The Best Spine Surgery Is the One You Never Need

A neurosurgeon’s guide to protecting your spine and health

Joseph H. Miller, MD | Neurosurgery, Northside Hospital Gwinnett

I operate on the brain and spine for a living. I find the work deeply rewarding, and for the right patient with the right problem, surgery can be life-changing.

But here’s what I tell every patient who sits down across from me: surgery is a tool for a specific job. It fixes structural problems — a nerve that’s compressed, a tumor that needs to come out, a segment that’s unstable. What it cannot do is make you healthy. It cannot undo years of deconditioning, poor sleep, and bad nutrition. And a spine that’s been neglected for two decades doesn’t suddenly become resilient because I took pressure off a nerve root.

So a surprising amount of my clinic time is spent on things that have nothing to do with the operating room. Below is the actual set of recommendations I hand my patients. It isn’t complicated, it isn’t expensive, and none of it requires a prescription. It just requires showing up.

1. Nutrition: Food Is Your Body’s Power Source

Everything downstream — tissue repair, muscle building, inflammation control, overall health — runs on what you put in your mouth.

Eat real food. Cut out the fake stuff. Minimize processed and refined sugar, refined carbohydrates, and seed oils.

Don’t drink your calories. Soda, sweet tea, juice, and sweetened coffee drinks are the easiest place in the American diet to take back ground.

This isn’t a fad diet, and I don’t hand out meal plans. But the evidence here has gotten hard to ignore. An umbrella review in The BMJ pooling 45 meta-analyses across nearly 10 million people found that higher exposure to ultra-processed foods was directly associated with increased risk of all-cause mortality, cardiovascular mortality, common mental disorders, and metabolic disease.¹ On the beverage side, a dose-response meta-analysis found that each additional daily serving of a sugar-sweetened beverage was associated with a 27% higher risk of type 2 diabetes and a 9% higher risk of cardiovascular disease.²

Why does a spine surgeon care about your metabolic health? Because diabetes, obesity, and inflammation are among the strongest drivers of degenerative disc disease — and because they are among the strongest predictors of a bad surgical outcome if you ever do end up needing me.

And if you smoke, this is the single highest-yield change you can make. Tobacco is a major independent risk factor for degenerative disc disease. Smokers have a greater need for surgery, more wound healing complications, increased pain perception, slower recovery, and lower satisfaction after surgery³ — and meaningfully higher rates of fusion nonunion.⁴ If you take nothing else from this article, take that.

2. Strength Training: The Highest-Leverage Habit You Have

Strength plus mobility significantly decreases the chance you will need surgery.

Your spine is a column of bones and discs held upright by muscle. When that muscle is strong and enduring, load gets distributed. When it isn’t, load concentrates on discs and facet joints — the exact structures that fail.

The prevention data support this directly. A JAMA Internal Medicine systematic review and meta-analysis found that exercise combined with education reduces the risk of an episode of low back pain, and exercise alone may reduce both the risk of an episode and the use of sick leave — while education alone, back belts, and shoe inserts showed no such association.⁵ Notably, the things people want to work — the belt, the ergonomic gadget, the lecture — are the things that don’t.

Starting goal: 2–3 sessions per week, hitting each muscle group 1–2 times weekly. Focus on upper body, core, and lower body.

The dose here is smaller than most people expect. A meta-analysis in the American Journal of Preventive Medicine found that any resistance training reduced all-cause mortality risk by 15%, with maximum risk reduction of 27% at around 60 minutes per week.⁶ Sixty minutes. That’s three twenty-minute sessions.

My Core Four

1. The McGill Big 3 — modified curl-up, side plank, and bird dog. These come from Dr. Stuart McGill’s spine biomechanics work, and the principle behind them is that core stabilizing exercises train muscle activation and posture patterns without producing excessive spinal loading.⁷ They build endurance, not max strength — and endurance is what keeps your mechanics clean at hour nine of a long day, which is when backs typically complain. Squat University on YouTube has excellent form tutorials.

2. Hanging knee raises — a favorite of mine, because the dead hang puts the spine in slight traction while you work the core. These take real strength; most people need to build up to them, and that’s fine.

3. Planks — I’m not a fan of Supermans for most patients, since they load the lumbar spine into end-range extension. Planks give you the same core work while keeping the spine neutral.

4. Reverse hyperextensions — excellent for the posterior chain, but start with very light weight. This is the one people most commonly rush.

3. Mobility and Stretching: Small and Daily Beats Long and Occasional

Goal: stretch every day. For me that’s often just a quick low back, hamstring, and IT band routine. Five minutes counts.

  • Hamstring and posterior chain. Tight hamstrings tug the pelvis into posterior tilt and rob the low back of its natural curve. I like the CastleFlex, but a resistance band works just as well.
  • Hip mobility. This one is underrated. Hips that don’t rotate or extend force the lumbar spine to make up the difference — every time you golf, garden, or reach into the back seat.

4. Cardio: Movement Is Medicine, and Walking Is the Cheapest Dose

Starting goal: 60–75 minutes per week, plus 7,000+ steps a day.

The 10,000-step target was a Japanese pedometer marketing campaign, not a scientific finding. The actual data are more forgiving. In the CARDIA cohort, adults taking at least 7,000 steps per day had a 50% to 70% lower risk of mortality than those taking fewer, and walking beyond 10,000 steps per day — or walking faster — did not further reduce risk.⁸

For back pain specifically, walking has now cleared a high bar. The WalkBack randomized trial, published in The Lancet, tested a progressive walking-plus-education program in adults who had just recovered from an episode of low back pain. Participants in the walking group went a median of 208 days before a recurrence, compared with 112 days in the control group — nearly twice as long — with reductions in back pain-related disability for up to 12 months and a high probability of being cost-effective.⁹

If you have active back pain, cycling and swimming are your friends. Both keep you conditioned with variable axial load through the spine.

5. Sleep: 7–8 Hours, Non-Negotiable

Sleep is when your body does its repair work. Skimp on it and everything else on this list underperforms — your training doesn’t consolidate, your appetite regulation drifts, and your pain threshold drops.

A dose-response meta-analysis spanning over 1.5 million participants found a U-shaped relationship, concluding that 7 hours per day of sleep should be recommended to prevent premature death in adults.¹⁰ The relationship with pain runs the same direction: in a large cross-sectional analysis of U.S. adults, 7 hours of sleep was associated with the lowest odds of chronic musculoskeletal pain.¹¹

Pain and sleep are bidirectional. Poor sleep amplifies pain; pain wrecks sleep. 

6. Light: The One Nobody Talks About

Get outside. Head to the River, Firefly Trail, or our parks when the weather is nice. Fresh air and natural light. Catch a sunrise. Catch a sunset.

Avoid phones and TV after sunset — and limit them as much as you reasonably can the rest of the day.

This sounds like wellness fluff until you look at the mechanism. Evening light exposure disrupts circadian physiology, suppresses melatonin secretion, and impairs sleep.¹² But here’s the part most people miss: bright daytime light protects you against it. People who spend their days in dim indoor light show substantially greater melatonin suppression when exposed to light at night, compared with those who got more daytime light.¹³

In other words, a morning walk outside isn’t just a morning walk. It’s buying down the cost of the screen you’ll look at tonight — and it gets you steps and sunlight in the same twenty minutes. It’s the highest-efficiency habit on this entire list.

When to Stop Self-Managing and Get Evaluated

Most back and neck pain improves with the habits above. Some of it doesn’t, and a small subset needs attention quickly. Get evaluated promptly if you have:

  • Progressive weakness in an arm or leg — a foot that’s catching, a grip that’s failing
  • Changes in bowel or bladder control, or numbness in the saddle region
  • Unexplained weight loss, fever, or night pain that wakes you and won’t settle
  • Pain following significant trauma, or in the setting of known cancer or osteoporosis
  • Severe, unrelenting radiating pain not responding to conservative care

The Bottom Line

Very few patients with back pain actually need surgery. Nothing above requires a gym membership, a supplement, or a specialist. It requires consistency — the least glamorous and most powerful variable in all of medicine.

And if you do end up needing surgery, every single one of these habits makes that operation safer and your recovery faster. The work is never wasted.

If you’re dealing with back or neck pain and aren’t sure which category you’re in, that’s a reasonable question to bring to my office. Figuring out who doesn’t need surgery is a large part of the job.

For My Referring Colleagues

Many of you see these patients long before I do — often years before. If you’d find it useful, below is a smart phrase you’re welcome to adapt into your own EHR and hand to patients with spinal complaints.

Copy, edit, make it yours.

.SPINEHEALTH

Recommendations for Optimizing your Health:

Nutrition: Food is your body’s power source. Eat Real Food. Cut out the fake stuff (avoid process/refined sugar, carbohydrates, and seed oils). Don’t drink calories.

Strength training: Strength + Mobility significantly decreases the chance you will need surgery

Starting Goal- 2-3 times a week and try to work out each muscle group 1-2 times per week (Focus on Upper Body, Core, and Lower Body)

Core:

1- McGill Big 3- Modified Curl-up, Side planks, Bird Dogs (Squat University on YouTube has great videos on these)

2- Hanging Knee raises- nice because they put the spine in slight traction. These take strength and often you will have to work up to this exercise.

3- Planks (I don’t love superman’s and recommend planks instead)

4- Reverse Hyperextensions- start very low weight on these

Mobility/Stretching:

Goal- I try to stretch everyday (often this is just a quick low back, hamstring, IT band stretch)

Hamstring/Posterior Chain stretching (I recommend the CastleFlex but bands also are great)

Hip mobility

Cardio/Aerobic Exercise :

Starting Goal- 60-75 minutes a week plus try walk over 7,000 steps a day

Cycling and Swimming are great options for people with back pain

Sleep

7-8 Hours

Light

Get outside and go for a walk. Head to the Riverwalk when the weather is nice. Fresh air and natural light. See the sunrise and sunset.

Avoid the phones and TV after sunset (and limit as much as possible the rest of the day)

SEEK PROMPT EVALUATION FOR: progressive weakness, bowel/bladder changes or

saddle numbness, unexplained weight loss or fever, night pain, pain after

significant trauma, or severe radiating pain not responding to conservative

care.

Joseph H. Miller, MD is a neurosurgeon at Northside Hospital Gwinnett in Lawrenceville, Georgia, specializing in brain and spine surgery..

References

  1. Lane MM, Gamage E, Du S, et al. Ultra-processed food exposure and adverse health outcomes: umbrella review of epidemiological meta-analyses. BMJ. 2024;384:e077310. doi:10.1136/bmj-2023-077310
  2. Meng Y, Li S, Khan J, et al. Sugar- and artificially sweetened beverages consumption linked to type 2 diabetes, cardiovascular diseases, and all-cause mortality: a systematic review and dose-response meta-analysis of prospective cohort studies. Nutrients. 2021;13(8):2636. doi:10.3390/nu13082636
  3. Rajesh N, Moudgil-Joshi J, Kaliaperumal C. Smoking and degenerative spinal disease: a systematic review. Brain Spine. 2022;2:100916.
  4. Berman D, Oren JH, Bendo J, Spivak J. The effect of smoking on spinal fusion. Int J Spine Surg. 2017;11(4):29. doi:10.14444/4029
  5. Steffens D, Maher CG, Pereira LSM, et al. Prevention of low back pain: a systematic review and meta-analysis. JAMA Intern Med. 2016;176(2):199-208. doi:10.1001/jamainternmed.2015.7431
  6. Shailendra P, Baldock KL, Li LSK, Bennie JA, Boyle T. Resistance training and mortality risk: a systematic review and meta-analysis. Am J Prev Med. 2022;63(2):277-285. doi:10.1016/j.amepre.2022.03.020
  7. McGill SM. Low Back Disorders: Evidence-Based Prevention and Rehabilitation. 3rd ed. Human Kinetics; 2015. See also: The McGill approach to core stabilization in the treatment of chronic low back pain: a review. medRxiv. 2022. doi:10.1101/2022.01.21.22269311
  8. Paluch AE, Gabriel KP, Fulton JE, et al. Steps per day and all-cause mortality in middle-aged adults in the Coronary Artery Risk Development in Young Adults study. JAMA Netw Open. 2021;4(9):e2124516. doi:10.1001/jamanetworkopen.2021.24516
  9. Pocovi NC, Lin CWC, French SD, et al. Effectiveness and cost-effectiveness of an individualised, progressive walking and education intervention for the prevention of low back pain recurrence in Australia (WalkBack): a randomised controlled trial. Lancet. 2024;404(10448):134-144. doi:10.1016/S0140-6736(24)00755-4
  10. Liu TZ, Xu C, Rota M, et al. Nighttime sleep duration, 24-hour sleep duration and risk of all-cause mortality among adults: a meta-analysis of prospective cohort studies. Sci Rep. 2016;6:21480. doi:10.1038/srep21480
  11. Association between sleep duration and chronic musculoskeletal pain in US adults: a cross-sectional study. Front Med. 2024;11:1461785. doi:10.3389/fmed.2024.1461785
  12. Zielinska-Dabkowska KM, Schernhammer ES, Hanifin JP, Brainard GC. Reducing nighttime light exposure in the urban environment to benefit human health and society. Science. 2023;380(6650):1130-1135. doi:10.1126/science.adg5277
  13. te Kulve M, Schlangen LJM, van Marken Lichtenbelt WD. Early evening light mitigates sleep compromising physiological and alerting responses to subsequent late evening light. Sci Rep. 2019;9:16064. doi:10.1038/s41598-019-52352-w
  14. Pocovi NC, de Campos TF, Lin CWC, Merom D, Tiedemann A, Hancock MJ. Walking, cycling, and swimming for nonspecific low back pain: a systematic review with meta-analysis. J Orthop Sports Phys Ther. 2022;52(2):85-99. doi:10.2519/jospt.2022.10612