Back Pain —
the right diagnosis changes everything

Most back pain does not need surgery. The criteria that suggest surgery may be appropriate are: failure of at least 6 weeks of structured conservative care (physical therapy, NSAIDs, activity modification); a specific structural cause confirmed on imaging that correlates with the clinical examination; and symptoms that significantly affect quality of life or function. Pain alone, without neurological deficit or confirmed structural cause, is rarely an indication for surgery. The more important question is whether your conservative treatment has been appropriately directed at the right source — SI joint PT is different from lumbar disc PT, and if the wrong source is being treated, the pain will not improve regardless of duration.

Not necessarily — and this is one of the most important points in back pain care. Disc herniations are extremely common, and many are asymptomatic or minimally symptomatic. Studies consistently show that a significant proportion of people with herniated discs on MRI have no back pain whatsoever. The clinical question is whether the disc finding on MRI explains your specific symptoms: does the level of herniation match the nerve root producing your pain pattern? Is there neurological deficit? Is the disc fragment large enough to cause significant compression? A disc herniation that does not correlate with the symptoms is not the diagnosis — and treating it surgically will not relieve the pain. Accurate diagnosis means confirming that the MRI finding is clinically significant before any surgery is planned.

Chronic back pain that does not respond to treatment usually means one of three things: the right diagnosis has not been made, the treatment has not been directed at the correct source, or the correct surgical option has not been offered. The most common missed diagnoses in chronic back pain are sacroiliac joint dysfunction (15–30% of chronic back pain, frequently not evaluated) and facet-mediated pain. If you have had lumbar MRI and been told it is "normal" or shows only "mild degeneration" while continuing to have significant pain, the SI joint should be specifically evaluated. If you have already had one or more lumbar surgeries without relief, the SI joint and adjacent segments should be re-evaluated before any further surgery is planned. A fresh consultation that starts from the beginning — history, examination, and all imaging reviewed personally by the surgeon — often identifies what has been missed.

Yes — before committing to lumbar fusion, a second opinion from a surgeon who can offer the full range of options is appropriate. The specific questions a second opinion should answer: Is the diagnosis correct, and has the SI joint been evaluated? Is your anatomy appropriate for TOPS rather than fusion (Grade I spondylolisthesis + stenosis + intact disc = TOPS candidate)? Is lumbar disc replacement appropriate (preserved disc height, no significant instability)? What form of MIS fusion is being proposed, and is it the right approach for your anatomy and level? A second opinion with a surgeon not certified for TOPS or disc replacement will produce the same fusion recommendation regardless of the anatomy — because they can only offer what they are trained to perform.

Back pain refers to pain localised to the back itself. Sciatica — more precisely called lumbar radiculopathy — refers to pain, numbness, tingling, or weakness that radiates from the back down the leg, following the distribution of a compressed nerve root. The two often coexist, but they arise by different mechanisms. Sciatica specifically indicates compression of a nerve root (usually by a herniated disc, bone spur, or stenosis) rather than pain from the joint, disc, or muscle itself. The pattern of leg pain — which specific area of the leg, whether it goes below the knee, and whether there is associated weakness or reflex change — helps identify which nerve root is involved and therefore which spinal level is causing the problem. See the dedicated sciatica page for full detail.

Yes — the consultation is an evaluation, not a prelude to surgery. Most patients with back pain are appropriate for continued or optimised conservative management, and that recommendation is made when it is the right one. Dr. Katsevman reviews all imaging personally and provides a complete clinical assessment — which includes a frank discussion of whether surgery is indicated, what the surgical options are if it is, and what the realistic expectations are. The goal is an accurate diagnosis and the right treatment plan, which for most back pain patients does not include surgery.