Fit Nation

Two Fixes for Bad Backs

As a neurosurgeon, I spend more than half my time helping patients cope with a surprisingly unremarkable problem: back pain. Despite the life-and-death challenges of treating complex brain tumors, vascular malformations and spinal trauma, it is this most commonplace of ills that consumes more than half my patient hours and that can be one of the most stubborn conditions for any neurosurgeon to manage.

Often the source of persistent back woes is sciatica, caused by a herniated, slipped or protruding disc that impinges on the sciatic nerve, sending pain all the way down the leg. Back pain, including sciatica, is one of the leading causes of workplace absenteeism and is the fifth leading cause of expenditures in U.S. hospitals each year. Given the ubiquity of the condition, you'd think doctors might have reached some consensus on the best ways to treat it, but you'd be wrong— and a new study released in late May may only make things less clear.

Patients with sciatica often complain not only of symptoms in the leg and back, but also of numbness and sometimes weakness. The pain can be absolutely unbearable, even likened to childbirth by one Mrs. Gupta, who is looking over my shoulder as I write this. Sometimes patients come into my office vigorously kneading their thigh in the hope it will bring some relief. They occasionally report that they are taking multiple pain medications— causing some of them to doze off as I try to take a medical history. People like this are tired of suffering and want the quickest fix possible. Often that means surgery. Around the world, approximately 1.5 million people each year undergo operations to relieve pressure on the sciatic nerve, a procedure that usually brings them the relief they seek. But new research suggests that over the course of time, surgery may be no better than nonoperative therapeutic methods.

In the study, published in the New England Journal of Medicine, researchers followed 283 patients who had suffered with sciatic pain for at least six weeks. Half of them were scheduled for surgery, and the other half were told to get conservative treatments— principally rest, gentle stretching and back-strengthening exercises, and, when needed, anti-inflammatories. Using various scales to measure dysfunction and disability, the investigators found that 95% of participants in both groups reported significant recovery after one year. That's good news for sciatica sufferers who are concerned about the risks of surgical complications, which can include bleeding or, worrisomely, accidental nerve damage that may only exacerbate the pain. What's more, surgery can cost a few thousand dollars, will leave you sore for a few weeks and requires a couple of months for full recovery.

So why would you opt for an operation at all? Speed, for one thing. In most cases, pain relief and perceived recovery come faster via a trip to the operating room than through exercise and medications. In fact, even in the current study, 39% of the patients who were initially assigned to receive conservative care opted for surgery anyway because they could no longer tolerate the pain.

Which course is right for you depends on the nature of your case. If you are getting progressively weaker or have pain that is searing and uncontrollable with conventional pain medications, you may need to go under the knife. Short of such extreme cases, most surgeons will wait a few weeks before pulling out the scalpel— often just long enough for patients to notice improvement with less invasive techniques. Whichever direction you choose to go, it's nice to know that if you must have a problem like sciatica, at least it's one of those rare conditions that have not just one good solution, but two. And in case you're curious, Mrs. Gupta opted for the operation and has never felt better.