Lower back pain and surgery

A literature review, led by Dr. Joseph Lee, published in the June 2010 issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS) suggests that a herniated disk is one of the most frequent causes of low back and leg pain in adults, but surgery is not for everyone. Between 60 and 80 percent of people will experience low back pain at some point in their lives

Disks, which are strong shock absorbers between the vertebrae, can begin to herniate or weaken when their jelly-like nucleus pushes against the outer ring due to aging or a sudden injury. This pressure against the outer ring is often what causes lower back pain.

"Orthopaedic surgeons can help by educating patients about the risks of back surgery and work with the patient to determine the best course of treatment, whether it be surgical or non-surgical," stated review co-author Mark Weidenbaum, MD, Director of Orthopaedic Spine Surgery, Department of Orthopaedic Surgery, New York-Presbyterian Hospital-Milstein Pavilion, Columbia University Medical Center, New York.

A herniated disk can sometimes be very painful and most people feel better with just a few months of nonsurgical treatment, which can consist of physical therapy, medications or epidural steroids. However, some patients are treated with a surgical procedure known as a diskectomy.

At least 200,000 diskectomies are performed in the United States each year, and potential diskectomy surgical techniques include:

• conventional open diskectomy ;
  
• micro-diskectomy; which is the most common technique
  
• minimally invasive (endoscopic) diskectomy; and
  
• open diskectomy with fusion.

"The main thing for patients who may be contemplating surgery for back pain is that it must be a mutual decision agreed upon by both doctor and patient. Both parties need to discuss the type of disk herniation and all the potential options for treatment before deciding on surgery," suggested Dr. Weidenbaum.

Many patients find relief after a diskectomy, but approximately 5 percent to 15 percent of patients experience a recurrent disk herniation, defined as back and/or leg pain recurring after a definite pain-free period from the initial surgery, then pain begins again. Treatment for recurrent lumbar disk herniation may include aggressive medical management and surgical intervention.

In addition, the review cited literature indicated that:

• Patients with larger herniations are more likely to experience a recurrence of pain; and
  
• Patients who had endoscopic surgery (less invasive) may be more likely to experience a recurrence than patients who had a more invasive procedure.

"When a patient has recurring pain, surgeons should perform a complete workup, including an MRI, to learn whether the cause is actually recurrent disk herniation or another problem, such as spinal instability," Weidenbaum notes. "If a patient has spinal instability a revision diskectomy isn't going to help that person—another type of surgery may be needed."