Opinion | Spinal Surgery Redux: Advancing Our Approach to Back Pain

Lower back pain has been the leading cause of years lived with disability since 1990, and it continues to be a significant concern for public health on a global scale. In the U.S., 72.3 million adults currently suffer from chronic low back pain — greater than the number of Americans with arthritis, diabetes, or heart disease, according to one large survey. More than a third of those surveyed (36%) rated their back pain as severe, and 44% reported experiencing pain for at least 5 years.

These statistics really resonate with me because I am among the millions of Americans with chronic lower back pain. About 23 years ago, I was diagnosed with spondylolisthesis. Although the condition was likely congenital in origin, I was told that it probably had been aggravated by my penchant for running and racquet sports. I endured a few years of persistent back pain for which epidural treatments became decreasingly effective. In addition to disrupting my concentration and productivity at work, it hampered my go-to stress reliever — playing tennis.

After resisting the advice of colleagues and other physicians to consider surgery, I finally capitulated. I vividly recall my anxiety before undergoing my first surgery (spinal fusion at L-5 to S-1 in May 2002), my frustration at not being permitted to walk, and my severe post-op pain that required oxycodone (Oxycontin) for a couple of weeks. Quite an ordeal!

Fusions of this type typically last between 10 and 15 years, so when I experienced a sudden onset of excruciating right-sided sciatic pain in July 2023, I could easily predict the likely trajectory of events. The usual non-surgical approaches (i.e., tapered doses of steroids, physical therapy, epidurals) did not relieve the pain and a second procedure was the only option. (On a positive note, the 21 years of pain relief I had after the first procedure is considered an excellent outcome.)

Even though spinal surgery techniques have advanced substantially in the intervening years, spinal fusion is still major surgery (i.e., general anesthesia, weeks to months of recovery). On the second time around (October 9, 2023), the most striking thing to me was how post-operative care management for spinal surgery has evolved over the past 2 decades. I was out of bed and walking on what is euphemistically referred to as “day zero” (i.e., the afternoon of my early morning procedure), and I spent only 2 nights in the hospital rather than 4. Advances in three particular areas are already making a huge difference in my recovery:

Targeted pain management. The opioid crisis forced surgical specialties to rethink their previous reliance on narcotics for pain relief. For example, major muscle disruption is now recognized as a key source of the pain associated with lumbar spinal surgery, and patients are discharged with antispasmodic medications and muscle relaxers (e.g., metaxalone, a skeletal muscle relaxant thought to block nerve impulses/pain sensors in the brain.)

Bone graft technology. Much of the pain I experienced after my first surgery was associated with bone harvesting from my iliac crest. Thanks to advances in donor bone (living or cadaver) preparations and synthetic materials, autologous bone harvesting is no longer necessary.

Bone healing technology. I was discharged home with a bone stimulator device. I wear the device (with electrodes placed on each side of my operative site) for 12 hours a day. There is ample research supporting bone growth stimulation as an adjunctive treatment to promote bone healing and growth post-fusion procedures.

I am incredibly lucky to have a loving wife of 43 years, adequate health insurance and, of course, the ability to pick the best surgeon, the best team, and the best hospital for my care. Being a patient in my own institution, where I have been on the faculty for more than 3 decades, was a source of real comfort. The nursing care was amazing and, as doctors surely know, nurses make all the difference! (Even the soothing “bath in a box” that I received each morning before rising from my hospital bed was a true healing experience.)

Bottom line: I believe that providing the quality of care I received to all patients should be a key goal of our industry.

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