“I’ve tried everything. Spinal surgery is my only option left.”
As I was about to leave my office, hurrying to not miss my daughter’s soccer practice, the phone incessantly rang, as if calling for my attention.
It was late. But the ringing wouldn’t stop.
I was torn between answering the phone one last time or hopping on my car to beat the after-school traffic and be present at my daughter’s soccer practice.
What if it’s a patient needing serious help?
Or a patient needing an answer to a critical question?
Or another with a “victory report?”
I dashed back to my office to answer the phone one last time. I just had to.
No sooner than I picked up the phone when I could hear my friend crying at the other end. Between her sobbing, I could only make out one string of words clearly:
“I’ve tried everything; spinal surgery is my only option left.”
Does this ring true for you lately?
I’ve heard this string of words from a number of my patients as well. A sense of surrender often accompanies them. Or an expression of desperation. A feeling of helplessness.
Yes, your back pain has persisted despite the many different interventions you have tried in the past:
- You’ve taken countless opioid pain medications.
- They have stabbed you in the back with spinal injections.
- They have cracked your back with spinal manipulation or “adjustments”.
- You’ve had multiple trips to the massage therapist in your neighborhood.
- You’ve followed all the exercises your physical therapist has taught you.
- You’ve bought all the fancy and expensive back pain relief equipment and contraptions.
- Is there anything else I missed that you have tried? (Fill in the blank here ______.)
With no hope in sight, you are now resigned to the very last option you most dread: spinal surgery.
In this article, I will help you make an informed decision by sharing with you the indications for surgery, what the results of different studies have taught us, and the treatment intervention you may not have heard of or tried.
Reasons for Spinal Surgery
- Do you feel that you are losing sensation in your buttocks or limbs (legs)?
- Is your leg or foot getting weaker?
- Are you having difficulty coordinating the movement of your feet?
- Do you have difficulty controlling your urge to urinate or move your bowels?
What I listed above are called neurologic symptoms that are associated with your lumbar spinal cord or the nerves in the area around your back.
Both your spinal cord and the nerves coming out of your lumbar spine are insulated by several membranes that can be vulnerable to damage by force or pressure.
Even a minor disturbance to a nerve’s structural pathway can cause dysfunction, resulting in the neurological symptoms I listed above.
The presence of one or more of the neurologic symptoms associated with damage to the spinal cord or spinal nerves warrants a thorough medical evaluation, and spinal surgery may indeed be indicated.
If you do not have any of the worsening neurologic symptoms listed above, back pain, in and of itself, should NOT be an indication for surgery.
What we’ve learned from spinal surgery studies
Spinal fusion is the most expensive form of elective surgery in the United States.
For patients without health insurance, spinal fusion surgery can cost between $80,000 to $150,000. A surgery using titanium implants instead of conventional implants usually falls on the higher end of the scale.
Granted that many people in the United States have health insurance coverages and only have to consider their out-of-pocket costs, it is not guaranteed that their insurance is part of the surgeon’s or the hospital’s “network” of insurances.
Additionally, the total cost of surgery does not end with surgery.
Many people forget they would typically require two to six weeks of recovery time, pain medications after surgery, physical therapy after surgery, as well as the cost of medical equipment, and assistive devices if needed.
That is not to mention the cost of lost time, work, and productivity.
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The number of spinal surgeries has increased exponentially, but the success rate has not.
The data from the Agency for Healthcare Research and Quality (AHRQ) revealed that, in 2011, there were 490,000 laminectomies performed in the United States, and between 2001 to 2011 there was a 70 percent increase in spinal fusion surgeries, from 287,000 to 488,300.13
This increased rate of spinal surgeries, unfortunately, did not correspond to an increase in successful outcomes.
A conservative estimate of 20 to 40 percent of these surgeries has failed to treat the pain.
According to the American Journal of Medicine, in the United States alone, about 80,000 spine surgeries fail annually.
Failed back surgery is fairly common.
Failure of surgery to resolve the pain is such a common consequence that a term has been coined to describe the condition: Failed Back Surgery Syndrome (FBSS).
The International Association for the Study of Pain defines failed back surgery syndrome (FBSS) as:
Lumbar spinal pain of unknown origin either persisting despite surgical intervention or appearing after surgical intervention for spinal pain originally in the same topographical location.
In other words, the surgery designed to relieve the pain has not resolved the pain, or the pain has recurred just as it was before surgery.
Up to 40% of patients have experienced continued pain after surgery, which is often referred to as Failed Back Surgery Syndrome (FBSS).
Know your preoperative (before) risks before deciding.
Many factors present before your spinal surgery determine its success.
- Accurate diagnosis. To ensure successful surgery, it is vital that the cause of your back pain be accurately diagnosed.
For example, if you have a herniated disc instead of a spondylolisthesis, the decision to have surgery and the type of surgery required will differ. A major cause of FBSS is inaccurate diagnosis, with as much as 58% of cases resulting from undiagnosed lateral stenosis.
- Behavioral factors, like smoking and obesity, affect outcome after spine surgery.
Smokers had a more regular use of analgesics, worsened walking ability, and inferior overall quality of life 2 years after surgery compared with nonsmokers.
Smoking is also associated with an increased rate of surgical complications such as impaired wound healing, increased rate of infections, and an increased rate of nonunion in spinal fusions.
Prior to surgery, this can be applied to a number of areas including optimized body mass and optimal emotional disposition.
- Psychological factors like depression and anxiety also affect the outcome.
A depressed individual is usually more physically ill, experiences more weakness, and returns to work at a significantly lower rate than those without depression.
- Lastly, economic influences are a factor in the outcome of your spinal surgery.
After spine surgery, workers’ compensation patients have dramatically worse outcomes than nonworkers’ compensation patients in almost every category, including post-operative pain, opioid consumption, functional ability, and mental well-being.
Know your postoperative (after) risks before deciding.
Much like you considered your risks before deciding on spinal surgery, also consider the risks present after the surgical procedure.
- Degenerative changes happen.
Surgery on your back leads to biomechanical changes within that region, putting additional stress on nearby structures. It can speed up degenerative changes in your spine, both above and below the fusion.
- Changes in biomechanics lead to joint pain, hypertrophy, atrophy, and spasms.
As I stated above, back surgery can change the biomechanics of your spinal column so that the muscles controlling your back’s movement are put under more tension. When the back muscles are tensed, this can cause stiffness, inflammation, spasms, and fatigue, which all may generate back pain.
Also, dissection and retraction during surgery can damage the muscles of your back.
- Hardware failure.
Pedicle screw loosening is a common complication and cause of failed back surgery syndrome (FBSS) after spine surgeries.
Spinal surgery is not something most surgeons would choose for themselves.
In her well-researched book, CROOKED: Outwitting the Back Pain Industry and Getting on the Road to Recovery, investigative journalist Cathryn Jakobson Ramin, reported several surgeons conceded to her that…
“Eighty to 85 percent of the time, although they can visualize an anomaly on the X-ray or MRI, they cannot with any certainty, determine the source of pain.”
At an American Academy of Orthopedic Surgeons conference in 2010, a hundred surgeons were polled as to whether they’d personally have lumbar fusion surgery for unspecific low back pain.
What is your remaining alternative?
As my friend was crying at the other end of the line and resigned to getting spinal surgery for her chronic low back pain, I shared with her the data and the results of the studies I outlined for you above.
I asked her what treatment interventions has she tried before deciding on getting spinal surgery.
She proceeded to narrate a laundry list of the usual suspects:
- Pain pills
- Steroid injections
- Chiropractic adjustments
- Physical therapy
- And a list of equipment and contraptions she’s bought and used over the years
It wasn’t her fault that all the treatment interventions she knew focused on treating a body part – her back.
That is the old but still dominant way of medical practice that we all have been conditioned to: the use of the biomedical model of medicine to treat chronic pain.
The biomedical model of health focuses solely on biological (or physical) factors and ignores the role of psychological, environmental, and social factors. For several decades, Western countries consider it the most effective way of diagnosing and treating diseases.
The model’s focus on the physical processes does not take into account the role and influence of social, psychological, or even environmental factors on your experience of pain.
That is how we all ended up with the quick fixes – pain pills, spinal injections, spinal manipulations, or spinal surgery. Quick fixes for a chronic pain problem.
Do you see the disconnect?
That is why using the biopsychosocial model of medicine is the only sensible and effective way to treat chronic low back pain.
That is what I shared with my friend who called me looking for an alternative to spinal surgery for her chronic low back pain problems.
I sent her articles and research studies on how brain training, graded motor imagery, meditation, visualization, and even writing can alter her mind and body’s response to pain.
I taught her how to use the biopsychosocial model of treatment by implementing strategies that empower her to calibrate her body’s “living pain alarm system” and help her to finally conquer her long, drawn-out battle with back pain.
In this article, How To Effectively Treat Chronic Low Back Pain Using The Biopsychosocial Model, I gave an example of a step-by-step framework to treat chronic low back pain using the biopsychosocial model.
Remember that phone call that almost got me late for my daughter’s soccer practice?
It was the phone call that saved my friend from spinal surgery.
Frequently Asked Questions
What are the different types of spinal surgery?
- Lumbar Decompression Surgery – The purpose of lumbar decompression surgery, also called a laminectomy, is to correct the narrowing of the spinal canal, also known as spinal stenosis.
During surgery, the surgeon will remove the lamina (a part of your vertebral bone) that is pressing against the spinal cord or spinal nerve root.
- Lumbar Discectomy – Discectomy refers to surgery to remove a damaged disc from a patient’s lower back.
Lumbar discectomy can be performed minimally invasively via arthroscopic surgery or openly via open spine surgery. Herniated discs in the lumbar spine are more commonly treated through open spine surgery.
- Herniated Disc Surgery – The surgeon will remove a part or all of the herniated disc in surgery to repair it.
Alternatively, the disc may be removed and the two adjacent vertebrae fused together.
- Spinal Fusion Surgery – Spinal fusion treatment involves attaching two adjacent vertebrae together so they do not push against each other.
In this procedure, the surgeon uses small screws and rods to connect the vertebrae, which are then left to heal naturally and fuse together. Occasionally, a small amount of bone will be taken from another part of your body in order to help fuse the vertebrae.
How serious is spinal surgery?
Any surgery carries a risk of complications. Surgery near the spine and spinal cord can result in serious or severe complications.
A potential complication could involve future pain or impairment, as well as the need for additional surgery.
Can screws come loose after spinal fusion?
Pedicle screw loosening is a common complication and cause of failed back surgery syndrome (FBSS) after spine surgeries.
The most common pedicle screws used by spine surgeons loosen or break over time. If pedicle screws loosen, it may result in new or worsening back pain.
How long is bed rest after back surgery?
The hospital stay could last between 1 and 3 days, or longer, if you have spinal fusion.
Rest is vital. Nonetheless, doctors want you to get up and walk soon after surgery. For most people, physical therapy starts within 24 hours of surgery.
Dr. Lex Gonzales, PT, DPT is an author and speaker who has been working as a licensed healthcare professional for over 24 years. On drlexgonzales.com he provides quality information and practical solutions you can use to achieve the best version of your healthy self.