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Back Pain
Pain in the back - Know when to operate
When back pain limits your lifestyle and conservative treatments don't help, surgery may offer relief. But it's not right for all types of back pain. In fact, back surgery is required only a small percentage of the time.
Injury, aging, improper body mechanics and normal wear and tear can all injure the spine. And damage to any component of the back — especially to nerves — can cause pain and other symptoms.
But, having a lot of back pain does not by itself mean surgery is required. For some people, surgery can even cause more problems. This may be especially true if a back problem isn't causing any symptoms other than pain in the back itself.
Most back problems respond to nonsurgical treatments. These may include:
- Limited activity
- Pain medication
- Heat or cold therapy
- Gentle massage
- Exercise
- Physical therapy
- Spinal manipulation
In most situations, an operation would not be considered unless conservative measures have failed, and even then it's often not indicated.
Where surgery may help:
Surgery is usually reserved for problems in which a nerve is severely pinched, the spinal cord is compressed, or the spine is unstable.
A physician may recommend surgery (sometimes immediately) if you have neck or back pain accompanied by symptoms of nerve damage. Symptoms may include:
Pain that radiates down your legs (sciatica) or arms
Pain, numbness, weakness or tingling in your arms or legs
Loss of bladder or bowel control
Back problems that have the best chance of being helped by surgery include:
Herniated disk — Between your vertebrae are "pads" of cartilage called disks. Normal wear and tear or strain may cause a disk to bulge or rupture (herniate). When a disk herniates, parts of the disk can protrude from their normal position between your vertebrae. Depending on the level of the spine involved, either leg or arm pain, numbness, tingling or weakness can result when a fragment of the herniated disk places pressure on an adjacent nerve.
Back pain caused by disk degeneration — This surgery occasionally may be recommended when back pain doesn't respond to other measures. The surgery is done only in specific situations, because the operation may not help when the problem is back pain alone.
Spinal stenosis — This is the narrowing of the openings (foramina) through which nerves exit the spinal canal, or a narrowing of the spinal canal itself. This narrowing can result from the development of bony growths (bone spurs) where disks have compressed and are allowing vertebrae to rub on each other. Bone or ligament that's pinching nerves or the spinal cord may need to be removed surgically.
Fractures — Direct injury to the spine may cause a bone fracture anywhere along your vertebral column. Spinal fractures may require surgery if the spine is unstable or the spinal cord or nerve roots are compressed.
Osteoporosis (loss of bone density) can weaken vertebrae, causing them to fracture or collapse. These can be a source of back pain. But doctors typically only operate on osteoporotic compression fractures that threaten the stability of your spine or cause pain that doesn't respond to other measures.
Infections and tumors — Doctors may operate to remove a tumor from your back or spine. Rarely, an infection in one part of the body can spread to the spine and produce an abscess that requires surgical treatment.
Spinal deformity — Scoliosis (lateral curvature of the spine), kyphosis (a humpback deformity) and spondylolisthesis (forward slippage of a segment of the spine) may require surgery if they're progressive, painful or causing nerve compression.
Surgical procedures:
The decision to have back surgery is based on many factors, including your overall health. Back surgery may take several hours. If the front of your spine needs to be reached, your doctor may make the incision in your abdomen or front of your neck.
The three basic types of back surgery are:
Laminotomy or laminectomy — These operations involve removing a small amount of the lamina (the back part of the bone over the spinal canal). During a laminotomy, just a portion of lamina is removed to relieve pressure on a nerve or allow the surgeon access to a disk that's pressing on a nerve. A laminectomy involves removal of the entire lamina.
Diskectomy — This involves the removal of a portion of a disk to relieve pressure on a nerve.
Fusion — Spinal fusion permanently connects two or more vertebrae in your spine to improve stability, correct a deformity or relieve pain. To fuse the spine, small pieces of extra bone are needed to fill the space between two vertebrae (the disk is removed first if the front of the spine is fused).
This bone may come from your own body (usually your pelvic bone) or a bone bank. Sometimes, wires, rods, screws, metal cages or plates are also used, especially if the spine is unstable or the operation is needed to correct a deformity.
Results and recovery:
Back surgery can help relieve pressure on spinal nerves and alleviate pain. But it's not a cure-all. Pain may continue, and recovery may take weeks or months, plus involvement in a physical therapy program. To prevent recurrent back problems use good body mechanics, keep your back muscles conditioned with regular exercise and stretching, and weight control.
Improved surgery techniques:
Less-invasive back surgery techniques are becoming more common:
Endoscopic procedures — A damaged part of a disk is removed through a flexible, tubelike device instead of through open surgery.
Vertebroplasty — This involves injecting bone cement into fractured and collapsed vertebrae. The cement hardens over a few hours, sealing and stabilizing fractures and relieving pain.
Kyphoplasty — This is similar to vertebroplasty, except that a balloonlike device is inserted to expand a compressed vertebra before cement is injected.
IDET — In intradiskal electrothermal therapy (IDET), a wire is passed via a needle into a torn disk. The wire is heated, which bonds the collagen in the disk to stimulate healing. The heat also deadens nerves in the disk that are causing pain.
New bone materials — Bone substitutes are strengthening spinal fusions and shortening recovery.
More than an X-ray needed before surgery:
The decision to have surgery should not be based on X-ray alone. Many back problems are visible on X-rays. But these problems may not cause symptoms or indicate a need for surgery.
To diagnose your problem, your doctors will perform a thorough medical evaluation, including:
A health history
A physical exam
Scans of your back and imaging tests, which may include X-rays, myelography, CT (computed tomography) scans or MRI (magnetic resonance imaging)
Before you agree to back surgery, consider getting a second opinion from a qualified neurosurgeon or orthopedic surgeon. Back pain can be a complex issue that may require a team of health professionals to diagnose and treat.
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