Blog No 25 Essentials of Back Surgery

Large synovial cyst at L4-L5

Soon after I began practicing neurosurgery, I wrote, “Why Back Surgery Has a Bad Name,” that was published in my local medical society’s periodical. Essentially, nothing has changed. The main reason for “failed back surgery” is because the patient was not a suitable candidate for surgery to begin with. Radiologists, under pressure not to “miss anything” (because  of liability concerns) include every minor abnormality, whether clinically significant or not. Some spine surgeons use the radiology report as their guide to performing surgery! Radiologists are experts at reading MRI scans, but they lack the experience to know when surgery is indicated, or what kind.  Unless your surgeon is basing their indication for surgery on their personal review of an imaging study, you should make a quick exit. Two additional reasons for not having a successful back surgery; the pathology was not adequately treated, or the surgeon caused an injury to an adjacent structure. 

Lay people generally know physical therapy is done before undergoing surgery.  This is a good rule, but there are exceptions. High-grade lumbar spinal stenosis can rarely be treated effectively with physical therapy alone, and it may make you worse.  An exceptionally large, herniated disc compressing a nerve root causing severe sciatica is a candidate for immediate surgery.  Don't be surprised if the parting advice from your surgeon may be: “when you can’t stand the pain come back to see me.” This supposedly sage advice given by professors to their students is often welcomed by patients as they are impressed their surgeon is not overly eager to operate to pay his mortgage.  However, this is often just bad advice.  I saw patients who had suffered with severe sciatica for months on end and when I performed a microdiscectomy their pain was relieved immediately and they wondered why they had waited so long. Moreover, when a nerve is compressed for long periods of time, the recovery may be incomplete, even after surgery.  The L5 nerve root (usually compressed from a disc rupture between L4 and L5) is especially finicky and may suddenly result in causing a complete foot drop and not recover even with surgery.

There are important differences regarding indications for surgery in the lumbar spine vs the cervical spine.  Narrowing of the cervical spinal canal with compression of the spinal cord, makes you at risk to suffer spinal cord injury (with a varying degree of paralysis) in case of a fall or motor vehicle accident.  (I once saw a patient with compression of  his cervical spinal cord with a history of seizures, and I warned him he might suffer paralysis with a seizure.  He actually turned up in our hospital after a seizure with partial paralysis.) This is not true with your lumbar spine as your spinal cord ends before it reaches your back.  The nerve rootlets (cauda equina) in your back can tolerate compression much better than your spinal cord. Patients frequently told me their surgeon had warned them of possible paralysis, if they didn't have surgery.  As a rule, you are not at risk of suffering paralysis from a lumbar disc herniation, but an exception is a massive disc extrusion.

Second opinions are overrated. When you get conflicting opinions, who do go with?  Start with a board-certified spine surgeon (preferably neurosurgeon) and try to find out their reputation in the community. I’m skeptical of Google recommendations when it comes to having surgery. Unfortunately, the advice from your internist may not be much better as their referral is often based on friendship rather than direct knowledge of the surgeon’s abilities.  Needless to say, the surgeon’s technical ability is of paramount importance when your spine or brain is involved. (This may change as surgery becomes more machine driven.) Never let a poor bedside manner deter you when selecting a surgeon.  Often the best advice comes from the operating team where the surgeon performs surgery—from the circulating nurse or the scrub technician. The problem is this information is often not available to a layperson.

In spite of it's bad reputation, spine surgery can change the quality of your life.  Don't let people who are clueless of its benefits control you decisions.

(I will be taking a 3-week hiatus from my blog writing.)

All photos by author

Axial view of lumbar spine showing sever stenosis

Axial view showing normal spinal canal

Setting up to perform microdiscectomy--we operate through the small tube with a microscope

This young woman had a tattoo directly overlying where my incision was required for microdiscectomy. Healed incision is along left side of butterfly's body  (I had a series of these patients, mostly women)