When to Have Back Surgery | Lower Back Pain

There are situations that call for necessary lumbar surgery, circumstances when surgery depends upon specific situations and times when surgery is not indicated. Identification of these temporal states is not that difficult when certain rules are applied.

What are the general indications for surgery?

Nerve compression that leads to motor weakness.
Nerve pain that is not tolerated or necessitates unacceptable reduction of activities due to pain.
Degenerative disc disease that causes intolerable back pain.
Deformity that is progressive.
Cord compression (remember that the L1 canal contains the conus medularis- the end of the cord.)

Nerve compression that leads to motor weakness

Nerve compression that leads to motor weakness is generally a surgical condition. Compression of a nerve can lead to dynamic pain (pain with walking that is relieved by sitting) or sitting pain but does not always have to be accompanied by weakness. This pain and numbness is not necessarily a surgical indication by itself (see next section below for further information).

If there is weakness of a major motor group (specific group of muscles) from nerve compression, more often than not surgery is indicated. The reason has to do with the integrity or relative “toughness” of the motor nerves.

Pain, numbness and paresthesias (pins and needles) involve the sensory, nociceptive and proprioceptive (location sense) components of the nerve. These portions of the complete nerve root are very sensitive to compression. That is, even slight compression or irritation will lead to symptoms. Conversely, being so sensitive they also have good ability to recover with therapy and injections without surgery. In addition, even some permanent minor deficits in these nerves (remaining skin numbness or pins and needles) are typically easily tolerated.

The motor nerves have a much greater capacity to resist compression than the sensory nerves. It therefore takes significant compression of the motor nerves to block function. Unfortunately, this also means that motor nerves have a poorer capacity to recover or regenerate than the sensory nerves.

If weakness only occurs in a small muscle group (L5 compression causing weakness in the extensor hallicus longus or big toe extensors), rushed surgery is probably not indicated unless the patient is a martial arts instructor, NFL place kicker or rock climber. However, if the weakness is in a major muscle group leading to foot drop or gastroc-soleus weakness, lack of recovery leads to gait disturbances and a limp.

The best chance for motor strength recovery is with surgery to decompress the nerve (microdiscectomy or foraminotomy). There still is a small chance that with surgery, the muscle strength will not recover but with surgical decompression, the chance of recovery is much greater than without surgery.

Nerve Pain that is not tolerated or necessitates unacceptable reduction of activities due to pain

This category is the most common reason patients choose to undergo surgery in the lumbar spine. Disc herniations or nerve compression from bone spur can cause leg pain. Compression of the sensory nerves leads to numbness. Compression of the nociceptive nerves leads to pain. Compression of the proprioceptive nerves leads to paresthesias (pins and needles).

These nerves are highly sensitive and even a small amount of compression will aggravate them. Pain can be substantial and paresthesias can drive some patients absolutely crazy. Nonetheless, without motor weakness, there is generally no need to immediately rush to surgery unless the pain is intolerable.

The reason is that these nerves being so sensitive also have good capacity to recover. Many times, patients in moderate pain can improve with epidural steroid injections, oral medications, therapy and time.

I use the three month rule for surgical indications for these types of patients. If the individual has made at least 50% improvement within three months (or has no desire to undergo surgery), then continuing conservative care is the path to take.

If the pain has not substantially improved in three months or pain relapses occur commonly during this period of time, surgery becomes the treatment of choice. Patients seem to do better if surgery is performed in the first three to four months than if surgery is put off until after six months of symptoms.

There are patients who at rest have little pain but with certain activities, develop incapacitating pain. This is dynamic pain caused by gravity’s effect on an unstable vertebral segment. Without load on the spine, the nerve root can tolerate the narrowed lateral recess or foramen. With loading however, the increased compression causes further compression and significant increase in pain precluding the desired activities.

If the inciting activities can be avoided to the satisfaction of the patient, surgery will not be necessary. For example, if the patient can switch from jogging to cycling and the leg pain is alleviated, surgery is not necessary. If however, the pain is associated with a non-negotiable activity restriction (a professional ball player who cannot field the ball or an auto mechanic who cannot turn a wrench), surgery will be indicated.

There is a subset of patients that show up on my doorstep with severe pain from an acute disc herniation. They lie moaning, curled up in the fetal position on my exam table or are seen in the emergency department on a stretcher after taking substantial amounts of pain medications. These patients need surgery to relieve the unrelenting nerve pain.

There is a subset of patients that have permanent injury to the sensory and pain nerves from prolonged exposure to compression. Surgery will decompress the nerve but not relieve the damage already incurred (see chronic radiculopathy).

Degenerative Disc Disease That Causes Intolerable Back Pain

Back pain from degenerative disc disease can be an indication for surgery. Back pain may be incapacitating but it is not generally life threatening. Back pain tends to wax and wane in many patients. When then is back pain an indication for surgery?

Patients with incapacitating back pain may be surgical candidates. Back pain must have been proven to be non-manageable (failed therapy and medication programs) and affect the patient’s lifestyle. If a patient can acceptably modify his or her lifestyle to reduce the pain to a tolerable level, surgery would not be indicated.

If however, the lifestyle change is not modifiable (a professional baseball player that cannot field a ball or a mechanic that cannot turn a wrench) or the modification is not acceptable (a patient cannot participate in recreational activities without substantial pain), surgery might be indicated.

First, prior to surgical consideration, back pain patients have to complete a thorough rehabilitation program associated with ergonomics (modifications in lifting and loading the spine). If the modification of activities is ineffective, other therapies may be instituted including epidurals and medications. If these treatments fail to relieve symptoms, surgery can be contemplated.

Back pain has to be present for more than three months and most patients considering surgery will have had at least six months of back pain. A surgical workup then can ensue. This workup might consist of imaging (MRI, CT and X-rays), diagnostic nerve blocks and discograms. If the pain generators can be identified, a surgical plan is formulated. Normally, the surgery is a fusion of the painful segment or segments. Artificial discs at this point in my opinion are not an option (see section on lumbar artificial discs for more information).

Certain disorders may cause back pain that do not specifically involve degenerative disc disease. Examples are isthmic spondylolisthesis and degenerative spondylolisthesis. These disorders also respond to fusion.

After a one level successful fusion, the patient can return to almost all sports and activities. If two levels are fused, the post-operative restrictions are somewhat greater. If three or more levels are fused, the patient has to understand that fusion and pain relief is being traded for spine stiffness and the post-operative restrictions are more stringent.

Deformity that is progressive

A spinal malalignment can be stable or progressive. Scoliotic curves and even individual segmental collapses can progressively deform over time. If the angulation can be predicted to continue or is observed over time with serial X-rays to progress, surgery is indicated. This is to prevent problems with correction in a curve that will progressively become larger over time.

A degenerative or isthmic (fracture) slip may progress and be predicted to continue to slip. This is an indication for surgery.

Pars fractures (isthmic spondylolysis) in a younger individual may have a surgical indication if the disc is still normal at the time of diagnosis (no annular tears) to prevent future annular tears.

Cord compression

Most individuals do not think of spinal cord disorders when the lumbar spine is discussed but the spinal cord (conus medularis) terminates behind the body of L1. A disc herniation or a large spur causing stenosis (narrowing of the canal) can cause dysfunction of the cord.

This compression may lead to bowel and bladder malfunction as well as possible motor deficits. At this level, this is a central nervous system injury and surgery is required in a timely basis.

Related Links

Donald Corenman, MD, DC

Average rating:

81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

When to have Lower Back Surgery