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Surgery for back pain.
When yes, when no.

Injections & surgery

Depends on the indication

NICE NG59 · Dutch LRS guideline

How do we rate this?

We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.

Score per procedure

  • Emergency surgery for cauda equina syndrome

    Necessary and urgent. Within 24 to 48 hours.

  • Herniated disc surgery after 6 to 12 weeks of persistent radiating pain

    Relieves faster; after one to two years the result is comparable.

  • Decompression for spinal canal stenosis

    Reasonable option after failed conservative care, but the evidence is mixed.

  • Spinal fusion for non-specific back pain

    Not better than intensive rehabilitation. NICE advises against it.

Whether an operation helps depends entirely on what is actually wrong. For a rare emergency it is necessary and urgent. For ordinary back pain without a clear cause it is one of the least effective things you can do. Those two extremes sit under the same word, which is why this page splits them out.

When surgery IS needed

How do we rate this?

We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.

Cauda equina syndrome Emergency surgery

Loss of bladder or bowel control, saddle-shaped numbness, increasing weakness in both legs. Surgery must take place within 24 to 48 hours to prevent permanent nerve damage. Decompression within that window gives a significantly better chance of recovering bladder function and muscle strength; every hour of delay reduces that chance. This is a rare but serious emergency.

Progressive severe neurological deficit

Increasing muscle weakness (for example foot drop) from a herniation not responding to 6 to 8 weeks of conservative treatment. Surgery can prevent further nerve damage.

Discectomy (herniated disc surgery)

How do we rate this?

We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.

In a discectomy the protruding part of a disc that presses on a nerve is removed. Start with the natural course: the Dutch guideline for lumbosacral radicular syndrome (2020) reports a median symptom duration of 16 days, and about 75% of people have substantially recovered after three months without any surgery.

The Sciatica Trial (Peul et al., NEJM 2007) showed that surgery provides faster pain relief, but that after one to two years the results are equal to conservative treatment. The Dutch guideline therefore advises discussing surgery after 10 to 12 weeks of insufficient improvement, as a shared decision. Around 40% of the people who first choose to wait are eventually operated on anyway.

There is an important nuance to “it evens out anyway”. Bailey et al. (NEJM 2020) studied people whose sciatica had already lasted 4 to 12 months. In that group microdiscectomy was clearly better than standardised non-operative care at 6 and 12 months. So waiting is sensible early on, but endlessly postponing is not automatically the better choice.

About the technique: the Dutch PTED trial (Gadjradj et al., BMJ 2022) randomised 613 patients across four hospitals and found that keyhole surgery through the side (PTED) is not inferior to conventional open microdiscectomy. Both are defensible; the choice mostly depends on what your hospital is experienced in.

Decompression for spinal canal stenosis

How do we rate this?

We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.

With a narrowed spinal canal the nerves get too little room, typically causing pain and heaviness in the legs when walking that eases when you sit or bend forward. In a decompression the surgeon removes bone and thickened ligament to create space.

NICE (recommendation 1.3.8) says to consider spinal decompression when non-surgical treatment has not improved pain or function and the imaging matches the symptoms. The evidence is genuinely mixed: a Cochrane review (2016) found no clear benefit of surgery over non-surgical treatment, while reporting complications in 10 to 24% of participants in the surgical groups of the studies that recorded them.

One thing is clear: do not let a fusion be added without a good reason. Försth et al. (NEJM 2016) randomised 247 patients and found that adding fusion to decompression gave no better outcome at 2 and 5 years, while it did mean a longer operation, a longer hospital stay and higher costs.

Spinal fusion (spondylodesis)

Not recommended for non-specific
How do we rate this?

We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.

Fusing vertebrae for non-specific back pain is not more effective than intensive rehabilitation. Three independent trials point the same way: Brox et al. (Spine 2003), Fritzell et al. (Spine 2001) and the British MRC Spine Stabilisation Trial (Fairbank et al., BMJ 2005). NICE is blunt about it: do not offer spinal fusion for low back pain unless as part of a randomised controlled trial. The risks (infection, degeneration of the adjacent segment, complications) do not outweigh the limited benefits.

May be considered for: unstable vertebral fractures, spondylolisthesis with neurological deficit, a tumour or infection, or severe instability not responding to other treatments. Those are specific diagnoses, not a description of ordinary back pain.

The same applies to an artificial disc. NICE (recommendation 1.3.10) states plainly: do not offer disc replacement in people with low back pain.

Figures from the Netherlands

About 11,000 herniated disc operations are performed in the Netherlands every year, more than 9,000 of them by neurosurgeons. Roughly 1 in 7 people with a symptomatic herniation is operated on; the rest recover without surgery. In 5 to 10% of cases a herniation comes back (Dutch Association of Neurosurgeons).

That same leaflet also says 80 to 90% of people operated on are satisfied with the result. We have deliberately left that number out. Being satisfied is not the same as your pain and your limitations actually having gone down, and it is the second thing we look at on this site. It also comes from the leaflet of the profession that performs the operation.

An operation is not a guarantee. Of nearly 7,000 Dutch patients operated on between July 2015 and June 2016, 23% needed treatment againafterwards: another operation, a nerve root block, or strong painkillers. The painkillers were the largest group, a good 1 in 7 (Schepens et al., Global Spine Journal 2023).

And where you live matters, though less than is often claimed. A study covering every Dutch adult between 2016 and 2019 looked at 119,000 people with these complaints, of whom nearly 15,000 had surgery. For the hernia operation itself, the chance differed by less than a factor of two between postcode areas. Where it does run far apart is fusion surgery: there the chance was up to five times higher in one postcode area than in another (van Munster et al., 2024). Good reason to ask which operation is being proposed, and why that one.

Questions to ask before you agree

  • What exactly is the diagnosis, and does the scan match my symptoms?
  • What happens if I wait another six weeks? What would change?
  • Which part of my symptoms do you expect the operation to solve: the leg pain, the back pain, or both?
  • What is the chance I will still have pain afterwards?
  • How many of these procedures do you perform each year?
  • Which non-surgical options have not been tried yet?

And remember: you are entitled to a second opinion. If you ask for a referral, your doctor has to cooperate unless there are compelling reasons not to (KNMG). For an irreversible procedure on your spine, that is a reasonable thing to use.

Herniated disc with sciatica: the usual path

  1. Week 0–8

    Conservative first

    Keep moving, physiotherapy if needed. About 75% recovers within three months.

  2. Week 8–12

    Evaluation

    Still severe symptoms? Referral to a neurologist.

  3. After that

    Deciding together

    Surgery relieves faster; after one to two years the result is comparable.

  4. Emergency

    Immediate surgery

    Cauda equina or progressive deficit: within 24 to 48 hours.

Key message

There is no single answer to “does back surgery work”. For cauda equina syndrome it is urgent and necessary. For a herniated disc with persistent radiating pain it is a reasonable choice after 6 to 12 weeks, mainly because it relieves faster. For back pain without a clear cause, fusion and disc replacement are not recommended. Ask which of these situations applies to you, and ask for a second opinion if the answer stays vague.

Sources

Next step

Do spinal injections work?Alarm symptoms? When to see a doctor