Conflicting opinions are unsettling, but they are rarely a sign that someone is wrong. Here is why they happen, and how to find clarity.
Have you received conflicting opinions from different clinicians about whether you need surgery for your spinal condition? It is disorienting, and it leaves you wondering whom to believe. Let me explain why it happens, because the reasons are more reassuring than you might expect.
Why there is rarely one right answer
In spine care it is genuinely rare for a problem to have a single solution.
Spinal conditions exist on a spectrum from moderate to severe, and that applies in two dimensions: clinically, in the symptoms you experience, and radiologically, in the findings on your scan. So for the same diagnosis and the same scan appearance, the right answer for one patient is not necessarily the right answer for another.
We all present differently, whatever the MRI shows. This is why I treat you, the patient, rather than your scan.
A worked example: sciatica from a herniated disc
Take sciatica caused by a slipped disc pinching a nerve.
The majority of patients improve within six to twelve weeks. Diving into surgery in the first few weeks is therefore often unnecessary.
Simple measures do a great deal: rest at first until the acute pain settles, then physiotherapy with stretches and exercises to give the nerve some freedom. Injections can sometimes calm the inflammation around the nerve, which accounts for most of the pain, and this alone can avoid surgery altogether.
But sometimes the pain persists well beyond that window without improving, or weakness develops in the leg as the nerve begins to fail. Preserving the function of that nerve, and therefore the strength in your leg, is what makes surgery necessary.
Even then there are different operations. Some of that comes down to the surgeon’s training and some to what suits you. It can be done endoscopically, with a small camera passed in from the side and instruments to shave away the disc. I generally prefer to work under the microscope, through a small incision at the back of the spine.
In this scenario, the quality of the decision rests on how thorough your consultation was: the history, genuinely listening to you, the examination, and close scrutiny of the neurological findings.
Where I see conflict most often
The commonest area of disagreement concerns degenerative disc disease, simple wear and tear in a disc, in patients with back pain alone rather than leg pain.
I have often seen patients offered a fusion for this. The difficulty is being certain the worn disc is actually the source of the pain. Degeneration is extremely common in people with no back pain at all. Over the age of 50, most people have more than one worn disc and no symptoms whatsoever.
In this situation I often request a SPECT CT scan. It provides information the MRI cannot, and helps establish whether that segment really is the pain generator. Where it is, fusion surgery can genuinely help.
Spondylolisthesis: another source of disagreement
Fusion is also commonly offered for a spondylolisthesis, where one bone has slipped forward relative to the one beneath.
If that is causing nerve compression, decompressing and fusing the segment will relieve the pain.
But the presence of a spondylolisthesis does not automatically mean the segment is unstable. Often it has become that way chronically. If there is nerve compression causing leg pain, sometimes all that is needed is a decompression alone. Where we have proven instability with dynamic X-rays showing movement at the slip, then yes, fusing it is appropriate.
You can see how two reasonable surgeons might land in different places here, depending on what they weighted.
What good practice looks like
Where decision-making is not straightforward and opinions may legitimately differ, the answer is a multidisciplinary meeting.
This means two or three surgeons in a room together, reviewing the images with a radiologist present, alongside one or more physiotherapists and a pain specialist, discussing the case until they reach a consensus. Decisions made this way are far more likely to be the right ones.
The key takeaway
We are all different, with different lifestyles and different needs. The same appearance on an MRI affects two people quite differently.
Age and other medical conditions enter the equation too, as does weighing the invasiveness of each procedure against its risks.
Which brings me back to where I started: treat the patient, not the test.
