A Major Summary of Findings About Spinal Surgery Recommendations

With more and more studies being published on the topic of spine surgery — when should surgery be done, what works, what doesn’t, when should X-rays be taken, and so on — a group of surgeons from six well-known surgery centers got together and reviewed the evidence. The result was this summary of six studies on spine surgery along with whatever recommendations were made by the authors of the studies.

The basic idea behind each study was provided first. Then a quick review of how the study was done as well as how the results were interpreted was reported. Finally, recommendations for clinical practice were offered. The evidence for each recommendation was rated from weak to strong to give surgeons an idea of how much to rely on the guidance from the study.

The six studies included: 1) imaging strategies for acute low-back pain, 2) surgery versus nonoperative care for lumbar degenerative spondylolisthesis, 3) treatment of spinal burst fractures with and without fusion, 4) vertebroplasty versus conservative care for osteoporotic spinal fractures, 5) bone graft substitute versus using patients’ own bone for lumbar spine fusion, and 6) effect of needle placement during cervical spine fusion on the disc.

Each of the six studies was either a very large, high-quality study or a systematic review of many other research reports on a single topic. These six studies cover a wide range of problems surgeons treat everyday. Cost weighed against the benefits in terms of final patient outcomes is an important part of each study. The studies were analyzed with this idea of cost-effectiveness in mind. The recommendations made represent the best evidence available at the present time.

Here’s a summary of the ways surgeons practice that might be influenced by the results of these studies:

X-rays and other imaging studies should NOT be done for patients with acute onset of back pain when there are no other red flags. Red flags are the warning signs, symptoms, and patient histories that suggest something more serious than a simple or temporary back problem.

Patients with degenerative spondylolisthesis have better results (less pain, more function) when treated surgically to stabilize the spine. There is strong evidence that the positive results and benefits seem to last (at least for up to four years) in the studies reviewed.

Burst fractures of the thoracolumbar spine can often be treated without surgery. But when there are signs of spinal cord compression, then surgery becomes an urgent matter. There is weak evidence to suggest that fusion from the back and side of the spine (posterolateral approach) isn’t the best way to treat this problem. When surgery is needed, the surgeon should approach the spine from the front and perform an anterior decompression (remove bone pressing on the spinal cord).

For patients with painful vertebral compression fractures caused by osteoporosis, there is no long-term advantage of having a vertebroplasty procedure over conservative (nonoperative) care. The vertebroplasty involves placing a needle into the fractured vertebra and injecting cement into it to stabilize the bone and keep it from further damage. However, the vertebroplasty procedure does offer faster pain relief in the early days of the fracture. That could be an important deciding factor for some patients.

Right now, using bone substitute materials for spinal fusions is fairly costly and not recommended for routine use. Patients can still donate their own bone though it does mean a greater risk of complications and problems at the donor site. The authors point out that more studies are needed in this area.

There was one final recommendation that will take a little bit of explanation. It has to do with using a needle inserted into the disc to make sure the surgeon is at the correct spinal level to perform an anterior cervical discectomy (remove the disc) and cervical spine fusion.

This method of checking works fine so long as the needle goes in the correct disc (the one that’s going to be removed anyway). But when the needle punctures a healthy disc at the next level (above or below the diseased disc), then that healthy disc is at risk for degenerative changes.

According to studies done, the practice of missing the correct disc space is more common than realized. Seventeen per cent (17%) of cases investigated had incorrect needle placement. And the risk of degeneration was three times higher for those previously intact discs. For now, it looks like there is a weak recommendation to avoid using the needle placement checking technique to confirm the disc space for discectomy.

Surgeons take information like this and present it to their patients when making recommendations and suggesting a plan of care for the problem at hand. Patients are free to choose to take the surgeon’s advice based on their own personal preferences or circumstances. Any decision that involves spine surgery isn’t taken lightly — any and all information that can be offered based on evidence is helpful.