CF 054: Lumbar Fusion Surgery and Its Evidence Or Lack Of
Today we’re going to talk about a great new paper coming to us from Internal Medicine Journal on Lumbar fusion surgery and it’s evidence or lack of. What’s the word on lumbar fusion surgery? We’ll tell you.
But first, here’s that silky smooth Chiropractic Forward bumper music
OK, we are back. Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.
You have glided all fast and furiously into Episode #54 and we’re happy to have you here smokin tires and all. Kill the engine and take a chill pill, won’t you?
Let’s talk a bit about the Diplomate of the Academy of Chiropractic Orthopedics program quickly. I’m sitting at around 76 of my online hours and I have to get 250 of those. Yes, if you were wondering, it is going by slowly here lately but I’m going to have a little time this week and weekend to put the pedal to the metal and get after it.
Some classes from this past week were migraines, migraines in children, thoracolumbar junction difficulties, and chronically injured hamstrings.
These courses come from a group in Australia and they really take the long road when it comes to spelling. Did you guys know that? The first thing that’s crazy about the Aussies is that they use esses instead of z’s. For example, recognize is spelled with an s rather than a “z”.
When you see the word orthopedic spelled orthopaedic, it’s because of them and the English. We take the shortcuts and say, hey, recognize has a z sound in it so let’s spell it with a z. Hey, orthopedic has an e sound in the middle of it so let’s drop the dumb a since we don’t need it and let’s just spell it orthopedic.
Here’s another one. Behavior. These goofy people spell it behaviour. They snuck in au right there at the very end of the word like they thought they were going to get away with it or something. Uh uh. Nope. We Americans don’t need the u at the end so we just end it in or. Because we’re cool and ain’t nobody got time for that crap.
The most annoying one is probably edema or estrogen. They start both of those words with an O. Who the hell would ever spell estrogen Oestrogen? Or edema spelled oedema? That’s absolutely uncalled for and I’d appreciate them re-evaluating their use of the English language in this manner.
I am currently designing some really cool stuff all based in research and current evidence that I think you will all be interested in. At least I hope you are because, from what I’ve seen in researching, it’s like nothing else out there.
Go to chiropracticforward.com right now while you’re thinking about it, just under this week’s episode, you’ll see an area where you can sign up for the newsletter. It’s only once a week and it’ll help us tell you about what we’re working on when we get it ready to go live!!
Now, let’s get to the reason for the season here.
The is titled “Lumbar Spine Fusion: What Is The Evidence(Harris I 2018)?” and it was written by Ian Harris, Adrian Traeger, Ralph Stanford, Christopher Maher, and Rachelle Buchbinder. I recognize at least two of these names from the low back pain series published in The Lancet earlier this year.
If you have not been through those papers, please listen to episodes #16, 17, and 18 of this Chiropractic Forward podcast for all the info you need on that.
Basically, in this paper, they say that lumbar spinal fusion is common and associated with high cost and a risk of serious adverse events. They state that they aim to summarize systematic reviews on the effectiveness of lumbar spine fusion for most diagnoses.
Of important note is where they say that they found NO high-quality systematic reviews and the risk of bias of the randomized controlled trials they found was generally high. For something as serious as lumbar fusion surgery. Where they cut into the body, take two vertebrae that usually aren’t unstable on each other, and then drive screws into them and affix hardware to fuse them together forever and ever amen.
No high-quality systematic reviews for lumbar fusion surgery and the RCTs out there generally carry a high risk of bias. Great. Duly noted. Awesome. Lumbar fusion surgery
No high-quality systematic reviews for lumbar fusion surgery and the RCTs out there generally carry a high risk of bias. Great. Duly noted. Awesome.
They go on to say that the available evidence doesn’t support a clinical benefit from lumbar fusion surgery compared to non-operative treatment or stabilization without fusion for thoracolumbar burst fractures.
They say that surgical intervention for metastatic carcinoma of the spine associated with spinal cord compromise improves mobility and neurological outcome. That was based on a single trial.
That was the high points of the abstract but let’s move in a little more and get on the micro level of this thing.
This study takes info from Australia and, in the land down under, lumbar spine fusion is the fourth most costly surgical procedure, behind knee replacement, hip replacement, and C-sections. For a procedure with no high-quality systemic reviews. The first word that comes to mind for me here is, “Damn.”
The most common reasons used for lumbar spine fusion procedures would be intervertebral disc disease (which nearly everyone beyond 50-60yrs old has), degenerative scoliosis, and spinal canal stenosis.
The main purpose here was to compare lumbar spinal fusion to non-operative means. Not to compare it to other surgical procedures.
As part of the conclusion, the authors say, “The available evidence does not support the hypothesis that lumbar fusion surgery confers a clinical benefit compared to non‐operative alternatives for low back pain associated with degeneration. Similarly, the available evidence does not support the hypothesis that spine fusion confers a clinical benefit compared to non‐operative treatment or stabilization without fusion for thoracolumbar burst fractures.
The available evidence does not support the hypothesis that lumbar fusion surgery confers a clinical benefit compared to non‐operative alternatives for low back pain associated with degeneration
Benefits of lumbar fusion surgery compared to non‐operative treatment for isthmic spondylolisthesis are unclear (one trial at high risk of bias). Surgical intervention for metastatic carcinoma of the spine associated with spinal cord compromise improves mobility and neurological outcome (based on a single trial).
Ideally, lumbar fusion surgery for spondylolisthesis, burst fractures, back pain or degenerative conditions (degenerative scoliosis, spinal stenosis, recurrent disc herniation or instability), should only be performed in the context of high-quality clinical trials until the true value for each of these conditions is established.
Until better quality evidence is available, treatment will continue to be guided by expert clinical opinion based on evidence at high risk of bias. Patients contemplating lumbar fusion surgery should be fully informed about the evidence base for their particular problem, including the relative potential benefits and harms of fusion compared with non‐operative treatments.
When Surgery Is OK
Let’s transition from that to an excellent guideline called When Surgery is OK and this comes from the legendary Dr. Stu McGill.
To keep this episode from getting too long and out of hand, let’s hit the highlights. This is a 3-page document so we’ll shorten it to the extent that makes sense while still squeezing the good stuff out of it. Use these thoughts and ideas when deciding if surgery is indicated.
Stu says to try the virtual surgery game and consider surgery only when it fails. Meaning pretend you had surgery today and tomorrow is the first day of recovery. It is characterized by gentle movements and activities but mostly a forced day of rest. The days following a typical post-surgical progression involves restricted activity. If this helps, no surgery at this time.
Consider surgery when neurological issues are substantial, such as loss of bowel and bladder control. Note: that does not include radiating symptoms like sciatica, peripheral numbness, atrophy, etc….
Consider surgery in cases of trauma. When structures are unstable and need to be stabilized.
Consider surgery only when the pain has been unrelenting and severe for a substantial period of time. Pain can be a terrible and misleading reason to get surgery.
Select the surgeon. Dr. McGill says everyone likes to state that they had the best surgeon. He has found that asking the nurses and physical therapists at the hospital which surgeon has the best results is a wise way to go.
Discuss the pain with the surgeon. Ask what the pain generator is and if they can cut it out. IF there are several tissues involved, chances of success are getting worse. Also if there is damage at several levels.
Clarify what the success rate is. What does success even mean in your case? Does that mean you survived or does it mean you did OK for a bit before relapsing into pain? You want long-term success to any and all other options available.
Beware of new treatments. That one should really go without any further discussion. Don’t be a pioneer on the patient side of surgical procedures.
Beware of disc replacement – Dr. McGill states in this paper that he has not seen a successful case as of the writing of the article.
Always exhaust the conservative options – He says you may believe that since you tried physical therapy and it didn’t help that only surgery remains. It just may be that the exact therapy tried was not the right one for your specific condition.
FREE MRI Review
Beware of institutes that offer to view medical images and, with no other information, advise patients on surgery. Pictures are not linked to pain. He argues that a thorough clinical assessment is absolutely essential. I want to butt in on this one. The laser institute and orthopedic surgeons are all over the commercials on TV with this one.
I will take this time to admit because they’re doing these free MRI reviews, I’m offering the same in my region but here’s why. It’s evidently enticing or they would not offer it and I KNOW for a fact they have a higher-paid marketing department that has decided it is indeed effective.
That’s one of the reasons I’m doing it but the real reason is because I know that the majority of these people, if they get a free MRI review at the osteopath or the laser spine institute, they’re very likely to be lined up for surgery whereas I, after a thorough exam, will be lining them up for conservative, non-invasive therapy and I can usually keep these people from surgery and useless shots.
There’s a difference. My free MRI review is to prevent them from surgery. Their free MRI review, in my opinion, is to QUALIFY them for surgery.
In wrapping this article or paper up, Dr. McGill says the following, “Tissues in the back become irritated with repeated loading. Consider accidentally stuffing a toe or biting the lip repeatedly – eventually, the slightest touch causes pain. This is symptom magnification because the tissues are hypersensitized. Reduction of the hypersensitivity in the toe or lip only occurs following a substantial amount of time after the accidental stub or bite has stopped.”
Dr. McGill goes on to say, “For example, people with flexion bending intolerance of the spine may replicate this every time they rise from a chair. Correcting this movement fault, metaphorically taking the hits away, results in less sensitized tissues, an increased repertoire of pain-free tasks, and a return of motion. Motion returns once the pain goes away.”
Boom. Snap. Pow. Shazam. KaBAM!! Superhero abilities via the chiropractor and ZERO surgery. How clever.
I don’t care what your chiropractic practice looks like. OK….I lie. As long as it doesn’t make mine look hokey or bad, then I don’t care what your practice looks like. Some are geared toward getting people out of pain. Some are geared to some wellness protocol. Some are floundering because they don’t know where they belong or exactly what they’re trying to accomplish.
I’ll admit that, at one point in time, I was one of them.
But, one common thread through all sorts of practices is this, we keep people from surgery. Maybe not 100% of the time but we do a hell of a job with the tools we’ve been given and I love the direction that opioids and lumbar fusion surgery failures are pushing our profession.
Sometimes even in spite of ourselves.
I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment instead of chemical treatments like pills and shots.
When compared to the traditional medical model, research and clinical experience show that many patients get good or excellent results through chiropractic for headaches, neck pain, back pain, joint pain, to name just a few.
Chiropractic care is safe and cost-effective. It can decrease instances of surgery & disability. Chiropractors normally do this through conservative, non-surgical means with minimal time requirements or hassle to the patient.
And, if the patient develops a “preventative” mindset going forward from initial recovery, chiropractors can likely keep it that way while raising the general, overall level of health of the patient!
Patients should have the guarantee of having the best treatment offering the least harm.
Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show or tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on iTunes and other podcast services. Y’all know how this works by now so help if you don’t mind taking a few seconds to do so.
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We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.
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About the Author & Host
Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger
Harris I, T. A., Stanford R, (2018). “Lumbar spine fusion: what is the evidence?” Internal Med J.