Back to basics
Published on 01 July 2011
A study looking into ways of improving the outcome of back surgery has thrown up some unexpected findings. Jane Tadman reports.
Can post-operative exercise and rehabilitation help people to recover from back surgery? Or is up-to-date information and advice just as good?
Those were the questions posed by Professor Alison McGregor when she embarked on an Arthritis Research UK-funded clinical trial involving more than 300 patients with back pain.
Although most people with back pain don’t need surgery, for a small number it can help. An operation called a discectomy relieves the pressure on the spinal cord caused by a prolapsed disc, and can be effective in reducing sciatica in up to 90 per cent of cases.
A second small group of usually older people whose back pain is due to spinal stenosis – narrowing of the space around the nerves in the spinal cord – can expect a 50 per cent improvement from an operation known as laminectomy or decompression surgery.
Post-operative care was patchy
Previous research had shown that post-operative care was patchy, minimal and varied from surgeon to surgeon, and Professor McGregor’s reasoning at the time of setting up the clinical trial was logical. By the time most people with low back pain undergo surgery, their spinal muscles are seriously de-conditioned because they will probably have been in severe pain and unable to have done much exercise for some time, so it made perfect sense to assume that a rigorous regime of exercise starting six weeks to three months after surgery would help them regain some fitness and more mobility.
It was equally intuitive to assume that giving patients a booklet based on clinical evidence and lots of good common sense about keeping active – stressing that activity will not harm the back but actually heal it – would also have a positive benefit.
Neither approach makes any difference
However, Professor McGregor, professor of musculoskeletal biodynamics at Imperial College London, has found that in fact neither approach makes any difference to the outcome of surgery in terms of functional disability.
As she prepares to publish the results of the six-year-trial in the journal Spine Professor McGregor is philosophical, believing that although it didn’t produce the outcome she’d expected, the study threw up a lot of interesting information that may help to improve the way that patients are treated after back surgery.
“We found that there was a huge discrepancy between expectation and what actually happened,” says Professor McGregor. “There was also a correlation between what you achieve and what you expect – if people had a higher expectation they got a better outcome because they tended to work harder at it.”
In general terms, people who had undergone discectomy surgery were happier and more satisfied with the outcome than those patients having laminectomy.
One important finding was that most patients’ condition didn’t improve much beyond three months after surgery – which was when the rehabilitation classes usually started. So it may be that rehab might have worked better had it begun sooner after surgery. Inevitably some patients remained nervous of exercising after the surgery because they feared it would damage their back in some way, which may go some way to explaining the fact that 41 per cent of those in the rehab class didn’t attend a single session.
Patients reported a number of negatives about their experiences of spinal surgery. These included a lack of information and advice, dissatisfaction with GPs in terms of diagnosis and management, disappointment with the outcome of the surgery and a perceived lack of respect by their surgeon.
“Many people consented to surgery because they were desperate, but they didn’t know what to expect and that rehabilitation after surgery was not routinely provided. Many felt isolated,” says Alison McGregor. “Some people found that unless they really pushed for answers they wouldn’t get them and that there was a real need to be assertive.”
She is now planning future research looking at ways in which the NHS can provide better care pathways for people who have spinal surgery, and to receive better information in different formats.
The patients’ experience
Colin Scott: in the rehabilitation and booklet group
Colin Scott had spent ten months off work in extreme pain before having a discectomy two years ago, so after the operation he was determined to do everything he could to get back to a normal life. His operation was a complete success and he was up and about after 24 hours.
A steward with British Airways, now aged 53, Colin attended all but one of the rehab classes after his operation and found them very useful. In fact, he still does the exercises now; largely pilates-type exercise to strengthen the tops of the legs and buttocks.
“I do understand that other people are not as diligent but I had had a very painful year or so and I was at the stage where there was no way I was going back,” says Colin, who was back at work full-time within three weeks of surgery. “I was determined to take advantage of everything.
“I didn’t find the back booklet as much use. I’m the sort of person who if you show me how to do something I will get it and then go and do it on my own. Sometimes people need to be encouraged but I am too young to sit down and not do anything; I wanted to get back to fitness.”
What Colin also found immensely helpful was the fact that from start he saw the same surgeon who operated on him all the way through.
He adds: “She suggested that I did the exercises and I felt that really boosted me. I was very lucky; it made a big difference. I was very happy with what happened to me. I had fantastic treatment with all the rehab, and, at the end of it, it meant I have got my life back. I can go walking with the dog, go swimming, go to the gym again. It’s made a massive difference to me.”
Steve Holdsworth: the “usual care” group
Forty-seven-year-old Steve’s experience of the aftermath of back surgery was not a particularly positive one. He was in the “usual care” arm of the trial. This meant he was not given any active treatment, so received no rehab, nor was he given the back surgery booklet. “Usual care” in his case meant no post-operative treatment at all.
Steve had had acute episodes of back pain on and off for years but two months before surgery he found he couldn’t stand up. He was in such agony he was taken to A&E for treatment, and on discharge he was advised to have an immediate MRI scan.
This revealed that he had extreme damage to his cauda equina nerve which had caused irreparable damage, leaving him with distressing symptoms, including incontinence and sexual dysfunction.
Although the decompression surgery he underwent at Charing Cross Hospital was a “success”, in that it reduced the pressure on his spinal cord and stopped the pain, the damage had been done.
“I was in hospital for two nights and although I couldn’t fault the in-house care, after I was discharged I was very much left to my own devices, which I was very disappointed with,” says Steve, who works as a fundraising manager for a small homelessness charity.
“Because the surgery was deemed a success as far as they were concerned, I was off the radar. But because the damage I had to my cauda equina nerve is so rare there wasn’t any sort of support group for it, and because the symptoms were nothing to do with my back, no-one was interested. It would have really helped to have had a bit of a more joined-up approach from the health service.”
Steve went back to work within two weeks of surgery and although he has ongoing problems, he no longer has back pain.
Mary Waddington: in the rehabilitation group
Mary’s decompression surgery two years ago was deemed a success and after ten months of sleeping just two hours a night because of intense pain, surgery to release the sciatica in her leg gave her much-needed relief. But it proved to be short-lived and she has had to undergo further surgery to release the femoral nerve in her leg as unpleasant sensations gradually crept back.
Mary, aged 62, who works as an extra in films and TV, found the rehab programme very helpful. “I was extremely grateful to have physiotherapy after the operation and I benefited from one-to-one therapy, because I was in the trial, but the NHS can’t run to that sort of provision,” she says.
Mary attended every rehab class at Charing Cross Hospital and tried to carry on exercising at home, but found away from the group encouragement her motivation waned.
Although back at work, she has had to adapt to a less active lifestyle: she has to lie down at least once a day and still has to have steroid injections for her back pain.
The Arthritis Research UK FASTER trial
More than 300 patients from seven hospitals in London took part in the £260,000 study, which compared the effectiveness of a rehabilitation programme and an education booklet for the post-operative management of people having discectomy or laminectomy.
Patients in the rehab group had a programme of supervised exercises, including general aerobic fitness work and stretching and strengthening exercises for the back, leg and abdominal muscles, twice a week for an hour and starting six weeks to three months after surgery. Patients in the booklet group were handed the educational booklet – based on evidence-based messages and advices – on discharge from hospital.
Some groups had both the rehab and the booklet, and each group was also compared with the “usual care”; which means whatever post-operative care individual surgeons normally employ – which might be nothing.