Considering surgery? A decision guideline

We talked with James N. Weinstein, D.O., M.S., director of the Dartmouth Institute for Health Policy and Clinical Practice. He is also chairman of the department of orthopaedics at the Dartmouth Medical School and the Dartmouth-Hitchcock Medical Center.

How long should a person wait before considering surgery for back pain?

Many common back problems–even those that cause severe pain–will resolve themselves over time. Patients without associated symptoms in their legs should generally wait a minimum of 6 to 12 weeks. If there is no improvement, and pain is severe and disabling, spinal surgery is an option to consider provided you have been properly evaluated by a surgeon and clearly understand the risks and benefits of the proposed treatment options.

What questions should patients ask their surgeon?

• Are you board-certified?
• How many surgeries like this did you do last year, and what were the results?
• Are the results (data) available to patients?
• Do you have a sense of how your patients who choose surgery do vs. those who choose not to have surgery?
• What makes you think that surgery is the right course of action?
• Will anything bad happen if I don't have surgery?
• May I talk to one of your patients who underwent a similar operation about a year ago?

What if the surgeon won't answer these questions?

Get a second and even a third opinion. Good surgeons welcome a second opinion. Patients can also use tools like the Dartmouth Atlas to compare rates of surgeries across regions and see if the "surgical signature" of their area makes them a high-rate region.

Why are you more likely to get back surgery if you live in one city than in another?

Your chance of having a back operation varies largely by where you live. The rate of spinal surgery in the U.S. has skyrocketed over the past two decades and is higher than anywhere else in the world. The related expenditures are staggering. In 2003 Medicare spent more than $1 billion on lumbar fusions alone.

Our survey found that those who underwent discectomies were significantly more satisfied (69 percent) than those who underwent spinal fusions (56 percent). If one surgeon recommends a fusion and another, simple discectomy, how do you know which operation is right for you?

When it comes to spinal surgery, less is more. Most patients in my practice come in for a second or third opinion, and I rarely recommend a fusion. If a fusion is a consideration it requires a lengthy discussion of risks—including longer hospitalization and blood transfusion—and an understanding of the rehabilitation involved. Patients need to know that they do have a choice, and their preferences and values matter.

More than a quarter of the respondents in our survey said they had not been informed about the risks of surgery, such as nerve injury, bleeding, and infection. How is that possible?

It is unfortunate that shared decision-making and true "informed choice" is not the norm. Patients want and deserve to have meaningful information presented to them about risks and benefits, particularly in cases in which treatment options are a toss-up.

What about minimally invasive techniques and other new technologies?

There are many new technologies available, and they are confusing to patients and their families. Knowing your doctor's experience and his or her results using these technologies is important. Patients should also ask if their doctor is involved in any way with the companies that produce equipment used for surgeries. This is not always an indicator of a conflict of interest, but a good surgeon will willingly disclose any involvement, however slight.

What about artificial disks?

The evidence for multiple-level disk replacement is less than adequate. The evidence for artificial disk replacement for back pain is still evolving. Patients should be cautious about new technologies generally. Because they are available elsewhere doesn't mean they are necessarily better, or that they are safe and effective.

How long does recovery take after lower-back surgery?

Twelve weeks seems to be the magic number (in order to avoid recurrence), but it really depends on the patient's job. A heavy laborer will require 12 weeks or more, but some sedentary workers return to work after a week or two.