Back Pain and Surgery

Pain expert Dr. Scott Fishman answers questions about back pain:

Q: Is surgery the best treatment for a bad back?


A: Bad backs are a frequent reason people opt for surgery, even though studies show that bulging discs usually shrink over time and that disc problems clear up in the vast majority of patients.

The most common back surgeries (laminectomy, spinal fusion, and discectomy) focus on structural repairs to discs or vertebrae. Any of these surgeries may be done alone or combined, depending on the patient. Laminectomy means a part of a spinal bone (vertebrae), called the lamina, is removed to relieve pressure on the spinal cord or nerve roots.

Spinal fusion melds one vertebral bone (the spine comprises a series of vertebral bones) to another to secure an otherwise dysfunctional spine. A discectomy removes a disc because it has become ruptured or herniated.

Herniation means that the disc's jelly-like interior has squeezed through the harder outer layer. This jelly substance, which is kept separate from other tissues by its strong outer coating, is extremely irritating to the surrounding nerves and tissues.

Surgery may attempt to clear out the irritating leakage. It often clears itself, which may be why most people recover over time from a disc rupture without surgery or any other particular intervention. In fact, it now appears that maintaining normal activities is the best approach to the average case of low back pain.

I have seen cases in which back surgery has miraculously cured long-standing pain. I also have seen cases in which people feel worse after surgery. Interviews with patients months and years after their surgery have revealed that upwards of ninety percent still feel pain and more than seventy percent still cannot do normal activities. Others say the success rate for living pain-free following back surgery is somewhat dependent on the source of the pain.

Back surgery usually is not performed solely for pain. Pain may be present, but the key objective usually is to treat a neurological symptom such as numbness or motor weakness. While surgery usually does the job as promised by restructuring bones or tissue or welding them together, it may not fully abolish the pain.

Many of the same patients that come to the clinic before surgery return after the operation, but their pain may have changed shape. The underlying cause of the previous pain may have been resolved, but these patients can be left with chronic back pain with a murkier cause.

The new problem may have as much to do with the old problem as having had an invasive operation on the back. A patient coming into the pain center after surgery actually may return with a different kind of pain because the operation has stirred the soup and produced a new flavor.

If you are thinking about surgery for a disc problem, keep in mind that a herniated disc does not always cause pain. Recent studies that examined the magnetic resonance imaging (MRI) results of the backs of thousands of individuals with no back pain revealed many with disc bulges and herniations.

On the other hand, some people have suffered for years with excruciatingly painful backs that look completely normal on all imaging. Herniation or disc bulges without accompanying pain call into question whether someone's back pain is truly related to the findings on their MRI or computerized axial tomography (CAT) scan. Significant structural problems indicated by a CAT scan or MRI should no longer automatically be considered the source of the pain.