Study Hopes to Draw Spine Surgery Guidelines

As our newsletter, “Better Care for Your Aching Back,” observed in September, back pain is the fifth most common complaint patients bring to their primary care doctors, and inappropriate treatment for back trouble is widespread.

This reality is the motivator behind an effort to collect comparative results of upper spine surgical outcomes in order to enable doctors and patients to better assess which surgical approach is the best, safest and most cost-effective for each situation.

As explained last month in the Wall Street Journal, (WSJ) the study examines treatment for spinal cord compression, which is the most common spinal cord problem in Americans older than 55. Three different surgical techniques currently are used for the condition, known as cervical spondolytic myelopathy (CSM).

As people age, they’re more likely to have neck stiffness, arm pain, numbness and weakness in the hands and legs, which are symptoms of normal wear and tear signifying degenerative changes in the upper spine. Strenuous activity, including sports, can make it worse.

The chronic condition can narrow the spinal canal, which puts pressure on the spinal cord. Compression coupled with repetitive motion damages the cord to the point where it’s difficult to move one’s extremities, and can even lead to paralysis.

Bones, disks and ligaments can all contribute to compression of the spine. Bone “spurs,” abnormal growths in the spine can be a factor.

Surgery is recommended, necessary, even, with severe compression, although physical therapy and other less invasive measures are therapeutic in less-severe cases.

One procedure, known as front or ventral decompression and fusion, involves cutting through the front of the neck, moving the voice box and esophagus to reach the spine, removing disks and bone spurs and fusing the vertebrae.

The two other techniques involving cutting through the back of the neck and either fusing the vertebrae or performing a laminoplasty, which enlarges the spinal canal to relieve pressure on the spinal cord and nerves.

No large, randomized studies have compared the merits of the three techniques.

“In spine care,” Dr. Zoher Ghogawala, a neurosurgeon, told the WJS, “we are faced with a lot of people suffering and desperate for treatment, but there is a lack of information about what the best option is based on their specific symptoms and diagnosis.” Ghogawala is co-director of the Comparative Research Effectiveness Center at Lahey Health’s Lahey Hospital and Medical Center, which is affiliated with Tufts University.

Given the confusion over best practice for these spinal procedures, patients generally get whichever one their surgeon has done the most, Ghogawala said. But that might not be the one that’s best for their circumstances.

Ghogawala, whose team devised the study, estimates that the number of CSM surgeries has nearly doubled in the last decade, to maybe as many as 200,000 a year. The cost for those procedures is estimated to be $4 billion a year in hospital charges alone.

According to the WSJ, studies indicate that 2 in 3 CSM patients improve with surgery, but complication rates might be as high as 17 in 100. Readers of this blog are aware of the reasons to be wary of spinal fusion surgery.

Ghogawala’s three-year study to compare the three surgical technique involves 10 large U.S. medical centers. One of its sponsors is the Patient Centered Outcomes Research Institute, which we’ve written about before as the congressionally mandated agency charged with helping to determine the most effective treatments using objective, science-based standards. The National Institutes of Health and a private foundation also are subsidizing the work.

One spinal compression patient profiled by the WSJ was a marathon runner and tennis player when he first began to feel numbness and clumsiness in his hands and pain across his shoulders and up his back. An MRI of his neck showed that vertebrae, disks and bone spurs were pressing heavily on his spinal cord.

He was advised by a neurologist to address the condition immediately. He sought several other opinions. “They were all very convincing about the best way – but every single one of them was dramatically different,” he said. “Here you are as a patient trying to figure out what’s best for you, but how do you sort this out?”

Ghogawal’s study is the best effort so far to be able to do that.

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