26 April 2016

Hugo Wilcken

People with chronic low back pain are expecting too much from spinal surgery, say 2 pain specialists.

That’s because work woes, depression or even financial opportunity may be driving the pain and preventing recovery, write Dr Leigh Atkinson from the Wesley Pain and Spine Centre, Brisbane, and Dr Andrew Zacest, from Royal Adelaide Hospital in a paper published online by the MJA.

Low back pain is best understood within a “biopsychosocial” framework, they explain, where even the expectation of a compo payout could prolong symptoms.

In fact, a NSW study of patients receiving workers’ compensation found outcomes after spinal surgery for low back pain were so poor that the operation couldn’t be recommended.

The authors say even if a physical injury is at the core of the pain, it is often enhanced and further prolonged by a range of psychological problems, including masked depression, childhood issues, substance abuse and poor pain behaviour.

Surgeons would be better off getting their patients to attend a multidisciplinary pain program to identify psychological issues that might complicate recovery, the authors say.

Instead, people see the spectacular success of hip and knee replacements and expect spinal surgery to be just as effective for their pain.

But while rates of spinal fusion surgery in Australia have almost tripled in 10 years, largely driven by private hospitals, the initial operation has at best only a 50% chance of success, with diminishing returns thereafter.

Surgical intervention for lumbar non-specific low back pain remains controversial, particularly since the pain is underdetermined and imaging is unhelpful, the authors say.

Imaging is essential for ruling out congenital or advanced disease, but it can also open up a Pandora’s box, as it will almost certainly identify degenerative changes in people aged from their thirties on.

However, there is very little correlation between these imaging findings and chronic low back pain, the authors note.

Last Reviewed: 26/04/2016



Surgical management of low back pain. Med J Aust 2016; online 26 April