Surgery for back pain is a last resort treatment. There are
basically two reasons for surgery for back pain:
- Neural element compression (or squeezing of nerve roots or
nerves) or pressure on the dura mater (the sac that surrounds the
spinal cord and nerve roots), and
- Back pain. Back pain itself has two main causes: muscle spasm
and mechanical pain.
What is a muscle spasm?
Muscle spasm is essentially a muscle pull or charley horse of
the back muscles. In this situation, the muscles of the back are
tender to the touch. Bed rest or inactivity does not usually
relieve the pain significantly. Muscle spasm, as an isolated
entity, is a non-surgical problem.
What is mechanical pain?
Mechanical pain is a pain that is deep and agonizing in nature.
It is not related to muscle spasm, and activity worsens the pain
whereas inactivity (such as bed rest) improves the pain. This pain
syndrome is significantly different than that of muscle spasm. It
is potentially a surgical problem in that instability can cause
mechanical pain. This is akin to a degenerative hip in an elderly
person in whom the pain is deep and agonizing in nature, is
worsened with walking, and improved with sitting or lying.
What is sciatica?
Sciatica and some central back pain problems can be related to
neural compression. Sciatica is caused by a disc herniation or
bulge that compresses or squeezes a nerve as it exits the spinal
canal. This pain usually is in the distribution of the nerve (where
the nerve goes in the body). Anterior dura mater pressure can cause
central back pain because of the rich innervation (nerve supply) of
this portion of the dura mater.
Discectomy is a treatment of choice for the problems mentioned
above. Laminectomy might occasionally be helpful. A discectomy is
usually performed through a small bony window.
What are the surgical procedures for back pain?
Laminectomy
A laminectomy involves the removal of a significant posterior
portion of the spinal covering. It is performed to relieve pressure
on the spinal cord.
Discectomy
Discectomy is a minimally invasive procedure in which herniated
disc material is removed, while the support structure of the disc
remains intact.
Spinal fusion
Spinal fusion is a process during which a number of vertebrae
are made to grow, or "fuse" together. Mechanical back pain is
usually treated with exercise and the strengthening of the support
system of the spine (muscle and ligaments). These treatments
stabilize the spine in a physiological manner. However, spinal
fusion occasionally might be needed in patients who truly have
mechanical pain and who have failed an aggressive non-operative
program.
Many controversies exist regarding fusion:
- Should the fusion be performed as an entity in and of itself or
with instrumentation?
- Should the fusion be anterior or posterior in location?
- Should cages or screws be used to supplement the fusion?
- How long should a fusion be?
- Should it incorporate one motion segment (disc), or two or
three motion segments?
All of these questions are appropriate and very difficult to
answer.
Remember, "spine surgery begets spine surgery." At least 20
percent of people who undergo an initial "simple operation" for
back pain or leg pain will undergo one or more additional
operations; these are usually people with chronic back pain.