Spine surgery is, and for the foreseeable future will remain, a controversial topic. We all know people who have had back surgery that still have problems. Some of you may also know people who have had back surgery that has worked quite well. You may have heard the terms laminectomy, discectomy, fusion, and decompression, to name a few. What do all of those mean and when is surgery necessary?
Of all people with back and neck pain, experts state that only 2% or 3% should ever need surgery. This means that the vast majority of these problems will have to be treated in a non-surgical way. There is a common belief among lay people that if the symptoms are bad enough one can always have surgery. This is simply not true. For most conditions of chronic back and neck pain there is no surgical solution.
The most common surgery that is done is laminectomy and discectomy. This means that an incision is made in the back and the muscles are stripped back to expose the underlying spinal column which is made up of bones and held together with ligaments. Inside the spinal column is the spinal cord which contains the nerve roots that run down the legs. The term laminectomy means that a piece of bone from the spinal column is removed. This is done in order to allow access to the underlying spinal cord and spinal nerve roots. These nerve roots can then be examined to make sure that there is no material compressing them, such as a piece of disc. If there is compression, the nerve is decompressed by removing the disc or whatever else is causing such compression. This type of surgery is most likely to be successful if the primary complaint is leg pain. When done for a primary symptom of back pain this type of surgery is much less successful.
Back fusions remain controversial. Some believe that the only indication for a fusion is if there is excessive movement (called instability) at certain levels of the spine. True instability is a rather rare phenomenon and therefore these surgeons do not believe that fusions should be done very often.
Another school of thought says back pain is most often caused by a degeneration of the disc space. If the pain is severe enough, it is felt that fusion at the level of the degenerated disc can prevent any motion and relieve pain. Although there are some patients who have done quite well after a spinal fusion, there are many who continue to have significant pain. Just because a neighbor happened to do well with a fusion does not mean that you will.
There are special situations such as progressive curvature of the spine and fractures of the spine where surgery is much more likely to be done. However, these patients represent only a very small percentage of the total back pain population and do not really apply for our purposes here.
What about those patients who do have surgery? Studies have shown that on average, these people lose 40% of the strength in their supporting musculature after the surgery. This deconditioning puts people at increased risks for further problems. Our experience has been that there is often a honeymoon period of several months to a few years after back surgery during which a patient feels fairly good. But as time goes on, it is not unusual to see an insidious increase in back or leg pain. This recurrence of pain may very well be preventable by proper reconditioning after surgery and by the use of a life time home exercise program. Unfortunately, very few post surgical patients follow such a regimen. We believe that all post surgical patients should undergo an aggressive rehabilitation program and then follow that up with a life time home program designed to keep the strength of the supporting muscles of the back at their maximum level. In this way you reduce the chances as much as possible of having a recurrence of your problem.
In summary, only a very small percentage of the back pain population has a condition for which surgery might be helpful. The vast majority of patients will have to find other ways to deal with their pain and disability. Exercise and fitness is proving to be the most successful and long lasting way to deal with this problem. For those who do require surgery, exercise and fitness is just as important if not more important. In order to prevent recurrence, these people must commit themselves to a lifetime of keeping their supporting muscles in shape.