This is an overview of spine surgery in regards to performing fusions or artificial lumbar discs for non-specific low back pain. I would like to make it clear that I am not intending to be critical of specific surgeons or institutions. The current indications are a result of a “cultural evolution” within the field of spine surgery.
I was personally very aggressive in performing these surgeries for about the first eight years of my practice. It took an unusual sequence of events to be able to gain the perspective that I have gained. Otherwise, I am quite sure I would still be aggressively performing surgery for non-specific low back pain. It was not until I had a high percent of my own patients do poorly after a technically well-performed surgery that I began to look at the whole situation much differently. I felt, as did my patients, that surgery was the “definitive answer” for low back pain. It was the way I was trained. Additionally, in 1986, when I first started practice, there was a whole new wave of technology that allowed us to more reliably obtain a solid fusion. For example, a fusion between the 4th and 5th lumbar vertebrae (L4-5) would have around a 40% chance of not healing regardless of the surgeon. With the new hardware, we could place screws and rods right into the spine, which dropped the rate to less than 20%. With the even more advanced techniques that have been developed the last ten years, I can hardly remember a patient that hasn’t fused on the first attempt. I not only performed these fusions, I did them with a lot of enthusiasm. I was shocked when the results were poor.
Many spine surgeons come out of their training with the same zeal. They are a product of the current culture. It is my goal to show you a different perspective. You will be better informed about whether to undergo a major surgery for your low back pain.
I will present the discussion in the following sequence:
- What do we know?
- What are we doing?
- Where can we go?