CLINICAL UPDATE
26-Oct-2010
By Richard Williiams, Orthopaedic Surgeon
From the perspective of the orthopaedic spinal surgeon, recent history in the management of low back pain has, if anything, led us to be more inclined toward non-surgical treatment alternatives.
What has become obvious over time is that careful patient selection is the key to satisfactory outcome regardless of treatment type. A patient’s ownership of the decision- making process is possibly the key factor in successful treatment of a low back disorder. For many people, becoming aware that they, themselves, must instigate back pain treatment is the defining moment on the road to a positive long term outcome. All too often patients become ensconced in the secure envelope of modern therapies and alternative treatments for lower back pain, being variably advised on causation and then ‘worked on’ at regular intervals, losing ownership of the condition and altering their expectations to adjust to the ‘security blanket’ of lower back pain where the cure need be provided by someone other than themselves, eg. their doctor, physiotherapist, chiropractor, etc. In reality, the answer to long term spinal health is mostly self-directed and frequently centred on aerobic conditioning and weight control. Large community-based studies show us that back pain is almost ubiquitous. From an evolutionary standpoint, one theory holds that as man stood erect a compensatory lumbar lordotic curve became required to balance the dorsal kyphosis of all quadrupeds. This lumbar postural change transferred weight to the posteriorly-situated facet joints leading to their ultimate degeneration. Increased abdominal girth lengthens the lever arm acting against the facet joints via this lordosis, predisposing for lumbar pain.
One deterrent to patient participation in long term aerobic exercise is fear of injury. The reason for this is often their translation of the model of injury of other body parts, eg. the knee, to their spinal condition. De-programming of this perception involves reinforcement that the musculature of the spine thrives on activity and rapidly de-conditions with inactivity. To overcome the negative psychological effect of spinal pain with sustained activity, it is often beneficial to exercise employing a technique with measurable input (such as walking on a treadmill), so that speed and duration to the point of discomfort can be seen to increase on a daily basis providing valuable positive feedback.
In taking a history of spinal pain, I always try to establish the patient’s aims of the consultation. Patients’ expectation of their treating specialist’s advice varies widely. Some are simply seeking an explanation of the nature their condition and its natural history with reassurance regarding their future, whilst others need the severity of their disability recognised and to be presented with more definitive options for treatment.
Treatment alternatives range from non- operative therapies, to radiological interventions and operative procedures. I advise interventional radiological procedures for one of two reasons. The first is to lend diagnostic weight to a suspicion of eg. facet joint pain or nerve root irritation. Temporary blockade can also give the patient an excellent impression of what can be realistically achieved with operation when more than one condition is contributing to the overall clinical picture. The second is to provide an alternative to operation, usually on a temporary basis. At this point, the distinction between central lower back pain and radicular leg pain (which frequently involves the buttock) becomes important. Although surgical treatments are, in the main, consistently more successful for leg pain than back pain, nerve root sleeve injection seems to provide substantial but short-lived relief for radicular pain. This is the opposite of what is frequently seen in lower back pain whereby interventional radiology can provide lasting relief in selected cases. The latter is particularly true of lumbar facet joint injection, particularly where an individual joint takes up radio-isotope on bone scan. Unfortunately, satisfactory response to facet joint blockade does not appear to correlate with success in subsequent spinal surgery.
Despite well-publicised debate about the choice of either lumbar disc replacement or lumbar fusion surgery in the treatment of intractable back pain, neither have gilt- edged results when studied across the large community of low back pain sufferers. A discernable difference between the two treatment options is yet to be established and the rate of success of either is rarely reported above 65%. Patient expectation is paramount in deciding on treatment for lower back disorders. Surgical treatment should always be viewed as the last alternative for lower back pain and a comprehensive appreciation of adverse prognostic indicators is required in the decision-making stage. Waddell’s well known signs in lower back pain assessment were intended to assist clinicians in detecting non-organic influences on pain perception for the sole purpose of identifying those patients unlikely to benefit from surgical treatment. Although their application has extended far beyond their intended purpose, these signs are still useful within the confines of their remit. Psycho-social conflict may manifest as somatic complaints, of which lower back pain is the most common.
Accordingly, in all patients considering operation for low back pain, I seek the advice of a specialist clinical psychologist in helping to identify those factors which are contributing to the overall clinical picture which are unlikely to respond to surgical treatment.
Some conditions, although designated ‘yellow flags’ of poor prognosis may be inextricably entwined with the somatic disorder. Depression is widely regarded as a poor prognostic co-morbidity, however may be profoundly adversely affected by lower back pain and vice versa. In cases such as this, a candid discussion with the patient regarding the relationship between the two conditions, pitfalls and expectations of any proposed surgery is essential, however the coexistence of depression and lower back pain is not necessarily a contra-indication to operation if a treatable lumbar lesion is demonstrated.
In summary, effective communication between doctor and patient is probably the most important factor in choosing the right pathway in the treatment of lower back pain. The clinician’s role is to educate the patient, allay anxiety by reassurance and to present a series of appropriate management options commensurate with the nature of the problem, its severity and the needs and expectations of the patient.