Low Back Pain: Consulting a Back Pain Specialist

"At this point, many patients start to become frustrated and it is time for them to make some choices about who should be coordinating their care," Dr. Heary said. "In my practice, I like to see patients at this stage so I can evaluate their condition and prescribe the best treatment options for them. I want to see their progress, or lack of progress, through each stage so I can determine what should be done next."

For patients with a history of back pain and who are currently experiencing symptoms that are interfering with activities, the first step is proper diagnostic testing to determine the cause of the symptoms and the severity of the problem. Imaging studies, including CT scans and magnetic resonance imaging (MRI), help the neurosurgeon determine the diagnosis and the degree of the disease. Standard x-rays are also useful to look for signs of instability in the spine.

Illustration courtesy of
Medtronic/Sofamor Danek.

"Imaging studies are helpful, but they aren't the only factor in determining what treatment options are available," added Richard Toselli, MD, a frequent lecturer on spine care and a neurosurgeon in North Carolina. "It's common for patients over 60 to have abnormal MRI findings, but no symptoms. Therefore, neurosurgeons must correlate the patient's symptoms with their imaging studies before considering a procedure."

Neurosurgeons are the only physicians who treat the entire spine -- both the spinal cord itself as well as the structures which can exert pressure on the spinal cord and nerve roots such as herniated discs or bony overgrowths from degenerative arthritis of the spine. Because neurosurgeons spend about 70 percent of their time treating spine problems and have been trained on diseases of the spine throughout their seven-year residency, they are familiar with all treatment options and can determine which option will be the most effective for each patient.

Conservative Treatment

Depending on the patient's imaging studies, symptoms and lifestyle, conservative treatment is most likely the course of action for most patients. Treatment options include physical therapy, weight control, steroid injections, non-steroidal anti-inflammatory medications, rehabilitation and limited activity. Neurosurgeons often work closely with physical therapists or physiatrists to coordinate treatment.

"All of these treatment options are still aimed at relieving the inflammation around the nerve," Dr. Toselli said. "In 90 percent of cases, one of these treatment options, or time itself, will help heal the problem. I usually pursue eight to 12 weeks of conservative therapy before considering surgery."

If Surgery is Recommended

If surgery is recommended, neurosurgeons have a variety of options available to help relieve the pressure on the nerve. The most common procedure is a discectomy, which involves removing the soft gel-like material in the disc. This procedure returns the disc to a more normal shape, relieving the pressure on the nerve.

Neurosurgeons sometimes also remove a small piece of bone near the disc and irritated nerve to gain access to the disc or to give the area more space to expand and swell in the future. If the nerve is being pinched as it goes through the opening in the bone on the way to or from the spinal cord, the neurosurgeon can also perform a foraminotomy, which is a procedure designed to expand the opening the nerve travels through.

With the spinal cord and nerves millimeters away, precision and delicacy are keys to a successful and safe procedure. Neurosurgeons often use an operating microscope to help magnify the nerves and discs. The neurosurgeon performs the procedure while viewing the affected area through a large microscope and this technique allows for better precision and a smaller incision.

Surgery is recommended when

• Leg pain limits your normal activity, resulting in diminished quality of life.
• You feel weakness or numbness in your legs.
• It is difficult to walk or stand.
• Medication and physical therapy are ineffective.

"The operating microscope has been used by neurosurgeons for years to increase visibility and accuracy while operating in the brain," Nevan Baldwin, MD, a frequent faculty member for courses on neurosurgical spine surgery and a neurosurgeon in New Mexico, said. "The technique translates beautifully in spine surgery and is a huge safety advantage for neurosurgeons and their patients."

If several nerves and discs are the cause of the pain or there is degeneration and instability in the spinal column, the neurosurgeon may opt to fuse the bones together with bone grafts and stabilize the vertebra with instrumentation, including metal plates, screws, rods and cages.

"Fusion will prevent the disc from bulging or herniating again," Dr. Baldwin said. "However, because of the metal instruments we use, there will be a limited loss of movement in the spine. The effect depends on where in the spine the fusion is done."

After any type of spine surgery, patients will continue to work with their neurosurgeon on an extensive rehabilitation program, including physical therapy, medications and reduced activity.

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