What is the role of surgery in the treatment of low back pain (LBP) and sciatica?

Updated: Aug 22, 2018
  • Author: Jasvinder Chawla, MD, MBA; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Answer

The benefit of lumbar spine surgery is not controversial in many clinical circumstances, such as neurologically dangerous segmental instability after major trauma, unstable spondylolisthesis, chronic or complicated spinal infection, and in cases of progressive neurologic deficit due to a structural disorder, such as a diskal herniation, neoplasm, fracture, deformity, or severe stenosis.

However, treatment for lumbar disk disorders (LDDs) is more controversial, especially, when a diskal protrusion affects adjacent neural structures, because soft diskal material can be resorbed. Also, current research purports that the relationship between an abnormal diskal contour and neural dysfunction does not correlate statistically with the size, shape or location of the imaged pathology, wherefore, biochemical and inflammatory factors are thought to play primary roles in pain mediation. Therefore, the biological influence of a lumbar disk herniation exerted through morphological, neurochemical, inflammatory, or neurophysiological factors would be expected to change over time and to be altered by passive and active nonoperative interventions.

Two clinical syndromes are thought to be associated with LDDs: primary back pain with minimal to no radicular symptoms and primary radicular pain or sciatica with minimal to no associated back pain. The most common cause of sciatica in working-aged persons is shown to be secondary to disk herniation. [249] Surgical treatment for sciatica is usually successful; however, it is less likely to benefit primary back pain from LDDs (diskogenic pain), and therefore, it is also more controversial. [217, 250]

Degenerative changes of the lumbar spine are universal over time; however, the relationship of these findings to LBP is unclear. Disk degeneration, annular fissures, small diskal protrusions, and facet arthrosis are commonly found in individuals without LBP. [251, 252, 253] Furthermore, longitudinal studies have demonstrated that the severity, chronicity, and disability associated with LBP correlates more closely with premorbid and comorbid psychosocial-related factors than spinal degenerative changes or LDD. [254, 255]

Surgery for chronic diskogenic LBP without radiculopathy has been demonstrated to be ineffective. [217, 256] Randomized trials of lumbar fusion compared with various nonoperative strategies have shown neither consistently good outcomes with surgery nor clear benefit over nonsurgical treatments. [257, 258, 259]

However, the average patient seeking care does not usually present with a single overt pathoanatomy, especially after 3-6 months, whereby, accumulating psychosocial and other operant factors contribute most to the persistence of pain and disability. The 1983 randomized control trial by Weber showed that a higher percentage of patients with tolerable sciatica without serious neurological deficit who were randomized to undergo laminectomy and diskectomy improved over at least the first year compared with those who underwent nonoperative care. Both groups in Weber’s study experienced a relatively slow convalescence when surgical techniques were characterized by comparatively large surgical exposure and a higher operative morbidity. [260]


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