What doctors don’t tell you
Taken as a whole, PLID surgery has a poor track record. The most recent review of the clinical data has shown that about half the standard operations need to repeated, as are a staggering 80 per cent of keyhole surgeries (J Gen Intern Med, 1993; 8: 487-96).

When discussing your surgical options, orthopaedic surgeons rarely tell you that:

* your back is likely to heal all by itself. Surgical intervention should not be a knee-jerk response, as spontaneous remissions are seen in more than 60 per cent of cases (Schmerz, 2001; 15: 484-91).

* with an open discectomy: - it won’t make you feel any better and, indeed, could make you feel even worse (as experienced by at least 4 per cent of patients) (Eur Spine J, 2005; 14: 49-54) - your back pain is likely to persist. About 75 per cent of patients have residual lower-back pain, 12 per cent of which is described as ‘severe’ (Spine, 2001; 26: 652-7) - you risk inadvertent damage to the surrounding nerves.

* with fusion: - you’re likely to suffer surgical complications. ‘Iatrogenic soft-tissue morbidity’, as it is known, is an almost routine hazard (Orthopedics, 2002; 25: 767-71) - common complications include excessive bleeding, nerve root lesions and recurrent disc herniation - the problem you had in the first place (Eur Spine J, 2003; 12: 239-46) - the surgeon could damage your internal organs. Perforations of intra-abdominal structures have been reported (Neurocirug [Astur], 2004; 15: 279-84) as well as rupture of large blood vessels (Eur J Vasc Endovasc Surg, 2002; 24: 189-95) - it may actually make the pain of PLID worse because of scarring or damage to the meninges. Henry La Rocca, clinical professor of orthopaedic surgery at Tulane University in New Orleans, points to “substantial” evidence that iatrogenic scarring of the nerve roots causes long-term pain, and that iatrogenic damage to the membranes covering the spinal cord can be “catastrophic” (Weinstein J, Wiesel S, eds. The Lumbar Spine. Philadelphia: W.B. Saunders, 1990).

In addition, spinal fusion has the highest failure rates. One reason may be that the operation puts an extra load on other parts of the spine. By locking the movement in one vertebral joint, fusion forces the adjacent joints to do 50 per cent more work than they were designed to do. This can lead to later PLIDs - as one osteopath puts it, “You simply chase the problem up the spine”.

Fusion brings other long-term medical problems such as osteoarthritis, probably due to friction between the unbuffered vertebrae. The patient is also left with a weaker spine and so a reduced quality of life.

Nevertheless, there are occasions when surgery is necessary to prevent paralysis. The tell-tale symptoms are specific - either faecal incontinence or an inability to pass urine. Both are caused by the prolapsed disc pressing on the nerves that control the bladder and/or the bowel, and indicate a potentially hazardous condition requiring emergency surgery. Secondary symptoms may be back pain or numbness in the pelvic area.

Medical alternatives to surgery
Chemonucleolysis using papaya enzymes is more effective than surgery in the long term, but may also have occasionally severe adverse consequences - in particular, a fatal allergic reaction. It can also cause severe back pain for up to three months after the procedure (Spine, 1996; 21: 1102-5). As a result, it’s now falling out of favour, especially in the US.