For back pain sufferers, surgery isn't always the answer

Surgery also carries a high price tag. Spinal fusion, for example, runs about $60,000. Medicare pays out nearly $1 billion for spinal surgery each year. Many physicians and surgeons are concerned that some of their colleagues may push expensive procedures because they have a stake in companies that produce the necessary equipment or devices. Dr. James Weinstein, a spinal surgeon at Dartmouth Medical School in Hanover, N.H., cites as an example the metal cages for spinal fusion that came onto the market in 1996 and were touted to doctors in an aggressive ad campaign. Surgery rates soared.

"It certainly is good for Wall Street and the companies that are selling the equipment, and good for many of the highly paid consultants," says Charles Rosen, director of the Spine Center at UC Irvine. "But it's not the best for patients."

Concerned with the rise in surgery rates, in 2006, Rosen founded the Assn. of Ethical Spine Surgeons (now the Assn. for Medical Ethics), which includes more than 200 spinal surgeons. The association calls for doctors who receive more than $50,000 in consulting fees to make their company connections known and consider recusing themselves from leadership positions such as editorship of scientific journals.

Doctors say the high-surgery trend is unlikely to change soon, but that education of doctors and patients is key. Deyo, among others, is developing patient decision-making guides, and studies have shown that patients who have more information are less likely to opt for an operation.

So how can doctors and patients define a good candidate for surgery? Andersson suggests patients should wait six months, trying other therapies, before opting for an operation. Deyo says a surgery candidate should have imaging studies that match the symptoms, and leg pain indicating nerve involvement. Filler says that one useful test is that if a localized anesthetic directed at the suspected problem does indeed numb the pain, it probably is the correct target for surgery.

There are plenty of treatment options to try before considering surgery. It is sometimes difficult to evaluate the effectiveness of therapies because most back pain fades regardless of treatment. And some newer treatments haven't had much evaluation.

The main thing, experts say, is to be informed. "There's been a big increase in the intensity of treatment for back pain," Deyo says. That intensity, he says, would better serve many if it focused more on finding the best therapy for each patient -- and less on the surgical quick fix.