Surgery Isn’t the Answer: (Not all the time) recognizing that you need a little bit of help, and asking for it. Understanding that you may have to undergo a few longer-term therapies before the “quick fix” of surgery.
Back surgery: When is it a good idea?
Trauma, aging, improper body mechanics, and normal wear and tear can all injure your spine. Damage to any part of your back or pressure on the nerves in your spine can cause back pain and other symptoms. If you have ongoing back pain, maybe you’ve wondered — could back surgery help?
In fact, back surgery is needed in only a small percentage of cases. Most back problems can be taken care of with nonsurgical treatments, such as anti-inflammatory medication, ice, heat, gentle massage and physical therapy. When conservative treatments don’t help, back surgery may offer relief. But it doesn’t help every type of back pain.
Do you need back surgery?
Back surgery might be needed:
- If you have a condition that compresses your spinal nerves, causing debilitating back pain or numbness along the back of your leg.
- In some instances when you have bulging or ruptured (herniated) disks — the rubbery cushions separating the bones in your spine. However, many people with bulging disks have no pain.
- If you have broken bones (fractured vertebrae) or other damage to your spinal column from an injury that leaves your spine unstable.
- If you have vertebral fractures and an unstable spine related to osteoporosis.
- If you’ve first tried conservative measures and they fail to relieve your back pain or other symptoms.
The following conditions may require surgery if they’re progressive, painful or causing nerve compression:
- Scoliosis, a curvature of the spine
- Kyphosis, a humpback deformity
- Spondylolisthesis, the forward slippage of a segment of the spine
- Spinal stenosis, narrowing of the spinal canal typically from arthritis
- Radiculopathy, the irritation and inflammation of a nerve caused by a herniated disk
- Degenerative disk disease, the development of pain in a disk as a result of its normal wear and tear
Consider all options
Before you agree to back surgery, consider getting a second opinion from a qualified spine specialist. Spine surgeons hold differing opinions about when to operate, what type of surgery to perform, and whether — for some spine conditions — surgery is warranted at all. Back and leg pain can be a complex issue that may require a team of health professionals to diagnose and treat.
Torn ACL Treatments
The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments of the knee. The incidence of ACL injuries is currently estimated at approximately 200,000 annually, with 100,000 ACL reconstructions performed each year. In general, the incidence of ACL injury is higher in people who participate in high-risk sports, such as basketball, football, skiing, and soccer.
Approximately 50 percent of ACL injuries occur in combination with damage to the meniscus, articular cartilage, or other ligaments. Additionally, patients may have bruises of the bone beneath the cartilage surface. These may be seen on a magnetic resonance imaging (MRI) scan and may indicate injury to the overlying articular cartilage.
It is estimated that 70 percent of ACL injuries occur through non-contact mechanisms while 30 percent result from direct contact with another player or object.
The mechanism of injury is often associated with deceleration coupled with cutting, pivoting or sidestepping maneuvers, awkward landings or “out of control” play.
Several studies have shown that female athletes have a higher incidence of ACL injury than male athletes in certain sports. It has been proposed that this is due to differences in physical conditioning, muscular strength, and neuromuscular control. Other hypothesized causes of this gender-related difference in ACL injury rates include pelvis and lower extremity (leg) alignment, increased ligamentous laxity, and the effects of estrogen on ligament properties.
Immediately after the injury, patients usually experience pain and swelling and the knee feels unstable. Within a few hours after a new ACL injury, patients often have a large amount of knee swelling, a loss of full range of motion, pain or tenderness along the joint line and discomfort while walking.
In nonsurgical treatment, progressive physical therapy and rehabilitation can restore the knee to a condition close to its pre-injury state and educate the patient on how to prevent instability. This may be supplemented with the use of a hinged knee brace. However, many people who choose not to have surgery may experience secondary injury to the knee due to repetitive instability episodes.
Surgical treatment is usually advised in dealing with combined injuries (ACL tears in combination with other injuries in the knee). However, deciding against surgery is reasonable for select patients. Nonsurgical management of isolated ACL tears is likely to be successful or may be indicated in patients:
- With partial tears and no instability symptoms39
- With complete tears and no symptoms of knee instability during low-demand sports who are willing to give up high-demand sports
- Who do light manual work or live sedentary lifestyles
- Whose growth plates are still open (children)
Patient Considerations – Active adult patients involved in sports or jobs that require pivoting, turning or hard-cutting as well as heavy manual work are encouraged to consider surgical treatment. This includes older patients who have previously been excluded from consideration for ACL surgery. Activity, not age, should determine if surgical intervention should be considered.
In young children or adolescents with ACL tears, early ACL reconstruction creates a possible risk of growth plate injury, leading to bone growth problems. The surgeon can delay ACL surgery until the child is closer to skeletal maturity or the surgeon may modify the ACL surgery technique to decrease the risk of growth plate injury.
A patient with a torn ACL and significant functional instability has a high risk of developing secondary knee damage and should therefore consider ACL reconstruction.
It is common to see ACL injuries combined with damage to the menisci (50 percent), articular cartilage (30 percent), collateral ligaments (30 percent), joint capsule, or a combination of the above. The “unhappy triad,” frequently seen in football players and skiers, consists of injuries to the ACL, the MCL, and the medial meniscus.
In cases of combined injuries, surgical treatment may be warranted and generally produces better outcomes. As many as 50 percent of meniscus tears may be repairable and may heal better if the repair is done in combination with the ACL reconstruction.
Hip replacement is an operation in which a damaged hip joint is removed and replaced with an artificial joint. There are many medical conditions that can damage the hip joint.
Reasons for Hip Replacement
The most common reason for hip replacement is osteoarthritis. Osteoarthritis occurs when the cartilage covering the ends of the bones where they meet to form joints breaks down. This causes the bones of the joint to rub together. Growths of bone, called spurs, may form around the joint. These changes lead to pain and stiffness.
Other possible causes of hip damage include injuries, fractures, bone tumors, rheumatoid arthritis, and osteonecrosis.
Rheumatoid arthritis is a condition in which the body’s immune system attacks the membrane that lines the joint. This can lead to pain, inflammation, and destruction of the joint. Osteonecrosis is a condition in which the blood supply to the bone is cut off, causing the bone to die.
Doctors often recommend hip replacement if pain and stiffness interfere with your ability to do everyday activities — particularly if other treatments have not helped.
Before Choosing Hip Replacement
Treatments your doctor will likely recommend first include exercises to strengthen the muscles around the hip, walking aids such as canes to reduce stress on the joint, and medicines to relieve pain.
Medicines for Hip Pain
Several different medicines can be useful for hip pain. For pain without inflammation, doctors usually recommend the analgesic acetaminophen.
For pain with inflammation, your doctor may prescribe a nonsteroidal anti-inflammatory drug such as ibuprofen or naproxen. For additional pain relief, your doctor may recommend acetaminophen and an NSAID, but you shouldn’t combine the two without first speaking with your doctor.
In some cases, stronger medicines may be needed. These include the analgesic tramadol or a product containing both acetaminophen and a narcotic codeine to control pain. For inflammation, doctors may prescribe corticosteroids; however, they should not be used any longer than necessary because of their harmful side effects.
Hip Replacement Isn’t for Everyone
For example, people with Parkinson’s disease or conditions causing severe muscle weakness are more likely to damage or dislocate an artificial hip. People who are in poor health or at high risk for infection are less likely to recover successfully.
If You Are Considering Surgery
The decision to have hip replacement surgery is one you must make with your doctor and your family. If you would like to consider hip replacement, ask your doctor to refer you for an evaluation to an orthopaedic surgeon, a doctor specially trained to treat problems with the bones and joints.
The surgeon must consider many factors before recommending hip replacement. Although most people who have hip replacement are between 60 and 80 years old, age is less of an issue than factors such as pain, disability, and general health. In fact, more and more people under the age of 60 are turning to hip replacement as a way to maintain function and quality of life.
People who are generally healthy are the best candidates for the surgery. Recent studies also suggest that people who choose to have surgery before advanced joint damage occurs tend to recover more easily and have better outcomes.
Physical Therapy or Surgery for Degenerative Disc Disease DDD
Physical therapy and other nonoperative treatments are just as effective at reducing pain and disability as surgical spinal fusion for patients suffering from degenerative disc disease (DDD), according to a recently published study conducted at Thomas Jefferson University Hospital in Philadelphia.
Results of the study, which were published ahead of print in World Neurosurgery, show that among 96 patients treated for DDD, there were no significant differences in outcomes between the 53 who were treated with lumbar fusion and the 43 who chose to pursue nonoperative treatment. Measured outcomes included pain, health status, disability, and overall satisfaction. All patients were cared for by the same psychiatrist.
All of the subjects in the study received a diagnostic lumbar discography procedure between 2003 and 2009, and were offered fusion surgery based on the discogram and magnetic resonance imaging (MRI) results. Researchers found that while all patients reported significantly lower pain scores, data for the 2 groups “do not demonstrate a significant difference for standardized outcomes measures of pain, generalized health status, satisfaction, or disability.”
Results from an APTA survey found that 61% of Americans experience low back pain, but only 4 in 10 seek relief through movement.
Therapy May be as Good as Surgery
Most physicians will tell most patients to not want rush into knee surgery. Physical therapy can be just as good for a common injury and at far less cost and risk, the most rigorous study to compare these treatments concludes.
Therapy didn’t always help and some people wound up having surgery for the problem, called a torn meniscus. But those who stuck with therapy had improved as much six months and one year later as those who were given arthroscopic surgery right away, researchers found.
“Both are very good choices. It would be quite reasonable to try physical therapy first because the chances are quite good that you’ll do quite well,” said one study leader, Dr. Jeffrey Katz, a joint specialist at Brigham and Women’s Hospital and Harvard Medical School.
A meniscus is one of the crescent-shaped cartilage discs that cushion the knee. About one-third of people over 50 have a tear in one, and arthritis makes this more likely. Usually the tear doesn’t cause symptoms but it can be painful.
When that happens, it’s tough to tell if the pain is from the tear or the arthritis — or whether surgery is needed or will help. Nearly half a million knee surgeries for a torn meniscus are done each year in the U.S.
The new federally funded study compared surgery with a less drastic option. Researchers at seven major universities and orthopedic surgery centers around the U.S. assigned 351 people with arthritis and meniscus tears to get either surgery or physical therapy. The therapy was nine sessions on average plus exercises to do at home, which experts say is key to success.
After six months, both groups had similar rates of functional improvement. Pain scores also were similar.
Thirty percent of patients assigned to physical therapy wound up having surgery before the six months was up, often because they felt therapy wasn’t helping them. Yet they ended up the same as those who got surgery right away, as well as the rest of the physical therapy group who stuck with it and avoided having an operation.
“There are patients who would like to get better in a ‘fix me’ approach” and surgery may be best for them, said Elena Losina, another study leader from Brigham and Women’s Hospital.
However, an Australian preventive medicine expert contends that the study’s results should change practice. Therapy “is a reasonable first strategy, with surgery reserved for the minority who don’t have improvement,” Rachelle Buchbinder of Monash University in Melbourne wrote in a commentary in the medical journal.
As it is now, “millions of people are being exposed to potential risks associated with a treatment that may or may not offer specific benefit, and the costs are substantial,” she wrote.
Surgery costs about $5,000, compared with $1,000 to $2,000 for a typical course of physical therapy, Katz said.
One study participant — Bob O’Keefe, 68, of suburban Boston — was glad to avoid surgery for his meniscus injury three years ago.
“I felt better within two weeks” on physical therapy, he said. “My knee is virtually normal today” and he still does the recommended exercises several times a week.
Robert Dvorkin had both treatments for injuries on each knee several years apart. Dvorkin, 56, director of operations at the Coalition for the Homeless in New York City, had surgery followed by physical therapy for a tear in his right knee and said it was months before he felt no pain.
Then several years ago he hurt his left knee while exercising. “I had been doing some stretching and doing some push-ups and I just felt it go ‘pop.’” he recalls. “I was limping, it was extremely painful.”
An imaging test showed a less severe tear and a different surgeon recommended physical therapy. Dvorkin said it worked like a charm — he avoided surgery and recovered faster than from his first injury. The treatment involved two to three hour-long sessions a week, including strengthening exercises, balancing and massage. He said the sessions weren’t that painful and his knee felt better after each one.