What spine surgery is actually for, what it can and cannot treat, and the truth about the risks.
One of the things I most enjoy about my work is the conversations I have with patients, and a good many of them turn on misconceptions about spine surgery.
So let me address the ones I hear most often, so you have a clearer picture of what surgery is for, what it can and cannot treat, and what the risks genuinely are.
Misconception 1: “Spine surgery is a treatment for back pain”
Most of the time we operate to protect nerves.
Compressed nerves in the lower back cause sciatica, with pain travelling down the leg. In the neck, compression causes pain travelling down the arm. Surgery decompresses those nerves to relieve that pain, and to preserve neurological function, particularly where the spinal cord is involved.
For back pain itself, the difficulty is identifying a finding on a scan that is definitely the cause. Abnormalities such as degenerative disc disease and worn facet joints are very common in people with no pain at all.
There are exceptions. Instability of the spine, demonstrable on X-ray, can be treated surgically by fusing the segment, and that does relieve back pain.
Misconception 2: “Surgery is an absolute last resort”
It may surprise you to find me challenging this one, given how often I discuss ways to avoid surgery.
But I believe in identifying your specific treatment goals, which are unique to you.
Take sciatica from a slipped disc compressing a nerve. In most people this settles within the first few weeks, so I would certainly not reach for the knife early. Once a few weeks have passed and symptoms continue, however, the options are physiotherapy, spinal injections, or surgery.
Depending on your needs, how quickly you need to recover, whether you are an active sportsperson, surgery may reasonably be the first-line treatment at that stage. Not because other things have failed, but because it is the most definitive way of relieving the leg pain. That is a very individual decision, and one we should discuss properly.
There are also situations where early surgery is clearly right. Spinal cord compression, from a tumour or a disc, causing weakness in the arms and legs, difficulty walking or loss of balance, calls for early intervention to preserve as much neurological function as possible.
The same applies to cauda equina syndrome, where all the nerves travelling to the legs and to the bladder and bowel sphincters are compressed. Pain in both legs, numbness in the genital region, urinary retention or incontinence. This is a medical emergency requiring immediate decompression.
Misconception 3: “Spine surgery is extremely risky, I could end up paralysed”
This fear comes up often, usually framed around paralysis or ending up in a wheelchair.
It is true that we operate in the vicinity of the nerves in the lumbar spine, and of the spinal cord higher up in the neck.
But the reality is that the risk of damaging all the nerves to your legs, or the spinal cord itself, is extremely low. This is particularly so today, with microscopes and endoscopes magnifying our view of the nerves we work around so that we can keep them safe.
Even when operating around the spinal cord itself and opening the lining of the spine, to remove a tumour for instance, we now use neurophysiological monitoring. Electrodes are placed on your arms and legs and on the spinal cord, allowing us to monitor signals passing between the brain and the limbs in real time. We can see immediately what we are disturbing, and prevent damage.
Misconception 4: “Once you’ve had spine surgery, you’ll keep needing more”
Having an operation on your spine is not signing up for a lifetime of surgery.
When we fuse a segment, there is a legitimate concern about adjacent segment disease. The segments above and below must move slightly further to compensate for the lost motion, and yes, this can cause some wear and tear.
But that does not mean it will be symptomatic. We may see it radiologically while the patient has little or no pain from it. Lifestyle factors afterwards matter a great deal, and the likelihood is that you will not need further surgery.
Misconception 5: “Surgery will cure all my pain”
This is where a thorough consultation matters most.
Return to sciatica. Nerve compression in the lower back causes some back pain at its onset, but mostly leg pain. It is the leg pain that surgery resolves. Patients often still have ongoing back pain afterwards.
That does not mean the back pain cannot be treated. It means surgery alone is not the whole solution.
This is precisely why I believe in multidisciplinary practice, working with physiotherapists, pain specialists and other colleagues who can address the aspects of your symptoms that an operation cannot.
The key takeaway
Which brings me back to where I started: establishing your goals.
What is it that your symptoms are stopping you doing? Answer that first, and the right treatment strategy follows from it.
If surgery is required, then with the right thought process and careful planning, good results can be achieved.
