When is it time for back surgery?

[SRS]

I’ve been reading the forum archives for back injury and surgery discussions and particularly those related to laminectomy and discectomy experiences. While it’s been very informative, there is one question that I’m still really struggling with. How do you know when it’s time for surgery?

I’ve had back problems since college, and now at 35 years old, things are getting worse. My last severe flare-up was around Christmas 2013. It pretty much put me on the couch for close to a week. I was able to get back in the gym within about two weeks to start with light squats and deadlifts. It helped, but leg pain persisted for a couple of months. I also noticed weakness in my right leg when squatting. After the first couple of weeks, the pain wasn’t too severe, but distracting and irritating. The pain made it difficult to make it through a day sitting at the office even with frequent stretching and walking. About three weeks ago, I tweaked my back while doing a warmup set of squats. I pushed through the workout, and two days later made things worse deadlifting at a normal work set weight. I made the mistake of letting my back round a bit on the last rep and knew immediately that I had made things worse. By the next day, I had severe leg pain and could barely walk around the house. Vicodin just took the edge off the pain. It was about a week before I could walk any significant distance, and I still have trouble sitting for long periods and persistent right leg pain, mostly adjacent to the tibia.

In the past, I’ve found that lifting helps a lot. In fact, it was my introduction to Starting Strength that provided the only substantial relief that I’d found since the problems started. Hanging from a pullup bar also helps, but only provides temporary relief.

My concern is that the flare-ups are getting worse in severity. The last two are the worst I’ve ever had. MRIs from 2010 and January 2014 show disc disease at three levels, L3/L4, L4/L5, and L5/S1. There is disc protrusion at all three levels with moderate to severe stenosis at L4/L5 and moderate stenosis at the other two levels. The 2014 MRI shows a worsening at L4/L5 since the 2010 MRI. I will likely be getting another MRI soon, which I expect will show further pathology.

My treating physician is fine with physical therapy and/or steroid injections, but thinks surgery will be needed at some point. A spinal surgeon, not surprisingly, thinks I need surgery now, although admits it’s not urgent. He wants to do a three-level laminectomy and discectomy.

I’m sick of feeling like an old man at 35 y/o, and while I’d like to avoid surgery, it will likely happen at some point. I’m seriously considering electing for surgery now to get it over with on my own terms and to avoid the need for an emergency procedure at some point in the future. But at the same time, the outcomes of this type of surgery seem very mixed. I don’t want to trade my current flare-ups and frequency for permanent pain and weakness. I’m somewhat encouraged that my leg pain corresponds to a radiological finding.

Here are my current lifts (all 3x5 weights):
Squat: 315 lbs.
Deadlift: 350 lbs.
Press: 140 lbs.
Bench: 225 lbs.

I know that you’re not a doctor and can’t offer medical advice, but I’d very much appreciate your thoughts as well as those from anyone else that’s been in this situation. Being able to continue to lift is important to me, and I’d really like to avoid making things worse either by not getting surgery now or rushing surgery.

[Mark Rippetoe]

I wouldn't be comfortable with a 3-level laminectomy as the only option. How many surgeons have you spoken with? I agree that you probably need to get something done, and I'd NEVER settle for a steroid injection when surgery was indicated. But there must be other options, and I don't think you asked enough people about the less-invasive ones.

[SRS]

Thanks. So far, I've only spoken with one surgeon, and my time with him was rushed given his extreme lateness and my other commitments. I plan to talk to the same surgeon again after an MRI and also get at least one additional opinion.

The surgeon's reasoning for the three-level procedure, which he was very certain about, was that all three levels were affected, and it would be possible to do surgery at the worst looking level, L4/L5, and still not relieve the pain. It makes some sense, but it may be a risk I'm willing to take. I'm very interested in what the second surgeon has to say and plan to ask a lot more questions.

[ajsalida]

Not sure if general folks are allowed to post here but you asked for opinions from people with similar issues.

I'd agree with Rip here, look into as many other non-invasive and less invasive options first. Also for the short term stop doing stuff that hurts, if that means no lifting so be it. Injections, depending on what type they are, may offer short term relief but cause further problems if relied upon often by interfering with tissue recovery. Cortisone and so forth will eventually cannibalize tissue you'd much rather keep, in addition to reducing inflammation. And narcotics etc for pain can get you into trouble fast, not just dependency but poor decisions are much easier on opiates (no way!?).

Good PT can help, traction can help if indicated. You haven't mentioned seeing a neurologist or a neurosurgeon but I'd advise consulting with both if there are neuro symptoms and it sounds like there are. MRI's alone can be misleading, in that many asymptomatic people appear to have abnormalities but have no issues, and vice versa, people with issues have unremarkable MRI's. Myelograms, EMG's, and other imaging techniques coupled with MRI give a more complete picture.

I hate to say this but a 3 level laminectomy may shut down your lifting and athletic life permanently, so I'd explore every option prior to consenting to that. It is very hard to make important decisions when you are in pain and/or on drugs. So stop lifting, get your head clear, and look into these options. Also should be obvious, something you are doing is making this worse, technique-wise or whatever, who knows, you may wish to have someone qualifies look at your form once the acute problems die down a bit.

I've has laminectomies at L5/S1 and L4/L5 when I was in my late 20's. Was dead lifting 495 for reps at the time. Initially it was just the first level, which then failed after a year, and then they redid that and the next one up. Then L5/S1 collapsed all the way and auto-fused. This was a mess that lasted years and I still have issues nearly 30 years later. I cannot imagine how hard a 3-level could get, recover/rehab wise, and the potential for further issues and do-overs goes up exponentially with each subsequent level. So stop lifting, rest up, get a lot of second and third opinions, get some good PT, re-assess with clear head. I hear a lot of good things about laser if that is indicated.

Not as relevant but related, I have also had c4/5/6 fusions/ACDF (front), they failed (of course) and needed to be redone (rear), then C6/7 blew out with significant neuro issues. They said I needed another fusion ASAP, I refused, tied a weight to my head and hung upside down for a bit and fixed it. This was days before I was scheduled for surgery, but with a 3-level C-spine fusion your athletic life is basically over, so I was desperate. That was nearly 15 years ago so far so good. DO NOT TRY THIS YOURSELF.

What I am saying is if you get spine surgery that is often just the beginning of a lifetime of subsequent issues. Often one holds out the hope that the surgery fixes the immediate problem, a final solution, but that is frequently not true. My situation has sort of worked out but took literally decades and it is now sometimes a full time job staying on top of it. For example, I can no longer sit at a desk all day, and need to lie down 1-2 hours almost every day, and that has really messed up where and how I can work.

Do not get cut on if there is even the remotest chance there are other options.

Good luck.

[DaveJF]

I've had two L5/S1 disc/laminectomies, last one about 11 years ago. First one was to take care of a ruptured disk, 2nd one ended up being mostly to remove scar tissue once they got in there. For both of those, I basically had to crawl around while waiting for the scheduled surgery even w/ Vicodin (but Thank God for the Vicodin).

The issues I have now: The disc is much thinner than before, probably limiting how much I can ultimately load it, and the scar tissue from the surgery itself, which seems to make it a lot easier for me to tweak the soft-tissues in the area; the 2nd surgery left much more scarring than the first. I have not had a major episode since but still do have periods of back pain in that area, mostly it seems from muscle or other soft-tissue.

When I had the first one done, they told me I would most likely end up having at least one more. The 2nd surgeon told me I'd be good for at most a 3rd surgery, then it would be time to look at fusion. Oh, and both surgeons said that surgery on L5/S1 would make it more likely that adjacent joints would develop problems.

I personally look back w/ some regret that I "jumped" into the first one - which probably lead directly to the 2nd one - wondering if there was something else I could have done. But at the time I had to get it taken care of asap b/c I was missing work, there was evidence of nerve damage happening, and of course the pain.

Ultimately it's your decision but if you are ambulatory and quality of life is still good I would do as Rip says and seek out other alternatives first, and at a minimum get a 2nd surgical opinion. If you do decide to have surgery, seek out the best you can find and make sure to have him describe to you exactly what he plans to do and how that plan will prevent you from either having follow-up surgeries (e.g.: to avoid scar tissue removal) or having more flare-ups. When you make the appt. tell them you will probably need more than 15 minutes or 1/2 hour to go over the surgical plan w/ the Dr. If they don't accommodate that, look for another Dr.

[Mark Rippetoe]

I've has laminectomies at L5/S1 and L4/L5 when I was in my late 20's. Was dead lifting 495 for reps at the time. Initially it was just the first level, which then failed after a year, and then they redid that and the next one up. Then L5/S1 collapsed all the way and auto-fused. This was a mess that lasted years and I still have issues nearly 30 years later. I cannot imagine how hard a 3-level could get, recover/rehab wise, and the potential for further issues and do-overs goes up exponentially with each subsequent level. So stop lifting, rest up, get a lot of second and third opinions, get some good PT, re-assess with clear head. I hear a lot of good things about laser if that is indicated.

Not as relevant but related, I have also had c4/5/6 fusions/ACDF (front), they failed (of course) and needed to be redone (rear), then C6/7 blew out with significant neuro issues.

You have a rather shitty spine. But I agree with the decompression recommendation.

[DaveJF]

One more thing...

In the past, I’ve found that lifting helps a lot. In fact, it was my introduction to Starting Strength that provided the only substantial relief that I’d found since the problems started.

I've done two SS LP's now about a year apart. Deadlifts were/are the only thing that "bothered" my back other than one time I tweaked it during a Squat warmup, but that was entirely my bad. In general though my back feels better day-to-day than it has in years, so my experience so far matches yours and DL's have been a big part of that.

With the DL's, my lower back felt the best both times as I progressed from the starting weight up to a weight of, say, 20 to 30% less than where I eventually started to really struggle with the weight. My form generally leaves something to be desired, but when I started to struggle of course the form broke down even more, and that's where I started to have more soreness/pain. Obviously regardless of form, the higher loading probably had something to do with this too. Also, I found I could recover from DL's only once per week after the weight got heavy for me.

Lessons for me are this: 1) Deadlifts done correctly can be part of the rehab for chronic back problems. 2) I need to plan for progression w/ DL's, but it needs to be tempered w/ the reality that I have an injured back; I can't match the progression or ultimately the 1RM of the typical young guy doing SS.

Also, I've read that proper loading can actually encourage discs to regain some of their cushioning ability, but it's a very slow process. I do not know if that is generally accepted or not. But, if that is BS, it can't hurt to strengthen the surrounding soft tissues as long as you're not re/injuring the discs.

Point is, and assuming none of the other exercises cause you problems, you just may have to temper your deadlift progression / expectations once you get over the current problems, and that may go a long way in avoiding problems in the future. At the least and assuming you don't suffer a major acute injury, it would set you up to better tolerate surgery.

Best wishes.

[ajsalida]

You have a rather shitty spine. But I agree with the decompression recommendation.

My spine is sulking.

On the traction, critical to know whether you have a compression related problem before you try it. Quick anecdote: my first c-spine fusions failed, but this went undiagnosed for a long time even after mounting problems. Original surgeons told me there was nothing wrong and I was imagining it. After 18 months of this nonsense, 2nd opinion doc just took a simple xray. One of the fusions was sheared in half, right through the bone graft, many bone spurs and filaments visible had been trying to reattach over and over, but clean break. Nothing holding my head on except tendons in the rear on facets. Yikes! Traction on that would have killed me.

Fast forward to the C6/7 disk blowing out. That was a direct result of a blow to the top of the head, a clear compression injury. Total loss of left arm control, no strength at all. Was benching 330 at the time just prior, could not even press an empty bar after. I reasoned at that point since surgery was already scheduled, and I knew the extent and type of injury, trying traction on my own had minimal down side risk. It worked, arm function came back immediately. Neurosurgeon said it was the stupidest stunt he'd ever heard of but wished me well when I cancelled surgery. He said I'd probably be back soon but like I said nearly 15 years later no problems.

So make sure exactly what you've got wrong before you start yanking your spine apart.

[GaryC]

My medical knowledge is rather limited, but my MRI is really similar. For me, the less I worked my back, the weaker it got and the more it hurt. The best thing I ever did was got really aggressive with the core work . Side bridges, cable wood chops, leg raises, reverse hypers all became a staple. I hang from a GHR or hyperextension twice a day for about 3 minutes, sometimes holding a 35lb plate.
Funny that my last chiro said I should only use dumbbells and not do any standing exercises. My current one says that I should not stop what I'm doing. (Safety squat bar, rack pulls, tons of bent leg good mornings, trap bar, log clean and press) Neurosurgeon just wanted me to get epidural.
In general, I'm encouraging you to do everything you can to strengthen the core to support the spine before you consider surgery. Your lifting days aren't over my friend.

[Mark Rippetoe]

Here's a rather novel idea: Since you guys have problems with pain associated with the parts of the spine that move, and since wiggling the damn things around -- "core" work, like side bends, situps, and back extensions -- causes the pain by mashing the defective pieces of the spine into the nerves and into each other, and since using an eccentric/concentric approach is unnecessary for a group of muscles whose function can be perfectly well performed isometrically by deadlifting and squatting, making them strong without all the wiggling around, why don't you just deadlift and squat, and let the parts that keep getting irritated by situps and core gayness settle down and heal.