The provider should give people complete information on the expected course of their low back pain and self-care options before discussing surgery. People should ask their provider about evidence favoring surgery or other (nonsurgical) treatments in their particular case. They should also ask about the long-term outcome of the recommended treatment. Would the improvements last, and if so, for how long? Another consideration when surgery is an option is the overall safety of the recommended procedure, weighed against its potential short-term and long-term benefits.
People should generally try all possible non-surgical treatments before opting for surgery. The vast majority of back pain people will not need aggressive medical or surgical treatments.
The most common reasons for surgery for low back pain are disk herniation and spinal stenosis. In general, surgery has been found to provide better short term and possibly quicker relief for selected people when compared to non-surgical treatment. However, over time, nonsurgical treatments are as effective.
It should be noted that surgery does not always improve outcome and, in some cases, can even make it worse. However, surgery can be an extremely effective approach to certain people with severe back pain that does not respond to other therapies.
Diskectomy or discectomy is the surgical removal of the diseased disk. The procedure relieves pressure on the spine. It has been performed for over age 40 years, and less invasive techniques have been developed over time. In appropriate candidates it provides faster relief than medical treatment, but long-term benefits (over 5 years) are uncertain.
Diskectomy is recommended when a herniated disk causes one or more of the following:
- Leg pain or numbness that are severe or persistent, making it hard for the person to perform daily tasks
- Weakness in the muscles of the lower leg or buttocks
- An inability to control bowel movements or urination
Most other people with low back or neck pain, numbness, or even mild weakness are often first treated without surgery. Often, many of the symptoms of low back pain caused by a herniated disk get better or disappear over time, without surgery.
When the soft, gelatinous central portion of an intervertebral disk is forced through a weakened part of a disk, it is called a herniated disk. Most herniated disks take place in the lumbar area of the spine. Herniated disks are one of the most common causes of lower back pain. The mainstay of treatment is an initial period of rest with pain and anti-inflammatory medications followed by physical therapy. If pain and symptoms persist, surgery to remove the herniated portion of the intervertebral disk may be needed.
Microdiskectomy is the current standard procedure. It is performed through a small incision (1 to 1-1/2 inch [2.5 to 3.8 centimeters]). The back muscles are lifted and moved away from the spine. After identifying and moving the nerve root, the surgeon removes the injured disk tissue under it. The procedure does not change any of the structural supports of the spine, including joints, ligaments, and muscles.
Other, less invasive procedures are available, including endoscopic diskectomy, percutaneous diskectomy (PAD), and laser diskectomy. The long-term benefits of these procedures are unknown, however. There is no evidence that any of these less-invasive procedures are as effective as the standard microdiskectomy.
Complications and Outlook
Most people achieve pain relief and can move better after microdiskectomy. Numbness and tingling should get better or disappear. Your pain, numbness, or weakness may not get better or go away if the disk damaged your nerve before surgery.
Scar tissue is a potential problem, since it can cause persistent low back pain afterward. Other complications of spinal surgery can include nerve and muscle damage, infection, and the need for another operation.
People are usually up and walking soon after disk surgery. However, it may take 4 to 6 weeks for full recovery. Gentle exercise may be recommended at first. Starting intensive exercise 4 to 6 weeks after a first-time disk surgery appears to be very helpful for speeding up recovery. Little or no physical therapy is usually needed.
Laminectomy is surgery to remove either the lamina, 2 small bones that make up a vertebra, or bone spurs in your back. Laminectomy opens up your spinal canal so your spinal nerves or spinal cord have more room. It is often done along with a diskectomy, foraminotomy, and spinal fusion.
Laminectomy is frequently done to treat spinal stenosis. Spinal stenosis symptoms often become worse over time, but this may happen very slowly. Surgery may help when your symptoms become more severe and interfere with your daily life or job.
Laminectomy for spinal stenosis will often provide full or partial relief of symptoms for many people, but it is not always successful.
Future spine problems are possible for all people after spine surgery. If you had spinal fusion and laminectomy, the spinal column above and below the fusion are more likely to have problems in the future. If you needed more than one kind of back surgery (such as laminectomy and spinal fusion), you may have more of a chance of future problems.
Some recurrence of back pain and sciatica occurs in half to two-thirds of postoperative people. Minimally invasive variations are under investigation. For spinal stenosis, the traditional approach is a laminectomy and partial removal of the facet joint. There is controversy whether performing a fusion procedure along with these procedures is needed.
Spinal fusion is surgery to fuse spine bones (vertebrae) that cause you to have back problems. Fusing means 2 bones are permanently placed together so there is no longer movement between them.
Spinal fusion is usually done along with other surgical procedures of the spine, such as a diskectomy, laminectomy, or a foraminotomy. It is done to prevent any movement in a certain area of the spine.
Conditions fusion may be done for include:
- Spinal stenosis
- Injury or fractures to the bones in the spine
- Surgery performed on 2 or more levels of the spine
- Weak or unstable spine
- Spondylolisthesis, a condition in which one vertebra slips forward on top of another
- Abnormal curvatures, such as those from scoliosis or kyphosis
The surgeon will use a graft (such as bone) to hold (or fuse) the bones together permanently. There are several different ways of fusing vertebrae together:
- Placing strips of bone graft material over the back part of the spine
- Placing bone graft material between the vertebrae
- Placing special cages between the vertebrae. These cages are packed with bone graft material.
The surgeon may get the graft from different places:
- From another part of your body (usually around your pelvic bone). This is called an autograft. Your surgeon will make a small cut over your hip and remove some bone from the back of the rim of the pelvis.
- From a bone bank, in a procedure called an allograft.
- A synthetic bone substitute can also be used.
The vertebrae are often also fixed together with screws, plates, rods, or cages. These are used to keep the vertebrae from moving until the bone grafts fully heal.
Future spine problems are possible for all people after spine surgery. After spinal fusion, the area that was fused together can no longer move. Therefore, the spinal column above and below the fusion is more likely to be stressed when the spine moves and develop problems later on. Also, if you needed more than one kind of back surgery (such as laminectomy and spinal fusion), you may have more of a chance of future back problems.
There are many video-assisted fusion techniques. These new techniques are less invasive than standard "open" surgical approaches, which use wide incisions. To date, however, the newer procedures have higher complication rates than the open approaches, and some medical centers have abandoned them.
Other Surgical Procedures
Percutaneous vertebroplasty involves the injection of a cement-like bone substitute into vertebrae with compression fractures. It is done under endoscopic and x-ray guidance.
Warning: The FDA has warned consumers that polymethylmethacrylate bone cement, used during vertebroplasty, could leak. Such leakage could cause damage to soft tissues and nerves. It is extremely important that the person is sure that the provider has had significant experience performing the vertebroplasty procedure. A major trial reported little benefit from vertebroplasty. More research is needed.
The provider injects bone cement into the space surrounding a fractured vertebra. (Vertebroplasty injects the cement directly into the vertebra.) Kyphoplasty is used to stabilize the spine and return spinal height to as normal as possible. Kyphoplasty should only be done if bed rest, medicines, and physical therapy do not relieve back pain. Those with severe fractures or spinal infections should not have kyphoplasty. More research on kyphoplasty is needed.
Artificial Disk Replacement
Total disk replacement is a newer procedure for people with damaged disks. It may be done instead of spinal fusion surgery, such as for people who do not have severe spine disease above and below the site of surgery.
The technique implants artificial disks (such as ProDisc, Link, and SB Charite). The surgery can be performed through small cuts using miniature tools and viewing devices. The artificial cushioning device replaces only the inner gel-like core, rather than the entire disk.
After disk replacement surgery, there is preserved movement in the spine above and below the site of surgery than there is after fusion surgery. This extra movement may prevent further disk degeneration.
Disk replacement surgery has not yet been shown to be superior to traditional spine surgery and sufficient long-term outcomes are still lacking.
Intradiscal Electrothermal Treatment (IDET)
Intradiscal electrothermal treatment (IDET) uses electricity to heat a painful disk. Heat is applied for about 15 minutes. Pain may temporarily feel worse, but after healing, the disk shrinks and becomes desensitized to pain. However, healing takes several weeks. While some studies have reported benefit, many consider the evidence to support the use of this procedure weak.