Back pain surgery doesn’t exist, but do not refuse to fuse

Never before has back pain been so widely discussed, and its management so hotly contested. Social media platforms like Twitter, Facebook, Instagram, and commercial television programs lately are all buzzing about the ‘boring’ topic of Chronic Low Back Pain. Even the Pain Medicine Faculty of the Australian and New Zealand College of Anaesthetists (ANZCA) “advised doctors not to refer patients with mechanical or axial low back pain for spinal surgery”, as quoted in the Australian newspaper (14 Febuary 2018).

I read with interest the article on page 48 of March 2018 Surgical News, about stem cell research and how the 9.4 Tesla MRI can demonstrate blood vessels and nerve fibres growing in degenerate and compromised lumbar discs… and how this may be the cause of chronic low back pain. The article made no link between the obvious disconnect between imaging features of degeneration and the manifestation of back pain symptoms.

Also, of interest was The Lancet Back Pain series in March 2018, publishing a more than doubling of DALYs (Disability-Adjusted Life Years) from Low Back Pain between 1990 and 2015, which followed on from the World Health Organisation’s Musculoskeletal Fact Sheet (February 2018), announcing that Low Back Pain is the single leading cause of disability globally and is not a condition restricted to old age.

Therefore, I wish to express a basic concept widely understood in every other field of medicine but poorly applied in the specialty of musculoskeletal pain and particularly spine region pain. The ubiquitous use of the term “Low Back Pain” and “Low Back Pain Surgery” is itself a problem and reflects a lack of understanding into the cause of back pain symptoms. News Flash: “Low Back Pain” is not a disease, it is a symptom.

Any article that I read that describes the management of “Low Back Pain” and uses this term interchangeably as a disease is indicative of significant misinterpretation of the true problem and reflective of the global prevalence of back pain symptoms.

To any spinal surgeon who might think they can cure low back pain symptoms with spinal stabilisation surgery (fusion or disc replacement), think again. Don’t stop reading here in disgust because, contrary to mainstream media’s objection to spine surgery for low back pain symptoms I know that many surgeries for back pain symptoms are deemed successful by patients and surgeons alike – otherwise we would not offer them to our patients.

But what if our “successful” surgery is merely an association and not causation of the favourable outcome. Have you wondered why just as many “back pain” surgeries also fail?

If we conceptualise ‘disease’ versus ‘symptoms’ we can apply a unifying theory that unravels the complexity of low back pain management, to assure success from our associated spinal fusion surgery “all the time” ― after all how can low back pain symptoms be effectively cured without first assigning causation to this condition. Imagine trying to treat headache, fever and rigor symptoms in Papua New Guinea without understanding the most common and prevalent cause being Malaria. Like wise we need a “malaria” diagnosis for “back pain”. Surely a disease of ultimate prevalence and disability as the World Health Organisation states, is not a result of multiple etiologies. Occam’s Principle teaches us this along side common sense and logic.

What if the disease causing back pain symptoms is Movement Dysfunction? It could drive spondylosis into spondylitis and pain free disc degeneration into painful discitis, and normal facet arthropathy into stenosing facet arthritis. Movement Dysfunction could drive central sensitisation, and maladaptive behaviours, further entrenching pain cycling, disability and compromising mental health.

Surgery is frequently considered to treat the structural break down in spinal integrity which theoretically is a consequence of Movement Dysfunction. Our researchers postulate that in the future, stem cells may be implanted to reduce the anguish associated with surgery, but even this new, exciting likely expensive technology will fail us and our back pain suffering patients if we continue to address only the symptomatic disc degeneration and ignore the causation – knowing full well that many discs are structural “train wrecks” with zero pain symptoms.

Physical therapists are the first to admit the failings of their expertise to effectively address back pain symptoms. Mostly for the same, but still unrecognised reasons. Improving someone’s core strength, administering gym based exercise or months of Pilates does nothing to improve a patient’s movement quality, even if they are following the prescription to move more. Patients just become stronger at moving poorly and continue on with their back pain symptoms, leaving physiotherapists and GP’s mystified with nothing else to offer but to recommend seeing the spinal surgeon.

As spinal orthopaedic and neurosurgeons, we need to protect and defend the imperative skilful art and huge association benefits of spinal stabilisation surgery which is currently under unjustified threat by numerous misguided commentaries.

First, we all must agree that our surgery does not cure back pain symptoms. No more so than oxygen curing pneumonia. It does not cure “back pain” because “back pain” is not a disease. When surgery “works” for back pain symptoms the thing that cured our patients was the fact that we gave them the opportunity to effectively address the root cause disease of Movement Dysfunction and once again move proficiently.

Patients with low back pain, whether they have surgery or not, require specific and distinctive movement therapy to reverse the disease that unifies the simple, but perceived complex puzzling symptoms of low back pain.

Movement Proficiency Enabling Surgery should be on our business cards and office windows if we are surgeons working with patients suffering back pain symptoms because although “back pain” surgery does not exist, Movement Proficiency Enabling Surgery is very real and works tremendously in conjunction with distinctive Functional Movement Therapy.

Don’t leave it to chance that your patients incorrectly get labelled after your perfect stabilisation surgery with Failed “Back Pain” Surgery Syndrome because if we agree that “Back Pain” surgery doesn’t exist – that label can’t possibly be correct. It is actually Failed Rehabilitation Syndrome, ignorance of addressing root causation and the omission of unique Functional Movement Therapy that failed. Not the non existent “Back Pain” Surgery.

References:

1. Johnson D, Hanna J. Why we fail, the long-term outcome of lumbar fusion in the Swedish Lumbar Spine Study. Spine Journal: Official Journal of the North American Spine Society 2017;17(5):754.

2. O’Sullivan P. It’s time for change with the management of non-specific chronic low back pain. Br J Sports Med 2012 Mar;46(4):224-227.

3. World Health Organisation Musculoskeletal conditions fact sheet [Internet]. 2018 From: http://www.who.int/mediacentre/factsheets/ musculoskeletal/en/ Accessed 13 April 2018.

4. Lancet series on low back pain [Internet] 2018 From: http://www. thelancet.com/series/low-back-pain?utm_campaign=tlwbackpain18 Accessed 13 April 2018.

5. van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo R, Koes BW, et al. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. European Spine Journal 2011 Jan;20(1):19-39.

6. Cochrane Reviews Back Pain Management http://www.cochranelibrary.com/topic/Orthopaedics%20%26%20 trauma/Back%20disorders/Non-specific%20low%20back%20pain/

7. Johnson D. Fifty percent improvement in Oswestry Disability Index scores in patients with chronic low back pain after eight weeks of NeuroHAB Functional Movement Therapy. Spine Journal: Official Journal of the North American Spine Society [submitted 2018]