Failure of Conservative Care

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I went to a national spine meeting in Philadelphia in the fall of 2005.  I was with one of my partners who is also a spine surgeon.  We had just heard two papers presented regarding the results of lumbar fusions in patients who were injured on the job and were on worker’s compensation.  The results presented were not very good.  They were only slightly better than not doing surgery.  The main reason cited for performing the fusions were “failure of conservative care.”  As we were discussing the presentations, we realized we had not heard a clear definition of “failed conservative care.”  The definition had not been presented in these papers.  Although we had heard that term throughout all of our careers, a generally agreed upon standard did not exist.

“Failure of conservative care” is the most common reason cited for performing a low back fusion or artificial disc.  There is not a clear definition of what the standard of conservative care should be.  Currently, I think a rough consensus of what is adequate non-operative care would be the following:

  • Persistent low back pain for more than three to six months
  • Six to twelve physical therapy visits
  • One to three cortisone injections
  • Many will insist on an evaluation with a psychologist who specializes in dealing with pain

Many centers have some very elegant resources that are well organized and effective.  However, I am referring to the remaining majority of  centers where these programs are not readily available.   There are several problems with this random approach:

  • Pain is affected by many factors.  Often, all factors need to be addressed simultaneously to be effective.  That is rarely done.
  • Treatment is geared towards the structural source of the pain, and the nervous system is not often addressed.
  • The surgeon may not know the physical therapist’s competency.  There is also large variation in the intensity and components of physical therapy.
  • Only a minority of physicians aggressively deal with sleep issues.  That is particularly true of surgeons.

This is not adequate conservative care.  We look at it as comprehensive care.