DEAR MAYO CLINIC: My back pain keeps getting worse. I've tried all the nonsurgical options, but is it time to consider surgery? 

ANSWER: It might be. The back is a highly complex part of the human body with several potential sources of pain — bones, joints, muscles and nerves.  

Joints: On the back of each spinal vertebra is a pair of facet joints that allow you to bend and twist. These two facet joints, together with the disc, enable the bones of the spine to move. Lower in the back is the sacroiliac joint, which connects the spine to the pelvis. As with any joint, these can be affected by arthritis and injury. The discs, which provide cushioning between the vertebrae, can slip out of place, allowing the bones to rub together. 

Muscles: An intricate muscle structure supports the spine. Strains, overuse and underuse can weaken and damage these muscles. 

Nerves: The spinal cord, which is a bundle of nerves, runs through the spine, ending where the mid back and lower back connect — about at your belly button. From there, nerve roots branch to each leg, providing function to your legs. Anywhere along the spine, but especially in the lower back, the nerves can become compressed. It's radiating leg pain that frequently drives patients to seek relief through surgery. 

The first step in finding back pain relief is to be assessed by a healthcare professional, who, as part of the examination, will check your ability to sit, stand, walk and lift your legs. You also may undergo some imaging. This assessment will help your clinician develop a treatment plan.  

Nonsurgical pain-relief options include: 

• Physical therapy. A physical therapist can teach you exercises to increase flexibility, strengthen back and abdominal muscles, and improve posture. Building these exercises into your daily routine can help prevent pain from returning. The therapist also can show you how to modify the exercises and your movement during a back pain episode.  

• Ice/heat. The use of an ice pack or heating pad can help relieve pain from muscle tension and spasms. 

• Pain relievers. These include nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil); acetaminophen(Tylenol); topical creams and patches that deliver substances through the skin; medicines containing opioids, such as oxycodone or hydrocodone (rarely used); and some antidepressants, including duloxetine (Cymbalta).  

• Muscle relaxants. If mild to moderate back pain doesn't improve with ice, heat or pain relievers, a muscle relaxant is another option.  

• Injections. If other measures don't relieve pain that radiates down the leg, an injection of cortisone plus a numbing medicine might help. 

• Other treatments. Yoga, massage, chiropractic adjustments and acupuncture also may bring relief. 

When these measures are no longer effective, patients typically seek out surgical options. For the best outcomes, it's essential that the surgical procedure matches the problem that needs to be addressed. These can include neurological compression, instability or spine deformity issues.  

A consultation with a surgeon usually includes an examination and imaging to pinpoint the problem, followed by a discussion of what surgical approach will provide the greatest benefit. After the consultation, you may want to talk over your options with family and friends or seek a second opinion to ensure you're comfortable with the plan. 

Before surgery, you'll be thoroughly assessed to determine if you're physically ready for the procedure. This will include evaluating your bone health and ensuring that any medical conditions are stable or optimized. 

The surgery depends entirely on what is needed to correct the problem. Some surgeries are relatively simple, while others may be quite complex. 

Recovery and healing depend on how extensive the surgery was. For instance, a herniated disc may require only a small incision, followed by a short period of limited activity. Recovery from a more involved surgery requiring a large incision may take months. 

However, most people fall somewhere in the middle of this spectrum. They generally feel pretty good within six to 12 weeks, although full recovery typically takes six to 12 months. 

Once a person has recovered, the key is developing a lifestyle that helps prevent back issues from returning. These include building good core muscle strength, increasing mobility, staying active, not smoking, and maintaining a healthy weight and diet. 

Being active and maintaining good core strength not only are essential to recovery from surgery, but they also are key to preventing back pain. 

Mel Helgeson, M.D., Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota  

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