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Failed Back Syndrome: The Disturbing Statistics: Presented at DG DISPATCH - AAPM

By Lisette Hilton

Special To DG News

MIAMI, FL -- February 20, 2001 -- Back specialists are discouraging the use of surgery as a therapeutic technique for patients with back pain.

Hubert L. Rosomoff, MD, called a moratorium on back surgeries when he realized that, after two weeks of rehabilitation, his back patients no longer required surgery. He said this approach can avoid the majority of surgeries.

"Following this kind of concept you can eliminate 99 percent of the surgical cases. In fact, the incidence of surgery if one really looks at this appropriately is one in 500."

Dr. Rosomoff was among the speakers in the session "Failed back syndrome," during the American Academy of Pain Medicine (AAPM) 17th annual meeting in Miami Beach, Florida, February 14 through 18, 2001.

Back in the 1970s, Dr. Rosomoff, medical director of the Comprehensive Pain and Rehabilitation Center at the University of Miami School of Medicine, did a lot of back surgery. The professor and chairman emeritus in the department of neurological surgery and professor in the departments of anesthesiology and orthopedics and rehabilitation at the University of Miami believed his patients were improving dramatically because of the surgery.

But he found out that wasn't the case when he started patients on an intensive pre-surgical rehabilitation program. He realized that after two weeks of rehab, patients no longer had indications for surgery.

That's when he called the moratorium on surgery, telling patients they'd have to go through rehab before he'd operate. "Nobody got operated on in the first six months," he said, with a resulting 99 percent drop in surgeries.

"Backs don't fail. Doctors do," said Dr. Rosomoff. He argued that the reason for failed back syndrome, defined by some as persistent pain after surgery or other interventions, often happen because initial patient evaluations are not complete. The source of the pain in most cases is not from the spine and surrounding nerves but rather from the muscles, tendons and ligaments that support the anatomy, he said.

Lynn Johnson, MD, was the moderator for the AAPM session. He said that failed back syndrome can occur in as many as 10 to 40 percent of patients who get some type of lumbar spine surgery.

Dr. Johnson is board certified in anesthesia and pain medicine and director of the Center for Pain Medicine of North Carolina, which is affiliated with East Carolina University School of Medicine in Greenville, North Carolina.

"This means there is an alarming prevalence to the syndrome," he said. "There is a lot of misunderstanding about what causes back pain at the outset, prior to surgery. Moreover, once they have had surgery and don't do well there are continued problems in not only diagnosis but management of the problem."

It is Dr. Johnson's opinion that, while back surgery has a place, there are too many surgeries being done. He said that in some cases doctors fail to appropriately apply conservative measures, such as chiropractic, physical therapy, injection therapy and minimally invasive surgical techniques, before suggesting surgery.

"Just about any approach is better than having surgery because all the studies have shown that, if you take a surgical population and nonsurgical population, they all seem do the same in five years," he said. "So if you can avoid surgery and the expense of surgery, obviously, you might do as well as the [patient] that gets [the surgery]."

Also on the panel, James N. Campbell, MD, professor in the department of neurosurgery and director of the Blaustein Pain Center at Johns Hopkins Hospital, in Baltimore, Maryland, agrees the problem of low back pain is ever-present.

He said that the fact that other countries, such as Sweden, have a lower volume of back surgery than the United States, which means that "… we're far away from reaching a consensus about what the right answers are to questions like: When should surgery be offered? Who are the right candidates for it? What are the expectations? What are the complications of surgery? What are the chances of making the patient worse?"

According to Dr. Campbell, neurosurgery has been oriented to addressing situations such as nerve root compression, which are relatively easy to address surgically. In these cases, most patients get good results - around 90 percent get relief from sciatica or leg pain problems, he said.

"But the more common problem actually is patients not presenting with clear-cut radiculopathy or sciatica," he said. In these cases, satisfactory results drop to about 60 to 70 percent of patients, according to Dr. Campbell.

"So, surgery has a role but the results of surgery are modest," he concluded.

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