08 Jan When to see a spine surgeon
Most people will experience back pain at some point in their life, and the vast majority of symptoms resolve without the need for medical intervention. This begs the question: when should you seek medical help for your back pain, and when is surgical intervention warranted?
Multiple etiologies can cause acute back pain. The most common etiology is a lumbosacral strain, which generally resolves with a short course of activity modification, anti-inflammatories medications such as ibuprofen or naproxen, and possibly physical therapy. Another common cause of acute back pain is a herniated disc. One of the hallmark features of a herniated disc is pain radiating into the buttock and/or leg (sciatica). This occurs due to compression of one of the spinal nerve roots from the disc herniation.
Chronic back pain is a different animal with very different symptoms. Chronic back pain generally develops over a period of several years. As the discs and tissues degenerate, symptoms slowly occur. When the ligaments and joints that support he spine hypertrophy and degenerate, compression of the neurologic structures occurs. This causes a complex of symptoms referred to as lumbar stenosis and neurogenic claudication, which generally presents with pain, heaviness, and fatigue of the legs. Degeneration of the lumbar spine can also cause loss of the normal curvature of the lower back. This can cause difficulty standing upright and often necessitates the use of a cane or walker as the patient ages. Deformities that are caused by degeneration of the disks include degenerative scoliosis and flatback syndrome.
So when is a surgical consultation indicated? It is generally agreed that most patients should first undergo a course of non-surgical management. The one big exception is a condition called cauda equine syndrome, in which severe compression of the nerves causes changes in bowel and bladder continence as well as leg pain and weakness. This is a surgical emergency. But otherwise, in the absence of severe neurologic deficits most patients with acute disc herniations should undergo 6 weeks of conservative management consisting of therapy, medications, and epidural injections. For chronic degenerative conditions, a longer period of conservative management is generally recommended. For patients with symptoms of neurogenic claudication, 6 weeks of conservative management should be undertaken prior to surgical intervention, and if a fusion is indicated due to instability or deformity of the spine, most surgeons recommend 3 months of conservative management before jumping to this invasive intervention.
While it is impossible to generalize recommendations to everyone suffering from back pain, the good news is that the majority of patients improve spontaneously with observation and conservative care, such as physical therapy, medications, and targeted injections. For the subset of patients that suffer from persistent pain and disability recalcitrant to conservative care, lumbar spine surgery often provides an effective solution.