Neurosurgical Management for the Patient With Benign Intractable Low Back Pain

Abstract

I n 1934, the classic report of Mixter and Barr’ on rupture of the intervertebral disc as the etiology of low back pain and sciatica was published. Within a short time, the procedure of disc excision became very popular and widespread. While early publications on the subject detailed the diagnostic criteria and surgical technique to be used in this patient population, it was not long before concerns were expressed about the results of operative management. Grant’ in 1944 reported that disc excision generally relieved the sciatic leg pain, but frequently the pain in the back remained, producing ongoing discomfort and disability. In his series of 150 patients, 52% were pain free and working, 37% were working with disability, and 11% were not working. These results were not much different from a group of his patients treated conservatively. Surgery was not, in his opinion, the only treatment for this problem. Similar results were presented by others at this time. Spurling and Grantham reported a 40% complete cure rate, with a 10% failure rate. These authors also made the astute observation that the incidence of dissatisfied patients was twice as large in the compensation group as in the entire group. They quoted Prince’s explanation for this phenomenon as the “universally deteriorating effect of insurance on the ethics of the human race.” In the series of Shinners and Hamby, only one-third of the compensation patients considered themselves cured by operation. They noted that the compensation patient was becoming more reluctant to admit to being “cured” by surgery than in an earlier study, and attributed this to difficulties in the rules for compensation adjustment. Analyses of the causes of failure from the operative treatment of lumbar disc lesions were soon presented. Greenwood et al5 studied their 5% of cases subjected to a secondary procedure. Dense adhesions around the nerve root were the most common finding. Reoperation was successful in 80% of noncompensation cases, but in less than half of the compensation ones. Armstrong6 enumerated a dozen causes of failure and he believed that one of these could be noted in almost all instances. We may infer that he was in favor of reoperation in many such cases. Thus, over 40 years ago the surgical community was beginning to grow a little weary of patients undergoing disc excision, particularly those in the compensation group. A significant number of patients either underwent a repeat procedure or were treatment failures. This reality has undoubtedly continued to this day. The current socioeconomic costs of the multiply operated low back pain syndrome are staggering and increasing. This has led some authors to question whether too much spinal surgery is in fact being performed in this country.7 Unfortunately, a large population with this problem already exists and more than likely will continue to grow. The recent decades have seen many and varied attempts at managing this patient group. Neurosurgeons are among those intimately involved with the management of many painful disorders, including back pain. This involvement may attempt to resolve the underlying mechanism for the pain. However, often the neurosurgical approach can only hope to achieve pallia-