Pain in the back? Talk to an Indy-area doctor before choosing surgery

For eight years Sandie Reed struggled with low back pain that became so debilitating she could hardly walk. The Angie’s List member from Fortville tried physical therapy, chiropractic care and cortisone injections before undergoing surgery to replace and fuse three discs in August 2007. “The pain was just taking away all quality of life,” she says. The following January, she was bowling, and now she snow skis, golfs and bikes. “I feel very lucky,” she says.

Like Reed, 80 percent of Angie’s List members who took a recent online poll say they’ve suffered from back pain. The majority of sufferers have lower back pain, experts say, because the bones in the upper and middle back don’t flex as much. While problems develop most often from genetic factors, high-impact sports, smoking and obesity also play a role, says highly rated orthopedic surgeon Dr. Herbert Biel. He practices at Indiana Orthopaedic Center and operated on Reed at Community Hospital North.

Various treatment options available

Treatment options include doing nothing at all — time heals most back pain, according to the National Institute of Neurological Disorders and Stroke — to physical therapy, chiropractic care, pain medication and acupuncture. If patients are still suffering after four to six weeks, Biel says doctors should use X-rays, MRIs or CT scans to get side, back and front views of the spine to check for instability. Most doctors agree surgery should be the last option.

“Ninety percent of patients don’t end up with anything surgical done,” Biel says. “It’s rare a patient should, on an initial visit, be told they need surgery unless they’ve had a few months of treatment or an immediate problem like a tumor.” Those who’ve tried alternatives and still endure pain should talk to multiple doctors about surgical options.

Ten percent of Angie’s List poll respondents say they’ve had back surgery and three quarters say it helped reduce their pain. Members report getting back surgeries from orthopedic surgeons who focus on the musculoskeletal system, and neurosurgeons who study the nervous system, spine and brain. Both are qualified to perform back surgery, doctors say, but it’s best to seek board certified doctors who specialize in the spine and who’ve completed a spine surgery fellowship, says highly rated Dr. Raj Rao, American Academy of Orthopaedic Surgeons spokesman.

It’s estimated doctors perform more than 1 million back surgeries every year. Laminectomy, which removes part of the vertebra to relieve nerve pressure, and spinal fusion, where vertebrae are joined, are the most popular inpatient procedures, according to the Agency for Healthcare Research and Quality. Other procedures include foraminotomy, in which bone is removed from the vertebrae to widen the space where nerves exit the spine; discectomy, which removes all or part of a disc; and disc replacement.

Doctors have developed techniques that use smaller incisions, and there’s an increasing number of patients who can benefit and be back to normal activity in a few weeks, says neurosurgeon Dr. Zoher Ghogawala of Burlington, Mass., who leads peer-reviewed clinical trials to better understand spinal procedures. Recovery for more complex surgery can take up to eight weeks and might include physical therapy and other exercises. Surgeries that use small incisions from the front of the body such as discectomy and neck fusions have good outcomes, Biel says.

back surgery playing golf activity Angie's List

Angie’s List member Sandie Reed says she's playing golf again after her back surgery from Dr. Herbert Biel

The most important aspect is getting the right surgery, Ghogawala says. “We don’t have clear-cut guidelines,” he adds. “Spinal surgery is a big deal, and most surgeons are good about cautioning patients about this.” When appropriately prescribed, he says it has an enormous impact on quality of life.

Ghogawala, along with other spine specialists, agree doctors have a high level of confidence in diagnosis if back pain symptoms are related to nerve problems. On average, those patients do much better with an operation. For back pain not involving pinched nerves, the diagnosis is less clear.

He recommends patients ask about the doctor’s surgery outcomes and the chances of needing a second surgery. Make sure the surgeon does follow-up appointments, not a nurse or a physician’s assistant, he says.

After interviewing three surgeons, member Sandie Reed chose Biel because he talked openly about the risks and recovery process. She underwent the more invasive fusion and disc replacement surgery to avoid potential future operations. She still experiences some stiffness, but she has no limitations except not being able to touch her toes. Reed, who paid a $5,000 deductible for the $150,000 surgery, says she doesn’t take her surgery success for granted. She exercises and stretches daily to keep her back in motion.

Consider less-invasive alternatives

Highly rated neurosurgeon Dr. Robert Sloan says 85 percent of his practice at Community Neurosurgery on the Eastside is treating spine disorders. Sloan typically performs minimally invasive surgeries because they require less operating time and less blood loss, he says. “A lot of people hear of horror stories that they should never have anybody touch their back,” says Sloan, adding he rarely first suggests surgery.

Patients should understand their condition, he says, and they should insist doctors show them test images and explain their physical exam. A doctor should discuss risks of procedures, such as stroke, pneumonia or kidney failure. Sloan says new technology and nerve function monitoring during surgery keeps risk of complications, especially paralysis, low.

Problems arise when physicians don’t react or treat complications fast enough, or if health or surgical emergencies are ignored, says attorney Bruce Kehoe, who specializes in medical legal issues at Wilson Kehoe Winningham on the near Northside. He recently settled a case for an Indianapolis woman who developed a blood clot after undergoing a laminectomy. He says he can’t name his client or the doctor because of the settlement, but says his client’s clot caused temporary paralysis, the need for a second surgery and continued complications including leg and back pain that forced her to retire.

“It shouldn’t be particularly worrisome if a patient looks at a doctor’s record and he’s been sued,” Kehoe says. “If there are a number of claims, then I might be concerned.” 

Do your homework

Experts suggest patients also ask doctors about the number of surgeries they perform. A study by the Congress of Neurological Surgeons says doctors who do more back surgeries have better outcomes. Doctors with at least 81 surgeries in four years, according to the report, had the most success, but Biel believes doctors should perform at least 75 back surgeries per year. Rao, with the AAOS, adds patients shouldn’t base surgery solely on numbers. “The number of cases a surgeon has done may be important, but equally important may be that they do [surgery] for the right reasons,” he says.

Experts say most people over age 40 have disc degeneration or even herniated discs. “We all have degenerative changes,” says highly rated orthopedic surgeon Dr. Michael Coscia. “Whether to operate really comes down to a discussion with a doctor and ultimately what patients decide is right for them.”

Before surgery, many doctors encourage patients to try chiropractic care. About 60 percent of patients at highly rated Mason Family Chiropractic & Wellness in Fishers have lower back pain, says owner Richard Mason. “You know within two to four weeks if you can help somebody,” he says. “There needs to be open communication between providers. Sometimes the surgeon is the only answer. Sometimes a chiropractor can make a difference.”

Physical therapy, which requires a prescription in Indiana, can also help to ease lower back pain, says Bryce Taylor, owner of highly rated Downtown Physical Therapy. “I think we fit somewhere on the continuum of care,” he says. “If PT fails, and steroids fail, often surgery follows.” Therapists first examine and then manipulate the body, helping the patient gain mobility with exercises as well as heat, cold and electrical stimulation.

Taylor starts by creating an exercise plan to reduce pain for patients such as former Indianapolis resident Fred Koss who experienced sudden back pain in the spring and was diagnosed with a compressed sciatic nerve. “I was a little skeptical about this,” says Koss, who follows exercises on his iPad. “Almost right away I saw improvements.”

How much does it cost?

Some insurance plans don’t cover physical therapy, so experts suggest checking with your provider. Each office sets its own rates, and Downtown Physical Therapy charges $120 for an evaluation and $92 per session.

Insurance does cover most spine surgeries, but some providers consider disc replacement experimental and require patients to pay out of pocket. Healthcare Blue Book estimates the fair market price in Indianapolis for a discectomy at $13,452; a laminectomy, $12,407; and $48,017 for a two-hour lumbar fusion, including physician, anesthesia and facility fees. The fair price represents what a health provider typically accepts from insurance companies as full payment, which is less than the billed amount.

Angie’s List member Patricia Eagles paid $500 out of pocket for a $19,000 laminectomy to relieve nerve pressure in July 2011. The Carmel member had lived for a year with pain and numbness before she discovered her problems were nerve related. “It got so bad, I thought ‘I can’t live like this anymore,’” says Eagles, who first underwent three rounds of cortisone injections.

After getting multiple opinions, she chose Coscia at highly rated OrthoIndy on the Northwest side, to perform the surgery. Today, she’s grateful she can do household tasks again, like watering her garden, without pain. “I thank my doctor every single day,” she says.

 — additional reporting by Matthew Brady

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