“Spine surgery” … These words provoke more trepidation and fear in a patient than any other form of surgery. Whether it’s a young college going student who has become a recluse because of back pain or an elderly patient who has become bedridden but the first response is always a big NO. This made me think, why has spinal surgery or more specifically lumbar spine surgery got such a bad name.
We shall limit the discussion today to basically lumbar disc or lumbar degenerative problems where back pain is the predominant symptom.
Let’s start with what are the indications for spine surgery. In my mind, these have not changed in the last few decades. There are only 3 conditions where someone should be advised spine surgery.
The clearest one is a condition where the patient has developed difficulty or even blockage in passing urine due to severe nerve compression in the back. This is actually a medical emergency that needs to be operated on at the earliest if once is to give the patient a chance of recovering his bladder function.
The second one is where the patient is developing a progressive weakness, this means some part of his leg, most commonly the ankle is getting progressively weaker over time, thus indicating increasing nerve damage due to compression.
The last but the most common and the most controversial one is pain. It does not mean that moment the patient comes with back pain he has to undergo surgery. But patients with back pain which is severe, who do not respond to adequate non-surgical methods like painkillers, physiotherapy etc. should be given the option of spine surgery. Usually, most of us like to wait for 4-6 weeks before thinking about surgery unless the pain is just too much and the patient is not able to function at all. Now the pain is a very subjective thing, what may be very severe for me may only be mild pain for someone else, so it’s never a clear indication for any kind of spine surgery. Then comes the reasons for back pain. Am sure all of us have experienced back pain at some point in our life and the majority of us have recovered without any therapy. So back pain can be due to multiple reasons, ranging from muscle sprains, mechanical pains, joints in the spine and multiple other unknown factors. The patient’s psychological state also makes a big contribution to how he/she perceives pain.
That’s why an adequate period of waiting and other modalities has to be given before surgery is to be considered an option. This helps in ruling out other causes of back pain as they are more likely to get better with time.
So why does spine surgery fail? Well like any other failure there are usually multiple causes for the same.
First, let’s begin with the surgical causes. As a spine surgeon, it’s my duty to make sure that I am treating the patient and not the MRI. It’s very common to see changes in most MRI’s, after all the spine which we are seeing has been bearing our weight since childhood and will have some wear and tear on it as we become older. Almost no one beyond middle age has a normal MRI scan, but that does not mean there is something wrong, most of the time we are just seeing age-related changes. But when we have a large disc or a narrow canal or bony slippage and when that correlates anatomically with the patient symptoms is when we can be sure that the outcome after spine surgery is likely to be optimal.
Selection of the right surgery also plays an important role, when to do just decompression or when to add fusion are still ongoing controversies in the world of spine surgery. At times there may be no clear-cut answer and this needs to be discussed in detail with the patient.
The surgeon’s skills and technique also play a major role in the outcome. Traditional surgery involved extensive muscle cutting and stripping which causes a lot of muscle destruction and unnecessary damage. Minimally invasive spine surgery tries to minimize the damage to the normal muscles and also tries to preserve the normal anatomy. But not all surgeons are well versed with the same, and it also requires specialized equipment which is not available at all centres.
Patient factors affecting outcome are also very important. It’s normal for one to expect that all problems would disappear after surgery. But that may not be the case for everyone. In spinal pain, there are usually multiple contributing factors that have to be taken care of before pain is controlled. Surgery usually takes care of the pressure over the nerves but factors like muscle weakness, tightness and muscular back pain will improve only with regular physiotherapy. For someone who has not been able to walk for a long distance before a spine surgery for typically a few months to sometimes years, cannot be expected to walk suddenly a few kilometres after surgery even if the back pain is completely gone as the body is not used to the effort and needs time to regain stamina.
Lastly, like any surgery, there are certain inherent risks and complications which may contribute to a poor outcome for the patient and may even require re-surgery or cause further complications. But with modern techniques, this has definitely reduced as compared to the past
A lot of people consider back pain as part of life and hesitate or fear to undergo any surgery for the same. But chronic pain can have far-reaching changes not only for the patient but also for the family. A young college going student who has developed a disc with severe pain slowly stops going out with friends, stops playing sports, tends to stay in his room and becomes depressed over time and not able to enjoy the life he should. An elderly gentleman with severe canal stenosis will slowly reduce his walking, leading to a gradual increase in weight and subsequently poor control of his sugars and blood pressure and gradually lose his social life and become confined to the house. Both of them may become dependent on painkillers and rarely even other drugs to numb the pain. So, back pain can affect the quality of life in many ways for different people. These same people when they undergo spine surgery, and especially minimally invasive spine surgery, not uncommonly tell that they should have gone in for it earlier and their life would have been better.
In conclusion, spine surgery has become more evolved over time and with current minimally invasive methods has become less painful with faster recovery. The right selection of the patient by the surgeon and also the right selection of the surgeon by the patient is very important for good outcomes. Surgery and post-op physiotherapy and rehabilitation both play an equal role in the recovery.
So, if the fear of surgery has been putting you off, then don’t let back pain destroy your life, consult the right spine surgeon and follow his advice.