Surgery for sciatica is usually considered when leg pain and/or weakness is persistent or progressive even after several methods of non-surgical sciatica treatments have been tried. In a few cases, surgery may be considered as the first option.

A few examples where surgery is considered as a first option are:

• Cauda equina syndrome—a medical emergency where nerve roots of the cauda equina are compressed and motor and sensory function in the lower body are lost.
• Tumors, collection of fluid (cyst or abscess), or severe fractures in the lumbar spine
• Bilateral sciatica—sciatica affecting both legs, may be caused by multiple level disc herniation, severe single level herniation, or central spinal stenosis.
• Infection in the pelvic region that does not respond to medication.

In addition, surgery may be considered when leg pain and/or weakness persists for more than 6 to 8 weeks despite nonsurgical treatments and/or when pain affects everyday activities.

Surgery is performed with the goal of eliminating the cause of sciatica and to control the leg symptoms such as pain and weakness. Back pain associated with sciatica, however, may not improve after surgery.

Microdiscectomy for Sciatica

Microdiscectomy is a common surgical approach used to treat sciatica that is caused by a lumbar disc herniation. In this surgery, a small part of the disc material under the nerve root and/or bone over the nerve root is taken out. While technically an open surgery, a microdiscectomy uses minimally invasive techniques and can be done with a relatively small incision and minimal tissue damage.

Research shows up to 86% of patients may experience sciatica pain relief after a microdiscectomy surgery.

Lumbar Decompression Surgeries

A number of surgical approaches are available to relieve various sources of nerve root compression or irritation, such as:

• Laminectomy. In this procedure, part or all of the lamina is removed in order to provide more room for the spinal nerves. It is most commonly done for sciatica pain caused by lumbar spinal stenosis. An estimated 75% to 90% of patients may experience pain relief after lumbar laminectomy surgery.
• Foraminotomy. In this procedure, the neuroforamen is enlarged by removing bony overgrowth, providing more room for the nerve root as it exits the spinal column through this opening.
• Facetectomy. This surgical procedure used to relieve compression on pinched nerves caused by degenerated facet joints. The facet joints are typically trimmed, undercut, or removed to relieve nerve pressure. It is estimated that 85% of patients may experience pain relief after a facetectomy surgery.

As appropriate, these procedures may be combined and performed at the same time. For example, a laminectomy procedure may be done along with a foraminotomy, and the surgery is called a laminoforaminotomy. Additional procedures may be done in combination with the above, include osteophyte (abnormal bone growth) and/or hypertrophic (overgrown) ligament removal.

As with any surgery, a number of risks are possible, including but not limited to a risk of nerve or spinal cord damage, bleeding, infection, clot formation, and continued symptoms post-surgery.

Research suggests that surgery for sciatica may provide better reduction in pain and improvement in functional outcome for up to 1 year as compared to nonsurgical treatments. However, in the long term (4 to 10 years), the outcome for both approaches are usually similar.1

The decision to have surgery for sciatica pain is typically a patient’s choice unless there is a medical emergency, such as cauda equina syndrome. The patient’s decision to have surgery is based primarily on the amount of pain and dysfunction, the length of time that the pain persists, the patient’s overall health, as well as the patient’s personal preference.

The primary purpose of back surgery or neck surgery is to correct an anatomical lesion in individuals who fail to show improvement with conservative (nonsurgical) treatment. Surgery is not an option for patients when an anatomical lesion accounting for their pain can not be identified.

Surgery is only useful to change a patient’s anatomy (e.g. remove a disc herniation). There is almost never any reason to consider exploratory surgery to “look” for a cause of pain.

Failing conservative treatment is not in and of itself an indication for surgery. An identifiable anatomic lesion is also necessary.

Advancements in Spine Surgery

Modern spine surgery has made major advancements in both technique and spinal instrumentation/implants over the past couple of decades, but by far the most significant advancement in spine surgery has been better preoperative imaging techniques, which have greatly improved the ability of surgeons to identify accurately and correctly an anatomic lesion as a cause of pain.

Specifically, magnetic resonance imaging (MRI scan) has revolutionized back surgery. It is most often the best test to identify an anatomical lesion responsible for the patient’s problem.

The most important factor in the determination of the success in spine surgery is proper preoperative diagnosis. Without an accurate preoperative diagnosis, even the most technically successful surgery has little chance for a successful outcome.

Although spine surgery is performed by either orthopedic surgeons or neurosurgeons, it is increasingly becoming a field unto itself. Many surgeons are doing additional specialized training in the field after their residency training (fellowship training).

Given the precision required for these more demanding surgical techniques, many orthopedic surgeons or neurosurgeons with fellowship training are choosing to focus more of their practice on spine surgery. Some believe that the increased level of specialty training and focus on the spine has contributed to enhancements in surgical technique, which in turn has led to overall improved success rates and reduced morbidity (e.g. reduced post-operative discomfort) with many types of spine surgeries.

Reasons for Spine Surgery

Spine surgery is typically an “elective” undertaking, meaning that it is considered as a possible approach to enhance a patient’s ability to function and decrease pain. However, just because spine surgery is elective does not mean it is not covered by insurance.

Elective surgery can be medically necessary. «Elective» just means that surgery of the spine is rarely an absolute necessity. Only in rare instances, such as for patients who have a progressive neurological loss of function or sudden onset of bowel or bladder incontinence, is spinal surgery actually necessary on an emergency basis.

Spine surgery can basically accomplish three tasks:

1. Decompress a nerve root or the spinal cord
2. Stabilize an unstable or painful segment with spinal fusion surgery
3. Reduce a deformity (e.g. scoliosis surgery in the thoracic spine).

Spine surgery is not done for exploration. The cause of a patient’s pain is not readily apparent with opening and exploring the spine. The preoperative evaluation and imaging results are what identify the problem and guide the design of the procedure.

Lumbar surgery refers to any type of surgery in the lumbar spine, or lower back, between one or more of the L1-S1 levels.

There are two general types of lumbar spine surgery that comprise the most common surgical procedures for the lower back:

Lumbar Decompression

The goal of a decompression surgery is usually to relieve pain caused by nerve root pinching. There are two common causes of lumbar nerve root pressure: from a lumbar herniated disc or lumbar spinal stenosis.

This type of pain is usually referred to as a radiculopathy, or sciatica.

A decompression surgery involves removing a small portion of the bone over the nerve root and/or disc material from under the nerve root to relieve pinching of the nerve and provide more room for the nerve to heal. The most common types of decompression surgery are microdiscectomy and laminectomy.

There are also a few alternatives available to the above two standard procedures, such as an X-STOP which is a possible option instead of a laminectomy for lumbar spinal stenosis.

Lumbar Fusion

The goal of a lumbar fusion is to stop the pain at a painful motion segment in the lower back. Most commonly, this type of surgery is performed for pain and disability caused by lumbar degenerative disc disease or a spondylolisthesis.

A spinal fusion surgery involves using a bone graft to stop the motion at a painful vertebral segment, which in turn should decrease pain generated from the joint. Spine surgery instrumentation (medical devices), bone graft procedures, and a bone stimulator are sometimes used along with spinal fusion.

There are also many surgical approaches to performing spinal fusion, such as ALIF, PLIF, XLIF, TLIF, posterolateral gutter fusion, anterior/posterior fusion, and certain minimally invasive approaches.

In addition to the above conditions, decompression and/or spinal fusion may be performed to address other types of lumbar spine pathologies, such as infection or tumors.