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Back pain: When is surgery necessary?

October 27, 2016 | UC Irvine Health
Back pain

Back problems are the nation’s No. 1 cause of missed work. But just because a patient has pain or spine problems, it doesn’t mean surgery is the answer.

In fact, too many people are undergoing needless surgery, especially for the lower back, because they aren’t getting a thorough diagnosis, says UC Irvine Health neurosurgeon Dr. Amer Khalil.

As many as 30 percent of patients who undergo lower back surgery need a second operation because the first one failed to alleviate pain and other symptoms, some studies show. And that figure doesn't cover the many people for whom no amount of spine surgery succeeds.

“Back surgery has a history of many problems,” Khalil says, “and one of the biggest problems is misdiagnosis. People end up with unnecessary surgery.”

Careful screening

The decision to perform surgery on someone with lower back pain involves a thoughtful matching of the patient’s symptoms with the results of screening tests such as X-rays and magnetic resonance imaging, or MRI, says Khalil, an assistant professor of neurological surgery and neurosurgery director of the UC Irvine Health Comprehensive Spine Program.

Those tests often show some sort of issue — a bulging disc, or perhaps stenosis, which is a narrowing of the space in the spine that can result in pressure on a nerve. Even if a patient has back pain and problems that show on imaging, that doesn’t mean the two are related, he says. And that’s why back surgery can have a bad reputation.

Imaging might show that two patients have equally bad stenosis, but one might feel terrible pain — which may or may not be related to the narrowing — while the other is pain free. The same may be true for bulging discs.

Identify causes and weigh your options

Khalil says he doesn’t recommend surgery for most lower back problems unless patients have pain, weakness or numbness in the legs, indicating nerve irritation — and even then, only if the cause of the pain can be clearly identified. Figuring out the difference means fully understanding precise details of the patient’s symptoms.

Given that 90 percent of people experience back problems by age 65 — by age 80 it jumps to 99 percent — people should weigh their options carefully.

For some patients with normal wear and tear in the lower spine, Khalil says the best answers are nonsurgical: physical therapy, massage, acupuncture and medication.

“You have to spend time with the patient. How severe is the pain? How often? When does it come, day or night? Does it go down to the leg, and if so, which leg and how severe? Does it make walking difficult? In the best scenario, the imaging findings correlate with the symptoms. Surgery in this setting has a high success rate.”

A misdiagnosed patient

Khalil especially remembers one dramatic example of a misdiagnosed patient.

“He originally went to another spine surgeon with weakness in the legs. Over weeks and months, he continued to have progressive weakness. They saw a stenosis in the lower spine and operated on him, but he continued to worsen and ended up in a wheelchair.”

The patient finally came to Khalil, who noticed something that hadn’t been taken into account before: The patient’s legs weren’t just weak, but also stiff, a symptom more consistent with upper spine pathology. Imaging revealed a benign tumor in the upper thoracic spine.

“A few months after surgery to remove it, he was up and walking around and went back to work,” Khalil says.

Specialized spine training

Spinal diagnosis and surgery can be performed by either orthopaedic surgeons or neurosurgeons such as Khalil.

Either way, there’s one element he believes is the key to making a correct diagnosis and preventing unsuccessful surgery: Find a doctor who has gone beyond residencies in those specialties and completed a fellowship specifically in spinal surgery.

Khalil did that at New England Baptist Hospital in Boston, which is known for treating complex spine problems. In fellowships working with leading specialists in the field, doctors learn the subtleties of combining examination and diagnostic screening with appropriate surgical treatment, Khalil says.

Too often, he says, “doctors treat the image. We have to go back to treating the patient.”

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