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The low-down on low-back surgery

By Roger P. Smith, Ph.D.

Ralph Waldo Emerson didn't have an M.D., but the 19th-century essayist showed medical acumen when he wrote, "Nature abhors the old, and old age seems the only disease." One common age-related ailment is spinal stenosis, a condition in which the spinal canal narrows, causing tingling, weakness, and/or pain in the lower back. And spinal stenosis is often associated with degenerative spondylolisthesis, the slippage of one lumbar vertebra in front of another. Treatment of patients who have degenerative spondylolisthesis with spinal stenosis has been the subject of much discussion, with no clear long-term evidence for one treatment over another. But recently the DMS-led Spine Patient Outcomes Research Trial (SPORT) released the results of the first long-term study comparing the effectiveness of surgical and nonsurgical approaches to helping such patients.

Those who got surgery showed "significantly greater improvement."

Conduit: The spine forms a conduit for the spinal nerves, which exit through small openings between the vertebrae. Discs, resilient pads with gel-like centers, cushion the vertebrae. And laminae are bony structures on the vertebrae (see the Spine Patient Outcomes Research Trial for diagrams and more about the seven-year, $21-million SPORT study).

Wear may cause the discs to become thinner and the vertebrae to rub together. Or a disc's soft center may bulge (a condition known as a slipped disc) or rupture (a herniated disc). Or bone growths, called spurs, may form between vertebrae. Any of these may cause narrowing, or stenosis, of the spinal canal, leading to compression or irritation of nearby nerves and sometimes to slippage of the vertebrae as well.

The standard surgical treatment for stenosis is a laminectomy-the removal of the lamina from the affected vertebra. It may be accompanied by spinal fusion to eliminate motion between the vertebrae. Alternatives to surgery are physical therapy, education, counseling, and/or nonsteroidal anti-inflammatory drugs.

Pain: A previous SPORT study showed that after two years, a laminectomy was more effective than nonsurgical treatment at relieving pain and improving function. The latest study, published in the Journal of Bone and Joint Surgery, reported that the benefits of surgery were still evident after four years. The study had 607 participants at 13 sites; 395 received a laminectomy, with or without spinal fusion, and 212 had only nonsurgical care. Those who got surgery showed "significantly greater improvement in scores for pain, function, satisfaction, and self-rated progress," the researchers reported.

"The rich data set collected from SPORT patients," says the trial's principal investigator, DMS's Dr. James Weinstein, is generating just the kind of comparative effectiveness research being called for nationally. Still, the decision to opt for surgery should not be made lightly, advises Weinstein, who notes that a spine treatment calculator is also available at the Spine Patient Outcomes Research Trial.

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