Alex Simotas, MD

Hospital for Special Surgery
Board Certified Physiatrist
Specializing In Spine & Sports Medicine

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When Is Surgery An Option?

The majority of all spine conditions can be treated with non-operative therapies. There are several scenarios with regard to spine conditions where surgery may be considered as a possible therapy.

Spine conditions can be separated into a few basic presentations:

  • Non-operative treatment is used and no surgery is applicable. This means that there is no available invasive surgical procedure with any proven effectiveness for this condition.
  • Non-operative treatment is preferred because an equally successful treatment outcome can be expected with or without a surgical intervention.
  • Surgical treatment may be indicated on the basis that there is clinical evidence that surgery will provide better outcomes. The risk / benefit ratio is low. In these cases, the outcome of surgery versus non-surgery should be compared with shorter and longer-term outcomes. For example: the short and long-term outcomes of treatment for disc herniation have been studied. Most evidence suggests that in more severe cases within the first year surgical treatment provides better outcomes and patient satisfaction. However within a few years, the differences in outcomes between the two alternatives of non-surgical intervention and surgery become similar, suggesting that non-operative treatment simply takes longer to improve the outcome.
  • Surgical treatment is suggested because non-operative treatment continues to fail to provide satisfactory results. In many cases the outcome of surgical treatment has unclear results and is suggested on the basis of some, but not all, patients getting good results. The risk benefit ratio must be assessed because surgery is very invasive (particularly in the case of spinal fusion). Some possibility exists of the condition worsening after the surgery.

There are a few situations when surgical intervention should be considered more urgently. A patient who is observed to have a progression of a neurological deficit after their initial presentation and this is presumed to be caused by a compressing lesion on the neurological elements in the spine (either spinal cord or nerve roots) is usually advised to undergo surgery as soon as possible. This is relatively rare so this does not apply to most patients with back and neck pain problems.

The neurological deficit may include a weakness and loss of sensation in a specific neurological pattern that gets worse and not better during treatment. Additionally, patients who have evidence of spinal cord compression and cord injury symptoms, a condition referred to as myelopathy, should be treated more aggressively. Myelopathy generally occurs in the cervical spine and thoracic spine because the spinal cord ends around thoracic spine vertebrae 12 (T12).

Spinal cord compression symptoms with a neurological loss are more likely to persistent if left untreated for extent periods.

If you are advised to undergo spinal surgery consider the following:

  • A second surgical opinion is a good idea, even in the most simple sounding spinal surgeries.
  • Always make sure you have a clear understanding of the goals of the surgery and what the chances are that all or some of your symptoms will resolve with the surgery.
  • Be aware of the potential risks of the surgery.
  • Consider receiving a consultation from a non-surgical specialist such as a physiatrist.
  • Review whether there are nonsurgical treatment options that have a reasonable chance of success.
  • Be wary of a surgeon who suggests surgery must be performed urgently without offering a specific reason for the urgency.