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The Orthopaedic Forum   |    
Debating the Value of Spine Surgery*
Edward N. Hanley, Jr., MD1; Harry N. Herkowitz, MD2; John S. Kirkpatrick, MD3; Jeffrey C. Wang, MD4; Morgan N. Chen, MD5; James D. Kang, MD5
1 Department of Orthopaedic Surgery, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232. E-mail address: edward.hanley@carolinashealthcare.org
2 Department of Orthopaedic Surgery, William Beaumont Hospital, 3535 West 13 Mile Road, Suite 744, Royal Oak, MI 48073. E-mail address: hherkowitz@beaumont.edu
3 Department of Orthopaedic Surgery, University of Florida College of Medicine-Jacksonville, 655 West Eighth Street, Jacksonville, FL 32209. E-mail address: john.kirkpatrick@jax.ufl.edu
4 Department of Orthopaedic Surgery, University of California-Los Angeles, 1250 16th Street, 7th Floor Tower, Santa Monica, CA 90404. E-mail address: jwang@mednet.ucla.edu
5 Department of Orthopaedic Surgery, University of Pittsburgh, Kaufmann Medical Building, 3471 Fifth Avenue, Suite 1010, Pittsburgh, PA 15213. E-mail address for M.N. Chen: morganchenmd@gmail.com. E-mail address for J.D. Kang: kangjd@upmc.edu
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from commercial entities (Medtronic, Alphatec Spine, Stryker, SeaSpine, Osprey, Aesculap, and Biomet).

This report is based on a symposium presented at the Annual Meeting of the American Orthopaedic Association on June 10-13, 2009, in Bonita Springs, Florida.

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 May 01;92(5):1293-1304. doi: 10.2106/JBJS.I.01439
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Extract

Surgery for many lumbar spine conditions remains controversial with disparate opinions on its value and a perceived lack of objective scientific justification. This discussion addresses the value of the information provided by the recent Spine Patient Outcomes Research Trial (SPORT) and the utility of surgery for the enigma of low back pain.
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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Jeffrey C. Wang, MD
    Posted on May 29, 2010
    Dr. Wang responds to Dr. Levin
    UCLA School of Medicine, UCLA Spine Center, Santa Monica, California

    I would like to address the letter written concerning statements made in the manuscript, “Debating the Value of Spine Surgery”. The author of the letter has stated that the references may have been misquoted in regards to the treatment of patients with lumbar disc herniations with an element of low back pain inclusive in the symptoms.

    This particular section of the manuscript was authored by me and begins with the clearly stated premise that when reviewing the numerous studies in the literature, there may be confusion when “grouping patients with the diagnosis or with symptoms of low back pain, mixes patients with multiple potential pain generators”. And it states that “in reviewing the literature, many studies examining the results of spinal surgery have a heterogenous group of patients with different primary diagnoses and may also have other associated symptoms in addition to low back pain.” The section then goes on to document studies where patients have defined diagnoses other than just low back pain and degenerative disc disease, and discusses the element of low back pain with the diagnosis of spondylolisthesis, lumbar disc herniations, and kyphosis/scoliosis, where the results of the treatment are better than patients with undefined low back pain. In this context, the references are meant to show that symptoms of low back pain that are co-existent with the defined pathologies of spondylolisthesis, lumbar disc herniations, and deformities, have a more favorable prognosis. The reference in question was intended in this context to illustrate the symptoms of low back pain associated with the herniated disc diagnosis. The last part of this section of the manuscript deals with unspecified low back pain associated with only degenerative disc disease and these references are not used to support disc surgery for the treatment of this entity.

    I thank the author of the letter for clarifying the point that this reference deals only with patients with lumbar disc herniations and is not meant to justify lumbar disc excision surgery for primary low back symptoms. This is a critical point and certainly clarity must be maintained not only by the authors writing on this controversial topic, but also by the reader when reading the actual article. I appreciate the comments made and hope that this information may help other readers who may misinterpret the intent of the references.

    Paul E. Levin, MD
    Posted on May 17, 2010
    Disc Surgery in Non-Radicular Lower Back Pain
    Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York

    To The Editor:

    “Debating the Value of Spine Surgery” (1), is a timely overview of the indications and benefits of spine surgery. In the section of the paper entitled “Spine Surgery for Low Back Pain: Does It Work?: Back Pain Surgery: Pro” the authors report that “there is good evidence that patients with herniated discs have a favorable outcome after operative interventions compared with that after nonoperative treatments specifically for low back pain”. The authors cite two references (references 3 and 25) to support this statement (2,3). I am concerned that the literature was misquoted to support the benefits of surgery for the management of low back pain in individuals with non-radicular (non-dermatomal) pain who also have imaging findings of a disc herniation.

    These references are both published findings from the SPORT (Spine Patients Outcomes Research Trial) trial. The SPORT trial demonstrated a greater improvement in low back pain when compared with non-operative treatment with surgical intervention of a lumbar disc herniation in individuals who met the SPORT inclusion criteria. These criteria included “symptoms and signs of lumbar radiculopathy…who had a disc herniation at a corresponding level and side on imaging…” (3). The SPORT trial does not demonstrate that lumbar disc surgery is effective in the management of non-radicular (non-dermatomal) low back pain with an imaging finding of disc herniation. In fact, in the absence of radicular complaints and corresponding physical findings it is not possible to ascertain if the disc herniation is “at a corresponding level and side on imaging…” (3).

    Back pain is a source of frustration for both the patient and the healthcare provider. The ability to identify the pain generator and subsequently successfully treat the etiology of the problem will be a welcome addition in the care of these patients. Presently, I do not believe that the medical literature supports the benefits of disc surgery in an individual without radiculopathy. This is an extremely important distinction to be made in counseling our patients in the benefits of lumbar disc surgery in the management of non-radicular (non-dermatomal) lower back pain.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

    References

    1. Hanley EN Jr, Herkowitz HN, Kirkpatrick JS, Wang JC, Chen MN, Kang JD. Debating the value of spine surgery. J Bone Joint Surg Am. 2010;92:1293-304.

    2. Weinstein JN, Lurie JD, Tosteson TD, Skinner JS, Hanscom B, Tosteson AN, Herkowitz H, Fischgrund J, Cammisa FP, Albert T, Deyo RA. Surgical vs nonoperative treatment for lumbar disc herniation: the Spine Patients Outcomes Research Trial (SPORT) observational cohort. JAMA. 2006;296:2451-9.

    3. Pearson AM, Blood EA, Frymoyer JW, Herkowitz H, Abdu WA, Woodward R, Longley M, Emery SE, Lurie JD, Tosteson TD, Weinstein JN. SPORT lumbar intervertebral disk herniation and back pain: does treatment, location, or morphology matter? Spine (Phila Pa 1976). 2008;33:428-35.

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