What This Means
Spine surgery is powerful when used appropriately—but it's not a cure-all. Surgery addresses specific structural problems: nerve compression, instability, or deformity. It doesn't fix muscle pain, doesn't eliminate all discomfort, and doesn't reverse age-related changes throughout the spine.
Understanding when surgery is unlikely to help prevents unnecessary procedures, avoids surgical risks, and directs patients toward treatments that actually address their problem. This section focuses on "negative knowledge"—what surgery can't do and when it should be avoided.
A good surgeon knows when NOT to operate. This protects patients from harm and ensures surgery is reserved for cases where it truly helps.
When Surgery Is NOT Appropriate
Red Flags Against Surgery:
- Imaging doesn't match symptoms:
MRI shows abnormalities, but symptoms don't correlate with imaging findings. Many people have disc bulges or stenosis without symptoms.
- Conservative treatment not tried:
Surgery should not be the first option unless urgent neurological symptoms exist. Physical therapy, medications, and injections should be attempted first.
- Primarily axial pain (back or neck pain only):
Surgery is most effective for radicular pain (arm/leg pain from nerve compression). Pure back or neck pain without nerve symptoms rarely improves with surgery.
- Diffuse, non-anatomic pain:
Pain that doesn't follow nerve distribution patterns or changes location frequently suggests non-structural causes.
- Unrealistic expectations:
Belief that surgery will eliminate all pain, restore youth, or fix problems beyond the surgical target. Surgery addresses specific structural issues—not general aging or muscle pain.
- Significant psychological overlay:
Depression, anxiety, catastrophizing, or secondary gain issues dominate the clinical picture. These need to be addressed before considering surgery.
- Active smoking:
Smoking significantly increases fusion failure rates and complications. Smoking cessation is required before elective fusion surgery.
- Severe osteoporosis:
Poor bone quality increases hardware failure risk. Bone health optimization is needed first.
- Uncontrolled medical conditions:
Poorly controlled diabetes, heart disease, or other conditions increase surgical risk. Medical optimization is required first.
What Surgery Can't Do
Understanding limitations is essential for realistic expectations:
- Surgery doesn't reverse age-related changes throughout the spine—only addresses the specific operated level
- Surgery doesn't eliminate all pain—it addresses nerve compression or instability, not muscle pain or arthritis elsewhere
- Surgery doesn't fix poor posture, weak core muscles, or biomechanical problems—physical therapy is still needed
- Surgery doesn't guarantee return to heavy labor or high-impact sports—activity modifications may still be needed
- Surgery doesn't prevent future spine problems at other levels—aging continues
When Conservative Treatment Is Better
Most spine conditions improve with conservative treatment. Surgery should be reserved for cases where conservative care has failed or urgent neurological symptoms exist.
Conservative Treatment Success Rates:
- Herniated disc: 80-90% improve within 6-12 weeks with conservative care
- Mechanical back pain: Physical therapy and core strengthening are more effective than surgery
- Mild stenosis: Activity modification, PT, and injections can provide years of symptom control
- Degenerative disc disease: Most cases stabilize over time without surgery
What Typically Comes Next
Step 1: Honest Assessment
If surgery is not appropriate, your surgeon should explain why and what alternatives exist. This protects you from unnecessary procedures.
Step 2: Comprehensive Conservative Care
Physical therapy (6-12 weeks), medications, activity modification, weight loss if needed, smoking cessation, and injections when appropriate.
Step 3: Address Contributing Factors
Psychological factors, sleep problems, deconditioning, and medical comorbidities should be addressed. These often contribute more to symptoms than structural spine problems.
Step 4: Reassessment Over Time
If symptoms worsen or new neurological deficits develop, surgical candidacy can be reassessed. Surgery may become appropriate if the clinical picture changes.
Questions Patients Should Ask
Why is surgery not recommended in my case?
What conservative treatments should I try first?
What are realistic expectations for conservative treatment?
Under what circumstances would surgery become appropriate?
What are the risks of delaying surgery if my condition worsens?
Should I get a second opinion?
What lifestyle changes can help my condition?
References
- 1. Deyo RA, et al. Overtreating Chronic Back Pain: Time to Back Off? J Am Board Fam Med. 2009;22(1):62-68.
- 2. Chou R, et al. Surgery for Low Back Pain: A Review of the Evidence for an American Pain Society Clinical Practice Guideline. Spine. 2009;34(10):1094-1109.
- 3. North American Spine Society (NASS). Appropriate Use Criteria for Lumbar Fusion. 2021.
- 4. Jarvik JG, Deyo RA. Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging. Ann Intern Med. 2002;137(7):586-597.
- 5. Brinjikji W, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR Am J Neuroradiol. 2015;36(4):811-816.
Authored by Dr. Marc Greenberg, MD — Greenberg Spine
Fellowship-trained orthopedic spine surgeon
Last updated: December 2024