Most pain in the lower back can be treated without surgery. In fact, surgery often does not relieve the pain; research suggests that 20 to 40 percent of back surgeries are not successful. This lack of success is so common that there is a medical term for it: failed back surgery syndrome.
Nonetheless, there are times when back surgery is a viable or necessary option to treat serious musculoskeletal injuries or nerve compression. A pain management specialist can help you decide whether surgery is an appropriate choice after making sure you have exhausted all other options.
According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), part of the National Institutes of Health (NIH), the following conditions may be candidates for surgical treatment:
- Herniated or ruptured disks, in which one or more of the disks that cushion the bones of the spine are damaged
- Spinal stenosis, a narrowing of the spinal column that puts pressure on the spinal cord and nerves
- Spondylolisthesis, in which one or more bones in the spine slip out of place
- Vertebral fractures caused by injury to the bones in the spine or by osteoporosis
- Degenerative disk disease, or damage to spinal disks as a person gets older
In rare cases, back pain is caused by a tumor, an infection, or a nerve root problem called cauda equina syndrome. In these cases, NIAMS advises surgery right away to ease the pain and prevent more problems.
NIH’s National Institute of Neurological Disorders and Stroke (NINDS) lists the following as some of the surgical options for low back pain. But NINDS also cautions that “there is little evidence to show which procedures work best for their particular indications.”
- Vertebroplasty and kyphoplasty. These procedures are used to repair compression fractures of the vertebrae caused by osteoporosis. Both procedures include the injection of a glue-like bone cement that hardens and strengthens the bone.
- Spinal laminectomy/spinal decompression. This is performed when spinal stenosis causes a narrowing of the spinal canal that results in pain, numbness or weakness. The surgeon removes the bony walls of the vertebrae and any bone spurs, aiming to open up the spinal column to remove pressure on the nerves.
- Discectomy. This procedure is used to remove a disk when it has herniated and presses on a nerve root or the spinal cord. Laminectomy and discectomy are frequently performed together.
- Foraminotomy. In this procedure, the surgeon enlarges the bony hole where a nerve root exits the spinal canal to prevent bulging disks or joints thickened with age from pressing on the nerve.
- Nucleoplasty, also called plasma disk decompression. This laser surgery uses radiofrequency energy to treat people with low back pain associated with a mildly herniated disk. The surgeon inserts a needle into the disk. A plasma laser device is then inserted into the needle and the tip is heated, creating a field that vaporizes the tissue in the disk, reducing its size and relieving pressure on the nerves.
- Spinal fusion. The surgeon removes the spinal disk between two or more vertebrae, then fuses the adjacent vertebrae using bone grafts 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.
- Artificial disk replacement. This is considered an alternative to spinal fusion for the treatment of people with severely damaged disks. The procedure involves removal of the disk and its replacement by a synthetic disk that helps restore height and movement between the vertebrae.
Some surgical treatments are not recommended by NINDS, which cautions, for example, that intradiscal electrothermal therapy is “of questionable benefit.” NINDS notes that radiofrequency denervation provides only temporary pain relief and that “evidence supporting this technique is limited.”
Back surgery can carry higher risks than some other types of surgery because it is done closer to the nervous system. The most serious of these risks include paralysis and infections.
Even with a successful surgery, the recovery time can be long. Depending on the type of surgery and your condition before the surgery, healing may take months. And you may lose some flexibility permanently.
Back surgery will almost always be performed under general anesthesia. In addition to the usual risks associated with anesthesia, there are risks associated with the patient lying face down on the surgical table.
This position changes the body’s hemodynamics — that is, how blood flows through the body. The position also limits the surgical team’s access to the patient’s airway. This requires extra care in the positioning of equipment, monitors, patient and anesthesiologist. It is extremely important to have a physician anesthesiologist in the operating room to make sure everything is set up correctly and to be able to take immediate action in case anything goes wrong.
Back surgery can cause a high degree of post-operative pain. You should consider a number of options for pain relief in the days and weeks after surgery. These options should be discussed with a pain management specialist who can explain the pros and cons of each option or combination of options, including their effectiveness, potential side effects, potential for addiction and impact on the recovery process.
Some factors to consider:
- Many of your options will involve medications such as opioids, nonsteroidal anti-inflammatory drugs, corticosteroids and local anesthetics. Sometimes more than one drug will be taken. This multimodal therapy can improve pain control while limiting opioid use.
- Opioids should be used with care to avoid addiction and manage side effects, some of which can be life-threatening.
- Alternative or complementary methods of pain relief that do not involve medicines should also be discussed.
Physician anesthesiologists who specialize in pain management can work with you before and after surgery to develop a plan tailored to your condition, personal history and preferences. They will consult with you after surgery to determine what is working and what is not, and they will adjust your pain management treatment based on the level of pain you are experiencing.
Physician anesthesiologists work with your physician team to evaluate, monitor and supervise your care before, during and after surgery, delivering anesthesia, leading the Anesthesia Care Team and ensuring your optimal safety.