THE OPERATIVE TREATMENT FOR LOW-BACK PAIN

1. The vast majority of cases of low-back pain can be relieved and the patient restored to functional usefulness without operative interference. 2. Correction of bad body mechanics by physical therapy, including stretching of contracted fascia or muscles, exercises, and the use of a good spine brace over a period of time, will restore the average patient to a reasonable degree of normalcy. 3. Orthopaedic operations for the relief of low-back pain should be performed only after diagnosis has been accurately established and osseous neoplasms or neurological lesions have been excluded. 4. Pathology of the low-back region which may call for operative interference includes tuberculosis or chronic sclerosing osteomyelitis of the lumbosacral or sacro-iliac joints, primary malignant neoplasms, lesions of the spinal cord, spondylolysis, and spondylolisthesis. 5. Arthrodesing operations are contra-indicated if there is evidence of chronic infectious arthritis of the spine or of other joints. 6. Patients with a psychiatric background, who show no definite pathology in the low-back region, are considered to be poor selections for operation. 7. Patients who are seeking financial settlement because of a compensable injury are not suitable for spinal-fusion operations until after financial settlement has been made, unless there are definite osseous changes which can be demonstrated. 8. In patients for whom arthrodesing operations are planned it should be possible to localize the lesion to the joint affected. Trisacral fusions are probably rarely indicated. Multiple-joint-fusion operations are often merely shot-gun procedures. 9. Operation may be justifiably recommended for the patient with chronic low-back strain, without definite roentgenographic evidence of local pathology, which cannot be relieved by the conservative program so that the patient can resume a reasonable degree of activity, and, particularly, for patients whose economic status requires that they do manual labor in order to earn a living. 10. In the author's opinion, an arthrodesing operation is the procedure of choice. 11. The operation itself is preceded by vigorous stretching and manipulation. It is further recommended that, in fusing the spine, care be taken that the normal lumbar curve be preserved. 12. If there is a sciatic neuritis, the surgeon should excise the articular facets on both sides between the fourth and fifth lumbar vertebrae and the fifth lumbar vertebra and sacrum. 13. The orthopaedic surgeon must be constantly alert to the fact that neurological lesions or primary osseous neoplasms may produce symptoms of low-back pain and sciatic neuritis. 14. The judgment and skill of the orthopaedic surgeon may be measured by his ability to select, from the great numbers of patients who consult him because of symptoms of low-back pain, those with real indications for operative treatment. His courage may be shown either in refusing to perform an operation when it is urged that he do so and his conscience and judgment say "no", or in his determination to operate when he is convinced that only by such a procedure can the patient be cured. 15. In his own practice the author fears that he has been overconservative at times and guilty of the sin of surgical omission. And yet, in so short a series as that presented here, at least five operations have been performed which subsequently have been the cause of regret.