A review of the evidence

Spinal Fusion Surgery

Epidural Cortisone Injection

Yoga, Exercise and Mindfulness

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Spinal Fusion:

There is very little evidence that spine fusion surgery for back pain is effective. It is very expensive, often leads to complications, often requires further surgery, and is associated with increased mortality (see references below).


Four trials have examined complication rates, reoperation rates and mortality rates. Two randomised clinical trials have compared surgery to non-operative treatment for back pain.

These have been summarised below:

1.     1. Conclusion:

Major spinal surgery in the adult is associated with a high incidence of intraoperative and postoperative complications. We identified a very high rate of previously unrecognized postoperative complications, which adversely affect hospital length of stay. Without strict adherence to a prospective data collection system, the true complexity of this surgery may be greatly underestimated.

http://www.thespinejournalonline.com/article/S1529-9430(11)01453-7/abstract

2.     2. Conclusion:

This Lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a workers compensation setting is associated with significant increase in disabil­ity, opiate use, prolonged work loss, and poor return to work status.

http://journals.lww.com/spinejournal/Abstract/2011/02150/Long_term_Outcomes_of_Lumbar_Fusion_Among_Workers_.9.aspx

3.     3. Conclusion:

Simple fusion and complex fusion were associated with increased risk of major complications, 30-day mortality, and resource use.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2885954/

4.     4. Conclusion:

Patients should be informed that the likelihood of reoperation following a lumbar spine operation is substantial. After fusion surgery, 62.5% of reoperations were associated with a diagnosis suggesting device complication or pseudarthrosis.

http://journals.lww.com/spinejournal/Abstract/2007/02010/Reoperation_Rates_Following_Lumbar_Spine_Surgery.18.aspx

5.     5. Conclusion:

Lumbar fusion surgery performs no better than combined exercise and cognitive therapy in patients with chronic low back pain and disc degeneration. Improvements in back pain, use of analgesics, emotional distress, life satisfaction, and return to work were not different, however, the complication rate in the surgical group was 18%.

http://www.ncbi.nlm.nih.gov/pubmed/12973134

 

6.     6. Conclusion:

No clear evidence emerged that primary spinal fusion surgery was any more beneficial than intensive rehabilitation. The potential risk and additional cost of surgery also need to be considered.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC558090/?tool=pubmed

 

The bottom line:

Fusion surgery performs no better than intensive exercise and rehabilitation for patients with chronic lower back pain. It doesn’t matter what surgical approach you use, whether or not you put any implants in, and whether or not the spine fuses.

The evidence illustrates that fusion surgery is a high risk procedure.

 

Steroid injections for low back pain

Many studies have demonstrated the ineffectiveness of epidural cortisone injections for lower back pain.

The most significant information comes from the two studies below:

1.      1. The database Cochrane reviewed all available evidence and concluded:

 “There is insufficient evidence to support the use of injection therapy in subacute and chronic low-back pain”.

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001824.pub3/abstract

2.     2. Similarly, the most rigorous study available on injections for lower back pain with lumbar radiculopathy state:

Caudal epidural steroid injections perform no better than saline epidurals or sham injections for the treatment of chronic lumbar radiculopathy”

http://www.ncbi.nlm.nih.gov/pubmed/21914755

The bottom line:

Epidural cortisone injections for subacute and chronic lower back pain, as well as radiculopathy, perform no better than a placebo injection.

Exercise, movement and mindfulness

Below is a review of the evidence for yoga, mindfulness and therapeutic exercise in the treatment of chronic lower back pain.

 

1.      Conclusion:

Yoga improves functional disability, pain intensity, and depression in adults with chronic lower back pain. There was also a clinically important trend for the yoga group to reduce their pain medication usage compared to the control group.

http://www.ncbi.nlm.nih.gov/pubmed/19701112

 

2.     Conclusion:

Both yoga and stretching were more effective than a self-care book for improving function and reducing symptoms due to chronic low-back pain.

http://www.ncbi.nlm.nih.gov/pubmed/?term=A+randomized+trial+comparing+yoga%2C+stretching%2C+and+a+self-care+book+for+chronic+low+back+pain

3.     Conclusion:

Offering a 12-week yoga program to adults with chronic or recurrent low back pain led to greater improvements in back function than did usual medical care.

http://annals.org/article.aspx?articleid=1033130

4.     Conclusion:

This 2012 literature review concludes that among the yoga studies published to date, daily function has consistently improved across almost all studies and back pain has followed a similar trajectory.

http://www.omicsonline.org/yoga-for-chronic-low-back-pain-new-evidence-in-2011-2157-7595.1000e108.php?aid=3798

5.     Conclusion:

Results showed that mindfulness is associated with significantly reduced pain intensity, pain catastrophizing, pain-related fear, and functional disability.

http://www.ncbi.nlm.nih.gov/pubmed/19944534

 

The bottom line:

Mindfulness, yoga and therapeutic exercise are inexpensive, will not lead to surgical complications or additional surgery, are not associated with increased mortality, and have high quality evidence supporting their effectiveness.

Additionally, the cumulative and synergetic effect of patients participating in an active intervention is empowering, encourages self-management, improves QOL, and reduces the cost burden of expensive health care.