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Spine Surgery: When Is It Right for You?

James Kang, MD, Chief of the Department of Orthopaedic Surgery at Brigham and Women’s Hospital (BWH), has a habit of talking patients out of spine surgery. It’s not that he doesn’t want to help you – quite the contrary.  

Spine surgeons in his practice perform surgery on less than 10 to 20 percent of the more than 800 patients they see each year. Dr. Kang is proud of that low rate, as his team’s goal, as ironic as it may seem, is to perform the least amount of surgery possible.

“Even in the hands of the best surgeons, there are certain risks associated with spine surgery, and the vast majority of patients with back pain can be treated effectively without surgery,” says Dr. Kang.

Most of Dr. Kang’s patients want to eliminate, or at least minimize, their back pain. Unfortunately, determining the source of that pain is elusive when there are no obvious correlating abnormalities on an MRI.

“We don’t always have a very good grasp of where back pain comes from,” explains Dr. Kang. “Can it come from disks? Yes. Can it come from the bones and the ligaments and the muscles? Yes. But we can never be sure where it comes from because we don’t have any diagnostic tests for pain. We have diagnostic tests for anatomy.”

In cases where back pain is localized to the central back and doesn’t occur regularly, says Dr. Kang, a patient can be treated by a primary care physician (PCP) with non-narcotic medications and counseling. By taking a short course of medication, gradually returning to non-strenuous physical activity, and getting short periods of rest, a patient with this type of condition should get better within a matter of days.

If the pain consistently occurs two or three times a year, or the pain lasts longer than a few days, a non-operative treatment like physical therapy might be warranted. This treatment should be accompanied by counseling aimed at discovering potential causes (e.g., poor body mechanics, or poor physical condition) and remedies for that pain.

When back pain becomes chronic – at least two or three episodes per month – your provider might order an X-ray and an MRI and refer you to a physiatrist, a spine expert who specializes in non-operative treatments. A physiatrist focuses on educating patients about their condition and the benefits of exercise therapy. They also prescribe medications and administer minimally invasive injections to treat pain and restore function. Most patients with low back pain alone will not require surgery.

“When patients present with low back pain, which includes pain that radiates down the leg (sciatica), this may signal a more serious condition whereby the nerves in the spine are being compressed,” says Dr. Kang.

The most common conditions that cause such neurologic symptoms (leg pain, numbness or weakness) are herniated discs or spinal stenosis. Less frequently, causes may be infections or tumors.

A physician uses an MRI to diagnose these conditions, and in some instances, surgery may be required so permanent nerve damage does not occur. In fact, spine surgery for these neurologic conditions are very successful in improving these symptoms and restoring the quality of life that patients seek.

Some common surgeries that are performed for these conditions include microdiscectomy, laminectomy, and spinal fusion. However, it must be emphasized that all surgeons will still use conservative measures prior to considering surgery.

If non-operative treatments fail to diminish the pain, a patient is still faced with a weighty decision. Spine surgery carries significant risks, including nerve damage, paralysis and infection. And, as with any surgery, spine surgery doesn’t come with a guarantee.

Yet, despite the risks, Dr. Kang knows from experience that spine surgery can dramatically improve the lives of certain patients.

“Some patients can barely get through their day, and they’d rather take the risk on the operation than continue to live in pain,” says Dr. Kang. “At that point, it’s a clear-cut decision for them.”