If you've ever wondered why the United States spends $2.3 trillion a year on health care, consider this: Back pain alone costs Americans $86 billion a year for surgeries, injections, pain pills and other treatments.
All of which bring — at best — mixed success.
Nearly everyone experiences back pain eventually. A report by the National Center for Health Statistics found that more than a quarter of adults had low back pain in the past three months. It's the second most common neurological ailment in the United States, trailing only headaches, according to the National Institute of Neurological Disorders and Stroke.
Why so much pain? Doctors say it's simple — Americans on average are older and fatter than ever before. Backs weaken and break down with age, and added weight accelerates the process.
What to do about it? That's not so simple.
Most people deal with the pain themselves, taking over-the-counter pain relievers, trying hot baths and ice packs, being careful not to strain their aching backs. But when home remedies don't bring enough relief, the next step is professional help.
More people are getting scans to diagnose their back problems, injections of steroids and other drugs to give them quick relief, powerful prescription narcotics — including opioids — and alternative treatments such as acupuncture and chiropractic care.
And increasingly, Americans are going for what they hope will be the ultimate fix: surgery.
Back surgery has become a booming business over the past decade. About 800,000 Americans have back surgery each year, according to the American Academy of Orthopaedic Surgeons .
More complex procedures such as spinal fusions — in which vertebrae are permanently bonded — have nearly doubled, from 203,000 in 1997 to 381,000 in 2007, according to the group.
But evidence is mounting that for many patients, surgery is no better at relieving pain than physical therapy and anti-inflammatory medicines. Some patients are even worse off after surgery, leading the profession to coin the term "failed back surgery syndrome."
Dr. Juan Uribe, a Tampa neurosurgeon, said most patients he sees come into his clinic demanding surgery before he has even examined them. He tells them surgery isn't right for everyone. And unlike other interventions, it isn't reversible.
Dr. Steven Atlas, an assistant professor at Harvard Medical School who has studied the escalation in back surgery, says too many surgeons don't take that kind of time to urge alternatives. Fact is, he says, doctors make more money doing procedures than counseling caution.
And they face pressure from patients who expect quick and complete results from modern medicine. Atlas says doctors and patients used to be satisfied if back pain could be relieved enough to allow a return to work and daily activities.
"And now, we live in a society where we're told we should have no pain," Atlas said.
Geraldine Martino, 64, of St. Petersburg said she wishes she had followed the wisdom of an earlier era. After years of back pain, she went to a doctor who told her the discs between several vertebrae were so deteriorated, she "was bone on bone.'' She tried a series of painkilling injections and a pair of spinal fusions in 2008 and 2009.
Now she is in so much pain, she spends much of her days in bed.
"I should have listened to what my father always told me when I was younger," Martino said. "Just take an aspirin and go on. Deal with it."
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Doctors say there are some good reasons to have back surgery.
For instance, if you're experiencing numbness or loss of bowel function, those are signs of nerve involvement that can often be helped by surgery. Tumors in the spine are another reason; so are some — but not all — fractures.
The trouble is that although back pain is common, pinpointing its cause — and determining the best treatment — is incredibly complicated, explained Dr. F. Reed Murtagh, a Tampa neuroradiologist.
The back is an intricate structure of bones, muscles and other tissues centered on the spinal column, which protects the spinal cord. Any number of problems — a pulled muscle, broken bone, herniated disc, pinched nerve, or any combination — can put a person in misery. (See graphic.)
Plus, pain is subjective — what is intolerable to one person isn't so bad to another. And if you've ever had back pain, you know how hard it is to pinpoint exactly what part of your back hurts.
Put it all together, and back pain is one of the toughest conditions to accurately diagnose, Murtagh said.
Uribe, the surgical director for spine services at the University of South Florida, adds that although back pain is as old as man, doctors are still learning about it.
"There are still areas of back pain we do not understand," Uribe said.
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If you decide you're a candidate for surgery, you face an array of choices.
To name a few of the most common: Laminectomies and discectomies are decompression procedures in which parts of bone or discs are removed to relieve pressure on the nerves. There are fusions, which permanently connect two or more vertebrae in your spine in an effort to relieve pain. And then there are a number of procedures used to treat fractures, such as vertebroplasty, in which bone cement is injected into the broken area.
Many traditional back surgeries involve incisions on the front or back of the patient, or both. They can be lengthy procedures involving rods, screws and other devices, and require hospital stays of several days. The bill for a spinal fusion, for instance, can easily top $100,000.
The demand for back pain solutions has spurred an emerging practice of treatments widely advertised as "minimally invasive.'' Many of these involve the use of scopes that are inserted through smaller incisions to address back problems.
The Laser Spine Institute in Tampa offers a number of minimally invasive treatments, all of which are done in an outpatient setting, allowing patients to leave within a matter of hours.
Business there is booming. The company performs about 450 procedures a month, compared with about 30 a month when it opened in Tampa five years ago, said Erika Mangrum, senior vice president of marketing. The company has also opened surgical centers in Arizona and Pennsylvania.
Company officials tout internal data that show high patient satisfaction. They advertise all over the country, and recently were featured on the daytime TV show The Doctors.
Ron Helinger, 54, of Treasure Island had surgery at the institute more than four years ago to address a herniated disc and spinal stenosis, which is a narrowing of the spinal column.
He said he had tried physical therapy, massage and painkilling injections, without relief. He said the surgery relieved his pain almost immediately, and he missed only two days of work.
"Four years and eight months later I'm totally fine," he said.
But then there are people like Benjamin Van Buren. The 76-year-old from Coral Gables was among nearly 200 people who responded to an item in the St. Petersburg Times seeking people who had back surgery yet were still in pain.
Van Buren says the Laser Spine procedures he received in 2008 and 2009 provided no help for pain from spinal stenosis and degenerating discs. He says the $16,900 he paid — his out-of-pocket cost — was a waste.
"I'm in the same place where I was," Van Buren said. "I can't walk, and I'm in tremendous pain."
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In recent years, several published studies have raised questions about back surgery:
• A 2006 Dartmouth Medical School study on surgery for a type of disc herniation found that patients who had nonsurgical treatments fared just as well as those who underwent surgery. Another 2006 study by researchers at Leiden University Medical Center in the Netherlands yielded similar results.
• Researchers with Oregon Health & Science University found that a majority of patients with general low back pain caused by conditions like osteoarthritis who undergo surgery don't get good results. That and other findings led the American Pain Society to recommended rehabilitation such as exercise and weight loss, plus medications as an effective alternative to surgery.
• The American Academy of Orthopaedic Surgeons announced this year that it was recommending against the use of the popular back procedure vertebroplasty — used to treat fractures — after a pair of clinical trials published in the New England Journal of Medicine found it to be ineffective.
• A study this year in the journal Spine that examined 1,450 patients in Ohio who were candidates for spinal fusion found that just 26 percent of the patients who had surgery returned to work after two years, compared with 67 percent of patients who didn't have surgery. The study also noted a 41 percent increase in the use of painkillers, including opioids, in the patients who had surgery.
As for minimally invasive laser spine procedures, Dr. H. Gordon Deen, a neurosurgeon at the Mayo Clinic in Jacksonville, wrote in a 2009 column on the Mayo Clinic website that "there are no clear benefits to laser surgery over more well-established spine surgery techniques that have proven to be effective." He said doctors at the Mayo Clinic neither use nor recommend laser spine surgery.
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So, what does work?
Many doctors say most back pain can be managed without extensive, expensive treatment. Murtagh, the Tampa neuroradiologist, suggests people experiencing back pain should wait six weeks before even getting an X-ray or MRI.
But he says doctors often don't tell that to patients — many of whom don't want to hear it, anyway. "Everybody wants something done right away," he said.
If surgery is recommended, Murtagh urges getting at least a second opinion, since some surgeons are more eager to operate than others.
Atlas, the assistant professor at Harvard, has found that a multidisciplinary approach is best for most people, one that involves therapy and exercise to improve flexibility and strength, and weight loss if needed, as well as judicious use of medication.
He also said people need to adjust their expectations. Unless you have a condition for which surgery is a well-proven remedy, the sad fact is that it may not be possible to banish all pain.
A more realistic goal, he said, might be improving function, and managing pain.
"Doctors can't cure chronic back pain. I'm not sure how many doctors start off by telling their patients that," Atlas said. "But the goal is to get their symptoms to a point where they can function."
Uribe, the USF surgical director for spine services, says he generally won't see patients unless they have spent at least six months to a year trying such nonsurgical treatments.
Even then, he says surgery is often not the answer. He estimates that of the 30 patients who are seen at his clinic every day, only three or four end up in surgery.
"I send them back to pain management, physical therapy, rehabilitation," Uribe said. "A lot of them leave frustrated and unhappy, but it's the best thing.
"I tell them, 'I can make money off you very easy. But that's not my game. I want you to get better.' "
Richard Martin can be reached at firstname.lastname@example.org or (727) 893-8330.