Monday, February 1, 2010

Surprise: Surgeons Downplay Surgery for Back Pain

A recently reported study in the journal Spine found that surgeons are less likely than family physicians or patients to view surgery as a preferred treatment for low back pain. Surgeons placed greatest importance on location of pain (leg vs back only), while physicians considered multiple factors, and patients placed high importance on quality of life symptoms. Better communication is essential for shared decision-making and appropriate action.

Researchers in Ontario, Canada presented hypothetical back pain scenarios to 131 surgeons (orthopedic and neurosurgeons), 202 family physicians, and to 164 patients with back and/or leg pain [Bederman et al. 2010]. The vignettes reflected 6 key clinical factors related to back pain: walking tolerance, pain duration, severity, neurologic symptoms, typical onset, and dominant location of pain. Each group rated their preference for surgery in each scenario and the factors affecting preferences were analyzed.

Unexpectedly, surgeons indicated the lowest overall preference for surgery, while family physicians had the highest preference. Surgeons placed greatest importance on the location of pain, with leg pain being more salient than back pain only; orthopedic surgeons had a significantly lower preference for surgery than neurosurgeons (p < 0.05). Family practitioners considered neurologic symptoms, walking tolerance, and pain severity to be of greatest and equal importance. Somewhat similarly, patients considered pain severity and its duration, and walking tolerance as the most important factors in choosing surgery. Older patients and those having a previous surgical consultation had significantly greater preferences for surgery to remedy their pain.

Clinical Concepts: The investigators note that when other treatments have failed, surgery can help patients with moderate to severe lower back pain, and family physicians play an important role in sending patients for surgical evaluation. However, according to this study — which was of limited scope — family doctors may be unaware of diagnostic factors that most commonly affect the chances of good outcomes from back surgery, such as the specific location of pain. Meanwhile, patients appear to favor factors that are highly related to quality of life and have little direct bearing on surgical outcomes. The final decision-making process should include the patient, family physician, and surgeon; all having a mutual understanding of factors that are most critical in determining successful back surgery. "This can directly result in a significant improvement in patient satisfaction with the healthcare process and even overall health status following treatment," the researchers write. An excellent overview for patients on back surgery, why it may be needed, and some common types is available from the Mayo Clinic [here].

Reference: Bederman SS, Mahomed NN, Kreder HJ, et al. In the eye of the beholder: preferences of patients, family physicians, and surgeons for lumbar spinal surgery. Spine. 2010;35(1):108-115 [abstract here].

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