Do you really need back surgery?

Most people have an opinion on this question one way or another. For the individual who is healthy, without pain and can perform the usual activities of daily living the answer is simple ”No I don’t”.  This is easily understandable. The real dilemma for the patient begins when they experience the severe, debilitating, pain associated with a herniated disc, “Sciatica” or the progressive disability of spinal stenosis.

The same individual confronted with the pain associated with these conditions at some point lowers their threshold on the decision to pursue surgery. The response to the opening question becomes “Anything you say, just get rid of this pain”. Severe chronic pain wears away at one’s mind and desperation sets in.

What is the truth about back surgery?  The decision you make may change your life forever, for better or for worse.  As a spine surgeon I confront these issues on a daily basis. I see the pain, suffering and desperation.  I have an enormous appreciation for what patients endure. I have sympathy and compassion for them. The truth is that for most common low back problems surgery helps. The real art is choosing the right surgery. Bigger isn’t necessarily better.

How do I approach the decision to offer surgery?  I look for and consider:

1. Red Flags: These are signs of an emergent medical condition that requires intervention. These people require immediate medical/surgical treatment to save their life or prevent an imminent catastrophe. Conservative treatment in these patients is not appropriate.

2. Onset, duration and severity of symptoms:  When and how did the problem occur, how long has it been going on, how bad is it? Is it improving, staying the same or worsening? Most problems related to herniated discs resolve on their own with a non-steroidal anti-inflammatory medication and rest. Where does this patient lie along that spectrum?

3. Diagnosis: Studies have shown that there’s clear evidence surgery can help three common problems:

  • A herniated disc with leg pain (Sciatica), this is when one of the shock-absorbing cushions in the back tear or rupture pinching a nerve;
  • Spinal stenosis, a gradual narrowing of the spinal canal causing pinched nerves and progressive inability to walk;
  • Degenerative instability (spondylolisthesis), which happens when the joints in the low back get loose and the bones slip causing pinched nerves.

The data shows that people with these conditions that choose surgery had better results with pain relief and ability to function than people who had non-surgical treatment.

4. Have conservative measures failed? Before surgical treatment is considered, in elective cases, conservative treatment is recommended for six to twelve weeks. The natural history of a disc herniation is that it improves on its own. Flare ups from spinal stenosis and instability often resolve.

5. Risks

What are the risks for this patient with the surgery needed to address the problem? Do the benefits of the surgery outweigh the risks?

The bottom line is that surgery is safe and appropriate in the right circumstances, the right patient with the correct diagnosis, and the right surgeon.