醫實注行
專家解讀“麻醉痛症專科”（亦稱“疼痛科”）及＂麻醉科＂專業知識及應用問題 - pain management
By Linda Carroll
Just a month after back surgery, Nancy Scatena was once again in excruciating pain. The medications her doctor prescribed barely took the edge off the unrelenting back aches and searing jolts down her left leg. “The pain just kept intensifying,” says the 52-year-old Scottsdale, Ariz., woman who suffers from spinal stenosis, a narrowing of the chanel through which spinal nerves pass. “I was suicidal.”
Finally, Scatena made an appointment with another surgeon, one whom friends had called a “miracle worker.” The new doctor assured her that this second operation would fix everything, and in the pain-free weeks following an operation to fuse two of her vertebrae it seemed that he was right. But then the pain came roaring back.
Experts estimate that nearly 600,000 Americans opt for back operations each year. But for many like Scatena, surgery is just an empty promise, say pain management experts and some surgeons.
A new study in the journal Spine shows that in many cases surgery can even backfire, leaving patients in more pain.
Researchers reviewed records from 1,450 patients in the Ohio Bureau of Workers’ Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses.
After two years, just 26 percent of those who had surgery returned to work. That’s compared to 67 percent of patients who didn’t have surgery. In what might be the most troubling study finding, researchers determined that there was a 41 percent increase in the use of painkillers, specifically opiates, in those who had surgery.
The study provides clear evidence that for many patients, fusion surgeries designed to alleviate pain from degenerating discs don’t work, says the study’s lead author Dr. Trang Nguyen, a researcher at the University of Cincinnati College of Medicine.
Unfortunately, for most patients with bad backs, there is no easy solution, no magic bullet. Pain management experts — and some surgeons — say that patients need to scale back their expectations. With the right treatments, pain can be eased, but a complete cure is unlikely.
In the wake of her operations, Scatena has turned to less invasive therapies. She’s learned to baby her back and to find ways to avoid irritating the nerves in her spine. She’s working to strengthen muscles in her lower back and abdomen so her spine will get better support. “I’ve been getting some relief from physical therapy,” she says. “And I hope that’s going to be permanent.”
27 million adults with back problems
A recent report by the Agency for Healthcare Research and Quality, a federal organization, found that in 2007, 27 million adults reported back problems with $30.3 billion spent on treatments to ease the pain. While some of that money is spent on physical therapy, pain management, chiropractor visits, and other non invasive therapies, a big chunk pays for spine surgeries.
Complicated spine surgeries that involve fusing two or more vertebrae are on the rise. In just 15 years, there was an eight-fold jump in this type of operation, according to a study published in Spine in July. That has some surgeons and public health experts concerned.
For some patients, there is a legitimate need for spine surgery and fusion, says Dr. Charles Burton, medical director for The Center for Restorative Spine 
Burton and others recommend that patients get a second opinion when back surgery is recommended for the treatment of back pain without neurological symptoms, such as sciatica, especially if other treatments haven’t been suggested first.
“We are very successful at improving leg symptoms," says Dr. William Welch, vice chairman of the department of neurosurgery at the University of Pennsylvania Medical Center and chief of neurosurgery at Pennsylvania Hospital. “We are less successful at treating back pain.”
Source of pain is often hard to pinpoint
The reason, Welch says, is that it’s often hard to pinpoint the exact cause of someone’s back pain. Even MRIs can be misleading because abnormalities, such as degenerating discs, can be seen on scans for virtually everyone over the age of 30 regardless of whether they have pain. Even when the surgery is a success, it rarely dispels 100 percent of back pain, Welch says.
And while many surgeons are careful about which patients they recommend for spine operations, some are not so discriminating, says Dr. Doris K. Cope, professor and vice chair for pain medicine at the University of Pittsburgh School of Medicine. “It’s a case of, if you have a hammer, everything looks like a nail,” she explains.
In general, the best results come about through a combination of approaches, Cope says. Each strategy may reduce pain by just 10 or 20 percent, but those percentages can add up so ultimately the patient’s pain is cut back by as much as 70 or 80 percent. Strategies can include exercise and weight loss, Cope says.
That advice resonates with Marilyn Seiger, a friend of Nancy Scatena in Scottsdale. Seiger opted to skip surgery, not wanting to follow her friend's painful path, even though her doctor recommended an operation to fuse two of her vertebrae.
She has gotten some relief from physical therapy, a back brace that reminds her to keep her back straight, and the occasional pain pill.
“I don’t know anyone who’s had surgery for back pain who had success,” says Seiger, 61. “I just figure this is part of growing older. We’re living longer than our bodies were meant to last and we’re just constantly shoring things up.”
