Effective Clinical Practice
Letter to the Editor
As a practicing orthopedic surgeon, I was amused by the article, “Medical versus Surgical Treatment for Low Back Pain.”1 Most busy surgeons will tell you that surgical treatment is practically never indicated for low back pain. I estimate that I treat about 100 patients before I see one who is a surgical candidate. And such patients have leg pain, not back pain, as their primary symptom. If this is induced by exercise and the patient is elderly, a diagnosis of spinal stenosis might be considered, but again, almost all surgical candidates have leg pain. Although magnetic resonance imaging can confirm the diagnosis (and direct the surgeon to the level of the abnormality), the decision to operate should be based on symptoms.
In fact, in my experience, if a patient has back pain, he or she is almost guaranteed not to improve with surgery. Rare is the patient who has single- or double-level degenerative disc disease who will respond to surgical fusion (usually less than one per year), and for that rare patient I would recommend surgery only if I personally have treated and gotten to know him or her over the course of a year.
I suggest that physicians consider the use of caring medical treatment in all patients with back pain and make a concerted effort to avoid surgical treatment. They will doubtless have superior results.
Richard A. Maun, MD
Oneida Orthopaedic Associates, PC
1. Birkmeyer NJ, Weinstein JN. Medical versus surgical treatment for low back pain: evidence and clinical practice. Eff Clin Pract. 1999;2:218-27.
THE AUTHORS RESPOND
We agree with Dr. Maun that most patients with back pain (or leg pain) and corresponding spine abnormality on imaging tests will do well with nonsurgical treatment. However, marked regional variation in rates of spine surgery, illustrated in our analysis, suggests that not all orthopedic and neurosurgeons share this conservative approach to management. Unfortunately, because scientific evidence is currently lacking, professional consensus about the role of surgery will await careful randomized, controlled trials focusing on outcome measures important to patients.
Nancy J. O. Birkmeyer, PhD
James N. Weinstein, DO, MS
Center for the Evaluative Clinical Sciences
Dartmouth Medical School