An episode of back pain is defined as back pain lasting for at least 12 hours and recurrent back pain would be defined as the presence of least two such episodes in a year 1. Repeated episodes of back pain cannot be classified as chronic back pain although such bouts of back pain have been present for many years unless each episode of back pain last for at least 12 weeks. Back pain that last between 6 weeks to 12 weeks is often classified as subacute back pain. There appears to be some consensus that low back pain which persists for at least 12 weeks can be classified as chronic low back pain and that which is present for less than 6 weeks can be classified as acute back pain. Is there justification for spinal fusion in the treatment of patients with non-specific low back pain?ĭefinition and classification of chronic low back painĪ review of the literature reveals that there is no uniform definition for chronic or recurrent low back pain although a uniform definition is essential for the study of prevalence and treatment outcome of low back pain. It is common knowledge that litigations in this arena in Malaysia is on the rise. When surgery is done for a symptom and not for a disease the outcome tends to be poor and this increases the risk of negligence suits. Besides this, there is a strong element of conflicts of interest which has caused a spike in spinal fusion rates. This ‘surgical lacuna’ has led many surgeons to believe that spinal fusion surgery will cure the patient of chronic low back pain and this is partly responsible for an exponential increase in rates of spinal fusion around the world. Surgeons are trained to treat conditions which are amenable to surgery and are not trained to treat patients who do not need surgery unlike the neurologists and cardiologists who are trained to treat patients who do not need surgery. This is partly due to an ‘orthopaedic surgery lacuna’ which is caused by the nature of training received by orthopaedic or spinal surgeons. Surgeons are treating the symptom back pain and not a disease, with surgery, when they offer spinal fusion as a modality of treatment to such patients. A pathoanatomical diagnosis cannot be made in these patients, even with modern diagnostic imaging techniques such as magnetic resonance imaging of the spine, and this makes the treatment of non-specific back pain difficult. In vast majority of the patients the cause of the pain is not known and such pain has been unscientifically labelled as non-specific back pain. Unfortunately the cause of back pain can be accurately diagnosed and treated in only a small proportion of the patients, where specific spinal pathology such as tumours, infection, fractures and nerve root pain caused by prolapsed disc or spinal stenosis, is present. Low back pain represents a common disabling and costly health problem. The devices industry has a significant influence on not only research publications in peer review journals but also on decisions made by doctors which can have a detrimental effect on the welfare of the patient. The spine, unfortunately, has been labelled as a profit centre and there are allegations of conflicts of interest in the relationship of doctors with the multi-billion dollar spinal devices industry. There is a growing tension between ethics and conflicts of interest for surgeons. Yet there is rapid rise in the rates of spinal fusion. Spinal fusion is a major surgery which can be associated with significant morbidity and occasionally with mortality. Therefore the outcome of spinal fusion in these patients can be no better than nonsurgical treatment. Surgical treatment of non-specific back pain where no pathoanatomical diagnosis has been established is bound to fail. There exist no causal relationship between imaging findings of degenerated disc, lumbar facet arthritis, spondylosis, spondylolysis and spondylolisthesis, to the pain in these patients. Despite the existence of sophisticated imaging techniques and a plethora of diagnostic test the source of pain in patients with nonspecific back pain cannot be established. The back pain in the rest of the patients where no pathoanatomical diagnosis can be made is often labelled, unscientifically, as chronic low back pain. A pathoanatomical diagnosis which fits into a classical disease model where successful treatment can be carried out, can only be made in 5% to 7% of the patients. For treatment to be effective the cause of the pain has to be established but unfortunately in 80% to 95% of the patients the cause cannot be determined despite the existence of modern imaging techniques. The treatment of chronic low back is difficult and is often ineffective. Chronic low back pain is a common, disabling and costly health problem.
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