05 Aug Evidence
I posted two articles to the “All The Rage” facebook page yesterday. One was about a New York Times article that called into question the practice of performing certain types of back surgeries when the data that exists suggests that it is no better than a placebo. The other was a first-person article by a doctor who became convinced that he had ALS despite the fact that all of the tests that he took indicated otherwise. Both articles deal with our cultural relationship to science and medicine, and our difficulty dealing with ideas or information that sit outside of our cultural understanding. We often blind ourselves to facts that don’t fit the narrative that we want to tell. The first article illuminates how the medical community does this in relation to practice while the second in some ways unintentionally, or subtextually, highlights the ways in which we often blind ourselves to the emotional truth of our lives.
When I posted the first article a very good friend of mine who is a surgeon, as well as someone who has had back surgery several times, commented, “The problem with using one published study of one type of spinal surgery and making sweeping statements about the ineffective nature of back surgery is just as bad and inflammatory as the medical community saying that all spinal surgery is effective.” The question that this Times article posted in the headline was “Why Useless Surgery is Still Popular”. I agree with him that the headline is inflammatory. However, the article raises many very serious questions about how the medical system, and those who work within it, make decisions about care. Gina Kolata’s article begins,
Before a drug can be marketed, it has to go through rigorous testing to show it is safe and effective. Surgery, though, is different. The Food and Drug Administration does not regulate surgical procedures. So what happens when an operation issubjected to and fails the ultimate test — a clinical trial in which patients are randomly assigned to have it or not?
The expectation is that medical practice will change if an operation turns out not to help.
It looks as if the onus is on patients to ask what evidence, if any, shows that surgery is better than other options.
Take what happened with spinal fusion, an operation that welds together adjacent vertebrae to relieve back pain from worn-out discs. Unlike most operations, it actually was tested in four clinical trials. The conclusion: Surgery was no better than alternative nonsurgical treatments, like supervised exercise and therapy to help patients deal with their fear of back pain. In both groups, the pain usually diminished or went away.
The studies were completed by the early 2000s and should have been enough to greatly limit or stop the surgery, says Dr. Richard Deyo, professor of evidence-based medicine at the Oregon Health and Sciences University. But that did not happen, according to a recent report. Instead, spinal fusion rates increased — the clinical trials had little effect.
Ms. Kolata’s article in the New York Times, mirrored an article that she had written nearly a decade earlier, which highlighted another back surgery study that came to similar conclusions. We were just starting our Dr. Sarno film at that point and I reached out to her to see if she would talk about her article for the film. She declined because as a journalist she “didn’t want to become part of the story”. However, without journalists writing stories like this it is very difficult for people who exist outside of the medical system to make sense of it. At the same time, those who work within a system are often very wary of the ways in which those outside it view, or write about that system. My friend was frustrated because as he put it, “The vertebroplasty study has to be reviewed as one investigational review and it has to be reviewed and presented in context. You can manipulate and present results of any study in a manner that supports a particular position.” Again, I see his point, but as I detail below, I could not find any studies that make a persuasive argument in favor back surgery. There are no doubt a great number of anecdotal stories that illustrate how one person or another had great success with back surgery, but there is very little evidence that back surgery works better than other treatments or a placebo- and it is both expensive and potentially dangerous.
I believe that most people want to trust that the medical system, as well as doctors, are acting based on solid science. This is the narrative that we have been delivered for so many years; that good medicine is evidence based practice. Unfortunately, in terms of treating pain, the treatment methods are often not built on solid science. Further, in 2011 the Institute of Medicine studied 10 different treatment methods and they found that none of the pain treatment methods currently in use work. This broad panel of experts found that there was no compelling evidence to support any of the practices. They also found that the costs associated with treating these issues had risen exponentially.
This is especially true when it comes to the treatment of back pain. Again, while I understand my friend’s frustration with the article I have had no luck finding any studies that make a persuasive case for surgery to deal with disc herniation or stenosis. In fact the opposite appears to be true. When I googled “studies on efficacy of surgery for back pain”, I found a couple that argued that it could be useful, but for the most part the conclusions I found pointed towards avoiding it. I have posted several of those below. This does not mean that nobody who has surgery sees a benefit. Instead it means that surgery seems to be no better in the medium to long term than non-invasive treatments. As Ms. Kolata’s article argues, less invasive and expensive options should trump surgery based on all the available evidence in regards to most back pain issues.
The other article I posted, by Dr Mert Erogul who thought he had ALS, begins with a discussion of his avoiding doing the “ice bucket challenge” last summer, and continues with the following paragraph,
Some time after that, in the autumn, I began to notice a certain hitch in my left leg when I walked or stood for too long. The knee would give out periodically, as if I had forgotten to attend to the basic task of keeping it straight. My leg was otherwise normal, it was strong, it didn’t hurt. I’m a doctor and so I looked at it. It looked fine. At the time my toddler son demanded to be carried up the stairs and everywhere, and I was riding my bike to work every day. Maybe, I thought, I was extending myself too far. Maybe I had reached my fabled turning point. A month or so after that, I started to have some numbness and an ache in my left arm and a feeling of clumsiness in that hand. Probably a pinched nerve, I thought, and did what most doctors do for medical problems, which is to take some ibuprofen. Soon after that, while I was giving a lecture to medical students one morning, the microphone slipped from my hand and fell to the ground. Medically speaking, dropping things is a big deal. I realized that something was happening, something troubling that I couldn’t ignore any more.
For anyone with even a passing understanding of Dr. Sarno’s work, or basic psychology, there are a lot of clues in this paragraph that point towards a mind body interaction as a possible reason for the physical issues that Dr Erogul was struggling with. These mind bodies issues become even more important given that the article goes on to point out that after many months of tests his doctors could find nothing physically wrong with him.
First, as Dr Sarno points out, people often get symptoms that are culturally relevant. One 1996 study he talks about shows that in Norway almost 35% of people in car accidents ended up with whiplash while in neighboring Lithuania virtually no one had it. The study suggests that because people in Norway generally had good health insurance they got treatment and compensation for the injury. In Lithuania this was not the case. The argument isn’t that all of the people in Norway were faking it for a benefit but instead that perhaps the expectation of whiplash somehow signaled the brain to react to the situation. Just as the unconscious fear of whiplash might lead to whiplash, the unconscious cultural awareness of ALS, coupled with the stress of parenthood and work, might create the impetus for the symptoms that Dr. Erogul experienced. Dr. Sarno points out in his lectures that if back pain came from degenerative issues such as disc problems or spinal stenosis then the incidence of them should increase as people age. However, the graph of their appearance lines up with the period of life when the stress of parenthood and work is greatest and decreases as people age. The fact that Dr. Erogul has these issues during perhaps the most emotionally challenging period of his life makes a lot of sense from that perspective. Dr. Sarno points out that his prescription is knowledge. Simply understanding the ways in which stress can produce symptomatology points towards dealing with the stress rather than the symptom. This is simply good medicine.
As a doctor, it is difficult to push back against patients who want a pill, or a simple magic cure- one that doesn’t require the patient to anything, or change anything about their life. However, the answer often lies partly within the soft matter of our brains rather than the soft tissues of our bodies. It’s important that we remove this blindness for ourselves.
Four Year Follow-Up of Surgical Vs Non-Surgical Therapy for Chronic Low Back Pain.
Long-term improvement was not better after instrumented transpedicular fusion compared with cognitive intervention and exercises.
Medical versus Surgical Treatment for Low Back Pain: Evidence and Clinical Practice
-conclusion – The literature comparing the efficacy of surgical and medical treatment for low back pain is limited. Not surprisingly, the use of surgery for low back pain varies widely across the United States. To establish clinical consensus, we need better evidence about the efficacy of surgery.
Effectiveness of Surgery for Lumbar Spinal Stenosis: A Systematic Review and Meta-Analysis
The relative efficacy of various surgical options for treatment of spinal stenosis remains uncertain. Decompression plus fusion is not more effective than decompression alone. Interspinous process spacer devices result in higher reoperation rates than bony decompression.
Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline.
Surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up in some trials. For nonradicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, but associated with small to moderate benefits compared to standard nonsurgical therapy.