Interdisciplinary chronic pain management vs. back surgery: Which is right for you?

Chronic pain management

Patients who suffer from chronic back pain understandably want to find a solution – and many hope for a ‘silver bullet’ that relieves most if not all of their pain. For many patients, the hope is that surgery is the best answer to relieve their pain quickly. While back surgery has proven successful in addressing a wide range of painful back conditions, several recent studies demonstrate that there exists a viable, effective alternative to back surgery - the interdisciplinary chronic pain management program, which can offer a better alternative for certain types of patients. When physicians make an effort to inform patients about the potential risks of spine surgery and benefits of chronic pain management programs, many patients come to accept a rehabilitation model over surgery.

The foundation of the interdisciplinary chronic pain management approach is to help patients view chronic pain outside the traditional medical model, i.e., the physician is responsible for finding a ‘fix’. Instead, interdisciplinary chronic pain management teaches patients to manage and cope with pain and its impacts through a combination of the following:

• Physical conditioning

• Education about risks and alternatives

• Psychological treatment, including relaxation training

• Vocational counseling to facilitate return to work

Several recent studies have shown that the chronic pain management approach can be as effective in treating spine pain as spine surgery. This article summarizes the latest research in chronic pain management so that patients can have an informed discussion with their physician if they are contemplating surgery.

Chronic pain management outcomes comparable to back surgery

The results of a 2003 study of 64 Swedish chronic pain patients with evidence of severe disc degeneration compared surgical to chronic pain management outcomes after a year of intervention.¹ These patients were randomly assigned to undergo either a lumbar fusion with posterior transpedicular screws and post-operative physical therapy; or a modified chronic pain management program involving cognitive-behavioral intervention with three daily physical exercise sessions for three weeks. The results showed that chronic pain management delivered as well or better than back surgery against the following patient satisfaction criteria:

• At one-year follow up, both groups had significant improvements in function, as measured by the Oswestry Disability Index (ODI), although the back surgery group had to contend with an early complication rate of 18%.

• There were no significant differences between the two groups in terms of pain, use of painkillers, emotional distress or ability to return to work.

• Fear-avoidance beliefs (those catastrophic thoughts that can actually exacerbate pain or maintain pain) were reduced significantly more in the chronic pain management group over the back surgery group. (Another study was conducted by an extended research team in 2006 with similar results.²)

Additional support for the use of interdisciplinary chronic pain management was confirmed in a larger trial that included 349 patients who were uncertain if they should undergo back surgery.³ These patients were randomly assigned to have either spine stabilization surgery (spinal fusion) or “intensive rehabilitation” (a chronic pain management program). Study participants were followed for 24 months, with the following findings:

• The patients treated with back surgery showed a slightly greater improvement in function as measured by the Oswestry Disability Index, but no other differences between the two groups were significant.

• Intra-operative complications occurred in 19 patients who underwent back surgery.

• A follow-up study of these same patients found that the cost of chronic pain management was far less than that for back surgery (by about 45%)⁴ , making chronic pain management more cost-effective than spinal fusion, a finding that was confirmed in later studies.⁵

• The percentage of patients returning to work two years after the start of the treatment was equivalent.

Chronic pain management may be preferable for certain types of patients

Based on the above study results, chronic pain management is a viable alternative to back surgery for chronic pain patients, especially for those patients who have one or a combination of the following characteristics:

• Have a high level of fear, anxiety or other identified psychosocial risk. Back surgery does not address these issues, whereas one of the goals of an interdisciplinary chronic pain management program is to help build a patient’s coping skills.

• Are uncertain about whether back surgery is the best strategy

• Expect poor outcomes from back surgery, either because of fear or a previously problematic procedure or failed back surgery. For patients with a history of failed back surgery, the success rate for repeat back surgery is quite low.⁶

• Are addicted to or dependent upon pain killers. Since substance abuse or overuse is associated with worse spine surgery outcomes⁷, patients with such problems would likely be better served by participation in a chronic pain management program than by having back surgery.

• Have unrealistically high expectations of the degree of pain relief achievable through back surgery. Some researchers⁸ have found that such expectations by patients who underwent surgery for spinal stenosis were associated with more pain and less satisfaction six months after surgery than those who had lower expectations of pain relief. (Conversely, higher expectations of improved functioning as a result of the surgery actually were associated with greater improvement in functioning and greater satisfaction.)

In cases where a potential surgical patient has any or a combination of the above noted situations or psychological characteristics, a chronic pain management program ought to be at least considered as an alternative to back surgery to avoid further patient disappointment, additional cost, and the possibility of continued pain even after surgery.

By: Andrew R. Block, PhD
May 7, 2007

References:

1. Brox, Sorenson, Friis, Nygaard, Indahl, Keer, Ingebrigtsen et al. (2003) studied 64 Swedish patients with evidence of severe disc degeneration lasting more than one year.

2. See, Brox, Reikeras, Nygaard, Sorenson, Indahl, Holm, Keller, Ingebrigtsen, Gurndes, Lange and Fris, 2006

3. Obtained by Fairbank, Frost, Wilson-MacDonald, Yu, Barker and Collins (2005)

4. (Rivero-Atlas, Campbell, Gray, Fairbank, Frost and Wilson-MacDonald, 2005)

5. Turk and Burwinkle (2005) in a separate review of the literature, confirm and extend such findings. They found that the chronic pain management approach is approximately 26 times more cost-effective in returning patients to work than is spine surgery.

6. As noted by a number of authors including North, Campbell, James, Conover-Walker, et al, 1999). (see also, Franklin et al, 1994).

7. Spengler, Freeman, Westbrook and Miller, 1980

8. Iverson, Daltroy, Fossel and Katz (1999)