I am an avid golfer. People who are my patients understand my great passion for this game. Many of these people are my patients because of a back pain problem that is impacting their ability to play golf. In April 2019, Tiger Woods, arguably the greatest golfer of all time, won the Pro Golfers Tour (PGA) Master tournament after years of physical decline and back surgeries. Woods’ victory was considered remarkable and miraculous because of the numerous failed back back surgeries he had. For Woods, it was the fourth surgery that was the “charm.”

Some of our patients have asked us about the spinal fusion surgery (the 4th surgery) that Tiger Woods had 4 years ago in 2017, this was the “successful” surgery. They want to know if this surgery may be right for them? We tell our patients the reality is very likely not. How come? I will let the spinal surgeons and back pain researchers discuss this with you now in this article.

People who have spinal fusion can return to golf. One study says about half of golfers having spinal fusion return to the game within one year.

Many of you have back pain, many of you know someone who had a spinal fusion surgery. It may be the success of that person’s surgery that sent you exploring spinal fusion for yourself. The question you may have of course is, “will spinal fusion help me?” For some of you the second question may be, “will I be able to play golf after the surgery?”

People do have successful spinal fusion surgeries. Some of these people are also able to return to the golf course. Here is a 2017 study (1) which explains the odds of a successful outcome.

• In this study, 34 patients who had a one of two level spinal fusion and were identified as regular golfers were followed after their surgeries to see how much golf they could play and how they did playing it.
• The average age of golfers who had the spinal fusion was 57 years old. (The youngest patient was 32, the oldest patient was 79.
• In 79% of golfers, pre-surgery back and/or leg pain significantly affected their ability to play golf.
• Within 1 year from surgery, of the 34 patients:
  • 65% of patients returned to practice and
  • 52% returned to course play.
  • 29% of patients stated that continued back/leg pain limited their play.
  • 77% were able to play the same amount of golf or more than before fusion surgery.
  • Of those providing handicaps, 80% reported the same or an improved handicap.

52% of golfers return to on-course play within 1 year of lumbar fusion surgery. The majority of golfers can return to preoperative levels in terms of performance (handicap) and frequency of play.

One thing that I want to point out in this study is that the golfer’s had a single or two level fusion. There was no data on three or more level fusions.

On Tiger Woods: “An outcome like his from fusion surgery is so rare it is like winning the lottery”

On May 15, 2019, New York Times health writer Gina Kolata published a story entitled: “How Tiger Woods Won the Back Surgery Lottery.” The reason for this title? It is explained by  Dr. Sohail K. Mirza, a spine surgeon at Dartmouth who said: “An outcome like his from fusion surgery is so rare it is like winning the lottery.”

Why is successful fusion surgery so rare? 

This was explained by Dr. Charles A. Reitman, co-director of the Spine Center at the Medical University of South Carolina in the NY Times article:  “People with a broken spine, for example, or scoliosis, which is severe spinal curvature, or spondylolisthesis, in which vertebrae slip out of place, tend to have terrific results, he said. But those are a tiny minority of fusion patients. The vast majority of fusion procedures are performed on patients with one or more degenerated disks, disks that are worn out, dehydrated, stiff and friable. And when those disks move, patients’ backs can ache.”

From the same article: Tony Delitto, of the University of Pittsburgh’s School of Health and Rehabilitation Sciences, says he tries to warn patients seeking fusion surgery for a deteriorated disk not to expect too much.“I would be very, very hesitant, and most surgeons would be very, very hesitant to tell patients that after fusion they would be pain-free,” he said.

Dr. Steven Atlas, an associate professor of medicine at Harvard said he tells patients that it is one thing for an athlete like Woods to have that operation — it may be risky but he also might get a few more years out of his playing career, which could be worth millions of dollars. But he cautions typical middle-aged patients. “Once they have that fusion, it can’t be undone,” Dr. Atlas said. “And it is likely that they will have future surgery down the road,” as a consequence of the instability fusion causes. “If your goal is cure, that isn’t what this is going to offer,” he said.”

Fusion surgery is very rarely successful – it is in fact a bad gamble

A study that appeared in the medical journal Radiologia (Radiology) (2) examined the traditional recommendations of sending a patient to get an MRI and then offering a fusion surgery based on what the MRI indicated. The researchers had concerns about the enthusiasm some surgeons had for surgery that was likely inappropriate.

This is from the study:

• Most imaging findings (Scans and MRIs), find degenerative changes that reflect anatomic peculiarities or the normal aging process and turn out to be clinically irrelevant.
• Imaging tests have proven useful only when systemic disease is suspected or when surgery is indicated for persistent spinal cord or nerve root compression.
• Many treatments (surgeries) have proven inefficacious, and some have proven counterproductive, but they continue to be prescribed because patients want them and there are financial incentives for doing them.”

The keywords of the research are “ineffective,” and “counterproductive,” for the patient.

I am going to continue on with the study from the Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York.. This study furthers the evidence that spinal fusion is at best a risky surgery. Here is the learning points of this research.

• “Not only is Intervertebral disc  degeneration seen on imaging studies not indicative of low back pain, but patients with discogenic back pain are also poorly indicated for surgery.”
• “Given the difficulties in determining who will benefit from surgery, the American College of Physicians recently updated their LBP treatment guidelines, recommending noninvasive, nonpharmacologic treatments as the first line of therapy.” (3)

In a study published in the Journal of Neurosurgery, Spine that examined patients with back pain, investigators found that patients in fact did expect to get an MRI when they have back pain and that the MRI will reveal exactly what the cause of their pain is. Not only that but:

• more than 50% of the patients would have a spinal surgery if their doctor told them they had an abnormal spinal MRI, even if they had no pain or restricted movement. 
• A large proportion of patients (33%) believed that back surgery was more effective than physical therapy in the treatment of back pain without leg pain.
• Nearly one-fifth of the survey group (17%) also believed that back injections were riskier than back surgery.
• CONCLUSION: “Patients overemphasize the value of radiological studies and have mixed perceptions of the relative risk and effectiveness of surgical intervention compared with more conservative management. These misconceptions have the potential to alter patient expectations and decrease satisfaction, which could negatively impact patient outcomes and subjective valuations of physician performance.”(4)

 

The evidence has been presented by leading surgeons and medical universities. The odds of having a successful fusion surgery, can be like winning the lottery, you can hope, but the odds will be against you.

Can we help you with your back pain without surgery? We would need you to come into our office so we can assess your situation and work to reduce your pain.

For more research see my articles:

https://stemcellinstitute2.com/lumbar-fusion-researchers-grade-risk-rewards/

https://stemcellinstitute2.com/mris-reason-ill-advised-lead-unnecessary-surgery/

Do you have questions? Ask Dr. Darrow

 

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References:

1 Shifflett GD, Hellman MD, Louie PK, Mikhail C, Park KU, Phillips FM. Return to golf after lumbar fusion. Sports health. 2017 May;9(3):280-4.
2 Kovacs FM, Arana E. Degenerative disease of the lumbar spine. Radiologia. 2016 Apr;58 Suppl 1:26-34. doi: 10.1016/j.rx.2015.12.004. Epub 2016 Feb 10.
3 Mosley GE, Evashwick‐Rogler TW, Lai A, Iatridis JC. Looking beyond the intervertebral disc: the need for behavioral assays in models of discogenic pain. Annals of the New York Academy of Sciences. 2017 Aug 10.
4 Franz EW, Bentley JN, Yee PP, Chang KW, Kendall-Thomas J, Park P, Yang LJ. Patient misconceptions concerning lumbar spondylosis diagnosis and treatment. J Neurosurg Spine. 2015 May;22(5):496-502. doi: 10.3171/2014.10.SPINE14537. Epub 2015 Feb 27.