Q&A: Surgery for low back pain

Low back pain is common, with about 80% of adults experiencing it at some point in their lifetimes. Fortunately, most people find relief from the pain with time, activity modifications, physical therapy or other nonsurgical treatments. For others, surgery is the best treatment option to improve the quality of their lives.

It's common to feel nervous about the prospect of surgery. That's why it's important to talk with the surgeon to learn more about the procedure and get answers to your questions.

T.K Schiefer, M.D., a Mayo Clinic Health System neurosurgeon, answers seven questions about surgery to correct low back pain.

1. How do you know when surgery is needed for low back pain?

"Usually we would try to exhaust all of our treatments that are nonsurgical first," says Dr. Schiefer. This could include activity modification, taking nonprescription pain medications and time.

"With time, however, if things are not going well, and especially if there's some pain going down one of the legs, there may be a need for surgery in the future," says Dr. Schiefer. "But even at that point, we still wouldn't just jump to surgery. We probably try some physical therapy first ― maybe a steroid injection into the spine to see if that will settle down some of the inflammation that's causing the pain in that nerve root ― and then see where we're at from there."

There are situations where surgery is the best option, including if the person has a history of cancer and it's spread to the spine, significant spinal instability, or if there is a new neurologic deficit. "One of the most common deficits is when the nerve root that gets pinched in the lumbar spine affects how we bend back our foot. That's called a foot drop," says Dr. Schiefer. "And in those cases with neurologic deficit, we say we probably need to move to surgery so that the deficit isn't permanent."

In this video, Dr. Schiefer explains when to know if you need lower back surgery:

2. What type of surgery can correct low back pain?

The type of surgical procedures will vary based on the cause of the low back pain. Dr. Schiefer explains that if the person has a disc rupture or herniation, surgeons can remove a small part of the bone to access the disc fragment and remove it, to create space and relieve the pressure. This is called a diskectomy or laminectomy. These procedures take 30 to 60 minutes. Many patients can go home the same day.

"However, as we age, there's more wear and tear on the spine, and sometimes there are more problems. Sometimes there's a slip of one vertebra on another. That's called 'spondylolisthesis,' and that may require more extensive surgery," says Dr. Schiefer. "Sometimes there's problems at multiple levels that may require more extensive surgery. The more surgery we do, the longer people have to stay in the hospital and the longer it takes to recover."

3. What is a lumbar fusion?

A lumbar fusion is a common type of surgery that can help with spine problems in certain situations and is performed to stabilize the spine.

"We're causing two bones to grow or fuse together," says Dr. Schiefer. "Instead of using a cast, we'll usually use screws and rods to connect the segments we want to grow together and fuse."

During the procedure, your surgeon may place a type of bone substance to bridge the gap between two levels so they will fuse together with time. The bone graft may come from a bone bank or your own body, typically your pelvis.

In this video, Dr. Schiefer explains what a lumbar fusion is and when it's a good surgical option:

4. Will a lumbar fusion affect daily activity?

Spinal fusion is a safe procedure, but it changes the way the spine moves.

"Fusions do have consequences. Our lumbar spine is mobile, and there are multiple bones and multiple segments," says Dr. Schiefer. "When you fuse one or more segments together, you take away some mobility there."

Lumbar fusion can place additional stress and strain on the vertebrae above and below the fused portion. This may increase the rate at which those adjacent segments wear out. This is called adjacent segment disease.

"In younger patients, there's a good chance in their lifetime they may require further fusion surgeries for those adjacent segments," says Dr. Schiefer.

5. What is a bulging disc? Do these always require a surgery to correct?

The low back, also known as the lumbar region of the spine, consists of five vertebrae labeled L1 through L5.

"In between those bones, there are discs that are softer than bone and are a bit like shock absorbers," says Dr. Schiefer. "With time, there can be some strain on those discs. Sometimes those discs will start to bulge and not be quite as contained in their normal space."

Dr. Schiefer explains that many people have bulging discs, but they do not experience back or leg pain. These people don't require surgery.

“It's not necessarily normal because that's not how we were born; but over time, this tends to happen to most people," he says. "Does it always need surgery? No, it definitely does not always need surgery."

6. Are there minimally invasive procedure options, and what are the benefits?

There are minimally invasive surgery options for lumbar surgery. These use multiple, small incisions to perform the procedure versus an open procedure, which uses larger incisions to access the spine.

"There are pros and cons to each, but we do both surgeries, and they are considered routine surgeries for us in our neurosurgical practice," says Dr. Schiefer. "The big advantages for minimally invasive procedures can be less operative time, less blood loss and quicker recovery."

In this video, Dr. Schiefer explains the types of minimally invasive procedures for lower back pain and how often he performs them:

7. What are some possible risks or complications with low back surgery?

Surgery on the low back is safe.

"Most of the back surgeries we do are not high-risk surgeries. Catastrophic complications are extremely uncommon, and it is low risk," says Dr. Schiefer.

The most common complication is disc recurrence. This occurs when a person has a herniated disc that is placing pressure on a nerve root. During the surgery, a portion of the disc material is removed to remove the pressure. A disc recurrence happens when a new disc fragment herniates after surgery.

"The medical literature says there's about a 10% to 20% chance that you might have more disc material come out after surgery and push on the nerve again causing a recurrent problem," says Dr. Schiefer. "That means 80% to 90% of people do just fine and don't have a recurrent problem, but 10% to 20% do have another problem, which may require another surgery."

In this video, Dr. Schiefer discusses the risks of low back surgery: