Lumbar fusion vs. nonsurgical treatment for chronic low back pain
Dr. Merson sees many patients who need back pain treatment in Boca Raton but are seeking a second opinion to spinal fusion therapy. Basically, they want to know the difference between lumbar fusion versus nonsurgical treatment for chronic low back pain.
It is not hard to wonder why they want to explore prolotherapy and platelet rich plasma therapy. Fusion surgery is a complex procedure, and new research questions the results and success of the procedure.
“Results following fusion for chronic low back pain are unpredictable and generally not very satisfying. The major reason is the absence of a detailed description of the symptoms of patients with back pain, if present, in a motion segment of the spine. Various radiological findings have been attributed to discogenic pain, but if these radiological signs were really true signs of such pain, fusion would have been very successful.” 1
Although MRI is appealing, its utility in assessing fusion remains unproven
At about the same time, research appeared out of the Netherlands saying that it was not possible, based on the current technology, to determine who spinal fusion, as treatment for back pain, would be predictable for: “No subset of patients with chronic low back pain could be identified for whom spinal fusion is a predictable and effective treatment. Best evidence does not support the use of current tests for patient selection in clinical practice.”2 This comes right out of the pages of the Journal of the American Academy of Orthopedic Surgery- “Although MRI is appealing, its utility in assessing fusion remains unproven.”3
Back in the hospital
Following a spinal fusion, the overall unplanned readmission rate was 8.4% at 30 days and 12.3% at 90 days.4
Is prolotherapy an option for your back pain? In one study, researchers found: “prolotherapy provided significant relief of sacroiliac joint pain, and its effects lasted longer than those of steroid injections”.
How about platelet rich plasma therapy? In one animal study, doctors found that even after fusion surgery platelet rich plasma therapy was effective in promoting accelerated healing.
Prolotherapy after failed back surgery
Researchers in the United Kingdom looked at the use of prolotherapy in patients who had failed to respond to conservative approaches including spinal manipulation and physiotherapy in (UK National Health Service) back pain clinic settings. These patients had longstanding and often severe pain and disability.
After a “short” bout of prolotherapy—3 injections over a 3 to 5 week period—they confirmed that 91% of respondents were better or not worse off after 12 months.5
Studies such as the one cited above have been circulating for years. Similar results were achieved in a 2005 study publish in the medical journal Pain Physician. In this study, the researchers took on the difficult cases: “Of the patients studied, 86% of patients had undergone prior lumbar spine surgery and all were referred for neurosurgical evaluation for possible surgery.”
Here is what the researchers reported: “Injection therapy of painful enthesopathies (soft tissue attachments to the bone, ie ligaments and tendons) can provide significant relief of axial pain and tenderness combined with functional improvement, even in ‘failed back syndrome’ patients. Phenol-glycerol prolotherapy provides better and longer lasting relief than injection with anesthetics alone. Prolotherapy provides over six months of relief for some patients but generally provides relief for only a few months. However, most patients described good to excellent relief, felt that the injections had been beneficial, and requested additional injections for recurrent or residual focal pain.”6
One of the most important things to note is that the patients in these two studies were patients who had already failed two conservative treatments or already had a surgery.
1. Nyström B.Spinal fusion in the treatment of chronic low back pain: rationale for improvement. Open Orthop J. 2012;6:478-81.
2. Willems PC, Staal JB, Walenkamp GH, de Bie RA. Spinal fusion for chronic low back pain: systematic review on the accuracy of tests for patient selection. Spine J. 2012 Nov 2. pii: S1529-9430(12)01276-4. doi: 10.1016/j.spinee.2012.10.001. [Epub ahead of print]
3. Selby MD, Clark SR, Hall DJ, Freeman BJ. Radiologic assessment of spinal fusion. J Am Acad Orthop Surg. 2012
4. Schairer WW, Carrer A, Deviren V, et al. Hospital Readmission After Spine Fusion for Adult Spinal Deformity. Spine (Phila Pa 1976). 2013 May 21. [Epub ahead of print]
5. Jacks A, Barling T International Musculoskeletal Medicine, Volume 34, Number 1, April 2012 , pp. 7-12(6)
6. Wilkinson HA. Injection therapy for enthesopathies causing axial spine pain and the “failed back syndrome”: a single blinded, randomized and cross-over study. Pain Physician. 2005 Apr;8(2):167-73.