When Should I Consider Back Surgery?

“Back Mechanic” is a book written by Stuart McGill PhD. to help back pain sufferers find their back-pain triggers. The book provides information that may help you avoid a need for back surgery and may help you to successfully find ways (with their doctor’s help) to treat and cure their pain triggers. This brief summary is not intended to replace the information contained in Dr. McGill’s book.  For a more complete understanding of his principles it is recommended that you read Dr. McGill’s book the “Back Mechanic”.


The following summary is not intended to diagnosis or treat your back pain.  You should consult with your medical doctor for guidance before starting any back-pain self treatment program.


“During an appointment for back pain, many doctors will spend far too little time with you, their patient; as a patient you may often come away from your appointment with no diagnosis at all or else a very specific conclusion that was reached merely by looking at the MRI or CT scan.” McGill suggests in his book the “Back Mechanic” that this “is already a failed back examination”.


Determining someone’s source of pain from glancing over some pictures is like looking at a photograph of a car, and with no other information determining the reason that the car will not start. Even when a diagnosis is reached, such as sciatica or a bulging disc, the assessment is hardly helpful in guiding you, the patient, to a cure. One of the most important things you (the back pain patient) should get from Dr. McGill’s book is that instead of focusing on the titles of your condition, you should focus on finding the cause of the symptoms and addressing them directly as a means of recovery instead of a surgical “Quick-Fix” or by using pain pills to hide your pain under a rug. A lot of people will claim that the pain is in your head but according to Dr. McGill most pain has a physical cause. Psychotherapy may help with a number of psycho-social factors involved in your pain syndrome but, like pain pills, this therapy fails to address the origins of your pain. Even if your doctor cannot determine the cause of your pain, Stuart McGill PhD suggests that there is one.


The goal of the “back mechanic” is to help you sort out the facts about your back pain from back pain fictions, find the causes of your pain and identify ways to treat that pain in order to avoid surgery or a life on pain medication.


You know more about your back pain than anyone else and what you know about your pain may help your doctor identify your “back pain trigger(s)” You can have more than one pain trigger. Share your answers to these questions to your doctor and get his/her thoughts.  


  1. Does your pain change in intensity? Do you ever have a pain-free morning or at least a few hours; if so, we need to understand why your pain changes. Understanding the reason guarantees that you can become pain-free again.


  1. When you roll over in bed do you encounter painful catches? If your answer is “yes” it may be a sign of spinal instability. Other signs of spinal instability would be painful stabs or shots of pain when moving such as reaching or even sneezing. If you have this condition you should avoid the chiropractor because the spine stretching exercises and many of the common back exercises that involve bending and twisting are, more likely than not, pain triggers for your condition.


  1. What makes your pain worse? If you are able to identify a specific activity that increases your pain, then your pain has a specific trigger.


  1. Was the initial cause of pain traumatic? Like a car accident, or a fall? Did your pain start slowly and continually get worse until a normal type movement caused a sharp or sudden onset of pain?


  1. Do you have any history of a condition such as osteoporosis? If you have such a condition then you probably want to avoid exercises that avoid compression loads on the spine. For example you would want to avoid golf which stresses the spine. On the other hand walking and swimming may be the exercise of choice but only if the spine posture is not bent over.


  1. Is the pain worse first thing in the morning? Do you have a large hollow in the low back area? Do you have a lot of meat on your buttocks area if so, neither will do well sleeping on a hard or firm mattress? What is your sleeping position? Some sleeping positions add stress to the spinal disc keeping them sensitive. Try different sleeping postures and find one where the natural curves of your spine or maintained.


  1. Does your pain increase throughout the day? This pain trigger pattern suggests that you were suffering from the cumulative loading of your back. As you continue to add load the pain continues to worsen. Pain that increases as your day continues, suggests that you are not practicing appropriate spine hygiene. You need to learn and practice conservative spine movement patterns and take rest breaks.


  1. Is the pain more concentrated in your middle back? This is a sign of a mechanical movement hanging at the thoracolumbar junction (Rib cage and top of the lumbar spine). There a specific exercise that can address this pain trigger.


  1. Does your back pain also radiate into your buttocks, legs, and feet? This pain is almost always due to a trapped nerve root in the lumbar spine that is made worse with specific activities. These activities usually involve a deviated posture such a spine flexion that causes the disc bulge to grow and place pressure on the nerve. Another possibility includes arthritis in which bone growth irritates the nerve with direct compression or with movement. Correcting your movement patterns will usually reduce and can aluminates the pain.


  1. Does the pain increased with fast walking or does it decrease? Slow walking will increase the pain if you have a disc bulge. On the other hand, power-walking and fast walking with your arm swinging about your shoulders will reduce the pain, turning the original pain mechanism into a therapy. On the other hand, persons with stenosis will find that walking simply adds to the cumulative load on their back resulting in the slow wind up of pain as the walking continues. This can be fixed by correcting you’re walking style and taking rest breaks.


When should you consider back surgery? The following are some of the recommendations found in Stuart McGill PhD’s 2017 book the “Back Mechanic”


You may want to consider surgery if:

  1. You have a loss of bowel or bladder function this can be a sign of a trapped or compressed nerve.


  1. You have radiating pain and numbness along with muscle atrophy (muscle wasting). An alternative treatment would be nerve mobilization mechanically based on movement therapy.


  1. Your pain is unrelenting and severe for a substantial period of time more than just a few weeks or months. Doug McGuff M.D., in his book “The Primal Prescription” related the story of a fellow “ER doctor who suffered an L5 disc herniation that produced such severe nerve compression that he developed atrophy of the muscles, foot drop, and partial paralysis. He refused to undergo surgery or even take a Tylenol. He suffered through the pain and drug his leg around on his ER shifts (he continued to work) for over 18 months when suddenly, all of his symptoms resolved. Within a few weeks his muscle mass and function returned to normal and he has been symptom-free since.” This is an example of a case where Mother Nature’s healing processes were not on the insurance company’s treatment schedule (treatment guidelines). 


For a back surgery to be successful your doctor must have accurately identified all of your pain source.


  1. Your doctor recommends a new procedure or treatment. Be very careful with new treatment approaches, do your research. For example, one new approach is disc replacement surgery. Will the new artificial disc accurately mimic the natural axis of a real disc? If not, then the artificial disc may put more stress on the two facet joints that make up the three structures of the joint and over time could cause significant arthritic changes.


  1. Beware of surgical recommendations based on a review of a CT or MRI scan. Studies have shown that a nasty looking ruptured disc may not be the source of your pain, while a healthy-looking disc may be the actual pain source. Cutting out a pain source based on a picture may increase the risk of a poor outcome.


  1. No surgery is without risk. You are a genetically unique individual; this means that what worked for one patient may not necessarily work for you. What is your doctor’s success rate with the type of surgery he is recommending for you? Is your doctor’s definition of a successful surgery the fact that you did not die? There are two types of success following the surgery: short-term success and the other is long-term success. According to McGill, the definition of success should include an expectation for a significant reduction in pain, your need for pain medication, and an increase in your functional abilities.


Some patients ask their doctor for permission to record the surgery discussion so that you can remember all their questions as well as the doctor’s answers. Ask your doctor how many surgeries, like the one he is recommending for you, he or she has performed successfully in the last year; the last five years? This is one case where practice does make your doctor a better surgeon. 


  1. Has your surgeon recommended a multilevel fusion for degenerative disc disease? There is an old adage “If the only tool you have is a hammer (Lumbar fusion) then everything (all pain generators) looks like a nail.”


  1. Your doctor recommends surgery that he has never done before. Do you want to be his guinea pig?


If the first surgery didn’t work and your doctor recommends a second surgery before you opt for a “try-and-try again surgical cure” you should ask your doctor:

  1. Why did the first surgery not work?
  2. Why does your doctor think a second surgery will work?
  3. What is my pain generator and can the pain generator be cut out successfully?
  4. Do I have more than one pain generator? If yes, which one is the greatest source of my pain? How will the new surgery address the causes of my pain?
  5. What is the anatomical problem with my back and how will the surgery correct this problem?
  6. Is my discogenic (disc caused) back pain episodic (a pain that comes and goes). If yes, how will the recommended surgery change the episodic nature of my pain?



The information provided by this summary is not intended to diagnose or treat any medical condition or back condition; nor is the information intended to be or given as medical advice. It is always a good practice to discuss information like this summary with your physician or another medical care provider(s).        

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