Lumbar Fusion

CF 160: The Failure Of Lumbar Fusion Surgery

Today we’re going to be talking all about lumbar fusion surgery and my growing disdain for the procedure. 

But first, here’s that sweet sweet bumper music

OK, we are back and you have found the Chiropractic Forward Podcast where we are making evidence-based chiropractic fun, profitable, and accessible while we make you and your patients better all the way around. 

We’re the fun kind of research. Not the stuffy, high-brow kind of research. We’re research talk over a couple of beers.

I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.  

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You have found yourself smack dab in the middle of Episode #160

Now if you missed last week’s episode, we talked about setting yourself apart in the way you treat migraines. This was an excellent episode that has no choice but to make you better. Make sure you don’t miss that info. Keep up with the class. 

On the personal end of things…..

I watched an ESPN 30 For 30 the other night. It was on Jim Valvano and his North Carolina State Wolfpack that won the national championship in basketball in 1983 I believe. It was such an unlikely story and some of his techniques were a bit wonky. 

For example, he used to make the team practice cutting down the nets from the goals after winning the championship. Far before it was ever even in the realm of possibility. The players said that was more than a little weird at first but that they came to enjoy it and it was just a part of goal-setting and visualizing. 

Visualization is such a big part of a mental process we can, and should, partake in. I myself forget to think to do it. Even though I know how impactful visualization can be. 

I can give you a personal example where visualization came in handy for me. I was a mediocre discus and shot put thrower in high school. OK, probably above average to be honest but I don’t want to pump my own tires too much. 

I ended up my junior year at 150’. That throw might win district but won’t do a lot for a guy at a regional meet. 

When my senior year came around, in the early Spring, I began getting recruited by a lot of colleges. Mostly DII colleges. One of the coaches recruiting me knew about my discus and shot put throwing. He recommended a book. It was called Peak Performance: Mental Training Techniques Of The world’s Greatest Athletes by Charles A. Garfield. 

This book was about relaxation and visualization techniques of the top athletes in the world. It was like nothing I’d ever read. Now, this was back in 1990. They may have improved visualization and relaxation techniques since then but I’m telling you, this book punted me into a different stratosphere on this stuff. I’ll put a link to it on biblio.com in the show notes for this episode. Go check it out. 

https://www.biblio.com/book/peak-performance-mental-training-techniques-worlds/d/1362768092?aid=frg&currency_id=1&gclid=Cj0KCQiAlsv_BRDtARIsAHMGVSZ40_eKAIMbAHTRPRIUrdGXJN5c6n4SG74XgCEYiPpihaJGbuny2QgaAmgHEALw_wcB

Anyway, while I was throwing in the low 160s in the discus and low 50-foot range in the shot put, when I got this book it was toward the middle of the season so it was a bit rushed. But I dove in immediately. 

Within two weeks I was at 168’ and then at the end of the season, I won state in Texas (not an easy feat with a state of 25 million people)  with a personal meet best of 176’ 4 1/2 inches. I beat my best throw of my junior year by 26’. Not only that but I went to state in the shot put. Most definitely my weak event and threw my personal best there. It was my best throw by about a foot which is a huge jump in that event ending up at 55’. Just a couple of inches from our school record. Not an accomplishment that would have ever happened without this book. 

i apologize. I went out on a tangent a bit there but I’m talking about this book and this visualization topic because it’s real and I know it can make a difference in your life and your practice. 

Listeners of this podcast know I’m not a hippy-dippy kind of dude. This isn’t a hippy-dippy thing. It’s real and I’ve experienced it. This book is meant for business as well. I encourage you to check it out yourself. 

That 30 For 30 is my favorite. It’s very inspiring and he has some great quotes in the show. You can Google his quotes as well to save some time. But, in one part, he was quoting Ralph Waldo Emerson and the quote was, “Nothing great was ever achieved without enthusiasm.”

For many of us, 2020 and COVID stole our enthusiasm. If you take Emerson at his word here, then that would mean that 2020 and COVID also stole our greatness. 

I want to encourage the listeners of the Chiropractic Forward Podcast to get your enthusiasm back. Get your greatness back. Do it right now. Make it a priority. Make it a foundation of your practice this month and let’s see what happens. 

Pass it down to your staff. Keep them pumped up. Even when or if numbers are down. My numbers are down. I’ve made no secret about that. But around here, we’re going to make enthusiasm a key ingredient of our values. Along with honesty, integrity, ethics, love, fun, and being evidence-based and patient-centered. When we add enthusiasm into that mix, I think we have a winning concoction. 

This discussion portion was meant to only deal with enthusiasm but I got to talking about Jimmy V and his visualization efforts and like an ADD guy, I saw a squirrel and just went that direction. Thank you for indulging me. I hope you found something helpful in it all. 

 em today. I first want to say that I am not against surgery for the right person and the right issue. If it’s needed and the last resort, well why the hell not? But a stat I came across a year or so ago said that out of the 56 million back pain sufferers in our country, only about 5% of them actually, truly, clinically need surgery. 

Then, as you’ll see, when you have something as invasive and impactful on life as lumbar fusion being performed so often with no improved overall outcomes on the back end of it all….well, don’t you have to be responsible and step back and take another look at that and ask yourself, what are we as surgeons doing this for, and should we continue?

Item #1

This first one today is called “Is Lumbar Fusion Necessary for Chronic Low Back Pain Associated with Degenerative Disk Disease? A Meta-Analysis” by Xu et. al. (Xu W 2020) and published in World Neurosurgery on November 27, 2020. 

Hot potato, hot potato, get ‘em while they’re good and hot!

Why They Did It

The authors wanted to evaluate the efficacy and safety of lumbar fusion versus nonoperative care for the treatment of chronic low back pain associated with degenerative disk disease.

Remember this is a meta-analysis. It’s right up there at the top of the research pyramid with systematic reviews. Meaning….it’s good stuff.

How They Did It

• They did a comprehensive duplicate electronic database search that included PubMed, Embase, Cochrane Library, and China National Knowledge Infrastructure. 
• They took studies published up to June 30, 2020
• The main outcomes including clinical results, complications, and all-cause additional surgeries were presented in the form of short and long-term follow-up results. 
• Six prospective studies involving 159 patients for short-term follow-up and 675 for long-term follow-up were included.

What They Found

• The 2 interventions exhibited little difference in regard to short- and long-term Oswestry Disability Index and visual analog scale scores for back and leg pain, 
• Lumbar fusion might bring about lower additional surgery rate 
• Lumbar fusion might bring about a higher complication rate in the long term.

Wrap It Up

“The present meta-analysis determined that fusion surgery was no better than nonoperative treatment in terms of the pain and disability outcomes at either short- or long-term follow-up. It is necessary for clinicians to weigh the risk of complications associated with fusion surgery against additional surgeries after nonoperative treatment. Considering lax patient inclusion criteria in the existing randomized clinical trials, the result needs to be further confirmed by high-quality research with stricter selection criteria in the future.”

So, since we know systematic reviews and meta-analyses are like computers, then we know that they are only as good as the data you put into it. What you put into it determines what you get out of it. If they haven’t done a lot of quality research on low back fusions, well then they won’t have a lot of good quality information to assemble a meta-analysis. Right? 

When we look at 6 studies with 159 patients for the short-term part and we have 675 patients for the long-term…..I’m not a researcher but, to me, that sure doesn’t seem like a huge sample size. Certainly not when you consider the number of lumbar fusions happening around the world every single day. For such an expensive and invasive surgery, you’d sure think there’d be more to go on out there for a project like this. Is it just me?

CHIROUP ADVERTISEMENT

Item #1 was a new paper. Now I want to re-visit a couple of papers we have covered on the podcast before. One in episode 144 and one all the way back in Episode 54. 

Item #2

Item #2 is titled “Lumbar Spine Fusion: What Is The Evidence?” by Harris et. al(Harris I 2018). and published in the Journal of Internal Medicine in 2018. 

Basically, in this paper, they say that lumbar spinal fusion is common and associated with the 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. 

Doesn’t that just give you a warm fuzzy feeling inside when a surgery like lumbar fusion doesn’t have a lot backing it?

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. 

Item #3

This one we covered in episode 144 is called, “Surgery for chronic musculoskeletal pain: the question of evidence” authored by Harris et. al(Harris IA 2020). and published in Pain Journal in September of 2020.

Why They Did It 

They say that globally, the most common reasons surgery is performed relate to the musculoskeletal system, and outside of injury, the most common reasons pertain to arthritis and back or neck pain. AKA – chronic pain. Chronic pain has become a special interest of mine after going through the orthopedic diplomat last year. It’s fascinating. 

They say, “Although the surgical treatment of chronic pain generally relies on attributing pain to objective, often visible changes on imaging studies, the causes of chronic pain are more complex and are strongly influenced by psychosocial factors.” 

Things like Yellow Flags. Go look up yellow flags and Annie O’Connor’s book called World Of Pain please and thank you.  Annie will be speaking at the Texas Chiropractic Association’s Winter Conference on March 5-6. I encourage you to be watching out on www.chirotexas.org for more info because you’ll be able to take this seminar from anywhere in the world. And I recommend you do because my hero, Dr. Anthony Nicholson from Australia will be one of the presenters. Dr. Carlo Amendolia, I will be a speaker at this thing, Dr. Brandon Steele, and Dr. Jay Greenstein as well. This is quite the conference getting put together, folks. So make your plans. 

They say that surgeries like debridement of degenerative joints and things of that nature ignore the complexity of chronic pain. They look at surgery as purely mechanistic in nature with little to no involvement otherwise and the procedures often rely on observational evidence only, rather than rigorous, comparative trials.  

In addition, they say that when the trials have actually been performed for these surgeries have been mostly subjective and measurements are usually not blinded to reduce the bias of the outcomes.  

Who really wants to go under the knife for anything other than having a mole cut off when the procedures have not been thoroughly investigated, researched, and tested? 

Uh hell no. No thank you. 

This paper was written to demonstrate that observational evidence is not adequate when you consider the costs and risks of surgical intervention. They advocate that surgical procedures should undergo randomized controlled trials with blinding and showing statistical and clinically important symptomatic improvement when compared to no surgery at all.  

Well no duh. Who on Earth would put something into widespread use….surgically that is…..without doing their due diligence through research? Well…..evidently everyone in the medical profession from this.  

Ultimately in this paper, the goal here was to quantify what kind of support exists in the literature for some common procedures.  

How They Did It

• The first thing to do was to identify the common procedures performed for chronic pain
• Secondly, they had to identify the number of published RCTs comparing each procedure to a control group treated without that procedure
• They did a search of the Cochrane Central Register of Controlled Trials
• Each paper was reviewed by two independent authors

What They Found

• A very low proportion of the RCTs on the selected procedures compared the procedure to not performing the procedure. 64 from the more than 6,735 studies. Less than 1% if you’re keeping track. Is that not stunning? And infuriating?
• Of those 64, only 9 were favorable to surgery. 
• When considering individual surgical procedures, the majority of comparative trials did not favor surgery 
• None of the studies using patient blinding for any procedure found it to be significantly better than not having the surgery at all. 

Wrap It Up We conclude that many common surgical procedures performed for musculoskeletal conditions causing chronic pain have not been subjected to randomized trials comparing them to not performing the procedure. 

Based on the observation that when such studies have been performed, only 14% (on average) showed a statistically significant and clinically important benefit to surgery; there is a need to produce such high-quality evidence to determine the effectiveness of many common surgical procedures.  

Furthermore, the production of high-quality evidence should be a requirement before widespread implementation, funding or professional acceptance of such procedures, rather than the current practice of either performing trials after procedures have become commonplace, or not performing comparative trials at all.” 

Wouldn’t you like to know that your mom’s spinal surgery procedure was fully vetted? It was researched against not doing it at all? They haven’t done that? 

Make memes and/or infographics from the sound bites I’ve given you here. You can use all of this stuff if you have a little imagination. 

Alright, that’s it. Y’all be safe. Keep changing our profession from your little corner of the world. Keep taking care of yourselves and everyone around you. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it.

Let’s get to the message. Same as it is every week. 

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The Message

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 rather than chemical treatments like pills and shots.

When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few.

It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient.

And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health!

Key Point:

At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints….

That’s Chiropractic!

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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 – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger

Bibliography

• Harris I, T. A., Stanford R, (2018). “Lumbar spine fusion: what is the evidence?” Internal Med J.
• Harris IA, S. V., Mittal R, Adie S, (2020). “Surgery for chronic musculoskeletal pain: the questions of evidence.” Pain 161(9): S95-S103.
• Xu W, R. B., Luo W, Li Z, Gu R, (2020). “Is Lumbar Fusion Necessary for Chronic Low Back Pain Associated with Degenerative Disk Disease? A Meta-Analysis.” World Neurosurg 146: 298-306.