Surgical Procedures
A great deal of research is being performed to help doctors understand and treat low back pain. Some of the more exciting research includes new forms of disc replacement that someday may be injectable, and research into gene therapy that may someday allow doctors to alter the aging process of the spine.
Indications for surgery: Surgery for low back pain should only be performed when a number of conditions have been met. The first is that nonsurgical treatment options have been tried and have failed. Surgery should not be done if an exercise program is effective but the person does not want to do it. The second condition is that the surgeon feels there is enough possibility that the individual patient will have a good chance of having a successful result with surgery. An example of this would be a person with severe degeneration at one level of their spine and normal findings at the other levels.
Another factor that goes along with this is that low back pain, like many other pain problems, can be worse during times of stress. It may not be a good idea to commit to an operation like this when there are other major stressful events going on in one’s life. Occasionally, the back problem can become more tolerable once the stress is reduced. The final factor is that the patient must decide if they are having enough of a problem to undergo an invasive procedure that is not guaranteed to work.
Surgical options: Historically, the most commonly performed operation for back pain has been spinal fusion. There are a variety of ways this is done but the basic idea is to take the painful segment of the spine and get it to become a solid piece of bone. This will eliminate motion and, in theory at least, if it doesn’t move, it shouldn’t hurt. This can be done through the back (posterior) or through the front (anterior), or sometimes both ways. Spinal fixation of some sort is often combined with some form of bone graft or bone substitute. Bone graft can either be obtained from another part of the skeleton such as the pelvis (autograft) or be donated bone that is processed and used in a spine fusion (allograft). The results of spine fusion for low back pain vary. A good result is a decrease in pain. It is very rare for someone to be completely out of pain after a spine fusion. Full recovery can take more than a year.
A newer technique that has recently been introduced in to the United States is disc replacement. The procedure involves removing the disc and replacing it with artificial components, similar to what is done in the hip or the knee. Doing this lets the segment of the spine keep some flexibility and hopefully maintain more normal motion. The recovery time may be shorter than with spine fusion because the bone does not have to solidify. Although it has been used in Europe for a number of years, it has only recently been used in the United States. Early results are promising.
Currently disc replacements are done through an anterior approach and are primarily done on the lower two discs of the lumbar spine.
