DEAR MAYO CLINIC: My brother was experiencing severe back pain last year and decided to see a neurosurgeon for treatment. Now he is experiencing little to no discomfort. When I think about seeing a neurosurgeon, I picture major spine surgery and a long, difficult recovery. Seeing that he is doing better made me reflect on my own situation. I have been dealing with some intense back pain myself. Am I at a point where I should schedule an appointment to see a neurosurgeon?
ANSWER: Back pain is common. As many as 80% of people experience it at some point, and about 90% of cases improve within six weeks. For that reason, acute back pain often does not require immediate evaluation by a neurosurgeon. Sciatica, which refers to pain that radiates down the leg, is also common and generally resolves in the same time course.
When to seek medical care
An MRI (a type of diagnostic imaging test) usually isn't needed in the first six weeks for low back pain or sciatica unless you have concerning symptoms. Patients should seek medical care right away if they have leg weakness, loss of bladder or bowel control, fever or chills, unexplained weight loss, a personal history of cancer, or recent trauma.
Initial management focuses on conservative care. This includes over-the-counter medications, such as acetaminophen or ibuprofen, and physical therapy. Bed rest is not recommended. Patients are encouraged to stay active and limit rest to no more than 48 hours.
Common causes of back pain
Common causes of back pain include muscle strain, inflammation involving the spinal joints or discs, poor posture, or sleeping in abnormal positions. Sometimes discomfort also may originate from abdominal or pelvic organs that can refer pain to the back.
Patients should first see a primary care clinician for evaluation and initial treatment. If discomfort lasts beyond six weeks, imaging should be obtained. If imaging findings are irregular and back pain or sciatica persist, referral to a neurosurgeon may be appropriate.
Imaging is generally not performed before six weeks because some abnormalities such as disc herniation may resolve over time. An MRI also can be misleading because degenerative changes are often seen on scans in people without symptoms, particularly with aging.
A common misconception is that a neurosurgery referral will automatically result in surgery being recommended. That is not the case. Many spine conditions can be managed without an operation and improve over time or with conservative measures.
When surgery may be considered
Surgery for pain is considered after nonoperative treatments, such as medication, physical therapy or injections, have not provided further relief and when imaging findings align with a patient's symptoms. Establishing the correct diagnosis is a necessary first step before contemplating surgery.
Conditions that may require surgery include scoliosis, spondylolisthesis, lumbar stenosis with claudication or radiculopathy, disc herniations, and sacroiliitis.
In most spine cases, surgery is elective rather than urgent. The decision depends on whether the benefits outweigh the potential risks.
Implants and surgical techniques have improved significantly in recent years. Minimally invasive approaches are more common, and surgeons may use advanced imaging, image guidance and computer software for planning.
Recovery varies based on the procedure performed. After less complex operations, patients often resume normal activities within about six weeks. During that time, heavy lifting, bending and twisting are restricted. More extensive procedures, including fusion, require longer healing times (six months to a year), though most people who perform desk work can generally return within six weeks. More physically demanding jobs may require up to three months.
In appropriately selected patients, many procedures offer a 70% to 90% chance of improvement. However, every surgery carries some risk, and thus, conservative measures should always be tried for pain unless a patient also has more urgent symptoms such as progressive weakness, infection or trauma.
Maintaining a healthy body weight, exercising regularly with both cardiovascular and strength training, not smoking, and following a balanced diet are important lifestyle factors to stay healthy, and they may help reduce back problems. They also can help reduce the risk of complications when surgery is required.
If discomfort becomes more severe or includes concerning symptoms, seek medical evaluation. A primary care clinician can determine whether referral to a neurosurgeon is appropriate.
While most back pain resolves without surgery, persistent or progressive symptoms deserve careful evaluation to determine the most appropriate next step.
Grant Mallory, M.D., Neurosurgery, Mayo Clinic Health System Eau Claire and La Crosse, Wisconsin
