Surgery

There is no hard and fast answer to whether you really need back surgery, although people who do elect for back surgery say their pain interferes with their mobility, sex life, and/or sleep that is taking away their life.  Your doctor may suggest that you see a surgeon if your back pain is unrelenting and treatments such as physical therapy, weight control, steroid injections, and non-steroidal anti-inflammatory medicationsdon't work.

Although it may seem counterintuitive, patients are more likely to heal on their own without surgery if they try to remain active rather than simply opting for bed rest.  Obviously, there are certain things you can't do when you are in a lot of pain, but the idea as proven consistently in studies is to try to stay as active as you can to get better on your own.

Electing for surgery to get better entirely depends on you, so make use of your resources to make a decision that's right for you.  Use our resources to see how minimally invasive spine surgery compares to open surgery.  See the success rates from studies of the different surgical treatments available such as discectomy, laminotomy, foraminotomy, artificial disk replacement, and spinal fusions.  Before undergoing any surgical treatment, you can consult our patient checklist to help guide you when seeking treatment from a surgeon.

In many cases, the conditions causing back pain cannot be permanently altered by nonsurgical treatment, even though these measures may relieve pain for a period of time. To determine how much nonsurgical treatment will help, a doctor may recommend such treatment first. However, surgery might be considered immediately if a patient has numbness or weakness that interferes with walking. The effectiveness of nonsurgical treatments, the extent of the patient's pain, and the patient's preferences may all factor into whether or not to have surgery.

The purpose of surgery is to relieve pressure on the spinal cord or nerves and restore and maintain alignment and strength of the spine. This can be done by removing, trimming, or adjusting diseased parts that are causing the pressure or loss of alignment.  Removal of the obstruction that has caused the symptoms usually gives patients some relief; most patients have less leg pain and are able to walk better following surgery. However, if nerves were badly damaged before surgery, there may be some remaining pain or numbness or no improvement. Also, the degenerative process will likely continue, and pain or limitation of activity may reappear after surgery.

What Are the Major Risks of Surgery?

All surgery, particularly that involving general anesthesia and older patients, carries risks. The most common complications of spinal surgery are a tear in the membrane covering the spinal cord at the site of the operation, infection, or a blood clot that forms in the veins. These conditions can be treated but may prolong recovery.

Patients who are thinking about surgery may want to ask the following questions:

• What are the benefits from surgery?
• What are the risks from surgery?
• What techniques will be used for the surgery?
• Where will the incisions be made?
• How long will the hospital stay be?
• How long will it take to recover from surgery?
• Is there chronic back pain after surgery?
• How flexible will the spine remain?
• Will the patient be able to do all the things he or she wants to do following surgery?

Contemplation of surgery should be within the context of expected functional outcome. The concept of "cure" with respect to surgical treatment by itself is generally a misnomer. All operative interventions must be based upon positive correlation of clinical findings, clinical course and imaging and other diagnostic tests. A comprehensive assimilation of these factors must lead to a specific diagnosis with positive identification of pathologic condition. For surgery to be performed to treat severe pain, there should be clear correlation between the pain symptoms and objective evidence of its cause.

In the most serious cases, when the condition does not respond to other therapies, surgery may relieve pain caused by back problems or serious musculoskeletal injuries. Some surgical procedures may be performed in a doctor’s office under local anesthesia, while others require hospitalization. It may be months following surgery before the patient is fully healed, and he or she may suffer permanent loss of flexibility. Since invasive back surgery is not always successful, it should be performed only in patients with progressive neurologic disease or damage to the peripheral nerves.

• Discectomy is one of the more common ways to remove pressure on a nerve root from a bulging disc or bone spur. During the procedure the surgeon takes out a small piece of the lamina (the arched bony roof of the spinal canal) to remove the obstruction below.
• Foraminotomy is an operation that “cleans out” or enlarges the bony hole (foramen) where a nerve root exits the spinal canal. Bulging discs or joints thickened with age can cause narrowing of the space through which the spinal nerve exits and can press on the nerve, resulting in pain, numbness, and weakness in an arm or leg. Small pieces of bone over the nerve are removed through a small slit, allowing the surgeon to cut away the blockage and relieve the pressure on the nerve.
• IntraDiscal Electrothermal Therapy (IDET) uses thermal energy to treat pain resulting from a cracked or bulging spinal disc. A special needle is inserted via a catheter into the disc and heated to a high temperature for up to 20 minutes. The heat thickens and seals the disc wall and reduces inner disc bulge and irritation of the spinal nerve.
• Nucleoplasty uses radiofrequency energy to treat patients with low back pain from contained, or mildly herniated, discs. Guided by x-ray imaging, a wand-like instrument is inserted through a needle into the disc to create a channel that allows inner disc material to be removed. The wand then heats and shrinks the tissue, sealing the disc wall. Several channels are made depending on how much disc material needs to be removed.
• Radiofrequency lesioning is a procedure using electrical impulses to interrupt nerve conduction (including the conduction of pain signals) for 6 to12 months. Using x-ray guidance, a special needle is inserted into nerve tissue in the affected area. Tissue surrounding the needle tip is heated for 90-120 seconds, resulting in localized destruction of the nerves.
• Spinal fusion is used to strengthen the spine and prevent painful movements. The spinal disc(s) between two or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal devices secured by screws. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together.
• Spinal laminectomy (also known as spinal decompression) involves the removal of the lamina (usually both sides) to increase the size of the spinal canal and relieve pressure on the spinal cord and nerve roots.

Other surgical procedures to relieve severe chronic pain include rhizotomy, in which the nerve root close to where it enters the spinal cord is cut to block nerve transmission and all senses from the area of the body experiencing pain; cordotomy, where bundles of nerve fibers on one or both sides of the spinal cord are intentionally severed to stop the transmission of pain signals to the brain; and dorsal root entry zone operation, or DREZ, in which spinal neurons transmitting the patient’s pain are destroyed surgically.