Spinal surgery

Spinal surgery has a very small place to play in the overall management of low back pain.

However, surgery occupies a much greater place in most people’s minds when they think about treatment for low back or leg pains.

It is important to understand what surgery can do, and perhaps more importantly as it is much more common, when surgery can do nothing for you or me to solve our back pain problems.

Spinal surgeons can in general do one of three major things:

Decompress nerves...to relieve pressure on them from surrounding structures.
Fuse segments...together to prevent movement and reduce pain
Correct spinal deformities...such as severe scoliosis (more common in teenagers)

Discectomy

Discectomy is a treatment for leg pain, not back pain. See sciatica for an indication of the underlying nerve root problems for which disc surgery is used. Practice varies and I will give a general indication of the system with which I am familiar.

To be considered for discectomy a person must have:

Severe, persistent, non-improving leg pain worse than back pain, for more than 6 weeks
Consistent examination including positive straight leg raise
Positive findings of disc prolapse on MRI scanning

All these conditions must be met for the surgeon to consider operation. If the leg pain begins to subside, the examination is unclear or the MRI does not show a significant disc prolapse then discectomy may be unsuccessful and therefore unwise. The surgeon may have to make a complex judgement in consultation with the sufferer in unclear cases.

In the UK, caution about intervening surgically in back or leg pain cases is strong. Work has shown that 90% of cases of sciatica recover spontaneously, so a period of waiting to see if the symptoms settle seems justified.

Discectomy further damages the disc and may make the segment less mechanically efficient, so may predispose people to later back pain problems, a much harder problem to manage.

See Microdiscectomy advice for more information.

Decompression

Discectomy is a form of nerve decompression but this term is commonly used to mean a different kind of operation, performed alone or along with spinal fusion.

Decompression is usually performed in older people who have the symptoms of stenosis, caused by the nerve cord being compressed by ligaments or joint enlargement.

Decompression surgically removes the ligaments or enlarged bony areas to allow the nerves to run freely. It can be done at one level or be a “multi-level decompression”. There is some caution in doing too large a decompression or at too many levels, in case this affects the stability of the spine.

Spinal Fusion

It is in the field of spinal fusion that the biggest problems arise in trying to understand how successful the operation is and the reasons for doing it. Scientific evidence is not clear whether this is a useful procedure to undertake in many cases.

Spinal fusion is a treatment for back pain, or “segmental failure” as it is often called, however leg pain may also be present. To be considered for spinal fusion, a person must have:

Severe and incapacitating back pain, with or without leg pain
Consistent findings on examination
The willingness to go through a large operation of uncertain outcome
Evidence of a target structure (cause of pain) on MRI scan or discography
No more than 2 lumbar levels affected

Longlasting back pain is not an indication for surgery - much more is required. It is necessary to identify the cause of the pain or intervention will likely miss the target. A structure causing the pain needs to be pinned down, or a particular disturbance in the normal movement of the back at a particular area.

Clear explanations for the pain are difficult to work out, especially in chronic back pain. “Exploratory” surgery, without a clear view of what is to be done, is NOT likely to be helpful.

Spondylosis, disc degeneration and instability are often given as reasons for performing surgery, but these “diagnoses” are observations from x-rays and scans, not definitions of the cause of the pain.

The results of spinal fusion using these ideas as diagnoses have not been impressive.

Is surgery ever essential?

Surgeons are seldom forced to operate on people, there is usually a choice. There are cases where surgery is thought essential without delay, and they are quite specific:

Cauda Equina syndrome

In these rare cases the sufferer has extreme pain and disability, loss of feeling in the lower body and incontinence of bladder and/or bowel. They are treated as a surgical emergency to prevent permanent loss of the affected functions. The cause is most often a very large central lumbar disc prolapse.
Progressive neurological loss

Loss of muscle power or feeling in part of a leg is well known in cases of nerve root compression, and may not be cause for surgical intervention. However, if the muscle weakness progresses and spreads, intervention may be needed to stop the worsening.

Severe and uncontrollable leg pain is another indication for intervention, as it may not be fair to make the person wait out the period until improvement occurs naturally.

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