Step 1: General Principles – The grid


There are four groups of patients:

  • IA—Structural lesion, low risk for chronic pain
  • IB—Structural lesion, at risk for chronic pain (high stress)
  • IIA—Non-structural lesion, low risk for chronic pain
  • IIB—Non-structural lesion, at risk for chronic pain (high stress)
  • An overview of how this looks is presented in this grid:
Low Risk for Chronic Pain


High Risk for Chronic Pain


Structural Lesion


Non-Structural Lesion





Step 2: The source of Your Pain

The first variable that must be clearly defined to your satisfaction is whether there is a defined structural problem.  Remember to be defined as a structural issue, the symptoms you are having must match the level of the problem.  For instance, if there is a bone spur next to your fifth nerve root, then the pain should be down the side of your leg into your great toe.  If the pain is just in your back or groin, then it does not match, and would not be considered a structural problem.

Aching Back? Why Surgery Is Not Indicated for Lower Back Pain, Case In Point, July 201.  (Reproduced with permission from Case In Point.)


Step 3: The impact of stress on your pain and decision-making

The next step is to determine whether you are in the type A or type B group. Be very honest with yourself whether you are handling your stresses well or if your coping skills are being stretched beyond your capacity.  Your doctor can give you some guidance and even steer you towards testing that can help you decide.  Everyone has stress.  However, if you are not sleeping well, having uncontrollable anxiety, and irritable you probably are in the B category.


Step 4: Understand the magnitude of the surgery

If the pain is in a matching distribution, then you must decide whether the pain is severe enough to undergo any surgical procedure.  You are the one having the pain.  We as physicians, can only guess at how much of a problem you are having based on what you tell us.  For example, pain that consistently limits your function and is there most of the day would seem like a severe enough problem to perform surgery.  However, patients will sometimes request surgery when they only have numbness and tingling.  If is uncomfortable then maybe surgery is worth the risk.  If it is just an annoyance, it should probably be left alone.

Sometimes the structural problem is compelling.  It is common to see extremely severe constriction of the nerves in the lower back and have the symptoms be fairly mild.  This is one situation that one should proceed with surgery.


Step 5: Making the final surgical decision

One final word of caution when making a decision to proceed with surgery.  Don’t make the decision because “there is nothing else that can be done.”  I have learned the hard way that getting into a bad business deal is much worse than missing a good one.  Another analogy would be in basketball when a player throws up a desperation shot.  The term commonly used is “throwing up a prayer.”  If you can break down the pain experience into its component parts, you can make a very specific informed decision jointly with your surgeon. It is a major permanently life-altering decision. Don’t cut any corners.




If you do not have a clearly defined structural problem, let it go. Our first role as surgeons is to define the issue. It is an area that we do well. The variation occurs in how we each define structural versus non-structural.  If you have a test that shows a “probable or possible” source of the pain, do not make any decisions at this point to proceed with surgery.