When you're in pain, back discomfort can feel like the end of the world, but it's not. There is nearly always a solution. Believe it or not, sometimes the most straightforward approach is to wait. The majority of back pain episodes resolve themselves within a few days or weeks. But sometimes they don't.

Even when back pain progresses from acute to subacute to chronic, practically every reason can be treated conservatively and without surgery. However, it can be difficult to determine when surgery is the best option vs when back pain can be handled without surgery.

So, when is back surgery necessary? Here are several symptoms that require back surgery.

1. The Pain Does Not Go Away
Research published in the Journal of General Internal Medicine found that 75 to 90 percent of acute low back pain cases recover completely within a month. That may sound like excellent news for folks suffering from back discomfort, but it's a cold consolation when you're already two weeks in and presumably have at least two more weeks to go.

There's no need to simply wait it out; several treatments can be tried during the acute stage of back pain. These may include:
- Physical therapy
- Nonsteroidal anti-inflammatory medications (NSAIDs)
- Corticosteroid injections
- Epidural nerve plugs
- Lifestyle adjustments, such as decreasing weight or quitting smoking
- Radiofrequency ablation

If these conservative treatments have not reduced or eliminated the pain after about a month, it may be time to see an orthopedic spine surgeon.

2. Pain Radiates Into the Arms and Legs
Radiating pain, also known as radiculopathy, is generally caused by pressure on a nerve root in the spine. In certain circumstances, surgery can be extremely beneficial.

Herniated discs and bone spurs are the two most common causes of radiculopathy. Each vertebra in the spine contains a shock-absorbing disc composed of a robust, fibrous outer layer and a soft, jellylike interior layer. Herniation occurs when the inner layer pushes through the outer layer. 

If the herniation pushes on a nerve root, the pain might spread to the portion of the body that the nerve serves. In contrast, bone spurs occur as a result of spinal osteoarthritis. Osteoarthritis is the breakdown of the articular cartilage that allows bones in a joint to move smoothly together. This cartilage wears away in spinal joints, known as facet joints, causing bone-on-bone contact, which can lead to the production of bone spurs or osteophytes. Bone spurs may then squeeze the spinal cord or nerve roots, causing nerve compression and radiculopathy.

Nonoperative treatment is frequently tried before surgery, especially in situations with radiculopathy. Radiculopathy can be treated surgically, which is very effective. The majority of operations aim to either remove the cause of nerve pressure, such as a discectomy or to open up the spinal canal, such as a laminectomy.

3. It Is an Emergency
Often, surgery for back discomfort is not immediately required. Surgeons frequently encourage patients to wait out the discomfort to see if it resolves on its own or with nonsurgical treatment. However, in other cases, back discomfort is an emergency, necessitating immediate surgery.

Emergencies can result from acute events and trauma, such as a car accident, or from a chronic ailment that has gone untreated and become an emergency. Cauda equina syndrome is one such example. Cauda equina is caused by severe, long-term compression of nerves in the lower (lumbar) spine, trauma, infection, or malignancy. Symptoms include:
- Sudden loss of bladder or bowel control
- Severe low back pain
- Serious weakness or numbness in the lower body
- Sexual dysfunction

Cauda equina syndrome can cause lifelong paralysis. Emergency surgery is required.

If you are experiencing back pain, schedule an appointment with an interventional physiatrist to determine the source of your pain and prescribe a treatment strategy that is appropriate for you, which may involve conservative pain management or surgery.