Nonoperative versus operative intervention in low back disorders

Examination of the patient is necessary to rule out those numerous causes of lumbosacral backache that need not involve the neurosurgeon. A variety of nonoperative treatments (rest, injection of tender pressure points, extradural injections, traction in which the pelvis is fixed and the chest and upper spine can be pulled from the pelvis, and manipulations of the spine) can be used with proper precautions. Injections of enzymes to dissolve the disc have had declining use among neurosurgeons because of actual or feared complications. Operations range from percutaneous disc excision or laminotomy with decompression of nerve roots, to disc excision with interbody fusion. Selection of proper operative treatment to be undertaken when an adequate period of conservative (nonoperative) therapy has been fruitless is controversial. Probably the simplest way of excising a disc with small incisions and minimal disruption of normal anatomic relationships is preferred.