Medical Edge Newspaper Column

Considering Back Surgery? Proceed With Caution

May 28, 2006
DEAR MAYO CLINIC:
About 10 years ago, I had surgery -- hemilaminectomy and foraminotomy -- on my lower back. Since then, I have been in constant pain in my back, legs and even my groin. I cannot walk across the room. I have had physical therapy, pain management, water exercise and everything except repeat surgery. Do you think additional surgery would help me? -- Seattle

ANSWER:
The short answer to your question, I regret to say, is an ambiguous "maybe."

Whether additional surgery might help depends on the specifics of your case, which means that a good deal of information needs to be gathered before making your decision. I would hope, moreover, that such care was employed before the original procedure.

Back surgery is not the method of choice for treating back pain, and it should only be used as a last resort when all other options -- less invasive ones -- have been tried and shown to be insufficient for the patient. These options include over-the-counter pain-relief medications, prescription medications, cortisone injections, physical therapies and transcutaneous electrical nerve stimulation (a weak electrical current is applied to specific points on the skin to relieve pain).

Back pain is difficult to diagnose accurately. If the cause has been misdiagnosed and surgery is performed too soon -- before other alternatives are exhausted -- it may not solve the underlying problem.

On the other hand, if surgery is indeed indicated, one should not wait too long. Prolonged compression of spinal nerves -- resulting from a herniated disk (disk material impinging on a nerve) or spinal stenosis (narrowing of the spinal canal pressing one or more nerves) -- can result in permanent nerve damage. But a window of six weeks to six months usually gives one more than enough time to explore noninvasive options or seek second opinions without incurring undue risk.

Your surgical intervention was aimed at relieving such nerve compression. A hemilaminectomy removes a portion of the lamina (a small bony plate that covers the spinal canal) and a foraminotomy enlarges the passageway through which a nerve root exits the spinal canal. These operations are frequently done at the same time to give the compressed nerve sufficient "elbow room," thereby relieving pain.

Let us suppose, for argument's sake, that these procedures were a judicious choice for you at the time. Their failure could result from a number of reasons. There may have been some major postoperative complications, such as infection, excessive bleeding or leaking spinal fluid, any of which could cause permanent nerve or bone damage. You may be diabetic or a smoker -- two groups that typically don't do well with back surgery because of more vulnerable nerve roots (diabetes) or a tendency toward osteoporosis (smokers).

It's also possible that the condition may have recurred. For example, only a part of a herniated disk can be removed; a later herniation, involving some of the remaining disk material, is thus possible.

In any case, your rightful concern is what to do now. And as you consider whether additional surgery is appropriate, I recommend that you proceed with caution, availing yourself of state-of-the-art diagnostic tests. You will need electromyography (EMG) and nerve-conduction tests to check for nerve damage, as well as magnetic resonance imaging (MRI) studies of the lumbar (lower back) and thoracic (middle back) sections of the spine. Where to go from there depends on what these tests show.

Major surgery is not your only recourse. Implanted devices such as spinal cord stimulators (analogous to heart pacemakers) and morphine pumps can sometimes give patients significant relief.

-- H. Gordon Deen, M.D., Neurosurgery, Mayo Clinic, Jacksonville, Fla.