Role of Spine Surgery for Chronic Pain

Surgical Decision Making

David A. Hanscom, M.D.

Spine surgery is often a good solution to structural spine problems. It is a very poor solution when the sources of the pain are muscles, ligaments, or tendons, or when the pain is caused by Mind Body Syndrome.

For a problem to be considered structural it must be:

• Clearly seen on a diagnostic test AND
• There must be clear symptoms

If either of these is not present, then the symptoms are not structural. Many patients have structural problems but no symptoms or the pain is felt in another place. Others have severe pain but normal diagnostic tests.

Every symptom could be structural or non-structural. Even if there is a seemingly clear source for the pain, it does not necessarily mean that is where the pain is coming from. Nerves are what cause the brain to feel pain and you brain does not care why or where the pain signal is coming from. Treating the pain pathways is always mandatory. This applies to every part of the spine from neck to hips.

Common anatomic (structural) diagnoses that you may hear are:

• Degenerative disc disease
  
  • Degenerated (loss of water from the center of the disc)
  • Bulging discs (the outer ring has collapsed a little)
  • Herniated/ruptured discs (the middle of the disc has broken through the outer ring)
  • Spinal stenosis (narrowing of the spinal canal, pushing on nerves)
• Spondylolithesis (slippage of one vertebrae on another)
  
  • Isthmic (small bony defect in the back of the spine)
  • Degenerative (the facet joints in the back of the spine have broken down and let the back bones move around)
• Spinal deformity
  
  • Kyphosis (hunchback)
  • Scoliosis (sideways spine curves)
• Broken bones

Tumor, infection, autoimmune disorders, and severe trauma have clear and special treatments that this book will not cover.

Overview – What May or May Not Be Causing Your Pain

Even if you have these problems they may not cause your pain. These factors make them more likely to be painful:

• Abnormal or too much movement between vertebrae (spine bones) (more than 3 to 4 millimeters)
• A pinched nerve.
  
  • The pressure can be from a bone spur or soft tissue in the spine
• Deformity that is:
  
  • Decompensated (your upper body is not centered over your feet) You can be tilted:
    
    • Forward
    • Sideways
    • Both
  • A scoliosis (sideways spine curve) that is worse when you are standing
  • Spine curving that gets worse
• A bone break that has not healed:
  
  • In babies under four months old
    
    • Medications—Prednisone, anti-inflammatories, etc., slow healing
    • Smoking and obesity also affect healing

These factors make spine problems less likely to cause pain:

• Little or no motion between vertebrae
• Completely collapsed disc space
  
  • The vertebrae have get stuck together
  • A disc that does not move will not be a source of pain.
• Narrowing around a nerve without pain
• Deformity that is:
  
  • Balanced (your head is centered over your feet)
  • The same when lying down or standing
• Unchanging for many years
• A spine break that has healed

These problems can cause back or leg pain. If the problem is just low back pain, then it is more difficult to find a clear structural source. With low back, neck or thoracic (mid-body) pain, muscles, ligaments, and tendons (soft tissue) are always involved. With just low back pain without sciatica, soft tissue rehabilitation (i.e. physical therapy) is the first step before surgery. Many people can avoid surgery with rehabilitation.

It is much easier to find the source of leg pain. True sciatica causes pain EXACTLY along the nerve. The pain may be felt just on some parts. The pain is usually steady and lasts hours at a time. Often a specific activity will set it off.

Surgery is Not the Only Answer

Many people feel that if all else has failed, surgery is the only answer. It is only the answer for a clear structural problem with matching symptoms. If you cannot clearly find the source of the pain then how can you fix it?

The other problem with spine surgery is that it could cause future problems. Often these can be worse than the original issue.

Surgery for a specific structural problem usually works well.

Surgery and Dentistry

You can compare spine surgery with dentistry. A dentist can usually find the structural problem in your tooth that is causing your pain. It can be an infected root or maybe a cavity that has gone down to the root. The chances of a dental procedure on that tooth relieving your pain is essentially 100 percent. But if your dentist cannot find the source of your pain and operates anyway, it is unlikely that he or she will solve your problem.

Summary

No matter the part of the spine, surgery is only indicated for a clear structural problem with matching symptoms. The discomfort should be severe enough to warrant the risk of surgery. As your surgeon is not able to experience your pain only you can and should make the final decision to proceed. Be very careful when choosing spine surgery. If you do not feel involved in the decision-making, then talk to another doctor. Get it right the first time.