As people navigate their spinal problems the question most will face is whether or not to have surgery and when. There are times when surgery must be the first option and the conservative approaches of chiropractics, physical therapy, medications and pain management are not appropriate. When there is a neurological deterioration or deficit from trauma or a chronic condition such as stenosis, spondylolisthesis and scoliosis are causing neurological damage surgery is necessary.
The harder issue is when the need for surgery is subjective, as is frequently the case with herniated discs. Sometimes it’s a choice between a longer road to relief with conservative treatments and it’s a judgement call based on the patient’s quality of life and predicted outcomes. As a spine surgeon I am well familiar with the paradox of two patients with clearly diagnosable identical spine problems, one is in agony and the other is perfectly fine yet they are anatomically indistinguishable in the diagnostic imaging.
The question is what treatment to access at which point – each pathway has its advantages and limitations. Surgery can do things that chiropractics, physical therapy, and pain management cannot – and is an excellent option once those two options have been exhausted. I have a network of pain doctors, chiropractors, physical therapists and physiatrists who I know are clinically excellent but more importantly will be honest and ethical in their assessment.
The painful reality – no pun intended – is that people can have a moderate disc herniation and be a superb candidate for surgery with a curative outcome yet wander in limbo and lose quality of life for far too long because did not seek an opinion from a surgeon. As a patient is seeking relief from the more conservative non-surgical tools (PT, Chiro, Meds, Pain Management) they should seek an opinion from a surgeon to hear their comparative opinion.
Some disc herniations resolve themselves, other can only be dealt with through surgical intervention as pain episodes ebb and flow. If a disc is torn or ruptured - only surgery can seal the cartilage back up or remove the portion that is pressing and leaking fluid on the nerve causing fiery radiating pain. Only surgery can opened the narrow channels of bone in the vertebrae that cause painful stenosis. The straightening and alignment of vertebrae for considerations like spondylolisthesis and scoliosis is achieved surgically, never through conservative approaches and may involve prosthetic tools that help such as stabilizing rods and cages. While every case if different a reasonable trial of physical therapy, chiropractics and pain management maybe effective
It is important for people to understand that there are generally recommended conservative treatment approaches to any spinal condition. But ultimately, the decision should be made between you and your surgeon on the basis of your quality of life and prognosis.
In 2006, the Journal of the American Medical Association (JAMA) published the Spine Patient Outcomes Research Trial (SPORT) study which compared patients suffering with sciatica who had lumbar discectomy surgery to those who had non-operative care. The data from hundreds of patients over 13 clinical sites and measured over several years showed that while both groups improved, those who chose surgery had better and more rapid improvement and satisfaction. (1)
When I see a patient and I diagnose them with a routine condition – the most common being disc herniation, spondylolisthesis, scoliosis, stenosis or degenerative disc disease– I tell them based on the severity of the condition that with chiropractics and physical therapy they may be able to avoid surgery and I refer them to colleagues. I also tell them that surgery can repair the condition if these fail and we set a time frame after which it will be apparent they need surgery.
The conversation about going forward with surgery should be between you and your surgeon, ideally with input from your pain management physician, physical therapist and/or your chiropractor. I frequently speak with those allied health professionals especially if I was the referring surgeon and ask their opinion. No one can force you to have surgery – but if you want to save yourself months of agonizing pain and schedule disruptions, a surgery can be a safe and appropriate option that will achieve an even better outcome.