Surgery for Back Pain

Operation bei Rückenschmerzen

The question of surgery for back pain could be one of the most controversial topics in medicine. Because in consumer and specialist media a lot of critical opinions are expressed that question the amount of back pain related surgeries. 1,2,3

There are many opinions and misunderstandings about when spinal surgery to treat back pain is really appropriate.

While some back pain patients feel better after the surgery and the symptoms actually pass, other patients complain that their suffering has not improved even after the surgery or that the pain returned after some time.

But what is the difference between these patients? And what can the person concerned do to really get the right treatment in their individual case?

The following article will attempt to shed more light on these aspects and to get to the bottom of three of the most common myths on the question of the usefulness of surgeries for the treatment of back pain by assessing the facts.

Myth 1: Surgery is only performed if it is absolutely unavoidable and the probability of success is correspondingly high.

As a matter of fact the frequency of spinal surgery has increased sharply in Germany in recent years.

The Bertelsmann Foundation found a 71% increase in back surgery in hospitals between 2007 and 2015. 4

These figures lead to a lot of criticism. It is often argued that these surgeries are too often carried out mainly for economic reasons. 5

However, while there are patients who benefit from spinal surgery with pain relief, there are in fact many patients whose pain does not improve as a result of spinal surgery.

Myth 2: Surgery always leads to freedom from pain in back pain, regardless of its cause

Fact is: The exact diagnosis is decisive for the success of the surgery.

As mentioned in our other articles: 80-90% of cases of back pain have no clear cause that could be eliminated as a goal of treatment. Experts speak of so-called nonspecific back pain.6

It is therefore not surprising that surgeries are not recommended for non-specific back pain from a scientific point of view. 7.8 Experts also agree in current guidelines that nonspecific back pain should not be a reason for surgery. 9

This is not surprising in itself – it seems logical that an surgery is especially successful when it is clear where the pain comes from.

Myth 3: If persistent back pain shows changes in the spine, surgery is the treatment of choice

Fact is: Nearly every person up to the age of 60 has changes in the spine that can be seen on medical images of the spine. 10 However most of these people have little or no discomfort. 

But this is exactly the problem: The grey area of changes, which can possibly cause pain but don’t have to, is large.

And it is precisely these changes caused by signs of wear and tear that pose a major challenge to surgeries, as there is a considerable risk of failure in the sense of a lack of pain relief.

Science sees the risk of a lack of therapeutic success through surgery on the back at up to 40% and has even coined its own term for this (“Failed-Back-Surgery-Syndrome”, i.e. the syndrome of the failed back surgery). 11, 12

How urgent are most spine surgeries?

In principle the following holds true for spinal surgery: Surgeries can be performed in a lot of cases but only in very few cases they are absolutely necessary.

Take a herniated disc of the lumbar spine for example: When surgery should be performed and when surgery can be performed

We would like to explain the difference using the example of surgeries on a herniated disc in the lumbar spine.

There are guidelines on the basis of current medical knowledge with the participation of experts (both surgeons and non-surgical doctors). 13 On the basis of what is currently known to medicine they make recommendations for treatment. However, the are not binding.

They quite specifically state the reasons for urgent surgery (so-called absolute indication): As soon as the herniated disc presses on the spinal cord or a nerve in such a way that a clear loss of muscle strength or bladder or intestinal function occurs. 13

In addition, the guidelines state in which other cases surgery is possible, but not necessary (so-called relative indication): If the symptoms do not improve despite pronounced non-surgical therapy and the symptoms clearly match the changes that can be shown on medical images. 13

This means that the surgery can be performed as an alternative treatment in most patients with herniated discs, but should only be performed urgently in a few patients.

The decision for or against surgery

In most cases, patients and doctors have the time for a detailed clarification.

The situation is similar for most of the other reasons why back surgeries are performed.

If nerves or spinal cord are not disturbed in their function and there is no injury that threatens the stability of the spinal column, the decision usually has time and should be made after detailed consideration.

Numerous scientific articles also see the detailed clarification and careful selection of patients by the surgeon (the so-called indication) as a very important contribution to avoiding unsuccessful surgeries. 11

Patients should also be examined for possible other factors before making the far-reaching decision to undergo surgery. There is an interplay between psychological factors such as stress or depressiveness and pain. 14

It is therefore not surprising that psychological factors have a decisive influence on whether an surgery is successful or not. 15,16, 17 But only very few patients receive appropriate examinations in the run-up to an surgery on their back, which can determine whether the above risk factors are present or whether a pain memory has already developed.

What can I do myself if back surgery has been recommended?

First of all, patients should check whether they feel that they have been sufficiently informed about opportunities, risks and alternatives to surgery by the attending physician.

Because the necessity of a back surgery can very often be checked by a second opinion with another doctor with as much experience as possible.

Many health insurance companies also offer special programmes for this purpose or arrange for experts – so it is often worth asking the insurance company. 18,19

These second-opinion programs can often advise the majority of patients to refuse surgical treatment. 20

Scientific studies also suggest that second opinions can help to identify unnecessary surgeries. 21, 22

Overall, the following principle applies: Patients should try to obtain as much information as possible from reliable sources prior to a back surgery. Because only then they can choose the best therapy together with the attending physicians.

This is also recommended by specialists in interviews: Patients should select the appropriate therapy together with a treating physician without fear and time pressure. 5

Try an alternative with the Kaia-Health App!

If you want to reduce back pain instead of having a surgery, check out the Kaia-Health App. This app enables the multimodal pain therapy to everyone. With less than 15 minutes of Kaia exercising a day, you strengthen and stabilize your back in the long run and you will be on the best path to a pain-free life. The app contains 150 back exercises, which were created in cooperation with the pain specialists of a large pain centre and uses them to create an individual training plan.

References
1: https://www.stern.de/gesundheit/ruecken/therapie/surgeryen-gegen-rueckenschmerzen-wegschaben--verkochen--absaugen-3560808.html
2: https://www.aerztezeitung.de/medizin/krankheiten/schmerz/rueckenschmerzen/article/857037/rueckenschmerzen-finger-weg-opioid-op.html
3: http://www.zeit.de/2016/11/rueckenschmerzen-surgery-wirbelsaeule-therapie
4: https://www.bertelsmann-stiftung.de/fileadmin/files/BSt/Publikationen/GrauePublikationen/VV_FC_Rueckensurgeryen_Studie_dt_final.pdf
5: http://www.focus.de/gesundheit/ratgeber/ruecken/therapie/tid-24925/rueckenschmerzen-85-prozent-der-ruecken-ops-sind-ueberfluessig_aid_709750.html
6: http://www.patienten-information.de/patientenleitlinien/patientenleitlinien-nvl/html/kreuzschmerz/kapitel-4
7: https://www.ncbi.nlm.nih.gov/pubmed/24012430
8: https://www.ncbi.nlm.nih.gov/pubmed/24200413
9: http://www.patienten-information.de/patientenleitlinien/patientenleitlinien-nvl/html/kreuzschmerz/kapitel-8
10: https://www.ncbi.nlm.nih.gov/pubmed/19532001?dopt=Abstract
11: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5106227/#b5-jpr-9-979
12: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590156/
13: http://www.awmf.org/uploads/tx_szleitlinien/030-058l_S2k_Lumbale_Radikulopathie_2013_abgelaufen.pdf
14: http://www.patienten-information.de/patientenleitlinien/patientenleitlinien-nvl/html/kreuzschmerz/kapitel-5
15: https://www.ncbi.nlm.nih.gov/pubmed/25955092
16: https://www.ncbi.nlm.nih.gov/pubmed/24417814
17: https://www.ncbi.nlm.nih.gov/pubmed/18806999
18: https://nordost.aok.de/inhalt/rueckenspezial-zweitmeinung-vor-einer-ruecken-op/
19: https://www.tk.de/techniker/service/gesundheit-und-medizin/behandlungen-und-medizin/orthopaedische-erkrankungen/bandscheibenvorfall-op-ja-oder-nein-2023610?ref=tkde
20: http://aspenmp.de/wp-content/uploads/2016/07/Zweitmeinung-bei-operativen-Eingriffen-TK.pdf
21: https://www.ncbi.nlm.nih.gov/pubmed/25947932
22: https://www.ncbi.nlm.nih.gov/pubmed/24340231