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Do You Really Need That Back Surgery?

Surgery is not necessarily the answer to persistent back or nerve pain

Patients and their families presented with the prospect of back surgery should ask lots of questions, according to experts in the field. The approach to easing back pain depends upon the source, the severity, the persistence and the trajectory of the pain.

“If it’s back pain and there’s no leg pain or minimal leg pain, then a patient or a family member should know that surgery is the absolute last resort,” said Dr. Christopher Bono, an orthopedic surgeon at Brigham and Women’s Hospital in Boston and president of the North American Spine Society. “It’s most of the time not even a good option. It has a pretty mediocre-at-best success rate for the treatment of back pain.”

Bono and other surgeons recommend alternatives to surgery for patients who have nonspecific pain, from conditions such as arthritis. Physical therapy, core strengthening, weight loss and stretching to improve flexibility may each help ease the pain.

Herniated Disc

Pain that starts in the back and radiates down an arm or leg may indicate a herniated disc, also known as a ruptured disc or a slipped disc. These mostly occur in the lower back, but can appear in the neck. The discs themselves are made of soft tissue that provide cushioning between the vertebrae and hold them together. When a disc deteriorates, usually due to aging, its tougher exterior can crack, allowing the softer interior to protrude. This herniation may irritate nearby nerves and result in pain, numbness or weakness in an arm or leg.

The Mayo Clinic lists surgical risks as infection, a tear in the membrane that covers the spinal cord, a blood clot in a leg vein, and neurological deterioration.

Nine out of 10 patients who develop a herniated disc can avoid surgery by refraining from certain positions, performing prescribed exercises and judiciously using pain medication, according to the Mayo Clinic.

Spinal Stenosis

Pain in the lower back or neck could also signal spinal stenosis, a narrowing of the open spaces within the spine that can put pressure on the spinal cord and the nerves that travel through the spine to the arms and legs. Back and leg pain that occur after two to three minutes of walking and dissipate when lying down may indicate spinal stenosis, Bono said.

This nerve compression may have no symptoms, but it can cause pain, tingling, numbness, muscle weakness, and problems with normal bladder or bowel function. (If you experience the latter, it may be an emergency requiring immediate surgery.)

Even though physical therapy and other alternative treatments usually yield little improvement for spinal stenosis patients, that doesn’t mean they shouldn’t be tried first. Bono recommends at least six weeks of these treatments as well as attempts to improve aerobic fitness.

When You Are Considering Surgery

Patients must weigh the options of living with the pain of a herniated disc or spinal stenosis versus the risks of the surgery itself and its aftermath. Here are some questions to ask your physician, from the Society for Minimally Invasive Spine Surgery and Spine-health.com:

  • What are the side effects, potential risks and potential complications of the surgery?
  • How do the risks relate to me personally?
  • What are the long-term consequences of the proposed procedure?
  • Why do I need to get an MRI, CAT scan and an X-ray before I have surgery?
  • How long will I be in the hospital?
  • How long is the recovery?
  • After surgery, how long will my pain last?
  • Will I have to take pain medication after my surgery? Will I become dependent?
  • Do I have to wear a brace?
  • Will I need physical therapy afterward?
  • When can I go back to work?
  • How many times have you done this procedure?
  • Are you board-eligible or board-certified?
  • Are you fellowship-trained in spine surgery?
  • Statistically, what is the success rate for this type of surgery?
  • What is your personal success rate, and how many cases of this type of surgery have you done?
  • May I talk to the last five patients on whom you’ve done a similar procedure?

These are the basic questions. Both sites provide several more, and WebMD has a list of pros and cons to back surgery. The Mayo Clinic lists surgical risks as infection, a tear in the membrane that covers the spinal cord, a blood clot in a leg vein and neurological deterioration.

Surgery is the only option for spinal stenosis patients who have lost control over their bowel or bladder, according to Dr. Daniel Park, a Michigan surgeon and spine editor of the American Academy of Orthopedic Surgeons’ OrthoInfo website. The goal of such surgery is to free up the nerve so blood flow will improve and the nerve itself might return to some level of function, Park said.

Types of Back Surgery

Open decompression surgery, also known as laminectomy, may be recommended for spinal stenosis. Laminectomy is a procedure to remove part of the vertebrae that covers the spinal canal. It may be part of a minimally invasive procedure.

Laminectomy may, on the other hand, be performed along with spinal fusion, a linking of adjoining vertebrae with metal hardware and a bone graft to stabilize the spine. Fusion is the most common type of surgery for back pain, according to WebMD. It is major surgery, usually requiring a few days in the hospital and up to several months for complete recovery, the Mayo Clinic says.

The Neurological Institute at the University of California at San Diego describes several types of minimally invasive back surgery, from anterior cervical discectomy (removal of a herniated cervical disc through a small incision in the front of the neck) to transforaminal lumbar interbody fusion (removal of and replacement of a disc with a spacer, through an incision to the side of the spine so that nerves and muscles in the back are less affected).

Minimally invasive surgery usually leads to quicker recovery and less pain than traditional surgery, Park said. However, patients should not expect a miracle.

“If the surgeon tells you you’re going to be great, I think that’s overestimating sometimes,” Park said.

Older adults are at higher risk for complications, not to mention the difficulties of getting rest in the hospital. They also tend to take twice as long to heal than younger patients, according to Park.

“Be positive and measure progress week-to-week instead of day-to-day,” he advised.

‘Failed Back Surgery Syndrome’

Time will tell if surgery works. Even if it alleviates the compression, the pain may persist, according to Bono.

“Prior to the operation, every patient should understand that the operation may not work, and if it doesn’t, there may not be (another) surgical option,” he concluded.

A patient whose condition falls into the category of “failed back surgery syndrome” may be a candidate for a spinal stimulator. This device is implanted under the skin near the spinal cord. Soft, thin wires with electrical leads on their tips are inserted through a needle to deliver electric current to the spine and block the sensation of pain.

These devices, made by major corporations such as Boston Scientific and Medtronic, are becoming more popular as technology advances. But there are risks with the treatment, as well. WebMD lists infection, leakage of spinal fluid, headache and bladder problems among them.

Much more detailed information about spinal conditions and treatments is available at the OrthoInfo website, and can help patients and their families formulate questions. The site includes links to other resources as well.

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