Back Surgery

Everyone with severe back pain is confronted by the inevitable concern--Will I need surgery? Too often, the decision is not well-thought out, made in desperation, or undertaken with unreasonable expectations. It is encouraging to note that only 5-10% of patients with radicular pain end up with surgery. Surgery should be strongly considered in the presence of demonstrable neurological compromise (that is if you have lost strength or absence of sensation in an extremity) that remains for more than a couple of days immediately after injury. This loss should be consistent and documentable by objective means such as NMRI and EMG (Electo-MyeloGraphy: a diagnostic technique wherein electrical impulses are measured from the spinal cord to the muscles to determine if the nerve is damaged.) It should be considered if intolerable symptoms have not been significantly alleviated after six weeks of failed non-surgical alternatives. The length of time elapsed without relief is probably the best indicator that the pain will not resolve without surgery.

Removal of the herniated disc material or "diskectomy" is warranted when the annulus fibrosus shows unmistakable signs of a prolapsed or extruded disc material. All of the surgical approaches to disc disease have one defining characteristic in common. They involve the removal of the offending nucleus pulposus or disc material from what ever abnormal anatomical space it finds itself, including the intervertebral space, the foramina (space where the spinal nerve root courses on its way out of the spinal canal), or the spinal canal.

When deciding whether to undergo a procedure in which someone is going to enter deep into the structural part of your body and remove some material wherein an error or bad luck can leave you a paraplegic, make every effort to determine the advisability of the technique and the qualifications of the physician. Don't go uninformed into one of the most important decisions of your life. Don't let your HMO intimidate you into accepting only the procedure they decided to pay for and don't fear doing research outside of your community to find the best institution in which to have the most appropriate procedure done by the most competent surgeon you can afford.

Of tantamount importance, if an immediate and persistent loss of function in an extremity occurs with a spinal injury or a progressive loss of neurological function occurs, surgery should be strongly considered to prevent permanent damage from compression of a nerve root. The presence of a foot drop (weakness such that you cannot lift the weight of your foot at the ankle) or a definite loss of sensation (that is, if you can stick a pin in the affected area and not feel it) constitutes a medical emergency. Weakness should not be defined as just a "giving out" with pain, and tingling feelings like the area is "asleep" (a paresthesia) are usually not signs of nerve damage that necessarily require surgical intervention. A significant weakness constitutes a profound failure of strength that doesn't allow normal movement, usually resulting in an inability to walk on your heels or toes or hold yourself up on the painful leg with a bent knee.

Surgery is said to not be indicated and should not be performed for a disc herniation without symptoms even if it appears to be compressing a nerve root on an imaging study. Surgery is also said to be not worth the pain, risk, and assumed benefit in syndromes of back pain without accompanying radicular pain (pain shooting down the extremity) or simply changes in sensation. If there is no loss of neurological function, surgery exposes the patient to the dangers of surgery without any predictable benefit. However, I have seen patients with such bad discs, that so continuously de-centralize and are so unstable that their only hope for a reasonably normal life would be to undergo surgical fusion of the offending disc unit. I even accept the reality that I may someday be forced to make this surgical decision for my own back.

If you are uncertain whether you need surgery or not, don't fear alienating your medical providers by asking sufficient questions to insure that you are making a fully informed decision. If they take any offense at your attempt to truly understand the risks, benefits, and alternatives, reconsider your decision to put your trust in that individual. They should never be too busy to adequately explain the merits and rationale for their particular approach to your problem. If you get the same anxious feeling as if when someone selling you aluminum siding is becoming visibly irritated when you attempt to actually read the fine print of the contract, hold off on your decision until you feel better about it.

Think about it, even if the success rate of percutaneous diskectomy is only fifty percent, it is only the equivalent of a large needle going into your back. The recovery from that is relatively minuscule compared to a spinal fusion or laminectomy in which the skin, muscle and sinew are splayed open, cut, torn, stretched and dried out by bright lights and every blood vessel that makes the fatal mistake of bleeding is electrically burned by a small smoking probe. Then, in the laminectomy, portions of the spinal bones are chipped away so that access can be gained to the posterior aspect of the disc. In the case of a spinal fusion, portions of the hip bone are harvested and used to build a plate of bone to make the formerly mobile spine, immobile.

Deciding to have anything like that done should only come after an attempt is made to exhaust all other opportunities for remedy and to acquire all the information possible to make an informed decision. A decision should be based upon the degree of symptoms compared to the alteration of lifestyle necessary without it as well as after it is done. There are people who have had the surgery and are glad they did because they were effectively healed. There are others who were surgically treated appropriately; but nevertheless got worse as well as those who got no appreciable benefit.

In my opinion, if it is determined on the basis of an imaging study (either CAT, NMRI, and/or Myelogram) that shows a compressed nerve in combination with an EMG (Electro-Myography=a test involving the use of tiny needles to measure electrical impulses reaching the muscles) that proves nerve damage, and the methods described in this book fail to help, then surgery is the only alternative to losing the neurological function of the extremity. Having a paralyzed leg or arm is no small matter and surgery is probably the only chance one has of preventing that complication. Usually, now-a-days, most surgeons won't proceed without satisfying those criteria; however, I still occasionally interview patients who have gone to surgery without actual documentable nerve damage, but this is rare lately in this litigious environment.

An important consideration that is sometimes over-looked in deciding to perform surgery is whether or not the nerve is permanently damaged to some degree when the disc is not actually compressing it. I don't feel that this situation is well treated or understood in the "black-and-white" world in which modern medicine sometimes paints itself. There are, you may be surprized to learn, grey areas of medicine still out there. I have seen several cases in which, immediately following the injury, there is definite nerve impairment that later resolves because a disc fragment at the instant of the injury transiently compresses the spinal nerve root then recoils back into a position closer to the center of the vertebral disc. This instantaneous collision with the nerve root can produce permanent nerve damage yet not be seen to be actively compressing the nerve on an imaging study. In this case, surgery probably cannot be expected to restore nerve function lost as a result of that happening. The nerve is permanently damaged, yet there is no continual compression by a piece of disc material. Even though the person may experience repetitive pain, the surgery probably isn't going to be that productive in the long run and, following the back pain management techniques delineated in this book is probably a superior plan.

There is good reason to believe that if one can keep the disc material centralized and prevent it from further impacting upon the nerve root, the body's healing process will fill in and scar down the area where the peripheral ligamentous structures were damaged and the granulomatous material that the body uses to fill in damaged spaces will additionally help prevent the disc from migrating to a position wherein it impacts upon the nerves.

In this event, operative diskectomy that does not remove the entire nucleus pulposus (as opposed to percutaneous needle diskectomy) would have been of no real, long-term benefit because, if anything, the process of taking out the disc material would only have made a larger opening in the ligamentous capsule of the disc unit which, over time and with continued flexion forces, would allow additional degenerating disc material to migrate out through the pathway created by a combination of the injury and the surgery.

However, if the imaging study shows continued compression that can't be helped by the techniques in this book and, the patient has neurological damage, there may be no genuine advantage to waiting. In this case, the nerve damage can be reduced or prevented by physically removing the putative piece of disc material. Here, the decision is not whether surgery is indicated, it is a matter of what type of surgery is best. I would favor percutaneous diskectomy; but if the disc material is so close to the nerve that the diskectomy needle might damage the nerve more in the process of trying to remove it, an open procedure might be the only alternative that makes sense.

There are several gradations of diskectomy which are arranged here in order of least to maximum trauma.

Further Reading

Introduction
TENS (Transcutaneous Electrucal Nerve Stimulation)
Ice and Heat
Acupuncture
Trigger Point Point Injections
Epidural Steroid / Aneshetic Injections
Chemonucleolysis
Surgery
Percutaneous Diskectomy
Microdiskectomy
Laminectomy
Artificial Discs
Fusion

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