Surgical Options for Back Pain

When should I have back surgery?
Surgery for back pain is a last resort treatment. There are basically two reasons for surgery for back pain. They are: (1) neural element compression (or squeezing of nerve roots or nerves) or pressure on the dura mater (which is the sac that surrounds the spinal cord and nerve roots), or (2) back pain. Back pain itself is mainly of two causes: (1) muscle spasm and (2) mechanical pain.

Muscle spasm
Muscle spasm is essentially a muscle pull or charley horse of the back muscles. In this situation, the muscles of the back are tender to the touch. Bed rest or inactivity does not usually relieve the pain significantly. Muscle spasm, as an isolated entity, is a non-surgical problem.

Mechanical pain
Mechanical pain is a pain that is deep and agonizing in nature. It is not related to muscle spasm, and activity worsens the pain while inactivity (such as bed rest) improves the pain. This pain syndrome is significantly different than that of muscle spasm. It is potentially a surgical problem in that instability can cause mechanical pain. This is akin to a degenerative hip in an elderly person in whom the pain is deep and agonizing in nature, is worsened with walking, and improved with sitting or lying.

What is sciatica?
Sciatica and some central back pain problems can be related to neural compression. Sciatica is caused by a disc herniation or bulge that compresses or squeezes a nerve as it exits the spinal canal. This pain usually is in the distribution of the nerve (where the nerve goes in the body). Anterior dura mater pressure can cause central back pain because of the rich innervation (nerve supply) of this portion of the dura mater. Discectomy is a treatment of choice for the problems mentioned above. Laminectomy might occasionally be helpful. A discectomy is usually performed through a small bony window.

What are the surgical procedures for back pain?

Laminectomy
A laminectomy involves the removal of a significant posterior portion of the spinal covering. It is performed to relieve pressure on the spinal cord.

Discectomy
Discectomy is a minimally invasive procedure during which herniated disc material is removed, while the support structure of the disc remains intact.

Spinal fusion
Spinal fusion is a process during which a number of vertebrae are made to grow, or "fuse" together. Mechanical back pain is usually treated with exercise and the strengthening of the support system of the spine (muscle and ligaments). This stabilizes the spine in a physiological manner. However, spinal fusion occasionally might be needed in patients who truly have mechanical pain and who have failed an aggressive non-operative program.

Many controversies exist regarding fusion. Should the fusion be performed as an entity in and of itself or with instrumentation? Should the fusion be anterior or posterior in location? Should cages or screws be used to supplement the fusion? How long should a fusion be? Should it incorporate one motion segment (disc), or two or three motion segments? All of these questions are appropriate and very difficult to answer.

Remember, "spine surgery begets spine surgery." At least 20 percent of people who undergo an initial "simple operation" for back pain or leg pain will undergo one or more additional operations. These are usually people with chronic back pain.