Accurate Diagnosis Before Back Surgery

Question: Discectomy, spinal fusion, or another treatment option?

My back problems started at least 10 years ago and the pain is progressively getting worse. In December my PCP sent me for physical therapy - that really did not help, and it actually made it worse after most sessions. I went for and MRI, and it showed I have two herniated disks, L2/3 and L4/5.

I went back to my PCP, who put me on Medrol, DosePak, Vioxx, Cyclobenzapr (Flexeril). These didn’t do anything. I talked to my PT and then went to a 4 week back stabilization class. That didn’t seem to make a difference for my problem, although I continue to do the exercises a few times a week.

I went to another orthopedic spine surgeon. He said the herniated disks didn’t seem bad enough to be causing the pain. After all this info, he thinks a discectomy with a fusion and cage would be the best. He figures the slippage is what is causing the pain, since the pain is mainly in my back.

Well, I then went for a second opinion to a neurosurgeon that was highly recommended by my PT. After he looked at the MRI, he told me that what he saw on the MRI didn’t need surgery. I had kind of figured the orthopedic surgeon was going to tell me a discectomy was what I needed, so when he said fusion that blew me away. Well, then, I had resigned myself to the fact that having the fusion would be best to get rid of the pain and that when I went to the neurosurgeon he would be setting that up; then the neurosurgeon said no to surgery.

So after all this I don’t know what to do next. I don’t know who to talk to. I just want to resolve this one way or another and get on with my life. Do you have any suggestions?

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Doctor's response: Accurate diagnosis is the most important factor

How you would respond to a spine fusion largely depends on what the disc looks like on MRI. If it is very collapsed and degenerated, and the cartilaginous endplates have eroded, then an anterior fusion has a high success rate, especially if all the other discs are relatively normal.

If there is just some decreased signal intensity (black disc), then a spine fusion is unlikely to work. There has to be substantial disc space collapse. In order for a discectomy to be successful, there has to be nerve root pinching from the disc bulge/herniation. Sometimes this has as much to do with how big your spinal canal is as opposed to how big a disc is.

If there is any doubt, a CT myelogram is a more sensitive test for nerve root pinching than a MRI scan. If the scans are otherwise negative, there is a chance that this is not from your back but from something else, such as nerve impingement from piriformis syndrome.

An accurate diagnosis as to the cause of your pain is the most important factor in determining whether or not any surgical procedure will be of benefit.

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In Spine-health’s Doctor Advice section, physicians respond to frequently asked questions about back pain issues. These responses represent the opinion of one physician, and do not necessarily reflect the views of the broader medical community. The advice presented has not been peer reviewed by Spine-health’s medical advisory board.

Written by Medical Reviewer