Back pain is the leading cause of disability worldwide. Spinal surgery has its place — but it is also one of the most over-performed procedures in medicine. The challenge for patients is distinguishing between situations where surgery is genuinely the best option and situations where it's being offered prematurely.
The evidence gap
For many common spinal conditions — degenerative disc disease, non-specific lower back pain, mild to moderate spinal stenosis — the evidence for surgery versus conservative management is, at best, equivocal. Multiple large trials have shown that surgical outcomes at 2 years are often no better than structured physiotherapy and pain management.
The exceptions are clear: cauda equina syndrome requires emergency surgery. Progressive neurological deficit requires urgent assessment. Specific structural pathologies with matching symptoms — such as a confirmed disc herniation causing sciatica that hasn't responded to 6–12 weeks of conservative treatment — have reasonable surgical indications.
Getting three opinions, not just two
Spinal surgery is a field where opinions diverge dramatically. One surgeon may recommend fusion, another decompression, a third may recommend no surgery at all. For this reason, I consistently advise clients facing spinal surgery to obtain at least three independent opinions — ideally from surgeons at different centres with different subspecialty training.
The surgeon trained in minimally invasive techniques will tend to recommend minimally invasive surgery. The surgeon trained in fusion will tend to recommend fusion. The physiotherapy specialist will tend to recommend physiotherapy. Understanding these biases is part of making an informed decision.
What to demand before consenting
Before agreeing to spinal surgery, you should have: a clear MRI or CT correlation between your structural findings and your symptoms; documentation that conservative treatment has been adequately tried; published success rates for the specific procedure proposed, for patients with your specific diagnosis; and the surgeon's personal outcome data.
If any of these are missing, you're making an irreversible decision with incomplete information. More on when a second opinion is essential.