ANN ARBOR, Mich.—Each week, Andrew J. Haig, M.D., sees patients seeking relief from continued pain after back surgery, sometimes referred to as “failed back surgery syndrome.” Many of these patients – often elderly – have been diagnosed with lumbar spinal stenosis – a narrowing of the spinal canal in the lower back that causes pressure on the nerves in the spinal cord resulting in buttock and leg pain.
Their surgery, while meant to relieve pressure on their nerves by fusing one or more vertebrae together, limiting motion but restoring health, ultimately leaves them in pain. Their diagnosis is often made using anMRI.
“Though using MRI to diagnose spinal stenosis is supported by the North American Spine Society and accepted by surgeons across the country, there is substantial research suggesting it is not a reliable method for diagnosing such conditions and it is not uncommon for me to treat someone who was offered spinal surgery for a diagnosis that was not caused by the spine,” says Haig, a physiatrist who specializes in the field of physical medicine and rehabilitation and who practices in theUniversity of Michigan Department of Physical Medicine and Rehabilitation’s Spine Program.
In the commentary, Diagnosis and Management of Lumbar Spinal Stenosis, published in the Jan. 6, 2010 edition of the Journal of the American Medical Association, Haig, and co-author Christy C. Tompkins, Ph.D., a research fellow in U-M PM&R, challenge NASS guidelines that support using imaging techniques alone, such as the MRI, to justify the most common reason spine procedures are performed in older people.
The authors cite three recent papers illustrating their stance and believe there is a better test for diagnosing spinal stenosis – electromyography.
“Electromyography, sometimes called EMG, is a procedure used to check the health of muscles and nerves that control those muscles. We feel that more specifically, a special technique developed by our team called paraspinal mapping can make the diagnosis with high certainty and can find other problems like neuropathy and muscle diseases that can fool doctors into thinking a person might have spinal stenosis,” Haig says. “In an NIH-funded research study and a separate Turkish study, the test was found to be highly specific for spinal stenosis.”
The authors say NASS guidelines should be re-examined and new guidelines should be developed that incorporate other diagnostic procedures and treatment options including three key steps in diagnosing and treating patients with lumbar stenosis: Finding and treating what is not stenosis first; clearly defining and treating the effects of stenosis second; and finally, using non-invasive surgical treatments for presumed, but non-definitive diagnoses first, before moving to surgery.
“When I hear their stories, I often find they were offered surgery by a physician who did not aggressively pursue other more definitive diagnostic tests and who did not offer other treatment choices,” says Haig. “Before agreeing to back surgery, the most important step is for patients to see an expert in non-surgical management of back pain, such as a physiatrist. A good physician is unlikely to recommend surgery for spinal stenosis unless a person has worked with a physical therapist for a month and attempted more conservative treatments to deal with the pain. If those options fail, additional testing can be performed, such as EMG to be sure the problem really is spinal stenosis.”