Why You've Been Given Conflicting Opinions About Spine Surgery, and How to Find Clarity

If two clinicians have told you two different things about whether you need surgery, you are not alone, and it does not mean one of them is wrong. Spine care rarely offers a single, obvious answer for each problem. The same diagnosis can lead to very different decisions, because no two patients are the same.

Here I explain why these differences of opinion happen, and how to find clarity when you are caught between them.

Why do clinicians disagree about spine surgery?

Spinal conditions sit on a spectrum from moderate to severe. That applies both to your symptoms and to the findings on your MRI scan. So for the same diagnosis and the same scan, the right solution for one patient is not necessarily the right solution for another.

We all present differently, despite what our scans show. That is why my job is to treat you, the patient, and not your scan. Two careful clinicians can look at the same images and reach different conclusions, simply because they are weighing your individual symptoms, your function, and your needs alongside the pictures.

When does sciatica from a slipped disc need surgery?

Take sciatica caused by a slipped or herniated disc pinching a nerve. The majority of patients improve within six to twelve weeks, so reaching for surgery in the first few weeks is often unnecessary.

Simple measures usually come first. Rest in the early days, until the acute pain settles. Then physiotherapy, with stretches and exercises that help give the nerve some freedom. Injections can reduce the inflammation around the nerve, which is often what drives most of the pain, and this can sometimes avoid surgery altogether.

Surgery becomes necessary when the picture changes: the pain persists beyond that window, things are not improving, or you start to develop weakness in the leg because the nerve is no longer working properly. At that point the priority is to protect the function of the nerve, and with it the strength in your leg.

What types of disc surgery are there?

When surgery is the right step, there is more than one way to do it, and the choice depends on the surgeon's training and the right approach for you.

One option is an endoscopic approach, where a tiny camera enters from the side and the disc is shaved away with small instruments. I often prefer to work under the microscope, through a very small incision at the back of the spine, to remove the disc.

In either case, the quality of the decision rests on the quality of the assessment: a thorough history, properly listening to you, a careful examination, and scrutinising all of the neurological findings.

Should you have a fusion for degenerative disc disease?

A more common area of disagreement is degenerative disc disease, simple wear and tear in a disc, in people who have back pain rather than pain running down the legs.

I often see patients who have been offered a fusion to ease this kind of back pain. The difficulty is that it is very hard to be certain the worn disc is actually the source of the pain. Wear and tear in the discs is extremely common, even in people with no back pain at all. In fact, most people over the age of 50 have more than one worn disc, and feel nothing.

In this situation I often request a SPECT CT scan, a different test that adds information the MRI cannot, and helps show whether that area is genuinely the pain generator. If it is, a spinal fusion can be helpful. If it is not, fusion is unlikely to solve the problem.

What about spondylolisthesis?

Fusion is also often offered for spondylolisthesis, where one bone has slipped forward relative to the one beneath it.

If that slip is compressing a nerve, then decompressing and fusing the segment can relieve the pain. But a spondylolisthesis does not automatically mean the segment is unstable. Sometimes it has been that way for years. If there is nerve compression causing leg pain, all that may be needed is to decompress the segment, without a fusion.

The deciding factor is stability. If dynamic X-rays show the slip is actually moving, then yes, fusing the segment is the right call. Without that proof, a fusion may not be justified.

How a multidisciplinary meeting helps you reach the right decision

When the decision is not straightforward, and opinions genuinely differ, the best practice is a multidisciplinary meeting.

This is where two or three surgeons sit together and review your images with a radiologist in the room, often alongside one or more physiotherapists and a pain specialist. The case is discussed openly until the group reaches a consensus. With that range of expertise looking at the same problem, you are far more likely to arrive at the right decision.

The bottom line: we treat the patient, not the test

We are all different, with different lifestyles and different needs, which is exactly why the same condition on an MRI affects us so differently. Age and other medical conditions also come into the equation, as does weighing the invasiveness and the risks of each procedure.

So if you have been given conflicting advice, it does not necessarily mean someone is mistaken. It usually means your situation sits in a grey area where careful judgement matters. The way through is a thorough assessment, the right tests, and, where needed, a team of experts reaching a consensus. As I always say, we treat the patient, not the test.

For more expert guidance on back and neck pain, visit spinemdt.com and sign up to the newsletter for free tips and updates from Mr Anthony Ghosh.