Surgery — What You Need to Know
Why Fusion Struggles with Nonspecific Low Back Pain
The Problem of Identifying the Pain Source
Fusion depends on accurately identifying which structure is causing the pain and then stabilizing it. But in nonspecific chronic low back pain:
- In the majority of cases, the pain cannot be traced to a single structure
- Multiple "pain generators" are often involved simultaneously
A comprehensive evaluation of all diagnostic tests used to select patients for fusion concluded that it was not possible to reliably identify which chronic low back pain patients would benefit from fusion. Patients are being selected for surgery on the basis of tests with insufficient accuracy.
Problems with Discography
Discography (provocative disc injection) was long used to determine "which disc is causing the pain" and guide surgical decisions. However, a series of studies by Carragee and colleagues revealed serious problems:
| Problem | Finding |
|---|---|
| False positives | A large proportion of people with no history of back pain test "positive" |
| Predictive accuracy | Psychological distress predicted future back pain better than discography results |
| Surgical outcomes | Success rates when operating based on discography are significantly lower than for structural conditions |
| Iatrogenic harm | Discs that underwent discography showed a higher rate of subsequent disc herniation |
In short: Discography cannot reliably distinguish patients who will benefit from surgery from those who will not.
MRI "Abnormalities" Are Not Automatic Reasons for Surgery
This is discussed in more detail on the Why Does My Back Hurt? page, but it bears repeating here:
Research has shown that the vast majority of pain-free adults have disc degeneration visible on MRI, and this proportion increases with age. By age 80, almost everyone shows disc degeneration — even when they have no pain at all.
Disc degeneration on MRI is like gray hair — it's a normal part of aging. It is not, by itself, a reason to proceed with surgery.