When nothing else works: Is back surgery right for you?

Surgery for back pain should usually only be considered after all other treatments have been tried and failed to provide relief.  In such situations, surgery may indeed be the only remaining option.  In order to understand the risks and potential benefits of various types of back surgery, it is important to re-visit the anatomy of the back.  It would be useful at this point to read (or re-read) the article “Going to the Source: How Back Pain Begins”.

Nerves in your spinal cord were not intended to be touched by anything, so even the slightest amount of pressure on a nerve from bony protrusions of the spine or a slipped disc can cause pain.  Surgical solutions for back pain are often performed to free the nerves from pressure.  Whether or not to consider surgery depends on the effect the pain is having on your life, and these are questions you should discuss frankly with your doctor.  Is the pain preventing you from doing what you want?  Is it wearing you out?  Is it unbearable enough for you to consider surgery, knowing that all surgery includes risk and that there is no guarantee that it will help?  Only you can answer these kinds of questions.

Even if you don’t have pain, however, pressure on the nerves may cause tingling, numbness, movement problems, weakness, and difficulty with bladder or bowel control.  These kinds of signals tell us that some kind of damage is being done to the nerve.  When this happens, surgery may be strongly indicated.

Surgery will not help pain from muscle strains or sprains.  But if symptoms come from structural problems with bones or discs, you may need surgery, which is a structural solution.  Below are descriptions of some of the more common types of back surgery, divided into two groups: Surgery for disc problems, and surgery for vertebrae problems.  (Please refer to “Going to the Source: How Back Pain Begins” for details about discs and vertebrae.)

Surgical options for discs

  • Discectomy

The discs in your spine are like “shock absorbers.”  Injury or degeneration over time may cause them to rupture (break) or slip (move out of place).  Both can cause the disc to press on nerves that project out of the spinal cord, causing pain.  Discectomy relieves this pressure by surgical removal of all or part of the offending disc, and this often helps reduce the pain.  (A disc that slips out of place cannot simply be “pushed back,” because the glue-like substance that originally held it in place has lost its integrity and no longer works.)

  • Intradiscal Electrothermal Therapy (IDET)

This is a less invasive option than discectomy.  A disc is like a rubber pillow with a tough outer surface and liquid inside.  If it springs a leak (ruptures), a “bubble” appears on the outer surface of the disc and may press on a nerve.  Sometimes, the surgeon can remove just the bubble—sparing the rest of the disc—by using a needle with heat.  This alleviates pressure on the nerve.

  • Artificial Disc

This is a relatively new treatment that is still under investigation and not in common use yet.  The goal is to put a new disc made out of artificial material between the vertebrae.  The material starts out as a liquid that is injected and which then hardens after it is put in place, sticking to the surfaces of the vertebrae.

Surgical options for bones

  • Laminectomy

There are bony “wings,” called laminae, which extend from the vertebrae, underneath which pass the nerves that project out of the spinal cord.  The laminae are not responsible for the structural integrity of the spine; their only purpose is to protect the nerves.  But if a lamina becomes overgrown as a result of arthritis (spinal stenosis) or prior injury, it can compress the nerve, causing pain.  The surgical solution is to remove the lamina.

  • Spinal Fusion

Sometimes, back pain is caused by too much movement of the vertebrae on top of each other, which may be the result of a disc-related problem.  It may also be caused by a prior discectomy.  The surgical solution is to fuse several vertebrae together so that they no longer move.  This may be accomplished by attaching the spine to metal rods and using bone grafts from other parts of the body that are inserted between the vertebrae.

  • Vertebroplasty

Sometimes, due to osteoporosis or some other condition, the bones get so fragile or brittle that they are in danger of disintegrating, causing the spine to collapse in those sections.  Surgical vertebroplasty involves injecting a kind of “bone cement” into the disc to strengthen and solidify it from the inside.

References

American Academy of Orthopedic Surgeons (2007). Disk replacement.  Retrieved March 3, 2008 from http://orthoinfo.aaos.org 

American Academy of Orthopedic Surgeons (2007). Spinal fusion. Retrieved June 19, 2008 from http://orthoinfo.aaos.org

Mayo Clinic Staff (2007). Back Surgery: When is it a Good Idea? Retrieved March 3, 2008 from http://www.mayoclinic.com