When to see a surgeon for low back pain

Considerations before seeing a spine surgeon for low back pain
Almost everyone will experience at least one episode of acute low back pain at some point in his or her life. While these episodes can be extremely painful and cause significant disruption in one’s life, most episodes of low back pain will get better with time (about 2 to 12 weeks) and non-surgical care.

Many patients with low back pain wonder if they will need back surgery and if and when they should consult a spine surgeon (an orthopedic spine surgeon or neurosurgeon who specializes in spine surgery). For most instances of low back pain, it’s advisable to start off with a physical exam by the family doctor (primary care physician) or from a chiropractor before seeing a spine surgeon.

A primary care physician can prescribe medications, such as non-steroidal anti-inflammatory drugs (e.g. Motrin), or for severe episodes of low back pain, non-narcotic pain medications (such as Ultram), or a short course of narcotic pain medications. They can also order physical therapy and refer to a chiropractor.
A chiropractor typically specializes in using mechanical means to alleviate the patient’s low back pain, including an adjustment or one of many modalities.

If the low back pain starts to get better early, the patient may usually resume normal activities in a gradual fashion and it will not be necessary to see a spine surgeon. Physical therapy and exercise along with back care education is most often recommended. A combination of improved everyday posture, ergonomics, and regular stretching and exercise all play an important role in good back care and helps lessen the chances of future episodes of low back pain and the possibility of eventually needing to consult with a spine surgeon.

Conservative care (non-surgical) specialists who treat low back pain
If a patient is not improving with general conservative care with their family physician and/or chiropractor, but wishes to avoid having spine surgery, there are conservative care specialists trained in the rehabilitation of musculoskeletal disorders (physiatrists or physical medicine and rehabilitation doctors). Physiatrists are specialized in treating musculoskeletal disorders, and many specialize in just spine care. The role of a physiatrist in treating low back pain is often much the same as a cardiologist’s role in cardiac care, or neurologist’s role in treating neurological disorders. Most patients with cardiac or neurological problems do not need surgery but do need specialized care if their condition is complicated or does not improve with general care. Many physiatrists work together with spine surgeons either in a spine center or within the local medical community.

Many physiatrists are now also becoming interventional pain medicine specialists and are trained to do injections, such as epidural steroid injections (anesthesiologists may also be pain management specialists and focus on injections). They may also be trained in diagnostic techniques, such as EMG’s. Physiatrists who specialize in treating back pain are capable of using a combination of these injection techniques, diagnostic tests, and physical exam to more accurately diagnose the source of a patient’s low back pain and target the conservative treatment. Most physiatrists are also able to advise a patient as to when it would be appropriate to consider spine surgery and seek a consultation with a spine surgeon.

Indications for when to see a spine surgeon for low back pain
Low back surgery is only capable of correcting anatomical conditions that result in either spinal instability or nerve pinching. If either of these problems is present on an imaging study and the patient’s symptoms fit with the clinical and radiographic picture, then spine surgery may be indicated. If there is no identifiable anatomic cause of a patient’s low back pain (e.g. that can be seen on an MRI scan, routine flexion extension films for instability, CT scan myelogram or discography), then back surgery is not an option. If non-surgical treatments fail to alleviate a patient’s pain, this is not in and of itself an indication for having spine surgery. There must also be an anatomical lesion that can be identified as the cause of the patient’s low back pain.

The decision on whether or not to undergo back surgery for low back pain is almost always the patient’s decision. Only in rare instances—such as cauda equina syndrome or an abdominal aortic aneurysm—is immediate medical attention required. The spine surgeon should be able to give the patient enough information about the pros and cons of the procedure to assist the patient with his or her decision making process. A spine surgeon who be either an orthopedic spine surgeon or a neurosurgeon that specializes in spine surgery.

Important factors that patients may want to consider prior to seeing a spine surgeon for their low back pain include:

Level of low back pain and/or leg pain. If the pain is not alleviated by non-surgical treatments and has continued for a few weeks or months, it may be time to see a spine surgeon. If the pain is severe (e.g. the pain is not eased by narcotic pain medications), then it may be advisable to consult with a spine surgeon sooner.
Ability to function with the low back pain . Perhaps even more important than the level of low back pain and/or leg pain is the patient’s ability to continue to function in everyday activities. If one is not able to go to work, drive to the store, and complete other activities of daily living, it may be advisable to consider spine surgery sooner rather than later.

Another consideration for patients to keep in mind is the scope of the back surgery. Some types of back surgery are much less invasive than others (e.g. a microdiscectomy is minimally invasive and does not change the anatomy of the spine, whereas most types of lumbar spine fusion surgeries are more invasive and do change the anatomy of the spine). This topic is covered in more detail on the following page.