Features July 2011 Issue

When Is Back Surgery a Good Idea?

In most cases, you won’t need it—but sometimes surgery can help relieve your pain.

Your back is hurting. You’ve tried ice, heat, massage, anti-inflammatory medications—even a short stint of physical therapy. Is it time to consider surgery?

That depends, says R. Douglas Orr, MD, a staff physician in the Center for Spine Health and the Department of Orthopaedic Surgery

at Cleveland Clinic.

"Realistically, if your only symptom is back pain, you probably shouldn’t be thinking about surgery until you’ve had pain for at least a year. And you should be doing the whole array of nonsurgical treatments during that time," Dr. Orr says.

Sticking with physical therapy is particularly important. "Most people go to physical therapy a few times, and when the pain doesn’t go away, they say it’s not working—so they stop. The problem is that physical therapy should be a commitment to an active exercise program for a minimum of three months, in spite of any discomfort it causes," Dr. Orr explains.

Most back pain is muscular, "and like any other muscle that’s out of shape and hurts, as you’re trying to get back into shape, it actually hurts more," says Dr. Orr. "People don’t have a problem with that when they start a walking program and their quads [thigh muscles] hurt. But for some reason, they don’t accept that the back muscles also can feel painful when you start to strengthen them."


When Surgery Might Make a Difference

Generally, low-back issues can cause back pain or leg pain, and "surgery is much more effective when you experience leg symptoms rather than back symptoms," Dr. Orr says. "That’s because back pain is just a symptom, not a diagnosis—and there are many causes of back pain, some of which respond to surgery and many which don’t." Leg pain, in contrast, generally is due to nerve compression, which may respond to spinal decompression surgery.

Surgery could also help mobile spondylolisthesis, where one of the spine’s vertebrae is out of alignment, has slid forward, and is moving abnormally. "That’s a leading indication for surgery in most practices," Dr. Orr says.

Another reason to consider surgery is a deformity such as kyphosis (excessive outward curvature of the spine) or degenerative scoliosis (abnormal lateral curvature of the spine). Surgery is also performed to treat infection, but infection is very rare. Of the nearly 300 or so spine operations Dr. Orr performs every year, perhaps only three would be due to infection.

When Surgery Doesn’t Work

Back surgery for the right indication—such as those described on page 1—usually is successful. But "back surgery for the wrong indications fails miserably," Dr. Orr says. "What has given spine surgery a bad name is people having fusions for back pain when there is no instability. They get an MRI because of the pain; it shows an abnormal disk and so they get a fusion. That’s a terrible indication because you don’t know that the disk is the source of the pain. Disk degeneration is a normal phenomenon of aging; everybody eventually suffers from it. Even if you’ve never had a day of pain in your life, your odds of experiencing low-back pain are equal to your age—20 percent for 20-year-olds, 50 percent for 50-year-olds, and so forth. By the time you turn 80, it’s 100 percent—everybody has disk degeneration. So surgery to treat degeneration is likely to fail."


Red Flags

Certain "red flags" indicate that an individual with back pain might be at higher risk of having something significantly wrong and out of the ordinary, Dr. Orr notes. These are: first onset of back pain under age 20 or over age 55, a history of cancer, constitutional symptoms (unintended weight loss, fever, chills, night sweats), or history of significant trauma.

"In the absence of those flags, there’s no indication to do an X-ray, MRI or any other diagnostic test for at least six weeks," Dr. Orr emphasizes. "At the six-week mark, if the person isn’t getting better with conservative treatment, consider an X-ray to try to get a more precise diagnosis." Because an X-ray is done in the standing position and most MRIs are done lying down, the two tests provide very different views of the spine, he adds. Generally, an X-ray should be taken first.

If there’s no evidence of an infection, tumor, or other rare cause of pain, stick with conservative treatment, Dr. Orr advises. "Most people with back pain will never need surgery and, because of possible complications, many people with chronic back pain will, in fact, be made worse with surgery unless they have an instability, deformity, or rare condition."