Connections: Low back pain: When is surgery the right choice? | Winter 2018

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From the OHSU Spine Center

Dr. Hiratzka

Jayme R. Hiratzka, M.D.

Dr. Hiratzka specializes in general orthopaedics and spine surgery. He works closely with neurologists, surgeons and other specialists to improve the health of people with back pain. Dr. Hiratzka is Assistant Professor of Orthopaedics and Rehabilitation at OHSU and Director of the OHSU Spine Surgery Fellowship program. He is board certified in orthopaedics.

Chronic, non-specific low back pain is a perennial clinical concern. Approximately 25 percent of the population has experienced low back pain for a month or more, and more than 80 percent of adults have reported the problem. By definition, non-specific low back pain is not traceable to a particular injury or other cause; much of this pain has a musculoskeletal origin.

Surgery – not always the endgame

Viewing surgery as the last chance for relief when other, conservative options have failed to resolve back pain can skew patient expectations, diminish commitment to other treatments and lead to disappointment when surgery does not actually eliminate pain and restore function.

Primary care providers are typically seasoned in dealing with non-specific lower back pain and prescribing conservative care. However, surgery has attained near-mythical status as the ultimate back pain solution. Patients may embark on a conservative course with the expectation that if their pain does not resolve, they need surgery. However, we recommend two main clinical paths: long-term conservative management or surgery only after conservative management options have been thoroughly explored. In rare cases of myelopathy or progressive neurologic deficits, surgery may be indicated more urgently.

Accurate diagnosis is the key to choosing the best path. For example, spondylolisthesis is an indication for surgery. Disc degeneration or facet arthropathy without neurologic concerns or instability are best treated with conservative management. A patient with radiculopathy or myelopathy may need surgery, while a patient with axial pain may be better served by injections and chronic pain management.

Which conservative treatments are best?

Exercise, non-steroidal anti-inflammatory agents, and heat are standard modalities to increase blood flow, relieve pain and improve function. Some patients benefit from careful spinal manipulation and chiropractic care, although practitioners and methods vary widely. Patients with cervical or thoracic stenosis should not receive active manipulation.

Chronic bracing leads to deconditioning, so we do not recommend bracing for more than brief periods. Some patients benefit from weight loss. Physical therapy offers the best outlook for improved function, if not immediate pain relief.

Starting with diagnosis

Finding the cause of back pain is optimal, if possible. However, it is not possible to definitively diagnose the pain's origin in many patients with low back pain. Imaging can help rule out surgical conditions, but does not definitively identify the "pain generator" in most cases.

The classic list of "red flags" for specialist referral has been shown to lead to unnecessary imaging. In addition, many patients with nonspecific back pain have at least one "red flag" sign. However, for the purpose of ruling out dire conditions and malignancy, it is worth reviewing these signs in the context of patient history and general health. A red flag alone does not necessitate specialist referral, but may prompt telephone consultation with a back-pain specialist or spine surgeon.

General references on low back pain

Global prevalence of low back pain

  • Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, Woolf A, Vos T, Buchbinder R. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012 Jun;64(6):2028-37. Epub 2012 Jan 9.

How many North American adults have low back pain?

  • Cassidy JD, Carroll LJ, Côté P. The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults. Spine (Phila Pa 1976). 1998;23(17):1860.
  • Deyo RA, Tsui-Wu YJ. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine (Phila Pa 1976). 1987;12(3):264.

On the presence of degenerative changes on imaging studies

  • Boden SD1, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8

The limited role of imaging

Magnetic resonance imaging (MRI) is both precise and costly. It can reveal degenerative changes of normal aging that are not the cause of patients' pain. For example, MRI from a patient aged 30 to 65 who has back pain of more than three months' duration, neurological symptoms, or both will almost certainly reveal stenosis, disc bulging and facet arthropathy. However, the presence of these changes does not mean they are causing the pain.

When MRI is ordered, contrast is not necessary unless a surgical revision is under consideration. It adds expense and raises additional issues, such as allergic reaction.

With this perspective, patients who do have suspicious neurologic findings should receive imaging relatively early. Patients without neurologic findings should receive no more than a plain X-ray for at least three months.

When to refer urgently

Patients requiring urgent referral to a specialist include:

  • Those with spinal cord or cauda equina compression symptoms, including urinary and bowel problems, "saddle" anesthesia and movement problems.
  • Patients who may have a spinal infection – Such as immunocompromised patients or those with recent history of epidural anesthesia.
  • Patients at high risk for cancer – Including those currently undergoing cancer treatment or with a recent history of malignancy.
  • Patients who may have a vertebral compression fracture.

Contact us

The OHSU Spine Center team is always happy to consult with you. If you have questions or would like to refer a patient for evaluation, please call the OHSU Physician Advice and Referral Service at 503-494-4567.