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When is Surgery Necessary for Neck or Low Back Pain?

Written by
Dr. Tony Magana
and medically reviewed by iCliniq medical review team.

Published on Sep 20, 2014 and last reviewed on Nov 14, 2018   -  4 min read



It is important for patients to understand the probability that surgery for neck or low back pain will improve their lives.

When is Surgery Necessary for Neck or Low Back Pain?

Over the past twenty years, spinal surgery for painful conditions of the neck and low back has become much more common and sophisticated. Surgery for low back and neck problems is often expensive, exposes the patient to the risks of complications, and requires time for recuperation. While many patients find great relief after surgery, there remain a considerable number of patients who, despite undergoing very technically advanced procedures, find their lives and pain unchanged. It is important for patients to understand how and if surgery will help in their case.

There are basically two types of surgery done for spinal problems in the neck and back.

1. Decompressive Operations

These operations remove abnormal pressure on the nerves to reduce neurological pain and give a chance for improvement in neurological dysfunction.

The benefit of decompressive surgery in improving neurological dysfunction and pain where there is a progressive weakness, numbness, and/or the presence of bladder, bowel, or sexual dysfunction is well established and accepted.

Patients with very minor dysfunction or neurological pain from a herniated lumbar disc, however, who have been treated without surgery, when compared with those who underwent surgery at one year's time seem to have the same outcome, meaning that the surgery for this population did not seem to be absolutely necessary.

2. Reconstructive Operations

These operations are performed when there is a concern that the stability of the spine, the ability of the spine to maintain its support and alignment safely, is threatened.

The benefit of reconstructive surgery, the joining of two or more adjacent vertebrae, was traditionally considered for those who had clinical findings of spinal instability. Instability means that the spine is not strong enough to resist injury from everyday normal stresses. If left untreated, this instability will lead to further deformity (misalignment or slippage of the vertebrae) and/or neurological dysfunction from nerve compression.

The benefit of reconstructive procedures for these types of spine pain sufferers as compared with those treated with rehabilitation alone is controversial. Patients who undergo reconstructive surgery still need to undergo extensive rehabilitation.

Imaging studies may reveal objective clinical evidence of instability of the cervical, thoracic, or lumbar spine. A plain X-ray should be performed with the patient flexing and extending the affected area of the spine to rule out occult instability as X-rays done in only the normal view may be misleadingly normal. Significant destruction of both facet joints or the vertebral body by trauma, infection, tumor, or surgery may create a need for a fusion may be seen on CT Scan of the spine or MRI of the spine.

Most patients with pain in the neck or lower back suffer pain not from pressure on the nerves, but it is hypothesized from dysfunction of the intervertebral discs which are the soft tissue shock absorbers between the vertebrae or the facet joints between adjacent vertebrae.

To date, no reliable objective test of measuring this phenomenon is known. So, that is often at best, an educated guess by the surgeon as what exactly is causing neck or low back pain without traditional signs of instability or nervous system compression. Provocative testing such as injecting the disc, called discography, are subjective in nature and not always reliable.

Lifestyle changes for those suffering from neck or low back pain without instability or nervous system compression:

  • Use the body the right way while lifting heavy things.
  • Lose weight if obese.
  • Change your occupation if it is a physically demanding one.
  • Get treatment for addiction to pain medication.

In the absence of significant neurological dysfunction or instability, pain associated with disc herniation or spine degenerative changes, a thorough trial of conservative treatment including physical therapy consisting of body mechanics instruction, stretching, and core strengthening, instruction in life style changes, and patient counseling with reassurance should be done before consideration for surgery.

Here is a rating of the relative benefit of neck or low back surgery indications.

Strong Indications for Surgery for Neck or Low Back Pain:

  • Significant neurological dysfunction where imaging studies corroborate the localization of dysfunction seen on clinical examination or physiologic studies like Electromyogram (EMG) and Nerve Conduction Studies (NCS) and when there is a great probability of neurological improvement following surgery.
  • Progressive subluxation (partial dislocation of a joint), slippage of a vertebrae relative to another, causing progressive neurological dysfunction.
  • The decompression of the spine is likely to render the spine unstable thus necessitating a reconstructive procedure as well.
  • Progressive compression of the nerves and/or instability of the spine either present or likely to occur in the future from a tumour, infection, trauma, developmental abnormality or previous surgery.

Equivocal Indications for Surgery for Neck or Low Back Pain:

  • Reconstructive procedures, fusion (the joining of adjacent vertebrae into one) or artificial disc placement for repeat herniated lumbar disc which has caused mostly leg pain and/or nerve dysfunction without instability.
  • Reconstructive procedure, fusion or artificial disc placement for pain mostly confined to the spine without nerve compression or instability for patients who have physically demanding jobs requiring heavy lifting. Most patients in this situation are still not able to return to their previous job.
  • Reconstructive procedures, fusion or artificial disc placement for pain mostly confined to the spine at single level of involvement with other discs being normal.

Weak Indications for Surgery for Neck or Low Back Pain:

  • Reconstructive procedures, fusion (the joining of adjacent vertebrae into one) or placement of artificial intervertebral discs in patients who have mostly leg pain from a herniated lumbar disc and no clinical instability for the first time.
  • Reconstructive procedures for patients who have multiple levels of disc abnormalities in the spine without instability or nerve compression for the treatment of low back or neck pain.
  • A devastating injury to the nerve or spinal cord will likely not improve following surgery. Patients with no motor function after a spinal cord injury have a low probability for return of function following decompression.

Consult a spine health specialist online to know the need for surgery for neck and low back pain -->


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Last reviewed at:
14 Nov 2018  -  4 min read


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