Sarah takes the mystery out of back pain surgery and explains your options
Caution regarding back surgery is not always the norm. Surgical interventions for back problems today in the USA (often the precursor to wordwide trends) are rising at an unprecedented rate, particularly spinal fusion (in the USA increased by 220%) and spinal implants (by 100%)*.
Spine surgery of today is also changing. In some respects it is less extensive, with a preference for discectomy or microdiscectomy (partial removal of the internal parts of the disc) rather than full-scale disc removal of the earlier laminectomy. This surgical procedure is usually in response to a diagnosis of 'acute disc prolapse'.
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Total disc replacement (TDR) is another type of back pain surgery that has seen a rising incidence in recent times. Alas, the results are not encouraging with quite high rates of re-operation (and wherever this benign term 're-operation' is used it fails to take into account the months of pain and misery suffered by the patient). No long-term benefit has been seen where TDR spine surgery prevents adjacent level disc degeneration. Complications too, from disc replacement back pain surgery may not be known for many years.
This TDR device acts more as a 'spinal spacer' to keep the vertebrae apart and prevent crowding down on the spinal nerves at that level. Its aim is also to prevent excessive weight-bearing through the delicate and highly wired facet joints at the same level.
Despite advances in making artificial discs out of softer polymer material rather than metal it is far from possible for a device such as this to attain the wondrous dual roles of a normal healthy disc: defraying impact while also a dynamic (ligamentous) segmental connector.
The newer M6L artificial lumbar disc, with its attempt to replicate the disc nucleus and the meshed disc wall, is seeking to provide more in the way of shock absorption and better segmental, by which it also hopes to minimise adjacent level degeneration. It will be interesting to see whether it too will stand the test of time.
The M6L artificial lumbar disc
Many literature reviews are diffident and found it difficult to exclude bias from studies that have been done but the overall picture is not encouraging, certainly in the long term: ' . . . . we believe that harm and complications may occur after years, we believe that the spine surgery community should be prudent about adopting this technology on a large scale, despite the fact that total disc replacement seems to be effective in treating low-back pain in selected patients, and in the short term is at least equivalent to fusion surgery' **
Re-operation rates are high for total disc replacement (TDR)
There is also a rising use of spinal implants, increasingly carried out as an out-patient rather than risking the post-operative complications of the in-patient experience. (There is a fair bit of cynicism about this trend, with doctors accused of having financial links with manufacturers of these devices, too numerous in number to mention.)
On the other hand, there is a rising incidence, particularly in America, of more complex operative procedures for the spinal condition of vertebral stenosis, where degenerative bony outgrowths are removed from the spinal canal. Despite excessive bone growth being not pain-making the practice of removal is flourishing and often involves extensive spinal fusion after surgical decompression.
Spinal stenosis is often misdiagnosed and that patients are undergoing surgery without proper diagnosis and clinical reasoning. This certainly appears to be the trend in the USA where a similar trend took place in removing 'slipped' discs. See Discectomy or the Myth of the Slipped Disc.
When patients have severe back and leg pain (sciatica) I believe it is often falsely attributed to disc prolapse, when in reality the findings are often coincidental. We also know that disc sequestration (or fenestration), where the disc nucleus breaks out through the wall of the disc, is unsuitable for surgical intervention since the process is self-resolving (the extraneous material reabsorbed by the body within a few weeks). The Cochrane Review which was fairly clear about the poor outcomes of surgery for back problems as compared to conservative treatment.
Jacobs et al
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