Spine surgery has a poor reputation for many patients. Unfortunately the reputation is deserved. Everyone knows friends, neighbors, colleagues, and family who have undergone multiple surgeries and have ended up almost crippled.  Spine surgery performed for vague indications often ends up with some very bad results.  However, if it is performed for specific identifiable structural abnormalities is predictably beneficial. It can also be almost miraculous in giving patients back their lives.  There are some principles you should be aware of that have a major influence on the outcome of surgery.  You can and should know exactly where you fit into the spectrum.

There are two sets of variables that affect the decision to undergo spine surgery.  The first set is the type of anatomic problem that is causing the pain.  Is it a structural lesion clearly identified on a diagnostic test?  Or is it a soft tissue non-structural problem that cannot be seen on a diagnostic test?  There is also the variable of the Mind Body Syndrome. The second issue is whether you are under a significant amount of stress, which may or may not be related to your pain.  If you are under a lot of stress and not coping well, it has been shown in hundreds of articles that your outcome from surgery will be compromised. The resultant set of choices regarding surgery falls into one of four categories.

This classification is not a validated system.  I was asked to give a talk at our national spine meeting in 2006.  The topic was the surgical selection of patients for spinal surgery.  The goal of the talk was to convey how I personally select patients for surgery.  It was while I was putting the talk together that this classification system came about.  It represents the internal paradigm I have when I am deciding whether to perform spine surgery.  It has evolved into being incorporated into many conversations regarding the best way to treat spinal pain.  Eventually, it will be refined and a version of it validated.  I assume there will be subgroups that will come out of future research.  At the moment, it is most useful to help conceptualize decision-making regarding treatment.

I have arbitrarily assigned numbers and letters to these variables:

• I—Structural lesion
  • A structural lesion is one that can be identified on an objective test and has a high probability of being the cause of your pain.  The clinical symptoms must correlate with the anatomic problem.
• II—Non-structural lesion
  • A non-structural lesion is defined as one that may possibly be the source of your pain.  However, it cannot be objectively identified on a diagnostic test.  If the diagnostic testing is based on your response to a painful stimulus, then it is by this definition “non-structural”.  There are too many variables in this situation to consider this type of diagnostic testing “definitive”.  Examples of this type of testing would be facet blocks and discograms.

• A—Stress levels acceptable and/or being handled well

• B—Stress levels overwhelming and/or having difficulty processing it

These are the resultant four groups of patients

• IA—Structural lesion, low risk for chronic pain
• IB—Structural lesion, at risk for chronic pain (high stress)
• IIA—Non-structural lesion, low risk for chronic pain
• IIB—Non-structural lesion, at risk for chronic pain (high stress)

• An overview of how this looks is presented in this grid: