Ask an Expert: Do I need back surgery?

Q: “My back problem seems to be getting progressively worse. I’ve been taking medication for the pain, but at what point should I consider surgery?”

Answer from Jeffrey Flemming, M.D., orthopedic spine surgeon, Spinal Deformities and Surgery, P.C., and Providence Spine Services:

I understand what you’re going through. And even though my problem will probably require surgery down the road, I’m doing everything I can to avoid it, or at least to put it off for as long as I can. That’s because, like most spine surgeons, I believe that back surgery should be the last option.

When — and whether — you should consider surgery depends on your diagnosis and the progression of your back problem.

Today’s surgical techniques can do wonderful things to reduce back pain that is caused by progressive degenerative conditions. Specifically, surgery can help correct painful spinal deformities, such as: 
  • Scoliosis: a sideways bend in the spine
  • Kyphosis: a forward bend in the spine
  • Spondylolysthesis: one or more vertebrae (the bones of the spine) that slip forward onto other vertebrae
Surgery also can help relieve nerve compression from a variety of causes, including:
  • Herniated or ruptured discs: bulges or ruptures in the pads between the vertebrae
  • Bone spurs: boney growths that dig into the nerves running through the spinal column
  • Spinal stenosis: a narrowing of the spinal column caused by a combination of several of these issues
However, most back pain is caused by other things — things that don’t really respond well to surgery. For most people with back pain, therefore, conservative (non-surgical) treatment is the best course of action.

Even in cases where surgery can help, conservative therapy is generally the first recommended course of action. Physical therapy, chiropractic, acupuncture, exercise programs and anti-inflammatory medications all can help relieve chronic and acute back pain. The right combination of these may help reduce inflammation and strengthen the supporting structures of the spine enough to halt, or at least slow, the progression of a degenerative condition.

Despite the best conservative efforts, however, some back conditions continue to worsen to the point where you’re down to that last option. And most people know when that point arrives. The people who come to see me usually have tried everything else, but they’re still getting worse. They’re either fed up with the pain, or they are starting to notice the symptoms of nerve compression, which can cause shooting pain, numbness or weakness in the legs, feet and buttocks.

Once the nerves start to get compressed or injured, conservative therapies can’t really help. You need to get the pressure off the nerve to stop the pain and prevent further progression and neurologic loss. That’s when it’s time to consider surgery.

All surgeries have their risks and limitations, which is why conservative therapies should be continued for as long as possible. But if it’s time for surgery, the good news is that most people in these situations respond very well and achieve noticeable improvements.  

July 2008