A patient walked into my office in Hoffman Estates last month with an MRI from a spine surgeon, a recommendation for lumbar fusion, and a single question: do I have to do this?
It’s the most important question in the spine world, and it doesn’t have a one-line answer. Sometimes surgery is the right path. Sometimes interventional pain management can avoid it for years or for the rest of a patient’s life. Knowing the difference is what this article is about.
What pain management actually is
Interventional pain management is a medical specialty focused on diagnosing and treating chronic pain using image-guided procedures, neuromodulation, and medication management — without operating on the spine itself.
The procedures I perform every week include epidural steroid injections, facet joint injections, medial branch blocks, radiofrequency ablation, sacroiliac joint injections, the MILD procedure (minimally invasive lumbar decompression), basivertebral nerve ablation (Intracept), spinal cord stimulation, DRG stimulation, peripheral nerve stimulation, and kyphoplasty for vertebral compression fractures.
What unites all of these is that they treat the pain generator without altering the structural mechanics of the spine. The spine still moves the way it moved before. The disc, if there’s a disc problem, is still there. The hardware question — fusion, plates, screws — is off the table.
What spine surgery actually does
Spine surgery is mechanical. The surgeon is changing the structural architecture of the spine — removing bone, removing disc material, fusing vertebrae together, sometimes implanting motion-preserving devices.
Surgery is unambiguously the right answer in specific situations. Severe weakness from a compressing herniated disc that isn’t improving. Cauda equina syndrome with bowel or bladder dysfunction. Progressive neurologic decline. A spinal fracture with instability. A tumor or infection. Profound spondylolisthesis with mechanical instability.
Outside of those clear situations, surgery becomes a judgment call — and the judgment depends on what the alternative pain-management path looks like.
Where the overlap lives
Most spine pain doesn’t fall cleanly into “must operate” or “must not operate.” The middle ground is where 80 percent of the decisions live, and it’s where the choice between pain management and surgery actually matters.
Lumbar spinal stenosis is the canonical example. A 70-year-old patient with neurogenic claudication — pain in the legs after walking a block, relief when leaning forward over a shopping cart — is a candidate for laminectomy. They are also a candidate for the MILD procedure. The MILD procedure preserves the surgical option for later if it doesn’t work. Laminectomy doesn’t preserve the no-surgery option.
Failed back surgery syndrome is another. Patients with persistent or recurrent pain after a previous fusion or decompression often have a hardware issue or an adjacent-segment issue that a second surgery could address — but the success rate of revision surgery is meaningfully lower than the success rate of the first surgery. Spinal cord stimulation has Level I evidence for failed back surgery syndrome. The data favors the stimulator over revision surgery for many of these patients.
Vertebrogenic low back pain — pain originating from the basivertebral nerve in patients with Modic Type 1 or 2 endplate changes on MRI — used to lead to fusion. Now it can often be treated with a single-session basivertebral nerve ablation (the Intracept procedure). The vertebra is left intact. The fusion option is preserved if the ablation doesn’t work.
In each of these cases, the question isn’t which is better. The question is which preserves my future options.
The principle: do the reversible thing first
When two paths have a similar probability of helping, the path that preserves more future options is usually the better path. That’s not a slogan — it’s how I think about every spine recommendation.
Epidural steroid injections preserve every other option. Radiofrequency ablation preserves most options. The MILD procedure is reversible in the sense that anything fusion-level can still be done after. Spinal cord stimulation is reversible — the device can be explanted. A trial period before permanent SCS implantation is built into the procedure precisely because reversibility is the point.
Spine surgery, especially fusion, is the least reversible step. That doesn’t mean it’s wrong. It means the bar is higher to choose it first.
When surgery should be first
There are conditions where I tell patients to go to the surgeon, not to me, and I refer them out the same day:
- Cauda equina syndrome: bowel/bladder dysfunction, saddle anesthesia, bilateral leg weakness — emergency surgery, not pain management.
- Progressive neurologic decline: weakness that’s getting worse week over week from a compressing lesion — this is a surgical decision.
- Acute spinal fracture with instability: depending on the type, surgery may be the right path.
- Spinal infection or tumor: not a pain management problem in the conventional sense.
- High-grade spondylolisthesis with neurologic symptoms: surgical territory.
For these, the worst thing I could do is delay a patient with months of injections that don’t address the underlying mechanical or neurologic emergency.
What the consultation conversation looks like
When a patient comes to me with a surgeon’s recommendation in hand, I do three things at the first visit. I review the imaging carefully and look for the specific finding that’s driving the surgical recommendation. I examine the patient. And I ask: what did the surgeon say about non-surgical options?
If the surgeon offered a thoughtful sequence of conservative steps that the patient has tried and failed, I take the surgical recommendation seriously and we talk about whether there’s still a non-surgical path that hasn’t been explored.
If the surgical recommendation came after a single visit and a single MRI, with little discussion of non-surgical options, I tell the patient honestly that they may benefit from a second opinion — and that they should ask about non-surgical alternatives before committing to a date in the operating room.
Both specialties, working together
Interventional pain management and spine surgery aren’t adversaries. The best outcomes happen when the two specialties communicate and coordinate. I have spine surgeon colleagues I trust, and I refer to them when surgery is genuinely the right answer. They refer back to me when conservative care is the better fit, when a patient isn’t a great surgical candidate, or when surgery has been done and pain has persisted.
The patient’s job isn’t to pick a side. It’s to make sure both perspectives are part of the decision.
If you’re trying to decide
If you’re sitting on a surgical recommendation and you’re not sure, here’s what I’d suggest:
- Get the imaging report and the recommendation in writing.
- Schedule a consultation with an interventional pain physician — fellowship-trained, board-certified — and bring the imaging.
- Ask: what’s the non-surgical version of this plan, and what’s the probability it would work?
- Compare the answer to the surgical plan honestly.
- If the answer is unclear, get a second surgical opinion too.
Patients in Hoffman Estates, Schaumburg, and the northwest Chicago suburbs who want this conversation can call (847) 981-3630 to schedule. I do not pressure patients away from surgery. If surgery is the right answer for the patient in front of me, I say so.
Dr. Keith Schmidt is a triple board-certified interventional pain management physician in Hoffman Estates, Illinois, serving Schaumburg, Arlington Heights, Palatine, Barrington, Rolling Meadows, Elk Grove Village, Inverness, Streamwood, and the northwest Chicago suburbs.