Stewart N has been a paramedic for over 15 years. It's
a tough job but he loves the high he gets from saving
a life — he wouldn't give it up for the world. Sadly,
he may have to do just that due to a back injury, which
he got while retiling the bathroom floor one Friday night.
The injury has made certain essential aspects of his job
like lifting a patient onto a stretcher literally unbearable.
Stewart's predicament is not uncommon — in Canada,
2% of the work force is disabled because of low back pain.
Stewart has taken leave to give his poor back a break
but the pain only seems to be getting worse. At this point,
he's willing to try anything to get his life back, including
spinal fusion surgery. But there may be a better option.
"Intensive rehabilitation is a
good way of managing chronic back pain, even if your
patient believes that surgery is the answer to their
problems," comments Dr Jeremy Fairbank, a UK orthopedic
surgeon at Oxford and co-author of two studies on rehab
therapy published in the May 23 issue of the British
Medical Journal (BMJ). Past evidence for the benefits
of back surgery has been fairly weak yet the procedure
has been steadily growing in popularity. This prompted
the UK National Health Service to voice the need for
more solid data. The research in the BMJ is a direct
answer to this call. And the results clearly support
rehab therapy as a first line approach.
REHAB'S
LESS RISKY
The first BMJ study was a randomized clinical
trial that followed 349 patients with chronic back pain
from 15 UK hospitals. The second study investigated
how cost effective both treatment routes were for these
adult patients. Spinal fusion surgery was performed
on 176 patients, while 173 others participated in an
intensive rehab program involving daily exercises, hydrotherapy
and behavioural therapy. After two years of followup,
surgical treatment was shown to have a slight advantage
over rehabilitation but the difference was small given
the potential risk and additional costs of surgery.
"Sadly, the results of both treatments are not brilliant,
but rehab is safer," sums up Dr Fairbank.
Twenty-eight percent of rehab patients
went on to have surgery. "This is of course better than
100% which was their plan at admission to the trial,"
he explains. "Spinal fusion seems to help some patients
with chronic low back pain. However, we must find ways
to identify these patients in advance using valid and
reliable classification systems. Until then spinal fusion
may, after all these years, still be regarded as an
experimental treatment," comments Dr Bart W Koes, professor
of general practice at the University of Rotterdam,
in an accompanying editorial.
BMJ
May 23, 2005;330:1233-39
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