RENEE MONTAGNE:

Hundreds of thousands of Americans have back surgery every year at a higher rate than any other country. Whether there are too many back surgeries is a hotly debated subject in orthopedics. NPR's Joanne Silberner examines the question of who should get surgery for lower back pain.

JOANNE SILBERNER reporting:

34-year-old real estate broker and amateur triathlete, Noah Hano(ph) has had back problems for almost 20 years.

Mr. NOAH HANO (Real Estate Broker) The first time I hurt my back, I was working in a grocery store stocking shelves, and I went to go lift a box and something popped, and I fell to the ground--and it was about three or four days of not really being able to function or move.

SILBERNER: 37-year-old organic farmer Peter Griffin also has a history.

Mr. PETER GRIFFIN (Organic Farmer): I've had back pain for many years. The last six or eight months my back pain increased sharply. It went from being a bad pain to a worse pain.

SILBERNER: He couldn't sit or bend over, a tough situation for a vegetable farmer. Each consulted Dr. James Weinstein at Dartmouth Medical School, one of the nation's leading experts on back pain. In fact, Weinstein has had back pain himself.

Dr. JAMES WEISTEIN (Physician, Dartmouth Medical School): I couldn't believe it. I was in the post office getting my mail, bending over to my post office box, and I couldn't get up. And I said, this couldn't be happening to me; I'm supposed to be the expert. And I literally had to crawl from parking meter to parking meter to get back to my car.

SILBERNER: Weinstein's diagnosis for both Hano and Griffin was straightforward. Each had a herniated disk. But knowing that didn't make the treatment decision easy.

Mr. WEISTEIN: If somebody has a broken hip, it's not a toss up--you have surgery. There isn't a question about what to do. If you hurt your back, that's a toss up--because there's all kinds of treatments.

SILBERNER: There's spinal fusion, fusing vertebra together; a discectomy, removing part of a leaking disk. There's a laminectomy, freeing up a pinched nerve or no surgery at all. A combination of watchful waiting and working through the pain.

Weinstein wouldn't tell his patients what to do. Peter Griffin.

Mr. GRIFFIN: He specifically said to me that he didn't want to make a recommendation one way or the other. This was a decision, you know, I needed to make in the context of my life, in the context of, you know, concerns I had.

SILBERNER: Weinstein gave Griffin and Hano the same information, all really, that there is to offer right now: two studies, one a 20-year-old publication from Norway showing that one year after consulting an orthopedist, 36 percent of people who didn't have surgery had improved compared to almost twice as many who had surgery. But at 10 years out, the numbers were about equal.

Hano, who decided not to have surgery, thought about the ten-year number.

Mr. NOAH HANO: For me, you know, that was all I needed to hear. As long as I could continue to function and I knew that there was some hope that I would, you know, that I would recover from it, then I was definitely going to take the non-surgical route.

SILBERNER: He has occasional pain, but it's not stopping him.

Mr. HANO: I am currently training for Ironman Coeur d'Alene, which is June 25th of this year. And I'm looking forward to it. That'll be my first Ironman distance race.

SILBERNER: Griffin heard his doctor's one-year numbers.

Mr. GRIFFIN: If I didn't have small children that, you know, I needed to chase after and lift on my shoulders, I might have made a different decision. I might have given the back more time.

SILBERNER: Orthopedic surgeons and neurosurgeons across the country are facing the same issue as Weinstein every day.

This day, Orthopedic Surgeon John Starr is doing a back surgery at Washington Hospital Center in Washington, D.C.

Dr. JOHN STARR (Orthopedic Surgeon, Washington Hospital Center): He's got arthritic changes of the back, he's got deformity and he's got pressure on the nerves.

SILBERNER: His patient is on his stomach, completely draped. All that's visible is an 8x4 inch swatch of his back. Starr is going to remove material that's blocking the nerve canals that branch off the spinal cord.

Dr. STARR: We're going to take stuff away--unroof, open up those canals, you know, cut the belt that's too tight.

SILBERNER: That is a decompression and he'll structurally stabilize the spine with hardware that looks just like that, hardware. Later, back in his office, Starr says in many cases, doing back surgery is easier than deciding if back surgery should be done.

Dr. STARR: I don't have the answer for the vast majority of patients. I have alternatives. And together, I'll hope to find the answer.

SILBERNER: The bottom line right now? Patients need to be involved in deciding whether or not to have surgery. Weinstein says involving patients in the decision may even help their outcome, whatever they decide.

Dr. WEINSTEIN: You lower the level of anxiety, you lower the level of fear. I think that those patients who have a preference and feel empowered may do better.

SILBERNER: Weinstein is heading a federally financed study of 1,200 patients with chronic lower back pain to compare the benefits of surgery versus non-surgery. Results are due this summer.

Joanne Silberner, NPR News.

RENEE MONTAGNE, host: If you'd like to ask Dr. James Weinstein a question, go to NPR.org and look for the link that says, Send us your questions on back pain. Next week, we'll post online Dr. Weinstein's responses to Ask Dr. Weinstein.

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