Back pain is very common in the United States. Eight out of 10 people will experience it some time in their lives. Back pain is also one of the most common reasons for missed work, outnumbered only by upper respiratory infections. The chances are, you or someone you know will experience back pain at some point in your life.

For back pain that doesn’t go away in a few days, it is recommended that you see a health care provider. There are many different causes of back pain. Most causes of back pain are mechanical. This means that they are not caused by more worrisome conditions such as cancer, fracture, infection, or inflammatory diseases. Mechanical causes of back pain usually respond well to conservative, non-surgical, treatment. This includes treatment offered by physical therapists and chiropractors, as well as over the counter medications and prescription medications.

The difficult questions arise when conservative care has been tried with poor results. How does one know whether to consider surgery? Here are a few points to consider when trying to answer that question:

  • Was the conservative care provider doing a good job? A good therapist should take a detailed history, which includes correctly identifying the cause of pain and any aggravating factors. They should set objective outcome markers so that you and your therapist know if the treatment is working after a predetermined amount of time. Therapy should be specific to you determined by a comprehensive evaluation and your daily activities and/or sports. Any aggravating factors in your life should be identified and removed in the first phase of treatment. They can then be modified and reintroduced later if needed. Therapy should usually combine some sort of manual therapy and exercise prescription, with the goal of self sufficiency over time. Good therapy will not always consist of both at any given time. In the acute phase, manual therapy may be all that is indicated for a time until the client is ready for exercise. In most cases, exercise should be introduced at some point. If you don’t feel like you had a great therapist, try someone else before considering surgery.
  • What is the cause of the pain and are there any other symptoms? Symptoms can be very important when determining if someone is a candidate for surgery. If pain is determined to be mechanical and is concentrated in the back, conservative care is usually a good option. Pain into the legs or arms can be more complicated. Pain in the leg or arm can be from irritation of a nerve root, called radicular pain, or muscular in nature, called myofascial pain. It is very important to differentiate between these two types when deciding on treatment. A skilled therapist or medical doctor can determine between the two. Myofascial pain into the leg, foot, hand, or arm can be treated with conservative care quite well. Radicular pain can be more challenging. Radicular pain from a disc herniation, for example, can be quite intense. Most discs will heal over time with conservative care, but the pain can be so debilitating in the meantime that surgery might be a better option. Tingling or numbness in the leg, arm, foot, or hand can mean nerve root irritation as well and should be taken seriously. Finally, loss of motor skills such as strength or the ability to move, should be taken very seriously and can be an absolute indication for surgery, as this can be slow to reverse or irreversible. Any symptoms into the leg, foot, arm, or hand require careful evaluation by a skilled practitioner to determine the cause.

Once these questions have been answered, a decision should be easier to make. One final factor to consider is the success rate of the procedure that you are considering. Speak to your health care provider about all options and what a reasonable expectation for outcome is for each option.

Dr. Jeremy James

Dr. Jeremy James founded and was director of the Aspen Club Back Institute in Aspen, Colorado, is the coauthor of the bestselling The Younger Next Year Back Book and earned his Doctor of Chiropractic from the University of Western States. Learn more about Dr. James here.