Surgery for back pain is a last resort treatment. There are basically two reasons for surgery for back pain:
- Neural element compression (or squeezing of nerve roots or nerves) or pressure on the dura mater (the sac that surrounds the spinal cord and nerve roots), and
- Back pain. Back pain itself has two main causes: muscle spasm and lower back pain.
What is a muscle spasm?
Muscle spasm is essentially a muscle pull or charley horse of the back muscles. In this situation, the muscles of the back are tender to the touch. Bed rest or inactivity does not usually relieve the pain significantly. Muscle spasm, as an isolated entity, is a non-surgical problem.
What is lower back pain?
Lower back pain is a pain that is deep and agonizing in nature. It is not related to muscle spasm, and activity worsens the pain whereas inactivity (such as bed rest) improves the pain. This pain syndrome is significantly different than that of muscle spasm. It is potentially a surgical problem in that instability can cause lower back pain. This is akin to a degenerative hip in an elderly person in whom the pain is deep and agonizing in nature, is worsened with walking, and improved with sitting or lying.
What is sciatica?
Sciatica and some central back pain problems can be related to neural compression. Sciatica is caused by a disc herniation or bulge that compresses or squeezes a nerve as it exits the spinal canal. This pain usually is in the distribution of the nerve (where the nerve goes in the body). Anterior dura mater pressure can cause central back pain because of the rich innervation (nerve supply) of this portion of the dura mater.
Discectomy is a treatment of choice for the problems mentioned above. Laminectomy might occasionally be helpful. A discectomy is usually performed through a small bony window.
What are the surgical procedures for back pain?
Laminectomy
A laminectomy is a surgical procedure that removes a portion of the vertebral bone called the lamina. At its most minimally invasive, the procedure requires only small incisions. The back muscles are pushed aside rather than cut and the parts of the vertebra adjacent to the lamina are left intact.
Discectomy
Discectomy is surgery to remove lumbar (low back) herniated disc material that is pressing on a nerve root or the spinal cord.
It tends to be done as microdiscectomy, which uses a special microscope to view the disc and nerves. This larger view allows the surgeon to use a smaller cut (incision), causes less tissue damage and speeds recovery.
Spinal fusion
Spinal fusion is a process during which a number of vertebrae are made to grow, or fuse together. Lower back pain is usually treated with exercise and the strengthening of the support system of the spine (muscle and ligaments). These treatments stabilize the spine in a physiological manner. However, spinal fusion occasionally might be needed in patients who truly have lower back pain and who have failed an aggressive non-operative program.
Many controversies exist regarding fusion:
- Should the fusion be performed as an entity in and of itself or with instrumentation?
- Should the fusion be anterior or posterior in location?
- Should cages or screws be used to supplement the fusion?
- How long should a fusion be?
- Should it incorporate one motion segment (disc), or two or three motion segments?
All of these questions are appropriate and very difficult to answer.
Remember, spine surgery begets spine surgery. At least 20% of people who undergo an initial simple operation for back pain or leg pain will undergo one or more additional operations; these are usually people with chronic back pain.