Back Pain: When is Surgery Appropriate?

Surgery can helpful for these two common back conditions:

• Disc herniation (called "ruptured disc" or "slipped disc")

• Spinal stenosis (abnormal constriction or narrowing)

Both of these conditions may result in nerve root compression ("pinched nerve") and cause leg pain and/or low back pain.

What are the symptoms of disc herniation?
Lumbar disc herniation may result in low back pain and/or leg pain. It may also result in leg weakness and may very rarely affect the nerves controlling the bowel and bladder, resulting in incontinence. The pain resulting from a disc herniation is typically greater when sitting (for example, riding in a car) than when lying down or standing. People with lumbar disc herniation usually prefer to stand than sit. Lumbar disc herniation is a condition that more commonly affects people who are less than 50 years old. Therefore, it has a significant economic impact on the general population since it affects people in their prime working years.

How is disc herniation diagnosed?
Lumbar disc herniation is suspected by a history of leg pain, with or without back pain, and is diagnosed by a physical examination and appropriate radiographic imaging tests (for example, Magnetic Resonance Imaging [MRI] or Computed Tomography [CT]). A neurological examination usually provides findings which suggest nerve irritation. An MRI or CT test must show nerve compression that precisely correlates with the findings of the physical examination.

What are the symptoms of spinal stenosis?
People with spinal stenosis typically have pain in their buttocks and legs while standing or walking. They may feel relief by sitting or by leaning over an object (such as a shopping cart while grocery shopping). Lumbar spinal stenosis is uncommon before the age of 50 and is rare before the age of 40.

How is spinal stenosis diagnosed?
As with lumbar disc herniation, lumbar spinal stenosis is also diagnosed by a history of leg or buttock pain provoked by standing or walking and relieved by sitting or leaning against an object. Unlike disc herniation, the neurological examination is usually normal. The diagnosis of spinal stenosis is made by radiographic imaging tests (MRI, CT or myelography) which show nerve compression at a level and location that correlates with the patient's pain.

Who can be helped by surgery?
Surgery is more likely to help relieve leg pain, rather than back pain, caused by a disc herniation or spinal stenosis. Patients who have a history of predominant leg pain and who have appropriate neurological and radiographic test results may be helped with surgery.

Surgery should be considered the final resort and the patient should have had an appropriate course of conservative (non-surgical) treatment before undergoing surgery.

What does the surgery involve?
The primary goal of surgery is the relief of nerve root compression causing leg pain. Therefore, whatever is compressing the nerve (for example, a disc fragment or a bone spur) is removed. This may be accomplished by several different methods. Under certain circumstances a fusion, which eliminates the motion occurring at one or more levels of the back, may also be performed during surgery. This may involve the use of hardware such as rods, hooks or screws.