhaps more than with any other medical condition, getting the best care really is up to you.

Back surgeries can fail for a devastatingly simple reason: The operation was not the right treatment, because the surgeon never pinpointed the source of the pain. As a result, patients may be just as miserable as they were before — or worse off — and a desperate number choose to try again. By two years after their first surgery, about 8 percent of patients have had another operation; by 10 years after, the rate jumps to 20 percent, an analysis of Washington State hospital data found.
That's why it's critical to have a thorough workup — to get a sense of the root cause of your pain, says Arnold J. Weil, M.D., director of the Non-Surgical Orthopaedic & Spine Center in Atlanta. X-rays and MRI scans can be helpful, too — but only if your doctor has good reason to suspect a particular problem. Go on a fishing expedition, and you could end up with the wrong diagnosis — and ineffective treatment. That's because high-tech images routinely uncover bulging discs and other scary-looking "abnormalities." Trouble is, those often have nothing to do with what's hurting. "If you took 100 people off the street and gave them MRIs, a third of them — even if they had no back pain whatsoever — would have obvious structural problems," says Dr. Rosen. At best, your doctor might be misled by your abnormal X-ray or MRI, or hope that the abnormality is the cause of your pain and that by fixing it, he'll make you better. At worst, says Dr. Rosen, "the doctor knows full well that the image could be a red herring, but the chance to 'fix' something, and get paid for it, is just too good to pass up."

Surgery: Just Say "Not So Fast"

Here's the crux of the problem: We tend to think of back surgery as the Big Fix — the treatment that will, if other approaches aren't successful, work. Sometimes, in our desperation to get our lives back, it may seem like a good idea to jump over those less invasive procedures and go right to the big one. That's a good call in a few cases — where there's a risk of paralysis, for example — but those types of emergencies are rare. Otherwise, "surgery offers specific therapy for specific conditions," says Dr. Deyo. It should never be seen as "worth trying" for pain. Such hope on the part of patients — too often reinforced by surgeons — leads to operations that offer no relief.
Discectomies (removal of the herniated part of the disc) are the most common back surgery. But spinal fusions (operations that involve joining the surrounding vertebrae) have been rising — from just over 150,000 in 1993 to 350,754 in 2007. And so has the controversy over their use. Fusions that are done for certain very specific conditions, such as spondylolisthesis (in which one vertebra has slipped forward over the one below), can have success rates of more than 80 percent. But that's not the usual case. When the surgery's done for a "simple" degenerated disc, the results are far less happy. Fewer than half of fusions are appropriate, experts estimate, and fewer than half are successful, research confirms. And surgical fusions don't come cheap: The average cost is about $75,000, not to mention months of rehab and weeks lost from work.

The takeaway: If a doctor recommends an operation, get a second opinion — always. A good surgeon will understand that you need to be comfortable with any decision, and should provide your tests and records, says Alex Ghanayem, M.D., professor of orthopaedic surgery at Loyola University Medical Center in Maywood, IL. For a truly useful second look, and to find out if you would benefit from surgery, go outside your doctor's practice or center and consult with different types of specialists. Specifically:
Find a Very Busy Doc
A quality, fellowship-trained spine surgeon (that means someone who has done a year of spine training after residency) is likely to have plenty of patients, says Andrew R. Block, Ph.D., director of pain programs at the Texas Back Institute in Plano. "He doesn't need to talk you into an operation that isn't in your best interest."
Start from Zero
Don't tell the second-opinion doctor what's been recommended, advises Stephen Hochschuler, M.D., cofounder of the Texas Back Institute. Let him take a fresh look at you and your tests. Then, if the advice is different, you can mention what the first doctor advised and get his views on that.
Cross Disciplines
Get a second opinion from a nonsurgical specialist. If you tell a surgeon that exercise and other nonsurgical options haven't helped, that could tilt the decision toward an operation. But often patients haven't given other strategies a thorough trial — something a nonsurgical specialist would pick up on during an exam, says Alicia Carter, M.D., a physical medicine and rehabilitation specialist at New York-Presbyterian Hospital in New York City.
Log Out
Stay away from Web-based services where you send your scans for a second opinion. "Don't get medical advice without a face-to-face interaction," says Dr. Ghanayem.
Get a Third Opinion
If the second doctor offers a wildly different recommendation, another physician can help you sort it out. Doctors at university-affiliated medical centers, who generally see many complicated cases, might be best in this role.

So What Does Help?

Most back pain eases with time — no matter what you do. There's a tendency to think that whatever you were trying when the pain did let up was the treatment that worked, not realizing that your back simply healed over time. That's why you can't assume that what worked for your book group pal or for Sally in Accounting will help you, too (plus, they may not have had the same problem). And scientific evidence isn't much more reliable than Sally. Some studies have been too small to conclude much of anything, while others were so badly designed, it would be risky to follow their conclusions. Yet, there are clues — evidence reviews that point to treatments that help many people:

Medications
Over-the-counter anti-inflammatories like naproxen (Aleve) and ibuprofen (Advil, Motrin) can reduce pain. In an extensive set of treatment guidelines issued by the American College of Physicians (ACP) and the American Pain Society (APS) in 2007, these meds were found to offer "moderate" benefit. While that may not sound encouraging, prescription painkillers also came in as "moderate."
Exercise
Your goal is to stretch and strengthen back muscles, which can bring significant relief as you ease tightening and spasms. The same ACP/APS set of guidelines found that exercise therapy and yoga, with its emphasis on stretching and body control, are the best workouts for back-pain sufferers. But don't "stretch through" or "push beyond" anything truly painful. A physical therapist can show you how to exercise safely and for the most benefit.
Spinal Manipulation
Some people swear by chiropractic treatments; others are skeptical. And the scientific evidence is just as mixed. A 2004 review of 39 randomized, controlled studies published by the Cochrane Collaboration found that "spinal manipulation was more effective in reducing pain and improving ability to perform everyday activities than sham therapy." But, the researchers concluded, "it was no more or less effective than medication for pain, physical therapy, exercises, back school, or the care given by a general practitioner" for patients with acute or chronic lower-back pain. If the pain's in your neck, think twice about chiropractic; it's rare, but neck manipulations can trigger a stroke.
Epidural Injections
Many women are familiar with epidurals, having experienced the shots' pain-numbing relief during childbirth. For backs, injections generally contain an anesthetic (like procaine), as well as a steroid (like cortisone) to calm inflammation. Epidurals can't cure back problems, but they may buy you some pain-free time while the disc has a chance to heal and shrink. Relief tends to be modest and short-lived (three months at most).
Acupuncture
In a recent, well-designed study of 638 patients with chronic back pain, those who received acupuncture (10 treatments over seven weeks) improved considerably more than a group receiving continued "usual care" (no special treatments — just medications, physical therapy, or whatever they'd been doing). Even after a year, the acupuncture group was significantly better off. But here's a surprise: Simulated acupuncture (stimulation of acupuncture points with a toothpick in the traditional needle-guide tube) turned out to be as effective as the real thing. Researchers speculate that stimulation of acupuncture points without breaking the skin — or a placebo effect — provided the relief.
Going HolisticMultidisciplinary programs teach everything from rigorous exercise to meditation — and have impressive success rates. At the Texas Back Institute's CoPE (Conquering Pain Effectively) program, for example, patients boost their mobility 50 percent, on average, while cutting their pain in half and their painkiller use by 75 percent. When Theresa Hesse of Mesquite, TX, went to CoPE in 2006, she was relying on strong painkillers in order to stay involved in family activities with her two kids. "I'm emotional and loving and busy, but I was just going through the motions," says Hesse, who'd had three failed back surgeries. The CoPE program is intense — 40 hours a week for four to six weeks; in the supervised setting, Hesse was able to work hard rebuilding strength she'd lost from years of protecting her back. Participants are also taught biofeedback, meditation, and other techniques to deal with pain and the depression and anxiety that often accompany it. Today, says Hesse, "I still have to use some pain medication — things are pretty messed up in my back — but I can live my life."

If you're interested in going to a pain program, look for one certified by CARF (the Commission on Accreditation of Rehabilitation Facilities). Most programs are covered (at least in part) by health insurance.
Increasingly, people are turning to pain centers sooner rather than later, say specialists from Texas Back Institute and Dartmouth's Spine Center. Based on their experiences with patients all along the spectrum, they've pinpointed strategies to help keep sufferers with an acute back problem from developing a chronic one:
Limit Narcotics
Unlike anti-inflammatories, the commonly used Percocet, Vicodin, OxyContin, and other opioids don't help heal your back. And they can be addictive.
Get Help
if you're emotionally down. Depression makes pain worse.
Set Goals
Tell your health team what you want to be able to do — go to work, drive — so you can make a plan.
Stay Active
When you're on bed rest, your family can begin to see you as the "sick person," which can be hard to reverse. It's also not great for your body (you lose muscle tone) or mind (you get depressed).
As Catherine Johnson found after going through the Dartmouth Spine Center program, even excruciating, life-limiting pain can be overcome. You may have to develop a mantra — "the pain will go away," "moving will make me feel better, not worse" — and you may have to try a number of approaches before you find the one that works. Most of all, you have to keep your skepticism meter set on high, so you won't be derailed by promises that can't be kept — and treatments that won't help.
Finding Dr. RightWith some doctors eager to do surgery you may not need — and that may well not help — it's not always easy to find a competent and caring physician who will do his or her best by you. Some guidelines, starting with two key "don'ts":
Don't trust the Internet.The doctor ads you see on patient-education sites may have been placed there by publicity agents for hospitals or spine centers, says Dr. Rosen. Often, their real agenda is to promote surgery.
Don't be wowed by big names.Some prominent surgeons have been implicated in questionable consulting practices. They may be highly skilled, but you want to be sure that whatever treatment is suggested will be best for you, not for a company that's researching a product.
Think local.Your own family doctor sees back patients before, during, and after treatment. He or she knows which specialists are doing the best jobs in your area. Worried your doc will simply refer you to his golfing buddy? Ask for more than one name, and ask why he likes these physicians best.
Check your state's Website.Type the name of your state followed by ".gov" and then look for links to "physician licensing" to confirm that the doctor has a current license.

Then check ethicaldoctor.org.This site, run by the Association for Medical Ethics, tells whether a surgeon is a paid consultant or distributor for products. If he is, you may not want to shun him, but you should ask about the connection and be comfortable with the answer.