Why Lumbar Spinal Surgery Isn’t All It’s Cracked Up To Be

Lumbar Spinal Surgery

Pain grips its claws into either side of your spine, relentless to never let go. Wringing your vertebrae like a soaked towel – its drippings electricity searching for ground. Persisting for months on end, the meds become like vitamins – inherently meant for good, but their immediate effects unfulfilling. The dilemma: take the conservative route or opt for surgery? Desperate for relief, you weigh your options.

Surgery of the Lumbar Spine is a controversial topic. Despite the controversy, however, these surgeries are being performed more and more often in recent years. It’s likely you know at least one person who’s had one. You might also know someone who’s chosen conservative treatment instead. So, which is better?

Lets explore…

Types of Lumbar Surgery and Their Outcomes

The lumbar laminectomy, also known as decompression, is surgery that removes the lamina – the back part of your vertebra – that covers your spinal canal. By removing the lamina, the spinal canal is opened up to take pressure off of the spinal cord and/or nerves.

Laminectomy success rates are roughly 80% – not too bad. It’s mostly effective for alleviating radiating symptoms (burning, numbness, tingling, weakness) in the legs related to Spinal Stenosis. It’s even been shown that decompression’s long-term success rates are slightly better than conservative care1,2,3,4,5.

Vertebroplasty is a procedure for osteoporotic fractures of the vertebrae in which bone cement is injected into the vertebra. Kyphoplasty is similar but uses a small balloon that lifts broken bone fragments into their correct location.

Neither procedure shows any significant evidence over conservative care or even placebo. Worse, there is a high incidence of fractures happening above and below the surgical site6,7,8,9,10. Due to all of their complications, most insurance won’t even cover these procedures.

Discectomy is a surgery to remove the central part of a disc that may be herniated and pressing against the spinal cord or a nerve.

Discectomy, similar to decompression, shows an average success rate of 80%11,12,13,14.

Spinal Fusion is a surgery that is meant to prohibit any motion at a painful segment – or multiple segments – of the spine. Fusion occurs via a bone graft, which causes two or more vertebral bones to grow together into one. Bone grafts can be synthetic, harvested from a cadaver, or used from the patient’s own hip.

As promising as they sound, no conclusions about the effectiveness of anterior, posterior, or circumferential fusion have been shown15.

To make things worse, fusions have a high rate of complications. There are roughly double the risks compared to decompression surgery, 6x the risk of blood transfusions, and double the postoperative mortality rate16,17,18,19,20.

All of this can be yours for an average cost of $34,00021.

Lumbar disc replacement is surgery that removes degenerated disc material between two vertebrae and replaces it with an artificial disc. The goal here is to relieve pain while maintaining more motion than other surgeries such as a fusion.

We’ve all wished science and technology would have gotten this right by now – then all of our problems would be solved. To date, though, no study has shown total disc replacement to be better than spinal fusion in its outcomes22.

What Have We Learned?

As it turns out, although there is substantial research on the topic, there is still no strong evidence favoring most lumbar surgical procedures based on the evidence23,24,25.

However, despite any specific reports of improved outcomes in the last 20 years, the rate of lumbar surgeries in the US continues to rise. Of particular concern is the rise of spinal fusions. Fusions show little effectiveness, have significantly high risks of complications, yet they are being performed more and more often.

I’m not suggesting that all surgeries are bad, or that all surgeons are evil – not in the slightest. We’ve just seen that decompression and discectomies actually have a pretty high success rate. Additionally, spine surgery has a well-established role in treating fractures and deformities. However, the benefits are more limited when treating degenerative disc disease26 (arthritis) – which tens of millions of people in the US currently have.

Spine Surgery Rates In the United States

From 1990-2001, spine surgery rates increased by 220% in the US despite any evidence of clearly defined indications or improved effectiveness27.

After the fusion cage was developed in 1996, spinal fusions rose by 77% in 200128.

Between 1990-1993, 9.4% of all patients with Degenerative Disc Disease had spinal fusion. Between 1997-2000, this increased to 19.1%29. To reiterate: this means 19% of the millions of people with arthritis had a fusion. This is alarming to me, especially with evidence that an MRI is likely to show degenerative changes whether you have pain or not.

The likelihood of having spinal surgery in the US is 5x higher than in the United Kingdom30.

Higher spine surgery rates should mean better outcomes though, right?

Actually, believe it or not, areas with higher surgery rates are sometimes associated with worse outcomes. For instance, studies show that in states where the best surgical outcomes occur, surgery rates are lowest, whereas in states with the worst results, surgery rates are highest31.

A Disturbing Trend

I recently wrote an article entitled Why Meniscus Surgery Isn’t All Its Cut Out To Be. In it I describe how the Partial Medial Meniscectomy Surgery shows no difference in outcomes when compared to a sham – or fake – surgery.

The reason I bring this up is that it is a similar problem to that of lumbar surgery. Although the results are far less than stellar, it continues to be done, even at an increasing rate.

I’m not one to judge motives or point fingers – my intent is to present the facts regarding these common surgical procedures so that you can be well-informed.

Does Physical Therapy After Lumbar Surgery Help?

Being a Physical Therapist, my mind goes to how I can help patients recover after these surgeries. Maybe if a good rehab program were put in place, they would see improvements and success rates would go up?

However, results from such rehabilitation programs following spinal surgery aren’t so favorable…

Outcomes in patients after lumbar disc surgery who underwent PT show favorable short term benefits, but no difference in the long term when compared to those who didn’t have PT32.

How About Physical Therapy Instead of Surgery?

In a recent study, 2 groups of patients with spinal stenosis were randomly placed in either a conservative treatment group or a surgery (decompression) group. After three months, most people in both groups got better. After four years, roughly ½ the patients in the conservative group were still better, whereas about 4/5 of the patients in the surgery group were better.

The interesting part of this study was that those who had continued pain after conservative treatment were offered delayed surgery and, for those patients, they had a similar result as the initial surgery group33.

This should offer you a great deal of optimism if you are suffering from spinal stenosis. With a 50% chance of improvement from conservative treatment, why not try PT first? If it does turn out to be unsuccessful, you can always opt for surgery later.

A similar study was conducted in patients with sciatica symptoms from a herniated disc. One group received conservative treatment, the other surgery (discectomy). After 10 years, the surgery group reported more complete relief of leg pain, improved function and satisfaction when compared to the conservative group. However, both groups showed similar outcomes when it came to back pain, work and disability34.

The Bottom Line

Bottom line with lumbar surgery as a whole: there is evidence that at least 1/3 of lumbar surgery patients continue to have significant persistent pain, disability and functional loss35,36,37,38,39,40,41.

My recommendation for you or anyone you know would be to consider trying physical therapy first. My belief is that surgery, unless life-threatening, should be a last resort. If surgery does become the only option, choose wisely. Look at the statistics – the outcomes and the potential complications – for yourself. Choose a surgery that has proven itself successful. To the same extent, go with a surgeon who supports your decision.

Question: What else have you heard about Lumbar Surgery? You can leave a comment by clicking here.

  1. Atlas SJ, et al. Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8-10 year results from the maine lumbar spine study. Spine 2005; 30(8):936-943. ↩︎
  2. Pao, J.L., W. C. Chen, et al. (2009). “Clinical outcomes of microendoscopic decompressive laminectomy for degenerative lumbar spinal stenosis.” Eur Spine J 18(5):672-678. ↩︎
  3. Weinstein, J.N., T.D. Tosteson, et al. (2010). “Surgical vs nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial.” Spine 35(14):1329-1338. ↩︎
  4. Fu, Y.S., B.F. Zeng, et al. (2008). “Long-term outcomes of two different decompressive techniques for lumbar spinal stenosis.” Spine 33(5):514-518. ↩︎
  5. Oertel MF, et al. Long term results of microsurgical treatment of lumbar spinal stenosis by unilateral laminectomy for bilateral decompression. Neurosurgery. 2006;59(6):1264-1269; discussion 1269-1270. ↩︎
  6. Schmelzer-Schmied N, et al. Comparison of kyphoplasty with use of a calcium phosphate cement and non-operative therapy in patients with traumatic non-osteoporotic vertebral fractures. Eur Spine J. 20098; 18(5):624-629. ↩︎
  7. Lin WC, et al. Refractures in cemented vertebrae after percutaneous vertebroplasty: a retrospective analysis. Eur Spine J. 2008:17(4):592-599. ↩︎
  8. Fribourg D, et al. Incidence of subsequent vertebral fracture after kyphoplasty. Spine 2004; 29(20):2270-2276; discussion 2277. ↩︎
  9. Hulme PA, et al. Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine 1976. 2006; 31(17):1983-2001. ↩︎
  10. Taylor RS, et al. Balloon kyphoplasty in the management of vertebral compression fractures: an updated systematic review and meta-analysis. Eur Spine J. 2007; 16(8): 1085-1100. ↩︎
  11. Korres DS, et al. Results of lumbar discectomy: a study using 15 different evaluation methods. European Spine Journal 1992;1:20-4. ↩︎
  12. Findlay GF, et al. A 10-year follow-up of the outcome of lumbar microdiscectomy. Spine 1998; 23:1168-71. ↩︎
  13. Loupasis GA, et al. Seven-to 20-year outcome of lumbar discectomy. Spine 1999;24:2313-7. ↩︎
  14. Yorimitsu E, et al. Long term outcomes of standard discectomy for Lumbar Disc Herniation. Spine 2001;26:652-8. ↩︎
  15. Gibson JN, Wadell G. Surgery for degenerative lumbar spondylosis: updated Cochrane Review. Spine 2005;30(20): 2313-2320. ↩︎
  16. Deyo RA, et al. Lumbar spinal fusion: A cohort study of complications, reoperations, and resource use in the Medicare population. Spine 1993; 18(11): 1463-1470. ↩︎
  17. Button G, et al. Three to six year follow up of stand alone BAK cages implanted by a single surgeon. Spine J. 2005; 5(2):155-160. ↩︎
  18. Blumenthal S, et al. A prospective, randomized, multicenter Food and Drug Administration investigational device exemptions study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: part I: evaluation of clinical outcomes. Spine 2005; 30(14): 1565-1575; discussion E1387-1591. ↩︎
  19. Brox JI, et al. Lumbar instrumental fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain 2006; 122(1-2): 145-155. ↩︎
  20. Fenton JJ, et al. Variation in reported safety of lumbar interbody fusion: influence of industrial sponsorship and other study characteristics. Spine 2007; 32(4): 471-480. ↩︎
  21. Deyo RA, Nachemson A, Mirza SK. Spinal-fusion surgery – the case for restraint. N Engl J Med.2004;350(7):722-726. ↩︎
  22. Freeman BJ, Davenport J. Total disc replacement in the lumbar spine: a systematic review of the literature. Eur Spine J 15 Suppl 3: S439-47, 2006. ↩︎
  23. Jarrett MS, Orlando JF, Grimmer-Somers K. The effectiveness of land based exercise compared to decompressive surgery in the management of lumbar spinal-canal stenosis: a systematic review. BMC Musculoskeletal Disord 2012; 13:30. ↩︎
  24. Phillips FM, et al. Lumbar spine fusion for chronic low back pain due to degenerative disc disease: a systematic review. Spine 2013; 38:E409-22. ↩︎
  25. Daubs MD, et al. Fusion versus nonoperative care for chronic low back pain: do psychological factors affect outcomes? Spine 2011; 36:S96-109. ↩︎
  26. Mirza SK, Deyo RA. Systematic review of randomized trials comparing lumbar fusion surgery to non-operative care for treatment of chronic back pain. Spine 2007; 32:816-23. ↩︎
  27. Deyo RA, et al. United States trends in lumbar fusion surgery for degenerative conditions. Spine 2005; 30:1441-5. ↩︎
  28. Deyo RA, Mirza SK. Trends and variations in the use of spine surgery. Clin Orthop Relat Res. 2006;443:139-146. ↩︎
  29. Deyo RA, Mirza SK. Trends and variations in the use of spine surgery. Clin Orthop Relat Res. 2006;443:139-146. ↩︎
  30. Cherklin DC, et al. An international comparison of back surgery rate. Spine. 1994; 19(11):1201-1206. ↩︎
  31. Keller RB, et al. Relationship between rates and outcomes of operative treatment for lumbar disc herniation and spinal stenosis. J Bone Joint Surg 1999; 81:752-62. ↩︎
  32. Danielson JM, et al. early aggressive exercise for postoperative rehabilitation after discectomy. Spine 2000; 25(8):1015-20. ↩︎
  33. Amundson T, et al. Lumbar Spinal Stenosis: Conservative or Surgical Management?: A prospective 10-year study. Spine 2000; 25(11):1424-1436. ↩︎
  34. Atlas SJ, et al. Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study. Spine 2005; 30(8): 927-935. ↩︎
  35. Atlas SJ, et al. Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8-10 year results from the maine lumbar spine study. Spine 1976. 2005; 30(8): 936-943. ↩︎
  36. Korress DS, et al. Results of lumbar discectomy: a study using 15 different evaluation methods. Eur Spine J. 1992; 1:20-4. ↩︎
  37. Findlay GF, et al. A 10 year follow up of the outcome of lumbar microdiscectomy. Spine 1998; 23: 1168-71. ↩︎
  38. Loupasis GA, et al. Seven-to 20-year outcome of lumbar discectomy. Spine 1999;24:2313-7. ↩︎
  39. Yorimitsu E, et al. Long term outcomes of standard discectomy for Lumbar Disc Herniation. Spine 2001;26:652-8. ↩︎
  40. Gibson JN, Wadell G. Surgery for degenerative lumbar spondylosis: updated Cochrane Review. Spine 2005;30(20): 2313-2320. ↩︎
  41. Button G, et al. Three to six year follow up of stand alone BAK cages implanted by a single surgeon. Spine J. 2005; 5(2):155-160. ↩︎
Get Your FREE eBook!
Turn Down Your Pain
Plus, I'll send you new articles and products as they become available.

Please note: I reserve the right to delete comments that are offensive or off-topic.

  • Michelle Wald

    One of the newest procedures is the disc replacement surgery. I have heard of great and not so great outcomes. I haven’t heard about long term results. Any word?

  • Michael Curtis

    Michelle, the disc replacement surgery is in my article. Not great outcomes from the systematic review I looked at from 2006.