Surgery for pain relief may not always be appropriate: study

Surgery to relieve chronic pain is sometimes resorted to too quickly, without considering possible after-effects, without a complete patient assessment, and without a thorough examination of possible alternatives, deplores a new systematic review.

Current data, the authors write, “strongly support a comprehensive approach to the management” of chronic back pain.

Patients suffering from low back pain should be evaluated for surgical treatment only “when the anatomical causes have been identified and multidisciplinary strategies have been implemented,” they add.

The study authors highlight several “very interesting” elements, said Dr. Anne Marie Pinard, head of the chronic pain department at CHU de Québec-Université Laval, including the existence of “silos” between surgical and non-surgical treatment of low back pain.

“It’s as if we were saying that non-surgical treatment isn’t well integrated,” she added. “The article is very interesting because it makes a sort of connection between the two.”

For example, we see that the presence of psychological factors, such as depression or anxiety, is a “predictor of surgical outcomes,” said Dr. Pinard.

“It’s not surprising, but it’s always interesting to hear about it because it’s not necessarily the first thing a surgeon will assess in a patient,” she emphasized. “It highlights the importance of also exploring this aspect, and not just the anatomical structure that is causing pain.”

No one questions the relevance of surgical intervention in an emergency, for example, for a patient at risk of paralysis, said Dr. Pinard. But in the field of chronic pain, the initial injury is rarely the sole cause of the problem, she pointed out.

The more chronic the pain becomes, the more confusing the situation becomes, said Dr. Pinard. This highlights the importance of a thorough physical examination, in an era when physicians are increasingly relying on imaging, she added—even if, sometimes, “imaging shows us things we’re not looking for” and draws attention to a problem that isn’t really a problem.

That said, the study authors find it “reassuring to see that emerging multimodal strategies are beginning to complement neurosurgical care.”

These strategies, they say, “should be integrated into the treatment plan as more substantial evidence becomes available.”

The emphasis on a multidisciplinary approach “underscores the importance of considering all available strategies in the management of chronic low back pain,” according to the American researchers.

“The authors say that people who don’t have an urgent condition should have access to rehabilitation teamwork for at least a year before considering surgery,” said Dr. Pinard.

Unfortunately, this is when reality sets in. Access to this rehabilitation care can be complicated and expensive, and therefore won’t be accessible to everyone.

“Unfortunately, we have patients who wait years before seeing us,” said Dr. Pinard. “I understand that at that point, the patient, the physician, or both are more likely to turn to surgery. It’s really a huge access issue.”

There’s a need to educate front-line workers, but also patients whose pain becomes chronic, she continued. This is especially true since the authors of the systematic review included studies in their work that show similar results when comparing operated patients to non-operated patients.

This is a very important aspect to emphasize, Dr. Pinard said, given that surgeries can have long-term consequences.

“I work in a pain clinic with a rehabilitation team,” Dr. Pinard said. “We never have a 100 per cent success rate, but we see people who improve very significantly (…) and who, initially, may have thought of surgery, which may seem like a magic solution.”

Patients’ attitude is often to say, “Quickly, cure me so I can get on with my life,” she added. But when faced with chronic pain, it is absolutely essential to assess the entire situation, whether it be physical, psychological, pharmacological, or even social, she said.

Ultimately, what we see is that “it’s a relative minority of patients who should have surgery for chronic lower back pain, in a context where they have access to rehabilitation,” said Dr. Pinard.

“There are people who should go through a rehabilitation team and, above all, have access to it without delay,” she concluded. “When it becomes chronic for four or five years, in addition to all the disadvantages that this has, the pain becomes less and less specific and more and more widespread, (…) and it becomes increasingly difficult to achieve good results both in surgery and in rehabilitation.”

The conclusions of this study were published in the Journal of Neurosurgery: Spine.

–This report by La Presse Canadienne was translated by CityNews