Treatment Decision Guide

Step 4: Treatment Direction

Pattern A: Continue Conservative Treatment

This may apply if:

  • Your symptoms are mild to moderate
  • The impact on your daily life is small to moderate
  • You have not yet tried conservative treatment sufficiently
  • You have no neurological symptoms, or they are mild

Recommended direction:

  • Adjust medications
  • Continue or intensify rehabilitation
  • Consider nerve block injections
  • Reassess after 3 to 6 months

Pattern B: Consider Surgery

This may apply if:

  • Conservative treatment has been tried sufficiently without improvement
  • Your symptoms are moderate to severe
  • The impact on your daily life is significant
  • You have neurological symptoms
  • You have not had surgery before
  • Imaging clearly shows where the nerves are compressed, and there is a structural problem

Recommended direction:

  • See a spine surgeon
  • Evaluate whether surgery is appropriate
  • Discuss the type of surgery (decompression or fusion)
  • A second opinion is also an option

Key consideration: Beyond "Is the pain neuropathic, and can surgery clearly fix it?", the scale and risk of the surgery are also important factors. If the compression site is clear and can be addressed with decompression at 1-2 levels, surgery is often effective. If imaging and symptoms do not match, or there is degeneration at multiple levels, SCS should be considered. If there is compression but multi-level fusion is needed, the surgical burden is large, so SCS should also be considered. If you are older or have health conditions that make surgical risk high, SCS, which is less invasive, should be considered as a priority.

Pattern B-2: Consider SCS (Surgery Is Possible but Would Be Major)

This may apply if:

  • Conservative treatment has been tried sufficiently without improvement
  • Imaging shows compression, but fusion at 3 or more levels would be needed
  • You are older, or health conditions make surgical risk high
  • You prefer a reversible (undoable) treatment
  • The more levels that need fusion, the greater the surgical burden and recovery time

Recommended direction:

  • Consult an SCS specialist and compare both surgery and SCS
  • Confirm that SCS may offer greater advantages when more levels need fusion
  • Use a trial to verify that SCS is effective before making a decision
  • A second opinion is also an option

Why consider SCS when multi-level fusion is needed: As the number of levels to be fused increases, so do the surgical time, blood loss, and risk of complications. Furthermore, fusing a large section of the spine can place additional strain on adjacent levels in the future (adjacent segment disease). SCS is relatively less invasive and can be removed if ineffective, making it a worthwhile option to try before committing to major surgery.

Pattern C-1: Consider SCS (Before Surgery)

This may apply if:

  • Conservative treatment has been tried sufficiently without improvement
  • Imaging does not match your symptoms
  • There is degeneration at multiple levels
  • Neuropathic pain is the main problem
  • Surgery is difficult (due to age, health conditions, or high surgical risk)
  • You have not yet had surgery

Recommended direction:

  • See a pain clinic doctor or SCS specialist
  • Evaluate your SCS candidacy
  • Consider a trial
  • Decide on permanent implantation based on trial results

What makes this pattern different: SCS is not "a treatment for people who cannot have surgery" -- it is an effective treatment option for neuropathic pain where structural problems are not clearly identified. When surgery cannot clearly address the problem, considering SCS early can help prevent the pain from becoming deeply chronic.

The supervising physician's perspective: The approach of considering SCS before surgery (Pattern C-1) is based on the supervising physician's clinical experience and evidence. Opinions may differ between medical institutions, so please discuss this with your own doctor.

Pattern C-2: Consider SCS (After Surgery)

This may apply if:

  • You had surgery but pain remains
  • Reoperation carries high risk
  • Chronic pain is the main problem
  • Imaging shows the problem has improved, yet pain continues

Recommended direction:

  • See a pain clinic doctor or SCS specialist
  • Evaluate your SCS candidacy
  • Consider a trial
  • Decide on permanent implantation based on trial results

Pattern D: Urgent Medical Attention Needed

This applies if:

  • You have urinary or bowel problems
  • Leg strength has suddenly weakened
  • Symptoms are deteriorating rapidly

Recommended direction:

  • See a doctor immediately
  • Emergency surgery may be necessary