Surgical / Interventional
 

Surgical / Interventional

Most everyone has back pain at some point in their lives. At any given time, twenty-five percent of the population report having low back pain. Deyo, R. A., Mirza, S. K., & Martin, B. I. (2006). Back pain prevalence and visit rates: Estimates from U. S. national surveys, 2002. Spine, 31, 2724-277. Forty-three percent of the population report having neck pain. Guez, M., Hildingsson, C., Nilsson, M., & Toolanen, G. (2002). The prevalence of neck pain. Acta Orthopaedica, 73, 455-459.

 

Fortunately, most cases of spine-related pain resolves within a few weeks to months. Andersson, G. B. (1999). The epidemiologic features of chronic low back pain. Lancet, 354, 581-585. Some people, however, continue to have pain and it doesn’t go away. Healthcare providers consider pain to be ‘chronic’ when it lasts longer than six months. Chronic low back pain affects about 10% of the population. Freburger, J. K., Holmes, G. M., Agans, R. P., Jackman, A. M., Darter, J. D., Wallace, A. S., Castel, L. D., Kalsbeeck, W. D., & Carey, T. S. (2009). The rising prevalence of chronic low back pain. Archives of Internal Medicine, 169, 251-258. Chronic neck pain affects 22% of women and 16% of men. 2

 

Patients with chronic back and neck pain commonly seek care with interventional pain physicians and spine surgeons. Interventional pain physicians are typically anesthesiologists or physiatrists who have obtained specialized training in providing interventional procedures like epidural steroid injections, nerve blocks, rhizotomies, and implantable pain control devices. Spine surgeons are typically either orthopedic surgeons or neurosurgeons who have developed a subspecialty in spine-related surgery.

 

Most patients assume that the healthcare they receive when sick or injured is effective. Chronic pain patients are no different and assume that procedures performed by interventional pain physicians and surgeons are effective. Of course, such interventional and surgical procedures can reduce pain. However, it’s important to know how often such procedures are effective.

 

Outcome research on health-related procedures demonstrates effectiveness by taking the average outcome of a given procedure. The average outcome is a way to estimate how effective a procedure is when individual patient results vary. That is to say, nothing works every time it is performed. Sometimes, patients are helped by a procedure and sometimes, of course, patients are not helped by the procedure, even when getting the same procedure. The average outcome is a way to estimate how effective the procedure is overall.

 

Sometimes, researchers compare the average outcome of a procedure with the average outcome of a sham procedure. A sham procedure is a feigned procedure where the patient is unaware that it isn’t the real thing. A sham procedure is the procedural equivalent of a placebo in a drug trial. Sometimes, it is too technically difficult or too unethical to perform a sham procedure when doing research. So, researchers then compare the average outcome of the procedure in question to the average of how patients do when getting no treatment whatsoever or when getting ‘treatment as usual,’ which is different from the procedure being studied.

 

It is important to know something about how effective interventional pain procedures and surgeries are. The following information is a review of the research literature on their relative effectiveness.  

 

Epidural steroid injections

Research on the outcomes of epidural steroid injections consistently shows that they are no more effective on average than injections filled with placebo. Arden, N. K., Price, C., Reading, I., Stubbing, J., Hazelgrove, J., Dunne, C., Michel, M., Rogers, P., & Cooper C. (2005). A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: The WEST study. Rheumatology, 44, 1399-1406. Ng, L., Chaudhary, N., & Sell, P. (2005). The efficacy of corticosteroids in periradicular infiltration in chronic radicular pain: A randomized, double-blind, controlled trial. Spine, 30, 857-862. Staal, J. B., de Bie, R., de Vet, H. C., Hildebrandt, J., & Nelemans, P. (Updated March 30, 2007). Injection therapy for subacute and chronic low back pain. In Cochrane Database of Systematic Reviews, 2008 (3). Retrieved April 22, 2012. van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcomes of invasive treatment strategies in low back pain and sciatica: An evidence based review. European Spine Journal, 15, S82-S89.

 

Rhizotomy

In a well designed study, Van Wijk, et al., van Wijk, R. M., Geurts, J. W., Wynne, H. J., Hammink, E., Buskens, E., Lousberg, R., Knape, J. T., & Groen, G. J. (2005). Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: A randomized, double-blind, sham lesion-controlled trial. Clinical Journal of Pain, 21, 335-344. tested rhizotomies, or radiofrequency neuroablation, against a sham procedure. They randomized patients into two groups – 40 patients receiving the real rhizotomy and 41 patients receiving the sham rhizotomy. The evaluators and the patients did not know which procedure they received. The investigators found no difference between the two groups in pain levels, activity levels, or intake of analgesic medications.

 

These results echoed a previous, double-blind study of rhizotomy versus sham rhizotomy. Leclaire, R., Fortin, L., Lambert. R., Bergeron, Y. M., & Rosignol, M. (2001). Radiofrequency facet joint denervation in the treatment of low back pain: A placebo-controlled clinical trial to assess efficacy. Spine, 26, 1411-1416. This earlier study did not find any significant difference between the two groups as well.

 

Spine surgeries

There are few studies on the effectiveness of back surgeries for chronic back pain. Of the available studies, the outcomes are mixed. In their attempt to review the research, Mirza and Deyo Mirza, S. K., & Deyo, R. A. (2007). Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine, 32, 816-823. found only five published, randomized clinical trials for fusion surgery. Two had significant methodological problems, which prevented them from drawing any conclusions. One of the remaining three showed that fusion surgery was superior to conservative care. The other two compared fusion surgery to a brief educational class on self-care for back pain. These two studies found no differences between the two groups at one and two year follow-up periods.  

 

In a large clinical trial, Weinstein, et al., Weinstein, J. N., Tosteson, T. D., Lurie, J. D., et al. (2006). Surgical vs. nonoperative treatment for lumbar disk herniation: The spine patient outcomes research trial (SPORT). Journal of the American Medical Association, 296, 2441-2450. compared patients who received surgery with patients who did not receive surgery and found no difference on average. They followed up with the patients two years later and again found no difference between the groups. However, in a later article, they showed that the surgical patients had less pain on average at a four year follow-up period. Weinstein, J. N., Lurie, J. D., Tosteson, T. D., et al. (2008). Surgical vs. nonoperative treatment for lumbar disc herniation: Four-year results for the spine patient outcomes research trial (SPORT). Spine, 33, 2789-2800.

 

In their review of the literature, Gibson & Waddell Gibson J.  N., & Waddell, G. (Updated January 6, 2007). Surgical intervention for lumbar disc prolapse. In Cochrane Database of Systematic Reviews, 2007 (2). Retrieved November 25, 2011, from The Cochrane Library, Wiley Interscience. concluded that there is only minimal evidence that lumbar surgeries are effective in reducing low back pain.

 

Implantable pain control devices

Research on spinal cord stimulators suffers from poor quality studies. A number of reviews of these studies show that there is limited evidence to support the effectiveness of spinal cord stimulator implants. Chou, R., Atlas, S. J., Stanos, S. P., & Rosenquist, R. W. (2009). Nonsurgical interventional therapies for low back pain: A review of the evidence for the American Pain Society clinical practice guideline. Spine, 34, 1078-1093. Taylor, R. S., Van Buyten, J., & Buchser, E. (2005). Spinal cord stimulation for chronic back and leg pain and failed back surgery syndrome: A systematic review and analysis of prognostic factors. Spine, 30, 152-160. Turner, J. A., Loeser, J. D., Deyo, R. A., & Sanders, S. B. (2004). Spinal cord stimulation for patients with failed back syndrome or complex regional pain syndrome: A systematic review of effectiveness and complications. Pain, 108, 137-147.

 

Research on the effectiveness of intrathecal drug delivery systems (aka “pain pumps”) also suffer from poor quality. In their review, Turner, Sears, & Loeser Turner, J. A., Sears, J. M., & Loeser, J. D. (2007). Programmable intrathecal opioid delivery systems for chronic noncancer pain: A systematic review of effectiveness and complications. Clinical Journal of Pain, 23, 180-195. found that intrathecal drug delivery systems were modestly helpful in reducing pain. However, because all studies are observational in nature, support for this conclusion is limited. Patel, V. B., Manchikanti, L., Singh, V., Schultz, D. M., Hayek, S. M., & Smith, H. S. (2009). Systematic review of intrathecal infusion systems for long-term management of chronic non-cancer pain. Pain Physician, 12, 345-360.

 

Author

Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain. The Institute for Chronic Pain is an educational and public policy think tank. Its purpose is to bring together thought leaders from around the world in the field of chronic pain rehabilitation and provide academic-quality information that is also approachable to all the stakeholders in the field: patients, their families, generalist healthcare providers, third party payers, and public policy analysts. Its aim is to change the culture of how chronic pain is managed through education and consultation efforts that advocate for the use of empirically supported conceptualizations and treatments of chronic pain. He also blogs at the Institute for Chronic Pain Blog.

 

References

Last Updated on Friday, 23 October 2015 15:32

Published on Friday, 27 April 2012 14:02

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