Correspondence
Surgical versus Nonsurgical Treatment for Back Pain
N Engl J Med 2007; 357:1255-1256September 20, 2007
- Article
To the Editor:
Weinstein et al. (May 31 issue)1 report an immoderate example of a pragmatic trial. In their study, the nonsurgical group received heterogeneous treatments involving a combination of at least 3 treatments from a pool of more than 50 therapies, whereas the surgical interventions involving decompression with or without fusion, and with or without instrumentation, added such variability that the study results are limited.1,2 The authors suggest that the pragmatic nature of the trial increases the generalizability of the study results. However, the major limitation (the lack of description and standardization of the interventions) compromises the internal and external validity of the study results. A complete description of the interventions provided is needed for clinician-scientists wishing to reproduce them.
Moreover, further information is needed regarding which patients should be referred for surgery as the first form of treatment. For instance, should patients with spondylolisthesis involving any stenosis be referred for surgery? Before routine surgery is recommended for degenerative lumbar spondylolisthesis, improved reporting of the interventions and patient populations in nonpharmacologic trials such as this one are required in order to arrive at conclusions that are convincing and meaningful.3
3 ReferencesBruno R. da Costa, B.P.T.
Bradley C. Johnston, N.D.
University of Alberta, Edmonton, AB T6G 2G4, Canada1
Weinstein JN ,Lurie JD ,Tosteson TD , et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 2007;356:2257-2270
Full Text | Web of Science | Medline2
Birkmeyer NJ ,Weinstein JN ,Tosteson AN , et al. Design of the Spine Patient Outcomes Research Trial (SPORT). Spine 2002;27:1361-1372
CrossRef | Web of Science | Medline3
Boutron I ,Moher D ,Tugwell P , et al. A checklist to evaluate a report of a nonpharmacological trial (CLEAR NPT) was developed using consensus. J Clin Epidemiol 2005;58:1233-1240
CrossRef | Web of Science | Medline
To the Editor:
As Deyo (May 31 issue)1 points out in his Perspective article, we certainly need more scientifically rigorous studies of the complex nature of spine surgery. The discussion of the proper timing of disk surgery reminded me of the difference in my thinking as a spine surgeon and as a patient. As a neurosurgeon, I have never recommended disk surgery within 4 weeks after the onset of symptoms. However, when I experienced a disk herniation on a Wednesday, I was willing to put up with only 48 hours of incapacitating pain before calling a colleague. I underwent magnetic resonance imaging Saturday morning and surgery Saturday afternoon, returned to work Monday, and was pain-free and performing aneurysm surgery on Tuesday. For me, as a patient, immediate surgery was much more conservative than the radical approach of canceling 4 to 6 weeks of my practice.
1 ReferencesBrian Copeland, M.D.
MidMichigan Medical Center, Midland, MI 48640
brian.copeland@midmichigan. org 1
Deyo RA . Back surgery -- who needs it? N Engl J Med 2007;356:2239-2243
Full Text | Web of Science | Medline
Author/Editor Response
We agree with da Costa and Johnston that a full description of the treatments is important in nonpharmacologic trials; however, in our study, a fixed nonsurgical treatment protocol was not feasible, given the state of evidence in this disease and the eligibility requirement of 12 weeks of symptoms during which patients received a variety of nonsurgical treatments before enrollment. We have previously described the nonsurgical treatments more fully1,2; the surgical treatments are fully described in our article.
We agree that it is crucial to understand the patient population from which the study results are derived and the patients to whom they might be generalizable. We reemphasize the inclusion criteria described in the methods section: “All patients had neurogenic claudication or radicular leg pain with associated neurologic signs, spinal stenosis shown on cross-sectional imaging, and degenerative spondylolisthesis shown on lateral radiographs obtained with the patient in a standing position. The patients had had persistent symptoms for at least 12 weeks and had been confirmed as surgical candidates by their physicians.” These patients were also significantly disabled by their symptoms, with a baseline mean score of 42 on the Oswestry Disability Index.
2 ReferencesJames N. Weinstein, D.O.
Jon D. Lurie, M.D.
Tor D. Tosteson, Sc.D.
Dartmouth Medical School, Lebanon, NH 03756
SPORT@dartmouth.edu 1
Birkmeyer NJ ,Weinstein JN ,Tosteson AN , et al. Design of the Spine Patient Outcomes Research Trial (SPORT). Spine 2002;27:1361-1372
CrossRef | Web of Science | Medline2
Cummins J ,Lurie JD ,Tosteson TD , et al. Descriptive epidemiology and prior healthcare utilization of patients in the Spine Patient Outcomes Research Trial's (SPORT) three observational cohorts: disc herniation, spinal stenosis, and degenerative spondylolisthesis. Spine 2006;31:806-814
CrossRef | Web of Science | Medline
Author/Editor Response
Copeland describes part of the range of patient preferences that occur with back pain and sciatica. As a neurosurgeon, he had advantages not readily available to most patients: immediate knowledge of a familiar diagnosis and prognosis, nearly instant access to expert care, and deep knowledge of the best local care providers. He had a satisfying job and several incentives for a quick return to work. He fortunately had immediate, complete relief and rapid recovery from surgery.
I know other physicians with unequivocal sciatica who were more averse to surgery, chose noninvasive treatments, and had more gradual improvement, yet never missed a day of work. However, many patients do need time off from work and time to consider their options. Many prefer to experiment with conservative care. For some, the diagnosis is ambiguous. Many who undergo surgery experience either less rapid recovery or complete pain relief. Thus, Copeland's usual approach to his patients seems as valid as his approach to self-care. Accommodating a range of well-informed preferences should be the goal of responsive care and shared decision-making.
Richard A. Deyo, M.D., M.P.H.
University of Washington, Seattle, WA 98195
