Tuesday, May 13, 2008

Back Pain - Treatment Options - Health - New York Times

Back Pain Eludes Perfect Solutions


BACK pain is one of the most common physical complaints, so it's no surprise that treatments for it have multiplied over the years. That ought to be good; instead, many patients find that sudden back pain opens the door to a world of medical confusion.

The effectiveness of virtually every pharmaceutical or surgical remedy, however, has been questioned. And for all the money sufferers spend on doctor visits, hospital stays, procedures and drugs, backs are not improving. The Journal of the American Medical Association reported that spending on back treatments jumped 65 percent to nearly $86 billion from 1997 to 2005, after adjusting for inflation. But during the same period, the proportion of people with reduced function because of spine problems increased, even after controlling for an aging population.

"Low back pain represents so many different diseases that there really hasn't been a breakthrough treatment," said Dr. Russell K. Portenoy, chairman of the department of pain medicine and palliative care at Beth Israel Medical Center in New York. "It's good for the public to know how little we know."

The mystery begins with the first doctor's visit. The exact cause of back pain is never found in 85 percent of patients, said Dr. Dennis C. Turk, professor of anesthesiology and pain research at the University of Washington and a past president of the American Pain Society. Even magnetic resonance imaging seldom sheds light; in many studies the scans have picked up spinal abnormalities in many people who have never reported back pain.

So what's a sufferer to do?

Narcotic pain relievers like OxyContin, used regularly by more than eight million Americans, can help, but doctors remain deeply divided over when to prescribe them. The painkillers can also be highly addictive and lead to mood changes.

"I think we are an overmedicated society, and I would not recommend narcotics for everyday back pain except for in most rare of circumstances," said Dr. James N. Weinstein, editor of the medical journal Spine and chairman of the department of orthopedic surgery at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

Alternatives to narcotics have proved problematic, too. Two anti-inflammatory drugs, Vioxx and Bextra, were taken off the market after being linked to heart attacks. And ibuprofen and aspirin can cause gastrointestinal bleeding or organ damage at high doses.

Spinal injections of steroids and anesthetics increased by nearly a third during the 1990s, but several scientific reviews found scant evidence that these provided more than short-term relief. Some doctors have begun prescribing drugs like Lyrica, an anticonvulsant, and Cymbalta, an antidepressant, to treat chronic back pain. But the data on antidepressants is also mixed. A study last fall in The Annals of Internal Medicine found that antidepressants help back sufferers, but this year a review by the respected Cochrane Collaboration, a nonprofit organization for health information, concluded there was no evidence that antidepressants offered relief.

While the quest for a safe and effective pain pill continues, Americans undergo more than 300,000 spinal fusion surgeries a year, at an average cost of $59,000 each, according to the National Center for Health Statistics. Almost as many undergo laminectomies or diskectomies to remove damaged vertebrae and disks.

For some, back surgery can be life-changing, eliminating pain and disability. But for others, it can have serious consequences. One study found that 11.6 percent of patients in the 78 spinal surgeries that were analyzed developed infections and other complications.

Newer procedures, like implants of medication pumps and stimulators, have received mixed reviews, too. The jury is still out on kyphoplasty, an outpatient procedure for patients with vertebrae fracture from osteoporosis. The doctor inserts a needle into the spine and inflates a balloon, then injects a cement, gluing the bones together. The procedure works only for some patients.

With such uncertainties, it is little wonder that many doctors have fallen back on more traditional approaches to easing the pain, like exercise or counseling. This year, the Accreditation Council for Graduate Medical Education began requiring that medical residents who want to become pain specialists study not only anesthesiology but also psychology, neurology and rehabilitative medicine.

The reality is that most people with back pain heal on their own, slowly, without major intervention. "The best treatment for straightforward back pain without a specific diagnosis is reactivating yourself to what you normally do as fast as possible," Dr. Weinstein, the Spine editor, said.


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