Most types of pain in the lower back can be treated without any surgery. In fact, in non indicated cases, surgery often does not resolve the pain; studies suggest that almost 20 to 40 percent of surgeries of the back are not successful to relieve the pain. This failure to correctly diagnose and prevent inadvertent surgery is so common that a medical term is coined for it: Failed back surgery syndrome.
Nonetheless, at times back surgery is a very viable option or necessary to treat serious musculoskeletal injuries, nerve compression or neurogenic claudication. Surgery should be considered only after exhausting all other options. Urgent surgery should be considered only in the case of Cauda Equina, impending Cauda Equina or post-traumatic unstable spine or paralysis or weakness in the limbs
When should I consider back surgery?
The following conditions can be considered for surgical treatment:
Herniated or ruptured disks which are compressing the nerves and severe pain is radiating to the legs. Disks are cushion like materials alternating between the bones of the spine and act like shock-absorbers
Spinal stenosis or narrowing of the spinal canal causing significant pain and limitation in walking distance due to pressure on the spinal cord and nerves
Spondylolisthesis is instability of the spine resulting in one or more bones in the spine slip over the other
Vertebral fractures caused by trauma to the bones in the spine or by osteoporosis
Degenerative disk disease or arthritis, or other form of damage to spinal disks as a person gets older
Occasionally,a tumor, an infection, or a nerve root problem like cauda equina syndrome is found as a cause of back pain. In these cases, surgery is advised right away to resolve the pain and prevent complications.
What are some types of back surgery?
There are multiple types of surgeries for back pain which is listed below. But clarity is still not there as to which procedures work best for any particular conditions.
Vertebroplasty and kyphoplasty. These procedures are used to treat compression fractures of the vertebrae caused usually by osteoporosis. These procedures include injecting a glue-like bone cement which hardens in a few minutes and strengthens the bone.
Spinal laminectomy/spinal decompression. This is done to treat spinal stenosis causing narrowing of the spinal canal that results in pain, numbness or weakness in the limbs. The surgeon removes the bone walls from around the spinal cord and any bone spurs. This opens the spinal column to remove pressure on the nerves and the roots.
Discectomy. This removes the offending part of the disk which has herniated and compresses a nerve root or the spinal cord. Laminectomy and discectomy are frequently done together to achieve an optimal result.
Foraminotomy. In this procedure, the surgeon enlarges the bony canal where a nerve root exits the spinal canal and provides larger space for movement of the vital structures without getting compressed by bulging disks or joints thickened with age from pressing on the nerve.
Nucleoplasty or plasma disk decompression. This surgery uses radiofrequency waves to treat low back pain due to a mildly herniated disk. The surgeon inserts a long needle into the disk under guidance of portable X-ray. A plasma laser device is then connected into the needle and the tip is heated, tissue in a small field around is vaporised in the disk. This reduces the size of the disk and relieves pressure on the nerves.
Spinal fusion. The intervertebral disk between two or more vertebrae is removed by the surgeon. The adjacent bones are then fused using bone grafts or metal implants secured by screws. Spinal fusion usually results in some loss of flexibility in the spine which is partially compensated by the spinal segments below and above it. Spinal fusion usually requires a long recovery period to let the bone grafts to get assimilated and fuse the vertebrae together.
Artificial disk replacement. This is a newer alternative to spinal fusion for the treatment in patients suffering from severely damaged disks. This procedure involves complete removal of the disk material and is replaced by an artificial disk. This helps restore the height and allows for movement between the vertebrae.
Other treatment modalities like intradiscal electrothermal therapy and radiofrequency denervation are not found to have any benefit in the long term.
What are the risks of back surgery?
Surgery to the back or spine carries higher risks due to its proximity to the spinal cord and nerves. The most serious of these are a rare possibility of paralysis and infections.
Even with a successful surgery, at times recovery can take a long time. Sometimes healing and complete recovery can take months depending on the type of surgery performed and your condition prior to the surgery. Surgery may cause some loss of flexibility permanently.
What type of anaesthesia is delivered during surgery?
Back surgery is almost always done under general anesthesia. Along with the usual risks of drug reaction, high sensitivity of the body associated with anesthesia, there are risks due to the patient lying face down on the surgical table.
Lying face down or in a prone position changes the flow of blood through the body. This position also limits the anaesthesia team’s access to the patient’s airway. This needs extreme care in the positioning of equipment and monitoring of the patient.
How do I manage pain during my recovery?
Back surgery if not managed correctly often leads to significant pain in post-operative period. You can consider a number of options for pain relief prescribed by the doctor in the days after surgery. These options can be considered after discussion with a pain management specialist to explain the pros and cons including effectiveness, side effects, addiction and recovery process.
Some factors to consider:
Many of your options will involve medications which may be opioids, non-steroidal anti-inflammatory drugs, corticosteroids and local anesthetics. Sometimes a combination of more than one drug will be taken. Multimodal therapies can improve pain control and limit opioid use.
Opioids use should be with care to prevent addiction and other side effects.
Alternative or complementary methods for pain relief which doesn’t include medicines must also be considered.
Many hospitals have a dedicated pain management team which include physician anesthesiologists who specialize in pain management can be important both before and after surgery to develop a tailored plan for your condition and preferences. They consult, and adjust your pain medications, based on the intensity of pain you are experiencing.