Back Pain Treatment Guidelines Often Ignored

Acute lower-back pain is estimated to be among the most common reasons for visits to healthcare providers. However, according to an extensive survey, more often than not, patients receive back care that is inconsistent with best-practice guidelines.

Researchers in Australia prospectively examined usual care provided for acute lower-back pain (LBP) by general practitioners (GPs) in their country and compared this with best-practice recommendations in international evidence-based guidelines [Williams et al. 2010]. Their survey examined care provided by more than 2,300 community-based GPs during 3,533 patient visits specifically for new episodes of LBP. To establish recommended treatment criteria, the researchers critically appraised guidelines from Europe, United States, United Kingdom, and Australia, and a systematic review of guidelines. There was a general consensus within the guidelines that the following recommendations for the clinical management of acute LBP are most important:

1. Use a diagnostic triage as a basis for management decisions and perform a more extensive examination if the medical history indicates possible serious disease or nerve root compromise.


2. Do not routinely order radiological or ancillary investigations.


3. Educate the patient; provide assurance of a favorable prognosis and encouragement to remain active and avoid bed rest.


4. Regular acetaminophen (paracetamol) is the first choice of analgesic. When this provides insufficient analgesia, regular nonsteroidal anti-inflammatory drugs (NSAIDs) may be tried. (Some guidelines recommend medicines containing opioids when NSAIDs provide insufficient analgesia.)


5. Review the patient's progress.

The researchers found that, although guidelines discourage the use of imaging for new cases of LBP, slightly more than one-quarter of patients (25.3%) were referred for imaging, primarily diagnostic x-rays and computed tomography. Nearly two-thirds of patients (65%) received a medication and, while guidelines recommend that initial care should focus on advice and simple analgesics (acetaminophen), only 21% and 18% of patients received these treatments, respectively. Instead, the analgesics provided were typically nonsteroidal anti-inflammatory drugs (37%) and opioids (20%), which are considered second-line therapies.

COMMENTARY: The researchers conclude that usual care provided by GPs for LBP does not match the care endorsed in international evidence-based guidelines and may not provide the best outcomes for patients. Furthermore, the unendorsed care may contribute to high costs of managing LBP and some aspects of the care provided carry a higher risk of adverse effects. One might question whether this situation is unique to Australia, but the researchers note similar outcomes of a study in the U.S. reported in 2005.

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Opioids Effective for Neuropathic Pain

Researchers have long contested the effectiveness of opioids as a first-line therapy for neuropathic pain. However, it may be time to put aside doubts: opioids do appear to help relieve neuropathic pain in many cases and the focus should now be on which patients can benefit most and for how long.

In a new report — presented briefly at the AAPM (American Academy of Pain Medicine) annual meeting earlier this month — patients with neuropathic cancer pain obtained consistent, long-term pain control with extended-release (ER) oxymorphone (Opana®). Overall, patients reported pain in the mild range throughout most of a one-year open-label study and only 11% discontinued because of lack of efficacy [Slatkin et al. 2010]. The small trial included 27 patients with neuropathic pain who began long-term treatment with ER oxymorphone following participation in a prior shorter-term study. Dose adjustments to improve pain control or tolerability were allowed throughout the 52-week extension phase. The median oxymorphone dose increased from 80 mg/d at baseline to 160 mg/d at 52 weeks — such increases were deemed largely consistent with the nature of the disease — and pain relief remained largely unchanged throughout followup. Eleven patients (41%) reported at least one treatment-related adverse event; most commonly dry mouth, constipation, or fatigue, which were not unexpected. [Disclosure: This clinical trial was supported by Endo Pharmaceuticals, the manufacturer of Opana and a Pain Treatment Topics supporter.]

Other evidence also endorses the potential value of opioids for neuropathic pain. In a recent blogpost we noted a case series of 100 patients treated effectively for 10 or more years with opioid analgesics for chronic noncancer pain; neuropathy was the primary diagnosis in 14 of those patients [see, Followup: Safety of Long-Term Opioid Therapy]. In a much more extensive analysis, the authors of a Cochrane Systematic Review examined 23 good quality trials of oral opioids tested for central or peripheral neuropathic pain [Eisenberg et al. 2006]. While short-term studies provided only equivocal evidence regarding the efficacy of opioids in reducing the intensity of neuropathic pain, intermediate-term studies (up to 70 days) demonstrated significant efficacy of opioids over placebo. Reported adverse events typical of opioid therapy (eg, nausea, drowsiness, constipation) were common but not treatment limiting in most patients (89%).

As with most research in the pain management field, investigations of opioids for neuropathic pain have been over-represented by small trials or case series reports and/or studies covering relatively brief time periods. Certainly, further and better research is needed; meanwhile, there does not appear to be compelling evidence against the consideration of opioid analgesics among first-line therapies that can be effective in select patients for cancer- or noncancer-related neuropathies.

References:
> Eisenberg E, McNicol E, Carr DB. Opioids for neuropathic pain. Cochrane Database Syst Rev. 2006;19(3):CD006146 [abstract here].
> Slatkin N, et al. "Long-term management of neuropathic cancer pain with oxymorphone extended release: Results of a 1-year open-label extension trial" AAPM 2010; Abstract 117. Also reported in: Bankhead C. AAPM: Opioid Gains Long-Term Control of Neuropathic Cancer Pain. MedPage Today [online]. February 2010 [available here].

Factors Behind Rx-Opioid Overdose Deaths Examined

Increasing incidences of fatal overdoses associated with prescribed opioid analgesics have raised concerns among government agencies, healthcare providers, and the public. A recent report from Lynn Webster, MD, and colleagues reveals some interesting factors that may influence accidental overdose deaths.

U.S. government data indicate that unintentional opioid-analgesic-related deaths increased by 214% from 2001 to 2005, reaching about 8,500 fatalities nationwide [NDIC 2009]. Yet, relatively little is known to help predict such tragic events and, thereby, possibly prevent them. At the recent AAPM (American Academy of Pain Medicine) annual meeting, Webster — of Lifetree Clinical Research and Pain Clinic, Salt Lake City, UT — and coauthors presented a case series report on 20 unintentional opioid-analgesic overdose fatalities [Webster et al. 2010]. Data had been gathered during a 3-year period from medical records included in legal actions surrounding the deaths. Here is a summary of findings:

• All decedents had been taking at least 60 mg/day of morphine-equivalent opioids for at least 1 year.


• The primary opioids involved in the deaths were methadone (50%, n=10) and hydrocodone (20%, n=4).


• Most deaths (65%, n=13) occurred within 1 week of a change in opioid dose and 3 of those occurred within the first day.


• A majority of deaths (55%, n=11) were discovered in the morning and, overall, 60% (n=12) of decedents were found in bed.


• Three quarters of decedents fell into the 14-35 and 46-59 age brackets, males outnumbered females by a 3 to 2 ratio. Four of the decedents were obese (BMI>30).


• In three-quarters of cases (n=15) physician prescribing error was judged to be the cause of death. The remaining 5 cases were associated with either patient noncompliance, excessive medication consumption, a defective medication patch, illicit substance use, or benzodiazepine/sedative overdose.

COMMENTARY: Obviously, this is a small and select case series, and Webster et al. caution that their findings cannot be generalized to all opioid overdose fatalities. Still, data of this sort are vital for understanding causes of such deaths and similar data gathering and reporting should be standard practice during postmortem investigations. Unfortunately, information available today from coroner or medical examiner reports or other sources is generally too meager and unreliable for meaningful analyses.

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Do Higher Opioid Doses Increase Overdose Risks?

Understanding Evidence-Based Pain Management (EBPM)

Along with increased prescribing of long-term opioid therapy for chronic noncancer pain, rates of fatal opioid overdoses have risen. In a large-scale investigation, patients receiving higher opioid doses were 9 times more likely to overdose than were those prescribed lower doses. However, from an evidence-based pain management perspective, this may be an example of making a mountain of publicity out of a statistical molehill.

Reporting in the Annals of Internal Medicine, a research team at the Group Health Research Institute, Seattle, Washington, examined nearly 9,940 patients attending a large Health Maintenance Organization [Dunn et al. 2010]. Each of the selected patients had received 3 or more opioid prescriptions within a 90-day period for chronic noncancer pain, such as back pain and osteoarthritis, between 1997 and 2005. Average daily opioid doses were calculated from an automated pharmacy database, and primary outcomes — nonfatal and fatal overdoses — were identified through diagnostic codes from inpatient and outpatient care records and death certificates. Data for this report were derived from a larger investigation — the Consortium to Study Opioid Risks and Trends (CONSORT).

During the 9 years of collected data, 51 opioid-related overdoses were identified, which included 6 deaths. Compared with patients receiving 1 to 20 mg/day of morphine-equivalent opioids and experiencing a 0.2% annual overdose rate, those taking 50 to 99 mg/d had a 3.7-fold (95% CI, 1.5-9.5) increase in overdose risk (0.7% annual overdose rate). Patients prescribed 100 mg/d or more had an 8.9-fold (CI, 4.0-19.7) increase in overdose risk (1.8% annual overdose rate). The study authors concede that the overall number of overdoses was small and the absolute number of overdoses occurred mostly among patients receiving low to medium doses, because prescriptions at those levels were much more common. Furthermore, the rates may be confounded by patient differences and by misuse of opioids in ways not intended by prescribing physicians. Still, they conclude that, “Patients receiving higher doses of prescribed opioids are at increased risk for overdose, which underscores the need for close supervision of these patients.”

CLINICAL COMMENTARY: Naturally, the medical news media had a heyday with this study report, with headlines broadcasting “new” dangers of opioid analgesics and an implication that prescribers are killing patients with high doses of opioids. However, a close examination of the research report raises important doubts:

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Followup: Safety of Long-Term Opioid Therapy

The prescribing of opioid analgesics for chronic noncancer pain is still shrouded by some controversy; particularly, when patients are continued on these medications for many years. However, evidence is growing in support of long-term opioid therapy for providing less pain, better function, and improved quality of life in select patients. Benefits clearly may outweigh risks.

Last August, we reported on a study by Forest Tennant, MD, of 24 patients administered strong opioid analgesics for from 10 to 35 years [see blogpost 10+ Years on Opioid Analgesics! What Happens?]. Overall, he observed that patients experienced significant pain relief and ongoing quality of life and physical functioning enhancements. At the same time, there were relatively few complications of the therapy, which were easily managed. However, this was a quite limited cases series of patients.

Now, writing in the January/February 2010 edition of the journal Practical Pain Management, Tennant has expanded his study four-fold to include 100 patients [Tennant 2010]. Patients ranged in age from 30 to 83 years, were 61% male, and had been administered opioids for 10 to 35 years. Significant causes of chronic pain being treated with opioids included spine disease (51%), arthritis (16%), peripheral neuropathy (14%), and headache (10%). A majority were administered a single opioid (62%), with those most commonly prescribed being hydrocodone (56%), oxycodone (25%), fentanyl (15%), and morphine (13%) [exact formulations are not specified in the report]. Far from becoming debilitated by ongoing opioid therapy most patients were able to read newspapers and other literature (97%), attend social events (89%), dress themselves (82%), walk unassisted (85%), and even drive a car (74%). Almost half of patients (45%) had been on a stable opioid dose without significant escalation for at least 3 years (range 3 months – 31 years).

CAVEATS: It is of interest that significant numbers of patients were benefitting from long-term opioid therapy for headaches and peripheral neuropathy, since some guidelines and clinical literature argue against the value of opioid analgesia in aiding these conditions. Therefore, further research in much larger patient populations appears warranted to explore these applications of opioids before indisputably accepting perspectives in the literature.

Unfortunately, Tennant’s updated and expanded report does not comment on the full range of risk factors that might be of concern. In his original report on only 24 patients, he noted that some developed other conditions during long-term opioid therapy, including tachycardia, hypertension, hyperlipidemia, diabetes, tooth decay, and weight gain. These could be medically managed and whether the conditions were pain related, opioid induced, or simply inherent in the patients and/or a result of aging was unclear. No neurologic complications such as hyperalgesia, dementia, tremor, or seizures were noted; nor were hepatic, renal, or gastrointestinal complications, except for minor constipation.

Tennant rightly concedes that even his expanded study of 100 patients does not incorporate sophisticated epidemiological techniques or the prospective randomization of patients to long-term opioid therapy. It is more of a preliminary “proof of concept” than a clinical trial. He writes that this study, or survey, was merely intended to answer a fundamental question: “Are there chronic pain patients in the United States who have taken opioids over 10 years and report less pain, better function, and have a better quality of life?” The answer clearly is “Yes.” Might some of the patients have done just as well if treated by other pain management modalities? Possibly so. Are there some patients who would not respond or thrive as well on long-term opioid therapy as those in Tennant’s cohort? Probably so. At the same time, however, when patients appear to be doing well on opioid therapy for chronic noncancer pain, Tennant believes, “there is no obvious reason to discourage opioid use or encourage pain patients to cease opioids.”

Reference: Tennant F. Opioid treatment 10-year longevity survey. Final report. Prac Pain Manage. 2010;10(1):47-48.

Nearly Half of Patients Misuse Their Pain Meds

Adherence to prescribed medication regimens is essential for effectively treating chronic pain conditions. However, a new study reports that therapeutic nonadherence, or “medical misuse,” of analgesics is common, with underuse more prevalent than overuse or abuse.

Researchers at a single multidisciplinary pain treatment center in Belgium assessed adherence to prescribed analgesic regimens in 281 patient during a 19-week period [Broekmans et al. 2010]. On self-reported measures nearly half (48%) of the patients were nonadherent, with 34% of them admitting underuse and 14% overuse of their prescribed medications. Overall, older patients were significantly more adherent, although age-group differences were not vast; the mean age in adherent patients was 54 years compared with 47 to 49 years in nonadherent patients. Underuse was significantly associated with taking non-prescribed analgesic agents as a form of supplemental self-medication. Overuse was significantly influenced by tobacco smoking, being prescribed opioid analgesics, and regimens requiring a higher number of medication doses per day. The researchers conclude that therapeutic nonadherence, especially underuse of medication, occurs frequently among patients with chronic nonmalignant pain; however, prospective research is needed to learn about the impact of such misuse on clinical outcomes.

FURTHER ANALYSIS: This was an observational study of European patients predominantly suffering from back pain (n=91), neuropathic pain (n=60), and fibromyalgia (n=42); persons with cancer-related pain were excluded. Patients overusing or underusing their medication only once were considered to be nonadherent, although the researchers claimed an alternate analysis using less stringent adherence criteria produced equivalent results (69% of under-users were doing so daily, as were 54% of over-users). Either over- or underuse might be considered as “medical misuse” of analgesics, since patients did not appear to be abusing or diverting the medications for nonmedical purposes. While 25% of participants admitted taking a non-prescribed analgesic agent, none of them claimed to have used illegal drugs (albeit, 13 patients acknowledged smoking cannabis occasionally, which may have been for analgesic effect). However, patients might be reluctant to admit illicit drug use, resulting in underreporting, and self-reports were not cross-checked via urine drug testing.

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Bogus Drugs & Opioids Touted by Online Pharmacies

The National Association of Boards of Pharmacy (NABP) announced that nearly all (96%) of the 5,200 Internet drug outlets that it evaluates were selling prescription drugs outside of pharmacy laws and practice standards that protect the public health. Pain practitioners need to be aware not only of what medications patients are taking but where those products are being purchased.

According to NABP President Gary A. Schnabel, RN, RPh, "There is a common misconception that prescription medications purchased from any website calling itself a pharmacy are safe." However, patients fail to realize that when buying medications from unknown sources online, established safeguards vanish, and the odds of getting counterfeit or substandard medication rise substantially.

Of the more than 5,200 Internet drug outlets NABP has assessed since May 2008, greater than 5,000 (96%) were found to be out of compliance with basic criteria for legitimate pharmacy practice and were posted as “Not Recommended” on the NABP website. Here are some of the infractions:

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Opioids Relieve Pain with Little Addiction Risk

According to a comprehensive updated Cochrane review, opioid analgesics effectively relieve chronic noncancer pain in most patients, with only a small (though not zero) risk of developing abuse or addiction. However, it must be appreciated that a portion of patients may have inadequate pain relief or develop intolerable opioid side effects; further research is needed to identify patients who will benefit the most.

Many still consider opioid therapy for chronic noncancer pain (CNCP) as controversial due to concerns about long-term effectiveness and safety, particularly risks of tolerance, dependence, or abuse. To expand and update an earlier Cochrane Review on this subject, investigators searched 10 bibliographic databases up to May 2009 [Noble et al. 2010]. They discovered for review 26 studies with 27 treatment groups that enrolled a total of 4,893 participants taking opioids for as long as 48 months. Twenty five of the studies were case series or uncontrolled long-term trial continuations, the other was a randomized controlled trial comparing two opioids. Twelve studies investigated administration of opioids orally (n=3,040), 5 transdermally (n=1,628), and 10 intrathecally (n=231).

Within each modality, a portion of participants discontinued opioid therapy due to side effects (oral, 22.9%; transdermal, 12.1%; intrathecal, 8.9%). To a lesser extent, insufficient pain relief was a cause of discontinuation (oral, 10.3%; intrathecal, 7.6%; transdermal, 5.8%). Serious adverse events were rare and signs of opioid addiction were reported in only 0.27% of participants in the studies that reported that outcome. All 3 modes of administration were associated with clinically significant reductions in pain in the majority of patients, but the amount of pain relief varied across studies. Findings regarding quality of life and functional status were inconclusive due to an insufficient quantity of evidence for oral administration studies and inconclusive statistical findings for transdermal and intrathecal administration studies.

CLINICAL COMMENTARY: Cochrane reviews — following well-developed protocols for data search, extraction, analysis, and validation of findings — are perhaps the most rigorous and robust approaches for assessing current knowledge of particular therapies. In this analysis of studies evaluating long-term opioids for chronic noncancer pain, both the quantity and quality of evidence were disappointing; so, clearly, better and longer-term trials are needed to help identify patients who are most likely to benefit.

Most of the patients in the reviewed studies had chronic back pain following failed surgeries, severe osteoarthritis, or pain related to nerve damage, so the findings cannot be extended to other conditions such as headache, fibromyalgia, etc. Opioid analgesia was not ideal for all patients; some discontinued therapy (especially oral opioids) due to side effects or insufficient pain relief; however, it is unknown whether they transferred to alternate opioids or administration regimens with greater success after dropping out of the respective studies.

Among studies assessing opioid abuse or addiction, only 7 of 2,613 patients (0.27%) developed such opioid-use problems, and the researchers estimated that the rate would be merely 0.14% if no addictive behaviors occurred among studies that did not report addiction rates at all (which seems speculative). Our own review of studies reporting rates of opioid analgesic abuse/addiction in patients with pain found a range of 0.19% to 3.7% (see PDFs at [Leavitt 2007, p. 1] and [Leavitt 2008, p 6]). While there have been inconsistencies across studies in definitions of abuse and addiction, or in distinguishing between patients with/without prior substance-use problems, the rates, even at the higher end, suggest that prescription-opioid abuse/addiction in patients with pain is not anywhere as severe or widespread as some authors and agencies have depicted. On the other hand, there have been some disturbingly high rates of illicit or unauthorized substance use (particularly marijuana) alleged in certain patient populations, but Noble et al. did not examine this concern. These issues need further and unbiased examination; meanwhile, during everyday practice, iatrogenic (therapy induced) opioid abuse or addiction might be considered as merely a rather rare side effect in very select patients.

REFERENCE: Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database of Systematic Reviews. 2010;1(#CD006605) [abstract/summary].

What You Need to Know About Acetaminophen Safety

Acetaminophen has provided safe and effective pain relief in adults and children for more than a century; however, writing in the Cleveland Clinic Journal of Medicine, the authors of a new review describe important risks and potential harms of the drug that must be taken more seriously by healthcare providers and patients. The article examines the epidemiology of acetaminophen overdose and the clinical management of related hepatotoxicity.

According to Amy Schilling, PharmD, and coauthors from the Cleveland Clinic, acetaminophen misuse is the leading cause of acute liver failure in the United States, and nearly half of toxicity cases are due to unintentional overdose [Schilling et al. 2010]. Concerned about this, the U. S. Food and Drug Administration (FDA) has mandated new labeling on acetaminophen packaging and is also considering (but still has not enacted) several measures: 1) reducing the maximum daily dose from 4,000 mg (possibly to 3,250 mg), 2) banning acetaminophen-opioid combination products, and 3) changing the current maximum single dose of 1,000 mg to prescription status, making 650 mg the highest nonprescription dose.

While acetaminophen (eg, Tylenol®, also generically called paracetamol or APAP) is an effective and relatively safe analgesic for many pain conditions, it also is far easier than patients (or practitioners) may realize to exceed the maximum 4 grams per day generally considered the upper limit of safety. Besides combinations with opioids, a wide range of products contain acetaminophen in their formulations; persons who do not study product labeling will not be aware of this, and others may not go to the trouble of calculating their total daily intake of acetaminophen from all sources. Acetaminophen hepatotoxicity can occur at much lower daily doses in patients who a) have liver disease, b) consume more than 3 alcohol drinks per day, c) are malnourished, or d) take medications or OTC products that induce cytochrome P450 enzymes. Severe, accidental acetaminophen toxicity generally is not a sudden event; rather it usually occurs during 3 or more days of harmful dosing, providing ample time for remedial actions if healthcare providers and patients are alert to warning signs and symptoms.

CLINICAL COMMENTS: We agree with the conclusion by Schilling et al. that the new labeling of acetaminophen products will be helpful but disagree with their suggestion that the other proposed FDA actions are “sensible.” Using data available from the FDA for 2005, we previously noted that more than 28 billion doses of products containing acetaminophen were distributed in the United States that year and, taking into account a conservative, worst-case scenario, we calculated that the severe adverse event incidence rate was only 0.14% affecting 0.001% of the U.S. population. Put another way, 99.86% of the time acetaminophen products were used safely [see: Acetaminophen Debacle; Much Ado About Very Little]. Furthermore, in their review, Shilling and colleagues emphasize that there is a safe and effective antidote for acetaminophen toxicity — acetylcysteine (Mucomyst®, Acetadote®, others) — that should be given immediately either orally or intravenously when overdose is suspected. Both approaches have incurred minimal adverse effects; although, IV administration may on some occasions (15% of cases) trigger anaphylactoid reactions, which can be medically managed [see also, Heard 2008]. Whether or not healthcare providers are widely familiar with this antidote, including when and how it should be administered to reverse acetaminophen-induced hepatotoxicity, needs examination. Interestingly, generic acetylcysteine capsules, as an antioxidant allegedly supporting liver health, are readily available without prescription via Internet sources.

The above commentary is not intended to dismiss risks or harms of acetaminophen misuse; however, overdoses could probably be reduced at least in half merely by early recognition of potential problems and/or more timely treatment of toxicity if it occurs. We agree with Schilling and her coauthors that, “To prevent unintentional acetaminophen overdoses, education of patients and healthcare professionals is urgently needed so that the dangers of consuming excess acetaminophen daily are understood.” However, their article also suggests that roughly half of all severe hepatotoxicity cases are due to intentional acetaminophen overdoses in suicide attempts, which raises the spectre of complex problems that education alone, or even limiting access to the drug, will not fully resolve.

REFERENCES:
> Heard KJ. Acetylcysteine for acetaminophen poisoning. N Engl J Med. 2008;359:285-292 [abstract].
> Schilling A, Corey R, Leonard M, Eghtesad B. Acetaminophen: old drug, new warnings. Cleveland Clin J Med. 2010;77(1):19-27 [full article PDF here].

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].