Can back surgery be predicted?

800px-flickr_-_official_u-s-_navy_imagery_-_a_doctor_performs_surgeryDo you want to have back surgery? A therapist highly trained in treating back pain can tell you the odds that you will end up on a surgical table. This is a great study for patients that are debating surgical intervention. If you are already scheduled for surgery, ask your physician for a second opinion from a specially trained PT. What do you have to lose? Not all PT’s are trained the same and if your PT didn’t do a thorough assessment, go see a PT certified or Diplomaed in Mechanical Diagnosis and Therapy. I would be able to give you an honest assessment of whether therapy will be able to help you. Seek out someone trained in MDT.

MORAL OF THE STORY:

With patients that present to the clinic sub-acutely, with complaints of lower extremity pain referred from the spine, a MDT evaluation in order to assess for CP would be beneficial to predict non-response to conservative care. Patients that do not demonstrate the CP are greater than six times more likely to require surgery than patients that demonstrate CP.

 

A Critical Appraisal of Centralization and its Ability to Predict Surgical Outcome

 

P: For patients with back and leg pain

I: can patients that do not demonstrate the centralization phenomenon (CP)

C: as compared to patients that demonstrate the CP

O: be utilized to predict a surgical outcome

 

Reviewer:

Vincent Gutierrez, PT, MPT, cert. MDT

 

Search:

Ovidsp with keyword terms “centralization and prognosis”. The results were limited to full text.   58 citations were found with no limit to year published.

 

Date of Search: February 2,2014

Re-evaluation date: February 9, 2014

 

Citation:

Skytte L, May S, Petersen P. Centralization: Its Prognostic Value in Patients with Referred Symptoms and Sciatica. Spine 2005;30(11):E293-E299.

 

Summary:

 

The purpose of this study is to evaluate the CP prognostic value in determining conservative or surgical treatment. This is a prospective cohort study of patients with unremitting back and leg pain, between 18 and 60 years of age. One hundred fourteen consecutive patients meeting these criteria were initially entered in the study and 54 patients were excluded based on the exclusion criteria. The exclusion criteria consisted of the following: previous lumbar spinal operation, pregnancy, serious spinal pathology, other serious pathology, Danish not the patient’s first language, symptoms present greater than 14 weeks and lack of consent.

 

Baseline data including the Nottingham Health Profile (NHP), Low Back Pain Rating Scale (LBPRS), demographic data and the Quebec Task Force (QTF) category of symptom referral. The examining therapist was blinded to the baseline data and performed a Mechanical Diagnosis and Therapy (MDT) evaluation in order to classify the subject as “centralizer” (CG), indicating that the most distal symptom was abolished and remained abolished upon returning to a neutral position, or “noncentralizer” (NCG), indicating no change during the MDT evaluation or the symptoms changed to a more distal location. Twenty-five patients were allocated to the CG and 35 patients to the NCG.

 

The treatment was the same for both the CG and NCG, consisting of “watchful waiting”. This included bed rest for those with neurological deficit and “light mobilization” for those without neurological deficit. Follow-up data was obtained at 1,2,3,6, and 12 months. Three patients from the CG and 16 from the NCG underwent surgery by the one-year follow-up. All patients were accounted for in the results.

Appraisal:

The authors satisfied six of the nine questions regarding the Quality Appraisal Checklist. A follow-up study, to establish the reliability of the results was not performed, and patients entered the study with varying acuity of symptoms. The examiner was blinded from the data collection, and the treating therapists were blinded from the examiner’s assessment.

 

Assessing the CP can predict conservative compared to surgical treatment requirements with 84% specificity and 54% specificity. The odds ratio (OR) for surgery in the NCG was calculated to be 6.17, with a 95% confidence interval (CI).

 

 

 

 

 

Author: Dr. Vince Gutierrez, PT, cert. MDT

After having dedicated 8 years to growing my knowledge regarding the profession of physical therapy, it seems only fitting that I join the social media world in order to spread a little of the knowledge that I have gained over the years. This by no means is meant to act in place of a one-one medical consultation, but only to supplement your baseline knowledge in which to choose a practitioner for your problem. Having completed a Master of Physical Therapy degree, the MDT (Mechanical Diagnosis and Therapy) certification and currently finishing a post-graduate doctorate degree, I have spent the previous 12 years in some sort of post-baccalalaureate study. Hopefully the reader finds the information insightful and uses the information in order to make more informed healthcare decisions. MISSION STATEMENT: My personal mission statement is as follows: As a professional, I will provide a thorough assessment of your clinical presentation and symptoms in order to determine both the provocative and relieving positions and movements. The assessment process and ensuing treatment will be based on current and relevant evidence. Furthermore, I will educate the patients regarding their symptoms and their likelihood of improving with either skilled therapy, an independent exercise program, spontaneous recovery or if the patient should be referred to a separate specialist to possibly provide a more rapid resolution of symptoms. Respecting the patient’s limited resources is important and I will provide an accurate overview of the prognosis within 7 visits, again based on current research. My goal is to empower the patient in order to take charge of both the symptomatic resolution and return to full function with as little dependence on the therapist as possible. Personally, I strive to be an example for family and friends. My goal is to demonstrate that success is not a byproduct of situations, but a series of choices and actions. I will mentor those, in any way possible, that are having difficulty with the choices and actions for success. I will continue to honor my family’s “blue-collar” roots by working to excel at my chosen career and life situations. I choose to be a leader of example, and not words, all the while reducing negativity in my life. I began working towards the professional aspect of the mission statement while still in physical therapy school. By choosing an internship that emphasized patient care and empowering the patient, instead of the internship that was either closest to home or where I knew that I would have the easiest road to graduation, I took the first step towards learning how to utilize the evidence to teach patients how to reduce their symptoms. I continued this process by completing Mechanical Diagnosis and Therapy courses A-D and passing the credentialing exam. I will continue to pursue my clinical education through CEU’s on MDT and my goal is to obtain the status of Diplomat of MDT. Returning back to school for the t-DPT was a major decision for me, as resources (i.e. time and money) are limited. My choice was between saving money for the Dip MDT course (about 15,000 dollars) and continuing on with the Fellowship of American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) (about 5,000 dollars), as these courses are paired through the MDT curriculum or returning to school to work towards a Doctorate of Physical Therapy degree. I initially planned on saving for the Dip MDT and FAAOMPT, but life changes forced me to re-evaluate my situation. The decision then changed to return for the tDPT, as my employer paid for a portion of the DPT program. My goal for applying to and finishing the Dip MDT and FAAOMPT is 10 years. This is how long I anticipate that it will take to finish paying student loans and save for both programs, based on the current rate of payment. I don’t know if I will ever accomplish what I set forth in the mission statement, but I do know that it will be a forever struggle to maintain this standard that I set for myself.

2 thoughts on “Can back surgery be predicted?”

    1. Thank you for your time, with regards to reading the article. An excellent book to follow-up with these thoughts is “Rapidly Reversible Back Pain” by Ron Donelson MD (an orthopedic surgeon). The concept of classifying patients is not new, but unfortunately there are not enough therapists trained to classify patients in this matter. The reasoning behind this could be as benign as they just don’t have the education or as sinister as they are not incentivized to help patients in fewer visits, as it would reduce the fee-for-service portion of therapy reimbursement. There are many articles that cover the concept of directional preference and centralization, but Long’s article is by far the most eye catching. She did a follow-up to this study, in which she had to give those in the other two groups the directional preference based exercises and the results were again dramatic. The second article is more enlightening that the first. When I get time, I will try to summarize it on the site.

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