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Mir H. Ali, MD, PhD
Orthopedic Spine Surgery
Patient Educational Series

Indications for Lumbar Spine (Lower Back) Surgery

While the causes of low back pain are many, the reason for low back surgery are few. One should be clear about the indications for low back surgery prior to undergoing any procedure. In my practice, the indications for low back surgery are limited to three reasons. This is explained to the patient on his/her initial visit so that both physician and the patient are clear if/when the surgery is recommended. Again, if there is anything other than surgery that would be helpful, it should be tried and even getting a second opinion should be explored if there is any doubt about the treatment plan.

The first indication for undergoing low back surgery is to prevent/address damage to the nerves are going to the bowels and bladder. The nerves that supply the lower extremities, the bowel, and bladder (collectively called the cauda equina) pass through the low back and if these nerves are severely compressed the bowel and bladder start functioning abnormally (or even stop functioning altogether). One of the initial symptoms that a patient may experience if this is indeed the case is a feeling of numbness and tingling in the areas between the lower extremities (perineal anesthesia) and he/she may notice changes in his/her bowel or bladder patterns. One of the first signs of trouble on a physical examination is decreased sensation in the private areas as well as abnormal tone of the rectum. This also may be accompanied by pain and/or weakness of the lower extremities.

The concern about compression of the cauda equina may be confirmed by obtaining a lumbar MRI. If these nerves to the bowel/bladder stop functioning normally, then surgery is required as soon as possible - usually within 6 to 24 hours to preserve and possibly restore bowel/bladder function. If surgery is not done in an expeditious manner, the bowel/bladder function may not return and continue to worsen over time. The prognosis of the condition worsens once the patient begins to have loss of bowel and/or bladder control. The prognosis is also worse when the patient has medical problems that affect the nervous and/or is older in age. The goal of the surgical procedure is to decompress the cauda equina and give it the best chance to heal.

The second indication for lumbar spine surgery is worsening weakness in the lower extremities. When a nerve is pinched, it may affect the signals that are sent to the muscles in the legs. Over time, if this nerve continues to remain compressed, then the innervated muscle may also begin to lose its strength and tone. This may then result in weakness in the leg. Early on, this weakness may be very subtle and only noticed by an astute physician. However over time, this weakness may become very obvious with a limp or a tendency to trip/fall, alerting the patient to a significantly serious problem. When someone initially presents for a pinched nerve, an adequate physical examination is performed and the leg strength is documented and recorded. If this continues to progress over the next few weeks, surgery is entertained to the limit the weakness and to restore normal strength faster. If this strength remains the same and/or improves, then surgery is less commonly considered. After about 3 months of observation, if the patient strength has not increased, then surgery can be considered to help return to normal strength. The goal of surgery is to decompress the nerve and - with time - the nerve will heal and restore normal signals to the muscle. Then, the muscle - in time - will also improve and return to normal strength.

The third reason to consider lumbar spine surgery is for lower extremity (leg or buttock) pain due to a pinched nerve that has not resolved despite a course of non-operative treatment. The non-operative treatment plan typically consists of oral medications, physical therapy, and one or more epidural injections. The course of non-operative treatment usually lasts about 2 to 3 months because prior research studies have shown that over 80% of people improve with respect to pain and function with non operative treatment / observation within 3 months. However, if the patient has severe disabiling pain that requires narcotic medication and/or repeated hospitalizations, then it would be considered cruel to make the patient wait 3 months in a state of extreme pain. In this case - albei rare - surgery is done prior to the three month period. If someone does not improve with respect to his/her symptoms within 3 months, then surgery should be considered to help expedite the return to normal function. Most people return to full activities - including running, biking, hiking etc. - within 3 months of the initial injury. The goal of surgery in this case would be to remove the pressure off of the affected nerve, thus removing the source of pain and allowing the nerve to heal over time and function normally.

Surgery should only be performed on the lumbar spine for the three reasons mentioned above Please note that chronic low back pain without bowel/bladder problems, weakness in the lower extremities, and/or lower extremity pain in the is not a commonly accepted reason for surgery. While surgery can be done for this reason, the rate of satisfaction is low and the need for subquent surgeries is much higher. Thus for isolated degenerative low back pain without the above-mentioned symptoms and without spinal instability, lifestyle modification and activity modification are recommended rather than surgery. Please discuss your specific complaints with a board certified orthopedic spine surgeon.

Mir H. Ali, MD,PhD
Director - Deerpath Spine Institute
Orthopedic Spine Surgeon - Rezin Orthopedics & Sports Medicine

Dr. Ali is a board certified orthopedic spine surgeon trained in the diagnosis as well as the treatment of non-operative and operative spinal disorders. Dr. Ali practices in the far western and southwestern suburbs of Chicago and utilizes surgery as a last resort when all other non-operative treatments have failed to relieve pain and/or reduce risk of nerve damage/injury. All recommendations on this site are for general situations and a particular situation requires evaluation before specific treatment recommendations can be made.