Surgery for Back Pain?

This question of when or if surgery is recommended for back pain is a very real one for those suffering. The answer to this question though, will absolutely depend on who you ask and maybe more importantly, who a person first chooses to see for their back pain.

Remember, as previously mentioned in this publication, back pain is very common (>80% individuals during their lifetime). Plus, the pain will subside in most instances in a few weeks. But what about when it does not? Where is the line where surgery is or is not indicated?

An important thing to remember is X-ray/MRI results do not equal presentation. This means a picture of the spine does not tell anyone exactly how that person will feel or function or how best to treat. A picture could look scary but the person is able to do everything with no pain. Contrarily, an image showing no abnormalities can be of a person in severe pain. So, we must start with this as the backdrop. According to Brinjikji et al somewhere between 68-88% of individuals between 40-60 years of age will show evidence of degenerative changes (translation= normal age-related changes). Additionally, 33-69% of those same individuals will have more significant age-related changes. Embedded within these statistics is the patient population studied had no pain. So again, imaging does not tell the whole story.

Back to where care starts. When care starts with physicians providing general advice and encouraging early imaging/orthopedic consults, these individuals are more likely to follow a path towards surgery. Results of a study by Fritz et al suggest this path is two times more likely to end up with a person having surgery compared to a person who begins care by seeing a physical therapist. This suggests potentially 50% of surgeries might be able to be avoided if people with back pain start their care with physical therapy.

All said, most will agree that surgery should be the last resort. All other treatment options should be exhausted before consideration of surgery. Pain and numbness/tingling in a leg are frustrating for sure, but in isolation are not the best reasons for surgery. However, there are some good reasons for surgery and lets now focus on that.

1) Loss of strength/function in a leg. If a person loses the ability to pump their ankle up/down or has trouble controlling their knee, surgery is necessary. In these instances, the messages from the brain/spine to the muscles are not being conducted well and needs to be addressed.

2) Falling due to loss of strength. Along with #1 above, the loss of strength that results in falling is an issue that needs to be addressed sooner than later. The longer the messages from the brain/spine to the leg are compromised, the tougher recovery may be and the potential for long-lasting effects.

3) Falls, motor vehicle accidents, and sporting trauma where there is evidence of a fracture or true spinal instability. These instances are not overly common but when present may need to be addressed via surgery.

4) New onset of bowel or bladder dysfunction associated with low back pain. This is a major concern and one that needs to be addressed quickly. This situation happens when there is pressure compressing the lower spinal cord blocking nerve messages below. Should anyone experience a situation like this, it is critical to seek urgent medical attention. It is important to have this pressure relieved quickly as long-term damage can happen should it not be addressed fast.

These are the four circumstances where surgery is clearly indicated. Short of that, all other conservative measures should be exhausted. These measures include medications, injections, and most importantly, physical therapy. Early physical therapy for back pain as previously discussed leads to the best outcomes for those with back pain.

References:

Brinjikji et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. Am J Neuroradiol 2015.

Fritz et al. Initial Management Decisions After a New Consultation for Low Back Pain: Implications of the Usage of Physical Therapy for Subsequent Health Care Costs and Utilization. Arch Phys Med Rehabil 2013.

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