offers the fastest relief -- but those who choose nonsurgical treatments get
Two separate studies reported in this week's New England Journal of
Medicine show that surgery is the fastest route to pain relief for two very
different conditions: severe sciatica and degenerative spondylolisthesis.
But the studies also show that these conditions do not worsen if surgery is
delayed -- and that nonsurgical treatments can relieve at least some of the
An editorial titled "Back Surgery: Who Needs It?" accompanies the
studies. Editorialist and back pain researcher Richard A. Deyo, MD, MPH, is
professor of medicine and director of the center for cost and outcomes research
at the University of Washington in Seattle.
"The people who truly need back surgery are those who need it to
preserve their ability to function," Deyo tells WebMD. "But short of
that, most back surgery is an elective procedure. It is not urgent. Patients
face real choices that are quite reasonable: either surgical or no
Sciatica: Surgery vs. No Surgery
Sciatica is pain or tingling that begins in the back or buttocks and runs
down the leg. The most common cause is a bulging disk in the spine. The bulge
presses against a nerve root, causing problems all along the nerves that branch
from that root.
Surgical treatment of sciatica relieves pressure on the nerve root by
removing a portion of the affected spinal disk. But sciatica often gets better
over time. Is surgery really the best choice? How long should a patient wait
before opting for surgery?
To answer these questions, neurosurgeon Wilco C. Peul, MD, head of the spine
intervention study group at Leiden University Medical Center in the
Netherlands, led a study of 283 patients with confirmed cases of severe
All of these patients' symptoms had lasted for six to 12 weeks. Even with
pain medication, they could barely walk and were not able to work around the
house or at their normal jobs.
Half the patients underwent early surgery, most within two weeks of study
entry. The other patients were assigned to "conservative treatment,"
which included pain management and physical therapy.
As expected, early surgery meant quicker recovery. But Peul and colleagues
were surprised by what happened in the conservative-treatment group.
"The most important result is that what we did not expect -- that in the
conservative-treatment group, most of them also had a quick recovery," Peul
tells WebMD. "It was slower than the early-surgery group. And 39% had
longer-lasting leg pain and needed surgery. But at one year, the results for
the two groups are nearly equal. Even at three and six months, the outcomes
were not that much different."
Patients whose surgery was delayed got just as good results as those who had
surgery right away.
"So for leg pain, if you cannot cope with the pain, there is a quite
good reason to have surgery early," Peul says. "But if you can stand
the leg pain and have enough medication and cortisone shots, you can postpone
and even evade surgery. And patients have to be informed that whether surgery
is done now or later, they will have the same outcomes."
Current recommendations are for patients to wait six weeks to see whether
their sciatica gets better.
"I think we should wait at least two extra months to see if the patient
is recovering. If not, or if the pain is worsening, surgery should be done
early if the patient is asking for it," Peul says. "If the patient can
sustain the pain, waiting is the best strategy. But if the patient very badly
wants to do it, early surgery is a good choice."
Surgery does not always work. Peul says that one in 20 patients with severe
sciatica has continued pain even after back surgery.
Spondylolisthesis: Surgery vs. No Surgery
Degenerative spondylolisthesis sounds bad -- and it can, indeed, be a very
painful condition. It's a disease of aging, occurring six times more often in
women than in men and affects black women in particular.
The condition occurs when one of the vertebrae in the lower spine slips
forward across another. This may cause spinal stenosis -- a narrowing of the
spinal canal that causes bone and soft tissue to press against a nerve. The
result is pain in the buttocks or legs while walking or standing.
Surgery involves laminectomy, an operation that removes part of the spinal
bone to relieve the pressure on the nerve. The procedure often includes fusing
the affected vertebrae with a bone graft.
Patients tend to be elderly, so surgery carries a risk. Is the risk worth
The answer is a qualified "yes," find James N. Weinstein, DO, of
Dartmouth Medical School in Lebanon, N.H., and colleagues. Weinstein and
colleagues report the two-year outcomes for more than 600 patients with at
least 12 weeks of symptoms from degenerative spondylolisthesis with spinal
Patients who underwent surgery had better symptom relief and better daily
function starting six weeks after the operation and persisting for at least two
But that doesn't mean surgery is for every patient.
"In this study, we see a greater benefit to surgical than nonsurgical
treatment," Weinstein tells WebMD. "But what has never been shown
before is the nonoperation patients do get better. So now there is a basis for
giving patients an informed choice about treatment options for this
Weinstein says that patients with spondylolisthesis should know that back
surgery is very likely to relieve their pain. But they should also know that it
won't bring them all the way back to normal levels of function. And it's also
important for them to know that if they don't want to undergo surgery, they can
still expect significant recovery.
So what should patients do?
"Go to a doctor who will share this information with you, who can
understand your preferences, and help you make the choice that is best for
you," Weinstein says. "This study shows surgery works a little better
than nonsurgical treatment. But there are patients who choose not to have
surgery. And that is a good choice, too."
By Daniel DeNoon
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