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Bill Yancy, MD, offers some wise words on Back Surgery

Comments by Bill Yancey, MD, 25 August 2012

Surgery has a very limited role in the treatment of back pain. Although it is probably offered to patients more often than is necessary (this is, after all, how surgeons make their living), there are a few good reasons to have surgery. A small number of surgeons think the only way to cure a medical condition is with cold, hard steel. There are also some surgeons whose only interest in the patient is in the fee they collect; they collect more for doing surgery than for talking patients out of surgery. Honest, ethical surgeons give the patient options and honest opinions. The problem may be in figuring out who is being honest and who isn’t.

Most insurance companies, especially workers compensation companies, would prefer not to pay for surgery, or long term rehabilitation instead of, or following, surgery. The less they pay out for procedures or physical therapy, the more profit they make. Stock holders like that; patients don’t. And if insurance companies can find a way to no longer be the financially responsible party, all the better.

Keeping the above two paragraphs in mind, some times surgery is a necessity. Statistically, necessary surgery probably falls in the range of 5% of cases. In another 5% of cases surgery may be appropriate because it saves the patient healing time and time off work, even if it does not affect the eventual overall outcome. This means that in 90+% of back pain cases, surgery is not needed! All surgery has the potential for complications, from pain to numbness to paralysis to death. Think hard about your choices.

In general, a patient needs surgery when surgery can save his life, repair an injury the patient’s body cannot, or shorten significantly the recovery from an injury or disease. When it comes to the lower back, there are five absolute indications for surgery, but several elective reasons. The absolute indications for surgery are the following:

  1. Cauda equina or conus medullaris syndrome. These situations happen when there is a very large central herniated disc that compresses severely the nerves in the lower spinal cord. Without surgery, the compression would lead to eventual loss of function of those nerves, paralysis of muscles, and/or loss of sensation.
  2. Intractable pain, i.e. unremitting, severe pain.
  3. Progressive neurological deficit, loss of sensation, proprioception, muscle control, etc.
  4. New incontinence or retention, bowel or bladder.
  5. Hemorrhage into the spinal cord.

The relative indications generally center on the relief of discomfort (less than intractable) and the shortening of recovery time from various problems: herniated disk, compression fractures, etc.

There are also several types of surgery: open, micro, and minimally invasive. Open takes less time, usually. The surgeon has a better view of the surgical field, but more structures are damaged and recovery is longer. Micro surgery takes longer; the field of view is smaller, but fewer structures are damaged and recovery is shorter. Minimally invasive surgery, in general, takes the longest; is the most difficult; has the narrowest field of view, but the shortest recovery time. There are trade-offs. Get the surgeon to explain them all to you. If he can’t or won’t, find another surgeon.

If someone uses the words, laser surgery, he is trying to impress you. Nothing more. Lasers have their place in surgery — usually cauterizing blood vessels. Very little surgery is done with a laser. A laser produces too much heat. Laser is a buzz word only. And the person using it is a salesman first — surgeon second. He wants your money; he’s not concerned with your best interests.

Bill Yancey, MD