3 Ugly Truths About Back Surgery

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Ron was a police officer. He had struggled for years with back pain with a searing burn down his leg. His MRI showed a compressed nerve that explained the burning pain. He tried therapy and medications but the pain continued to be unbearable. According to medical guidelines, he was the perfect candidate for back surgery to relieve his symptoms. I referred him to a neurosurgeon confident he would have a great outcome. But here's the thing...

Back surgery is unpredictable

Ron returned to me for a follow-up after his surgery; it was one of my most humbling moments in medicine. After the operation, his leg pain was no better. Worse, during the operation, he was not positioned properly and the nerve in his hand was permanently damaged. He lost strength and dexterity in his right hand. He could no longer work as a police officer. He lost his career, and the use of his right hand—and he still had searing leg pain.

Many are worse after surgery

A significant portion of people have worse pain and disability after back surgery. As a disability doctor, these people filled my clinic. For many, the pain was worse after surgery. For others, unexpected nerve damage and paralysis left them with bladder incontinence or difficulty walking, in addition to unchanged back pain.

My greatest precaution is for those with non-specific low back pain or pain from widespread back arthritis (degenerative disc disease). Non-specific low back pain is when there is no clear structural reason for the pain. Back pain arises from many pain generators; the discs, bones, muscles, nerves, and even the brain (see nociplastic pain below) can produce pain. If there is not a clear, singular target, surgery will not help the pain.

In the absence of compressed nerves causing leg weakness or bladder problems, back surgery offers a low likelihood of success. Even in properly selected patients, like Ron, almost 40 percent of people report chronic pain and moderate disability in daily activities five years after surgery.

Back surgery doesn’t fix nociplastic pain

Over time, pain can shift from an injury, such as a back disc, to coming from the nervous system (brain and nerves). This pain type, called nociplastic pain, arises from disordered pain processing within the nervous system.

Nociplastic pain is not relieved by injections or surgery. Procedures worsen the pain since this pain type makes the nerves more sensitive.

When nociplastic pain is driving the symptoms, the treatment approach is different. You don’t put a cast on a paralyzed arm from a stroke because the cause of the injury isn’t in the arm; it’s in the brain. The problem is deeper, in the nervous system. The same is true for treating nociplastic back pain.

Chronic low back pain often involves nociplastic pain. You can read more about its treatment in my book, Sunbreak: Healing the Pain No One Can Explain.