When a patient receives pain management treatment for back pain, the goal is to try and avoid the need for an operation. But sometimes this is just not possible. In what situations is surgery indicated and pain management deemed a failure?
The first qualification that needs to be clarified is whether or not the patient is dealing with a quality of life issue or one that has an absolute indication for surgery. The quality of life issue is something such as arthritis which never killed anybody, or degenerative disc disease where it is also a form of an arthritic type condition.
Degenerative disc disease may very well be exceptionally painful to a person suffering from it, but as with arthritis the condition is not fatal and can often be tolerated.
So that's the first clarification needs to be made is whether or not it's a quality-of-life situation or otherwise. Problems that fit into the otherwise situation are dramatic situations where there is a fracture that is unstable, or a nerve root is being pinched and the patient is suffering motor weakness from it. Additionally, there are a couple emergency situations in the spine, one of which is called cauda equina syndrome.
Cauda equina syndrome is when the spinal cord is getting pinched near the bottom of the area around T12 or L1 and patients are at risk of losing their bowel and bladder function which may become a permanent situation if not addressed within 24 hours. It is an unusual diagnosis but an emergency one.
So if the patient has an emergency situation and cauda equina is present then an operation should be performed within 24 hours. If the patient has a fracture and instability from a trauma situation, then surgery is indicated as well and the specific timeframe will depend on the extent of an individual's injury.
If it is a quality of life disease such as arthritis then the patient should try nonoperative forms of treatment such as chiropractic manipulations, physical therapy, spinal decompression therapy, medication management, or interventional pain treatments from a pain management doctor. Over 90% of the time, these suffice and allow patients to continue working, playing with their children, and socializing satisfactorily while avoiding surgery.
The general rule is that if a patient tries consecutive conservative treatment for over six months with degenerative disc disease, then surgery can be considered. Considering that the surgical outcomes for a spinal fusion for degenerative disc disease are typically in the 50 to 70% satisfactory outcome range, it's really should be considered a last resort.
For patients dealing with spinal stenosis of the lumbar spine, this too is considered a quality of life decision. Arthritis causes soft tissue and bony overgrowth in the spinal column, and multiple nerve roots can start to get pinched which can cause sciatica and pain in one or both legs of the patients. Patients should try physical therapy, epidural injections, medications such as neurontin or some pain medications, and other nonoperative treatments just as with degenerative disc disease.
When a patient has a pinched nerve from a herniated disc, it is prudent to also try and avoid surgery. Granted, the surgery has low risks associated with it, but it is not a risk free proposition.
When a patient has muscle weakness from a pinched nerve, it is appropriate to consider surgery after 2 to 3 months of watching and waiting to see if it's going to get better. The concern is that if over 3 to 6 months are spent waiting, even if a technically perfect surgery is performed the muscle weakness may never improve. Additionally the patient has considerable nonoperative treatment over a period of 6 to 12 weeks and it is not getting better with the pain, surgery becomes indicated to simply get rid of the pain.
These are some of the indications for surgery but as mentioned before the main qualification is to determine whether or not surgery is absolutely indicated, or simply a function of a quality-of-life procedure.
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