Specific symptoms and signs of unstable back segments and curative surgery?

Jens Ivar Brox

doi:10.1016/j.sjpain.2016.12.001

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Specific symptoms and signs of unstable back segments and curative surgery?

Jens Ivar Brox

Published/Copyright: July 1, 2017

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From the journal Scandinavian Journal of Pain Volume 16 Issue 1

Low back pain is reported to contribute to more burden and disability than any other illness or disease [1]. This is a paradox, considering that low back pain is a normal phenomenon that normally resolves without any professional treatment. We may ask if all the available treatments and long spells of sick leave are doing more harm than good.

1 Selection of patients with sever persistent low back pain for surgery

For some patients persisting low back pain is a nightmare that invades and deteriorates their life. In this edition of Scandinavian Journal of Pain, Bo Nyström and co-workers propose criteria for selecting patients for surgery based on a study of severely disabled middle aged women [2]. The study is small, lacks a control group and includes only a few predictors. The strength of the study is the long follow-up and evaluation by an independent researcher, the deceased neurologist Henrik Weber from Norway [3]. The first author is an experienced Swedish spine surgeon who strongly believes that lumbar fusion should be reserved for patients with segmental pain [4].

2 Segmental back pain

Nyström et al. uses the diagnostic label of segmental pain. This can be defined as pain caused by one or more of the structures constituting a single spinal segment, or two or three segments. This term is debated, guidelines do not advocate its use [5]. Specific segmental pain is classified as non-specific low back pain because we have no valid methods to discriminate it from other causes of low back pain. An experimental study found that stimulation of the disc evoked an increase in the multifidus muscle activity on multiple levels while the introduction of lidocaine in the facet joint reduced muscle activity predominantly at the same side and level [6]. Discography was considered to be a useful tool to identify painful discs until Carragee et al. observed that the same percentage from asymptomatic and symptomatic populations reported pain after standard discography [7, 8, 9]. Facet joint degeneration or arthritis is observed in the majority of the asymptomatic population older than 50 years of age and the pretest probability of this finding on MRI is about 30% in a 30 year old person [10]. The evidence of the effectiveness of facet joint injections is sparse according to a recent systematic review [11].

3 Finding the painful segment(s) and then choosing the best treatment

Today we are still faced with the problem of identifying patients with segmental pain, then to find the correct level(s) and finally to choose the best treatment. The first assumption that legitimates fusion is that segmental pain is caused by instability and that fusion does not permit any axial movement. The next assumption is that fusion will cure the pain problem or at least reduce pain. Two recent trials question the importance of fusion in patients with spinal stenosis and degenerative spondylolisthesis [12, 13]. The latter is believed to be associated with a progressive risk of instability [14, 15, 16]. In the two trials additional fusion was not found to add benefit to decompression alone [12, 13]. In practice, even in properly selected patients, the effect may as well be related mainly to placebo. Previously, vertebroplasty for osteoporotic vertebral fractures were believed to be effective, but two high quality trials showed that it was not more effective than placebo [17, 18].

Current trials assessing the efficacy of lumbar fusion have included patients with chronic low back pain [19, 20, 21, 22]. To be candidates for inclusion in these studies patients had degeneration at one or two segments, tempting to say similar to their age matched asymptomatic controls. We cannot exclude that the lack of specific criteria is the reason why results after fusion were not superior to multimodal rehabilitation.

4 Artificial disc and motion preservation surgery – also as effective as placebo

Another possible hypothesis is that although segmental pain could be properly diagnosed, fusion is not the best treatment. Motion preservation, inserting an artificial disc, was expected toimprove results and reduce the risk of adjacent segment degeneration. In practise the motion preservation theory is not supported and adjacent segment degeneration is mainly the result of the general degenerative process [23, 24]. The placebo effect is underestimated, particularly in surgery [25]. Some recent trials of commonly used procedures conclude that sham surgery is as effective as surgical repair [17, 18, 26].

5 Can context sensitive therapeutic effect (placebo) last for 18 years?

The study in this edition of Scandinavian Journal of Pain examined outcome at 1, 2, 4 and 18 years after monosegmental posterior lumbar interbody fusion without internal fusion. The study included mainly women reporting a miserable back situation and duration of symptoms for a mean 7.7 years. Many had previous failed surgery for disc herniation and these patients are not reported to benefit from lumbar fusion [20]. In the study reported in this edition of Scandinavian Journal of Pain, 14/38 patients described their back situation as good 4 years after surgery, while 24/38 described symptoms as much better than before. At 18 years about 50% of the patients described symptoms as much better. Improvement was mainly related to patient characteristics reported in a questionnaire before surgery. Patients reporting back pain origin in the midline and stabbing pain upon sudden movements in general improved, while surgery was not effective in those who did not.

6 Concluding remarks and implications

Too many patients have lumbar fusion for persisting low back pain [27, 28]. Many attempts have been made to select those who may benefit. Large quality registers have been developed in Sweden and Norway. The factors identified by Nyström et al. should be included in these registers in order to evaluate if they are predictive in larger populations, particularly in those with severe symptoms.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2016.10.007.

Neck and Back Outpatient Clinic, Department of Physical Medicine and Rehabilitation, Oslo University Hospital, P Box 4950, Nydalen, 0424 Oslo, Norway.

Conflict of interest: None declared.

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Published Online: 2017-07-01

Published in Print: 2017-07-01

Articles in the same Issue

https://doi.org/10.1016/j.sjpain.2016.12.001