Trend toward surgery to relieve pain escalates, but is that good?

By VIRGINIA ANDERSON
The Atlanta Journal-Constitution
02/16/04

Maybe it's the baby boomers, again. Maybe it's the prevalence of MRIs and other 
diagnostic tools, and technological advances that have expanded the array of treatment 
options, including surgery, for the back.
 

BACK TO BACKS
o Whose back hurts? The Duke study identified women as the chief complainers about back 
pain. Of the 26 million adult Americans who have back pain, 55 percent were women, 88.3 
percent were white, 61 percent were married. Average age was 48. 
o The most common spine surgery to relieve back pain is lumbar fusion, in which a 
surgeon removes a disc and installs brackets to keep discs apart.
o The annual per capita expenditures for patients with back pain were 1.6 times higher than 
those without back pain ’§" $3,498 vs. $2,177.
o When compared with those with private insurance, patients who had government-
supported insurance had higher expenditures, especially in the areas of inpatient care, home 
health services and prescription drugs.
KEEPING IT STRONG
The best way to treat a bad back? Prevention. Many lower back problems are caused by 
incorrect posture and movement. Here are some things you can do to keep your back 
strong:
When lifting, bend at the knees, not the waist. This is especially true for the parents of 
young children. 
Avoid twisting and bending at once, as in raking a pile of leaves and putting them into a 
bag. Instead, bend at the knees, straighten up and then move. 
Strengthen your abdominals. This gives you a stronger torso, which supports your back.
Stretch and strengthen your quadriceps muscles in the upper part of the legs. 
Stretch your back. Draw it up as a cat does for 20 to 30 seconds and then release. Lie on 
your back and pull each leg toward you, one leg at a time, and hold for 20 seconds. 
Consider a back cushion if you have a sedentary job, and a back support brace if you stand 
all day. The cushion works well in a car or airplane, too. 
When you do hurt your back, bring out the ice instead of the heating pad. Place a towel 
between your back and the ice pack if it's too cold.
ã Virginia Anderson Whatever the reasons, the back suddenly is front and center of heated 
discussions about treatment costs and methods, and a two-year national study is under way 
at 11 medical centers across the country to study the benefits of back surgery.
 
Back pain is the eighth most frequent reason for an American to seek medical help. Patients 
suffering from back pain cost more that $90 billion annually in health care expenses, with 
about $26 billion directly attributable to treating the pain, according to Duke University 
Medical Center researchers. The Duke team also found that 25.9 million adults reported 
back pain in 1998.
 
Back surgery, which has increased 60 percent in 10 years, is also catching its share of flak. 
An editorial in last Thursday's New England Journal of Medicine questioned whether a 
lumbar spine fusion, a surgery in which lower vertebrae are grafted together, is appropriate 
to relieve back pain, given the surgery's complexities.
 
The surgery is used to repair bulging or ripped disks that many believe to be the source of 
low back pain. Recovery can take months, and it doesn't always increase a person's 
mobility.
 
In fact, most back complaints can and should be addressed nonsurgically, surgeons said.
 
"The majority of times, pure neck or pain back is a strained ligament or muscle," said Dr. 
Chris Clare, an Atlanta neurosurgeon, "and the best way to treat it is through rest and 
maybe anti-inflammatories."
 
If the pain persists, doctors usually order an MRI to look at the soft tissue in the back. The 
spinal disks dry out with aging, compressing the vertebrae. That can cause a bulge, also 
known as a herniated disk, and bone spurs.
 
Many herniated disks heal on their own. But when there's radiating pain, or pain that goes 
into the limbs, or a loss of feeling, a pinched nerve may be at fault.
 
Even then, the doctors said, they exhaust all other treatment options, such as rest, physical 
therapy, massage and chiropractic treatment before recommending surgery as a last resort.
 
Last year, 151,000 surgeries to relieve lower back pain were performed, the New England 
Journal of Medicine reported.
 
At Emory's Spine & Orthopedic Center, surgeons discuss among themselves the pros and 
cons of a procedure, carefully weighing all options.
 
"That discussion goes on all the time," said Dr. John Heller, director of Emory's Spine 
Fellowship program. "I won't say that every spine surgeon is a paragon of virtue, but the 
decision to operate is not something we take lightly, either."
 
But to anyone who has felt the searing pain of a bad back and gotten relief, the discussions 
seem moot.
 
Many patients who are now pain-free after months or years of back pain, or those who lost 
mobility from spine problems, are convinced that surgery gave them back a life they 
thought they had lost.
 
Alpharetta investment banker Dennis Kraebel underwent a new procedure last year to 
relieve compression in his spinal column, a condition called stenosis.
 
The condition is frequent as disks narrow with age; it is why people lose height as they 
grow older. In Kraebel's case, however, stenosis was so pronounced that he experienced 
temporary paralysis.
 
While it took four months for Kraebel to regain total use of his arms and neck after 
surgery, he is elated with the outcome.
 
"I'd do it again in a heartbeat," said Kraebel, 60, who also is a carpenter on the weekends 
in a construction company he operates with his son. "This thing came out fantastic."
 
Kraebel, an avid skier, opted for a more complicated surgery called laminoplasty. It was 
done by Emory surgeon Heller. Laminoplasty would not limit Kraebel's range of motion as 
much as a fusion would, Heller said, even though the procedure is actually more invasive 
than a fusion.
 
Kraebel's decision paid off. Ten months later, he was back on the slopes in Utah, going 
down the same trail that had tripped him.
 
"The only thing that bothered me, really bothered me, was waiting for the first fall," 
Kraebel said.
 
It came the first day, with a skid down a powder-packed, steep slope.
 
"But then it was over, and I was OK, and it was wonderful. It was like I slayed that 
demon."
 
Doctors are more willing to try to help patients in their 50s and 60s because of advanced 
surgical techniques and also because of the patients' good health and fitness, they said.
 
"Here's a guy who's in excellent health, an avid skier, phenomenal athlete who's looking 
probably at 30, 35 more years of life," Heller said. "That wouldn't have been the case 
years ago with people his age."