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injury is most common in young adult men. It is estimated that 63% of new traumatic injuries occur in individuals between the ages of 16 and 30 years, with a 4:1 male:female ratio [19].

Epidemiology of LBP

LBP is a very common health problem in western industrialized countries. Up to 80% of Americans report having LBP at some point in their lives, most often between the ages of 30 and 50 years. To put this in perspective, table 1 lists the incidence of LBP compared to a variety of other neurosurgical disease states. In addition, clinically significant sciatica is seen in 5% of the US population. Recurrent episodes of LBP occur very frequently, and a considerable number of people have permanent discomfort from LBP. Chronic LBP is present in 3-7% of the population in western industrialized countries [20-22]. In the USA, back pain is the most common cause of activity limitation in people younger than 45 years [23], the second most frequent reason for visits to the physician, the fifth-ranking cause of admission to the hospital, and the third most common cause of surgical procedures [21]. About 2% of the US workforce are compensated for back injuries each year [21]. In 1988, the annual combined cost of back pain-related medical care and disability compensation in the United States was estimated to be between USD 26 and USD 56 billion [24].

LBP affects men and women equally, with onset most often between the ages of 30 and 50 years. It is the most expensive cause of work-related disability in terms of workers' compensation and medical expenses. Risk factors for chronic LBP include heavy lifting and twisting, bodily vibration, obesity, and poor conditioning, although LBP is common even in people without these risk factors [21, 22].

Recovery from nonspecific LBP is generally rapid. One study reported that 90% of patients seen within 3 days of LBP onset recovered within 20 weeks [25]. However, in cross-sectional studies, which oversample patients with multiple visits, the prognosis is less favorable. These studies may best reflect the experience of primary care physicians, and suggest that one third of patients are substantially improved at 1 week, with two thirds improved at 7 weeks [26, 27]. Recurrences are common, affecting 40% of patients within 6 months. Most recurrences are not disabling, but the emerging picture is that of a chronic problem with intermittent exacerbations, analogous to asthma, rather than an acute disease that can be cured [22].

LBP is second only to upper respiratory problems as a symptom-related reason for visits to a physician [20, 21]. Unfortunately, there are wide variations in care, a fact that suggests there is uncertainty about the optimal approach to management. In addition, there is evidence of excessive imaging and surgery for LBP in the United States, and many experts believe the problem has been 'overmedicalized' [22].

The association between clinical symptoms and radiographic imaging shows little correlation. Most diagnostic evaluations focus on exclusion of herniated discs, stenosis, infection, neoplasms, and trauma. However, up to 85% of patients with isolated LBP cannot be given a precise pathoanatomical diagnosis, with nonspecific terms, such as 'strain', 'sprain', or 'degenerative process', commonly used [20]. Strain and sprain have never been anatomically or histologically characterized, and patients given these diagnoses might accurately be said to have 'idiopathic LBP' [22].

Patients with chronic LBP (i.e., pain duration more than 3 months) use health services more often than most other patient groups [20]. Spontaneous recovery in these patients is slow and unpredictable, and the return-to-work rate after 2 years absence from work due to LBP has been shown to be exceedingly low. At any given time, about 1% of the work force is chronically disabled because of back problems [28].

In contrast, the natural history of herniated discs is more favorable. Improvement is the norm, although it is often slower than improvement in LBP alone. Only about 10% of patients have sufficient pain after 6 weeks that surgical intervention is considered. Sequential MRI studies reveal that the herniated portion of the disk tends to regress with time, with partial or complete resolution in two thirds of cases after 6 months [29]. Patients with herniated discs who undergo surgery do not return to work earlier than those who receive nonsurgical therapy, although they have better symptomatic and functional outcomes [30].

A paradox exists in that the American economy has become increasingly postindustrial, with less heavy labor and more automation and more robotics, while medical advances in spine treatment with diagnostic imaging and new forms of surgical and nonsurgical therapy have developed. At the same time, however, work disability caused by back pain has steadily risen! The positive aspect is that most back pain patients will substantially and rapidly recover, even when their pain is severe. This prognosis holds true regardless of treatment method or even without treatment. Only a minority of patients with back pain will miss work because of it. Most patients who do leave work return within 6 weeks, and only a small percentage never return to their jobs.

Variations in Treatment for Spinal Disorders

Patients with neck and back pain seek care from general practitioners, chiropractors, orthopedists, neurosurgeons, rheumatologists, and others. There is a wide variation in how doctors care for patients with neck and back pain, with evidence of excessive imaging and surgery for the problem. In most cases of LBP, patients recover within a few weeks of the onset of symptoms. The fact that LBP often resolves spontaneously may partially explain the proliferation of unproven treatments that may seem to be effective. When patient descriptions are standardized, physician recommendations for neck and back pain evaluations vary enormously. Rheumatologists are twice as likely to order blood work to rule-out arthritic conditions. Neurosurgeons are twice as likely to order imaging studies. Neurologists are 3 times more likely to order EMGs [28].

Surgical procedures for herniated discs and spinal stenosis accounted for 83% of the more than 188,000 spine surgeries done in Medicare patients in 1996-1997. There were approximately 39,000 discectomies, 90,000 lumbar decompressions, and 27,000 cervical spine procedures. The remaining 32,000 procedures were for other spinal conditions. Overall, spine surgery rates increased by 57% over the 10-year period from 1988 to 1996, from 2.1 to 3.4 per 1,000 Medicare enrollees (fig. 1) [31].

There remains significant variation within the United States in the use of surgery for many spine-related problems. Rates of spine surgery vary more than any other common inpatient procedure. In 1996-1997, rates of spine surgery varied by a factor of 6, from 1.4 per 1,000 Medicare enrollees in the Bronx, N.Y. hospital referral region to 8.6 per 1,000 Medicare residents in Bend, Oreg. Cervical spine procedures accounted for 14% of the spine surgery performed in the Medicare population in 1996-1997; rates of cervical spine surgery varied by a factor of more than 10, ranging from 0.16 to 1.72 per 1,000 Medicare enrollees in the different hospital referral regions [31].

The use of spinal fusion displays a wide variation among geographic areas, as well as varying from 0.3 to 3.0 per 1,000 Medicare enrollees (fig. 2).

Fig. 1. Increase in rates of spine surgery among Medicare enrollees (1988-1997). Overall surgery rates increased by 57% between 1988 and 1997 [from 31, p. 29].
Fig. 2. Rates of spinal fusion varied by a factor of almost 10, from 0.3 to 3.0 per 1,000 Medicare enrollees, after adjustment for differences in population age, sex and race (1996-1997). Each point represents 1 of 306 hospital referral regions in the United States [from 31, p. 38].

The proportion of patients undergoing spine surgery who received a spinal fusion increased from 23% in 1993 to 29% in 1997. During the same period, the proportion of patients undergoing fusion who received hardware fixation devices rose from 50 to 60%. Among Medicare patients undergoing laminectomy for

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Fig. 3. Use of fusion with surgery for lumbar spinal stenosis (1996-1997). Fusion was used in at least 40% of lumbar decompression procedures in 12 hospital referral regions. In 10 regions, fusion was used in less than 10% of operations [from 31, p. 41].

lumbar spinal stenosis, the use of fusion varied from 4% of the operations to 56%. Figure 3 shows the variation across the United States in the use of fusion with surgery for lumbar spinal stenosis [31].

It is unlikely that the large degree of regional variation in the use of spine surgery reflects regional differences in the incidence of disease. Instead, regional variation in surgery reflects differences in physician practice style -physicians in some regions of the United States are simply more inclined to recommend surgery in patients with surgically treatable conditions of the spine. The likelihood that patients will undergo particular surgical procedures of the spine is remarkably variable. This is apparent on a local level, as well as with 'surgical signatures' reflecting the practice patterns of individual physicians and the local medical culture. Neighboring regions with similar demographics

Fresno Modesto Alameda Salinas San Francisco San Jose San Mateo Stockton County County

■ Lumbar discectomy ■ Decompression for lumbar stenosis ■ Cervical spine surgery

Fig. 4. The surgical signature of spine surgery in 8 California hospital referral regions (1996-1997). Patterns of spine surgery - the 'surgical signatures' of hospital referral regions -varied in idiosyncratic ways. This graph compares rates of three kinds of spine surgery in 8 California hospital referral regions to the national average [from 31, p. 44].

Fresno Modesto Alameda Salinas San Francisco San Jose San Mateo Stockton County County

■ Lumbar discectomy ■ Decompression for lumbar stenosis ■ Cervical spine surgery

Fig. 4. The surgical signature of spine surgery in 8 California hospital referral regions (1996-1997). Patterns of spine surgery - the 'surgical signatures' of hospital referral regions -varied in idiosyncratic ways. This graph compares rates of three kinds of spine surgery in 8 California hospital referral regions to the national average [from 31, p. 44].

and about the same per capita numbers of spine surgeons can have very different signatures for spine surgery. Figure 4 shows the variation in spine surgery in eight different hospital referral regions. The rate of lumbar discectomy was 41% higher than the national average in the Stockton, Calif. hospital referral region, but the rate of decompression for lumbar stenosis was 7% lower than the average. By contrast, the rate of lumbar discectomy in Fresno, Calif. was 39% below the average, but the rate of cervical spine surgery was 9% higher than the national average. In San Jose, Calif. the rate of decompression was 54% below the average, but the rate of lumbar discectomy was only 2% below the average [31].

Among the surgeons who performed spine surgery in Medicare enrollees in 1996, 3,011 were orthopedic surgeons and 2,934 were neurosurgeons. Overall, neurosurgeons performed 64% of all spine surgery among Medicare enrollees, compared to 36% by orthopedists. The proportion of spine surgery performed by either neurosurgeons varied markedly among hospital referral regions, from 19% in Akron, Ohio to 99% in Rapid City, S.D. The relative contributions of orthopedists and neurosurgeons also varied widely according to the kind of procedure. While neurosurgeons performed 85% of surgical procedures on the cervical spine, they performed only 59% of decompressions for lumbar stenosis. Neurosurgeons and orthopedic surgeons were quite different in their use of fusion for some types of spine surgery. While both performed noninstrumented fusions in about one third of cervical procedures, orthopedic surgeons were much more likely to

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Back Pain Revealed

Back Pain Revealed

Tired Having Back Pains All The Time, But You Choose To Ignore It? Every year millions of people see their lives and favorite activities limited by back pain. They forego activities they once loved because of it and in some cases may not even be able to perform their job as well as they once could due to back pain.

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