Lower Back Pain Treatment: Are Orthopedic Surgeons Hiding Something From Their Patients?

There are several key areas of orthopedic surgery that are current and developing enough to warrant timely blog posts. One of these is the treatment of lower back pain. This is of particular interest to me, as I have herniated a lumbar disc myself. I am not in a rare situation though. Lower back pain is a major financial burden for Americans, as a Duke University study found that the annual cost of lower back pain treatment in America exceeded $25 billion, or 2.5% of all national healthcare expenses.

Lower back pain manifests itself in two forms: axial and radicular. Axial pain is concentrated in the lower back and can be caused by aggravation of the soft tissue surrounding the spine. Improper lifting technique, for example, can put strain on the tendons and ligaments that support the spine, and thus allow more severe damages to take place. These can lead to radicular pain, or pain that is no longer confined to the lower back. Radicular pain is often referred to as sciatica. A patient typically suffers from pain that shoots down one or both legs, either intermittently or chronically. At its worst, this pain can be accompanied by numbness or loss of strength in the affected limb or limbs.

The anatomy of a sciatica-stricken lower back is fairly simple. Each vertebra in the spine is separated from its neighbor by a lumbar disc. The primary function of this disc is shock absorption. Lumbar discs are shaped like a jelly doughnut. They have a tough outer layer, known as the annulus fibrosus, and a softer inner layer, called the nucleus pulposus. See diagram below for clarification. When a disc ruptures or becomes herniated, the nucleus pulposus pushes out into the space normally contained by the annulus fibrosus. This makes the disc as a whole bulge out into the surrounding space. A bulging disc can impinge on nerve roots that exit the spine next to the discs, and in doing so cause pain to be experienced all along the path of that nerve. When the bulging disc is in the lower back, the impinged nerve tends to run to one of the legs.

For many years, the gold standard treatment for radial lower back pain was surgery. There are several different procedures that are in common practice today, and each one has pros and cons for a given patient’s situation. In each procedure, the basic goal is the same: to relieve pain caused by nerve root impingement. One method involves shaving down the herniated portion of the disc, thus returning the outer shape of the disc to its natural curve. This releases pressure on the nerve, but permanently weakens the annulus fibrosus. Another method, known as a discectomy, involves either the removal or dissolution of the herniated disc. The two vertebrae are then fused together to prevent any motion between them. This method can be a great relief for some patients, but it decreases flexibility in and permanently weakens the lower back. One of the more recent developments is called a total disc replacement. An interactive video detailing this procedure can be seen here.

In contrast to this newest procedure, over the past few years surgical techniques have generally become less and less invasive. Orthopedic surgeons are now commonly performing laparoscopic microdiscectomies rather than open surgeries to speed up recovery time and lessen any chance of infection. Treatment plans have similarly taken a step away from the traditional surgery route. Many surgeons now advise that surgery is not necessary for any patients but those with the most serious disc herniations. Each of the twenty-four orthopedic surgeons who gave their opinions on back.com felt that the best course of action is to start with rest and non-steriodal anti-inflammatory drugs (NSAIDs), then advance to exercise and stretching, then try cortisone injections around the affected area, and finally to proceed to surgery if nothing else has given the patient relief. It is amazing how uniform this treatment plan is from doctor to doctor. It is not by any means the only method prescribed by doctors around the country, but it evidently has a pretty strong following.

There are a few issues with this treatment plan. Several recently published studies contradict the idea that following this protocol will lead to resolution of lower back pain. The first, a recent review of 65 studies comprising over 11,000 subjects with lower back pain, has concluded that NSAIDs like ibuprofen are no more effective at treating symptoms from radial pain than simple painkillers such as Tylenol. It also concluded that NSAIDs were only slightly effective at relieving pain for these subjects. Another study published by the British Medical Journal has shown that exercises and lifting technique education are not effective at relieving back pain. As written in Science Daily, “a group receiving both training and an assistive device was compared to a group receiving training only and another control group which received nothing -- there was no difference in back pain [after one year].”

I find it very odd that orthopedic surgeons would be advocating a treatment plan that calls for NSAIDs, education on posture and lifting, and stretching and exercises for the back considering that these elements of the treatment have been shown to be ineffective. Is it possible that these surgeons know that eventually their patients will come crawling back for surgery after months of ineffective exercise and stretching? Many people are averse to the idea of having surgery on their back and will only consent when they feel it is their only option for relief. If surgeons were only promoting alternative therapies to add credence to their own surgical specialty, then what a wicked game that would be.

I cannot believe that any medical professional would knowingly give out bad information to a patient simply to make surgery seem like a better option. Instead, I think that these surgeons believe that many back pain sufferers can simply get better on their own. Given time, many (some estimate up to 80%) patients will regain most of their strength and learn to live with whatever pain lingers. I believe that what the common treatment plan does is give the majority of patients the time that is necessary to begin to heal themselves without surgery. After all, this has been my own personal experience with back pain. I herniated a disc in my lower back almost 18 months ago, and I am finally to the point where I could declare myself as being 90% better. I was given the standard treatment plan – first rest and painkillers, then stretching and exercise, and I was told that surgery would be held as a last resort. I ended up not taking that last resort because my pain went away quickly enough. The stretching and exercise involved with this treatment plan worked well for me because it gave me something to do while I waited for my pain to go away. Whether it went away because of what I was doing or simply on its own does not matter because in either case, I recovered. And when it comes to lower back pain, that’s really what counts.