Back surgery: To have or not to have
Is your back bothering you at the moment? Do you have a history of back problems? If you answered “yes” to one or both of these questions, you’ve got lots of company. Low back pain is an extremely common condition: 80 percent of people experience at least a bout of it some time during their lives. Rest, some pain relievers, and perhaps some exercises help it go away.
But for thousands, the pain lingers, and may become severe and debilitating. Depending on the underlying cause and the severity of the condition, surgery may be an option. But deciding to have surgery, especially of the back, is never simple. There’s a popular belief among the general population that back surgery is fraught with more danger than other orthopedic surgical procedures. Popular procedures in treating the back have been questioned, and sometimes new ones get introduced even before we really know how well they’ll work in the long haul. Likewise, physical changes to the spine may cause excruciating pain in one person, but no pain in another, so it’s hard to go by physical findings. There are also variations in practice patterns among surgeons doing surgery on the back. Among laymen. therefore, there’s much confusion and difficulty to figure out whether surgery to the back is necessary or not.
Back Basics
Although we talk about strong-willed people having strong backbones, your spine is actually a flexible, curvaceous stack of 24 vertebrae (33, if you count the fused vertebrae of the sacrum and coccyx). They are held together by tough ligaments, and the spinal cord runs down the space in the middle. The five lumbar vertebrae are the largest, as they should be, because they must support much of your body weight when you’re upright. Most back problems come from this lower, weight-bearing region — thus, the “low” in low back pain. You don’t hear it used much anymore, but lumbago is the old word for low back pain.
In between the vertebrae are discs, so infamous for “slipping.” Their outsides are made of a tough fibrous tissue (annulus fibrosus) that holds a squishy substance (nucleus pulposus) inside. Intervertebral disks (that’s the full medical term) are little mini-water beds that cushion the vertebrae so we don’t have bone rubbing on bone. Unfortunately, as we get older, our intervertebral disks gradually dry out, so by about age 50, the tough exterior and soft interior merge. They also thin out, which puts additional pressure on the vertebrae and makes the back less flexible.
Three Categories
Most back pain can be grouped into three major categories:
• Sprains and strains. These are the most common causes of back pains. The pain is the result of damage to the ligaments and muscles — the “soft” tissues that support the spine. Sprains are injuries to ligaments. Strain is a general term that’s usually used in reference to muscle. If it isn’t too serious, a back sprain and strain will often clear up in a few days or weeks, as long as you give it some rest, perhaps take an over-the-counter pain reliever and, in more serious cases, get some physical therapy. But recurrence is common. Without following a regular exercise program that stretches and strengthens back muscles and ligaments, about 40 percent of patients will have another episode within a year.
• Pinched nerves. This category includes any condition that compresses the roots of nerves as they peel off in pairs from the spinal cord, a little like the off-ramps coming off a major highway. (A brief, technical aside: Although they’re commonly referred to as pinched nerves, strictly speaking these spine-related conditions impinge on the roots of the nerves. Nerve roots become nerves an inch or so out from the spinal cord.)
Herniated disks (a slipped or ruptured disk) are the main cause of spine-related pinched nerve roots. The outer casing of the disk weakens and gives way, so the nucleus pulposus — the gelatinous substance inside — pushes out and causes a bulge. If the bulge sticks out too far, or a piece of the misshapen disk breaks off, it can irritate the nerve root (see illustration). Sometimes the disk impinges on the root of the large sciatic nerve that supplies the back of the leg. The result is sciatica — pain and numbness that radiates down the buttock and the thigh and, sometimes, all the way to the toes. Spinal stenosis is the other major pinched nerve syndrome and a common problem in older people. The spinal cord and nerve roots thread through openings in the vertebrae with little room to spare. Spinal stenosis occurs when bone spurs (osteophytes) and other tissues narrow these openings, so the nerve tissue gets squeezed and irritated. Symptoms often include leg pain, cramping, and weakness that gets worse with standing or walking. As with sciatica, these leg problems sometimes may not seem like they’re coming from the back.
• Degenerative disease. With age, vertebrae get brittle and break, even without a fall or some kind of trauma. In addition, the spine’s facet joints, where the vertebrae interlock with one another, tend to get arthritic as we get older.
Decisions, Decisions
You don’t get surgery for sprains and strains. Rest is important, but bed rest of more than a couple of days is counterproductive; you and your back rapidly get out of shape. A return to normal activities as soon as possible is the best medicine for a sprain and strain.
Surgery is sometimes used to treat pinched nerves. If you have a herniated disk, the part that is impinging on the nerve can be removed, if necessary. Lumbar diskectomies, as these operations are called if they involve the disks in the lumbar region, are the most common operations for back and leg problems in countries like the
Findings from a clinical trial reported in the November 2006 issue of the Journal of the American Medical Association stirred the lumbar diskectomy pot a little more. The study involved about 500 patients with herniated disks and leg pains. They were randomized to either surgery or nonsurgical treatment and then followed for two years. Nonsurgical treatment was left to the discretion of the doctors and patients, and it ran the gamut from pain relievers to physical therapy to acupuncture to steroid injections.
By some measures (sciatic pain, self-reported progress), the surgical patients did fare slightly better. Results from a companion study that wasn’t randomized suggested that surgery may also provide quicker relief. Still, the overall results from the main randomized study showed no statistical difference between surgery and nonsurgery — although don’t equate nonsurgery with nontreatment. This study was widely interpreted as showing that lumbar diskectomy may not be warranted, considering that people assigned to nonsurgery did just as well after two years. But another interpretation is that all the nonsurgical treatments for herniated disks have caught up with diskectomy. An editorial accompanying the study said that the toss-up results show that the decision whether to have surgery is a matter of patient preference more than anything else.
Spinal stenosis can be treated surgically by removing bone spurs or parts of the vertebrae (laminae, portions of the facet joints) that are pressing in on the nerves. Studies have shown good results, with any lingering pain controlled with medication. Degenerative disease can be treated with spinal fusions, an operation that involves grafting two neighboring vertebrae together to create more stability. But doctors are beginning to question whether too many spinal fusions are being done, and some recent research calls into question how effective they really are.
However, you should certainly seek surgical help right away if you experience weakness of the legs, disturbances of bladder and bowel function, or numbness around the anal and genital regions (known as saddle anesthesia). These symptoms suggest compression of the cauda equina, the bundle of nerves that emerges from the spinal cord in the lower spine, so named because of the resemblance to a horse’s tail. Any suspicion that the cauda equina is being “squeezed” requires medical assessment and possible emergency surgery to avoid permanent damage. Likewise, back pain that comes on suddenly also needs immediate attention. A sudden backache can be the first sign of several cancers. Fever and chills with back pain is another red flag: They could be symptoms of an infection on or near the spine.
Rule Of Thumb
Barring an emergency, however, it’s a good rule of thumb to put off surgery for at least a few weeks after symptoms start. In some cases, waiting allows the problem to improve by itself. Specialists can bring great expertise and experience to bear on various medical conditions, back pain included. Consult as many doctors as you think you may require. Together, they may provide the right mix of experience and objectivity that you need before you make that important — often backbreaking — decision.
