or does it?

Ask around, and you’ll hear it constantly: “back surgery doesn’t work.” As a spine surgeon, I hear this from patients, from other physicians, and nurses. Yesterday an ER nurse practitioner told methat lumbar spine operations don’t work. What struck me was that she’d had two neck fusion surgeries — anterior cervical procedures — with excellent results! 

The funny thing…I don’t totally disagree with her. And that’s exactly why I wrote this article.

The Uncomfortable Truth About Spine Surgery

Too many patients undergo lumbar spine operations they don’t actually need. In certain markets — Atlanta included — spine surgery can be lucrative, and that financial incentive has, unfortunately, shaped practice patterns across the country. I would see this frequently in my last practice. A patient would have surgery and drive to see me for a second opinion as to why they were still in pain after surgery. When I reviewed their imaging, the uncomfortable truth was often the same: they never needed an operation in the first place.

This is the real reason spine surgery has a reputation problem. It’s not that surgery doesn’t work — it’s that surgery is too often performed on patients who were never good candidates to begin with.

Why My Approach as a Spine Surgeon in Gwinnett Is Different

The key to a successful spine operation starts long before the operating room. It starts with asking the right question: does this patient actually need surgery?

Many patients with back pain, and even leg pain or sciatica, will not benefit from an operation — no matter how good the surgeon or how advanced the technique. This is where conservative decision-making matters most. In medicine, “conservative” has nothing to do with politics. It means being genuinely reluctant to operate unless surgery is truly necessary, rather than defaulting to surgery for most patients who walk through the door.

In my practice, I typically recommend surgery for only 10 to 12 percent of patients referred to me for a possible operation. The rest are candidates for nonoperative care — physical therapy, strength training, core conditioning, or other treatment approaches designed to avoid surgery altogether. Determining who genuinely needs an operation is, in my view, the single most important skill a spine surgeon brings to a patient’s care.

I hold myself to a simple standard, drawn from the Golden Rule in the Gospel of Matthew: treat others as you would want to be treated. If I wouldn’t recommend an operation for myself, my wife, or my children under the same clinical circumstances, I won’t recommend it for my patients either.

Who Actually Needs Spine Surgery?

To separate necessary surgery from unnecessary surgery, it helps to define the clinical situations where an operation genuinely helps.

Lumbar Spinal Stenosis

The majority of patients who truly need spine surgery have lumbar spinal stenosis — narrowing of the spinal canal, most often from arthritic degeneration, that compresses the nerve roots traveling down into the legs. Stenosis can result from several causes:

•      Degenerative changes (most common)

•      Disc herniation (though most herniations resolve on their own without surgery)

•      Tumor (uncommon)

•      Infection or other rare causes

If you have spinal stenosis, there’s still a good chance you can improve without surgery. But among patients who ultimately do need an operation, stenosis is the most common diagnosis.

Spinal Instability

Instability is a less straightforward category, but it’s the second major reason surgery may be necessary.

In trauma, instability is easy to define: a significant fracture or fracture-dislocation that makes it unsafe for a patient to even stand without stabilization clearly requires surgery.

Degenerative or arthritic instability is less clear-cut. This includes spondylolisthesis — a shift of one vertebra relative to another — which is sometimes accompanied by a pars defect (also called a pars fracture or spondylolysis; these terms are used interchangeably). It sounds alarming to be told you have a “fracture” in your spine, but the vast majority of these are stable and do not require spinal fusion. I see this frequently in young athletes — rowers, soccer players, football players, and lifters, particularly in powerlifting — as well as in patients of all ages. Most of these cases respond well to nonoperative treatment: aggressive medical management, core conditioning, and structured strengthening.

An important subset of patients with what I call functional coronal plane instability are those with scoliosis. I will write another article on the nuances of scoliosis treatment. 

Degenerative Disc Disease — Proceed With Caution

Degenerative disc disease represents, in my opinion, the least reliable indication for spinal fusion. Over time, the discs that cushion the vertebrae wear down, triggering an arthritic cascade that can lead to pain and remodeling of the vertebral end plates — sometimes producing what’s called Modic changes, a form of inflammation similar to stress fractures within the bone. This can create a self-perpetuating cycle of pain and further degeneration.

Even so, the vast majority of patients with degenerative disc disease do not need surgery. Only after years of significant, unrelenting pain — and after nonoperative options have been exhausted — does an operation become appropriate for a small subset of these patients.

A Word on “Disc Bulges”

If there’s one term I’d like to retire from medical vocabulary, it’s “disc bulge.” It shows up constantly in radiology reports, pain management notes, chiropractic evaluations, and even reports from neurosurgeons and orthopedic surgeons — but it’s an imprecise, largely nonclinical term. In most cases, a disc bulge simply reflects the normal bowing of the disc’s outer ring (the annulus) that comes with age. Nearly every patient over 50 will show some degree of disc bulging on imaging. It is not, by itself, a reason for surgery. A finding has to rise to the level of a true disc protrusion or disc herniation, with a corresponding clinical picture, before any operation is worth considering.

What Success Actually Looks Like After Spine Surgery

Patients and referring physicians alike deserve honest numbers, not surgeons “shooting from the hip” with success rates. The standard I hold myself to: an operation should carry a success rate above 90 to 95 percent before I recommend it — with rare exceptions, such as certain trauma, epilepsy, or malignant brain tumor surgeries, where the risk of not operating outweighs a lower success rate. Spine surgery doesn’t carry that kind of urgency, so the bar for success should stay high.

For patients with degenerative lumbar spinal stenosis, normal spinal alignment, and no instability, published reoperation rates run in an enormous range of 2 to 22 percent — from recurrent stenosis, new instability, or an inadequate initial decompression requiring a second procedure. In my own practice, reoperation rates for lumbar spinal stenosis have run closer to 1 to 5 percent, though exact comparisons are difficult given how much patient presentations and procedures vary.

Fusion surgery carries similarly high success rates, but expectations matter. Patients often hope fusion will resolve every symptom entirely. In my experience, success means a significant reduction in pain and a real improvement in quality of life — not perfection. I have personal experience with this: I’ve had back pain, and through conditioning, strength training, and regular exercise, I remain fully active. Patients who commit to strengthening their core after recovery are consistently the ones who see the best long-term outcomes.

For me, success isn’t just resuming activities of daily living. It’s getting back to the activities that make up a full life — playing with grandchildren, helping a son or daughter move into a college apartment, working in the garden, or simply doing the things you love (not sure anyone actually loves golf but golf!) without being limited by pain. No outcome is ever perfect, and I tell my patients that up front. But a patient who is meaningfully better than before surgery — with a real, lasting improvement in quality of life — is a success by any reasonable measure. That’s about as close to perfect as we get this side of heaven.

I ask every patient at follow-up: Are you better now than before surgery? The answer is yes 19 out of 20 times. 

Considering Spine Surgery? Start With a Conservative Opinion

If you’re a patient dealing with back or leg pain, or a physician looking for a spine surgery referral partner in Gwinnett who won’t rush a patient to the operating room, I’d welcome the conversation. My approach is straightforward: rule out surgery before recommending it, and when surgery genuinely is the answer, pursue it with a track record of high success and low complication rates.

Joseph H. Miller, MD is a spine and neurosurgery specialist at Northside Hospital Gwinnett in Lawrenceville, Georgia, providing comprehensive neurosurgical care of the brain, spine and peripheral nerves in Gwinnett County and the greater Atlanta area.

This article is for general educational purposes and does not substitute for a one-on-one evaluation. Every patient’s spine is different, and treatment recommendations should always be individualized.