Does back pain always need surgery?

“The doctor said I have a disc, so I must have surgery.” Or: “My back hurts so much I think something is completely broken.” We hear these a lot. The short answer is: most of the time, no. But there are signs you should not ignore.

Where does back pain come from?

Back pain often gets better by itself within a few weeks. The most common causes:

• muscle injury or strain
• a slipped disc (disc herniation) pressing on a nerve, which can cause sciatica
• spinal stenosis, which is more common at older ages
• very rarely: a broken bone, a tumour or an infection

Which one it is, a doctor works out from an examination and sometimes imaging. The image alone is not enough; many people have a slipped disc and do not know it, because it does not always cause symptoms.

What helps?

The first steps are usually the same:

• Stay active. Long bed rest is not recommended. Walking, swimming, yoga or Pilates may help.
• Suitable painkillers. Anti-inflammatories such as ibuprofen help many people, but they do not suit everyone. Paracetamol alone is not recommended for back pain. Ask a doctor or pharmacist.
• Heat or cold. An ice pack wrapped in cloth for pain and swelling, and a hot pack for spasm.
• Physiotherapy and exercise, when several weeks have passed and you are not better.
• Stopping smoking. Nicotine weakens disc tissue.

For a disc that presses on a nerve, most cases get better without surgery, and strict rest is not advised.

When should you see a specialist?

• the pain has not improved after several weeks of home treatment
• the pain has stopped you from doing daily tasks
• the pain is worse at night or does not ease with rest
• weight loss with no reason, or a lump in the back

If symptoms continue for more than four weeks, referral to a spine specialist such as a neurosurgeon is recommended. Most sciatica and nerve pain from the neck gets better within days to weeks.

When does a doctor think about surgery?

Surgery is usually discussed when several things come together:

• treatment without surgery (medicine, physiotherapy) has not eased the pain
• nerve pain has limited life
• leg weakness or numbness is getting worse
• control of the bladder or bowel is affected (urgent)
• standing or walking has become difficult
• general health is suitable for an operation

If symptoms have not improved with other treatments, or weakness and numbness are getting worse, your doctor can refer you to a specialist to talk about surgery.

The decision to operate is made by the surgeon and patient together. Remember that the benefit of an operation must be weighed against its risk, and that there is no guarantee it will work for every patient, although many report a significant reduction in pain.

Signs that cannot wait

If back or leg pain comes with any of these, call 115 at once or go to an emergency department (115 is Iran’s emergency number):

• numbness around the anus or genitals
• being unable to pass urine, or loss of control of urine or stool
• weakness or numbness in both legs

Back or leg pain that began after a car crash or a heavy blow is an emergency too, so call 115 at once, although it is not a sign of pressure on the nerves at the bottom of the spine. The article “Red flags for back pain” gives all of them in detail.

Questions to ask the surgeon

• What exactly is my problem? What does the image say and does it match my symptoms?
• What treatment do we start now and when do we reassess?
• What happens if I do not have surgery? Is there any risk?
• Which signs should make me come back sooner?
• If an operation is needed: what operation, with what benefit and what risk?

Every patient’s plan is different; ask your doctor about your own situation.