Back and neck pain are among the most common complaints in clinical practice, affecting up to 80% of adults at some point in their lives. Despite its prevalence, the causes and presentations of these conditions are diverse, ranging from benign mechanical strain to serious structural pathology and possible neurologic compromise. From a surgical perspective, understanding the spectrum of disease, distinguishing operative from non-operative cases, and tailoring management to each patient is essential for achieving optimal outcomes.
Most patients with neck or back pain experience symptoms that are self-limiting and respond well to conservative treatment. Mechanical pain related to posture, muscle strain, or degenerative changes often improves with core strengthening, postural retraining, physical therapy, and patient education. Medications can provide additional relief; nonsteroidal anti-inflammatories and acetaminophen are typically first-line, while muscle relaxants or agents targeting neuropathic pain, such as gabapentinoids or serotonin-norepinephrine reuptake inhibitors, may also be used depending on symptoms and the patient’s pain profile. Interventional procedures, including epidural steroid injections, facet joint injections, and selective nerve root blocks, are indicated for patients whose symptoms persist despite non-invasive conservative care and who demonstrate clear nerve root involvement. Lifestyle factors including weight management, smoking cessation, and optimization or comorbidities play a critical role in symptom control and recurrence prevention.
Surgical evaluation is considered when pain persists despite conservative management, neurological deficits progress, or structural instability is identified. Decisions to operate require careful correlation between clinical findings and imaging. As a surgeon, when there is a disconnect between imaging and clinical findings, we are obligated to retreat, pursue more workup or fall back on non-invasive treatments. In the cervical spine, radiculopathy or myelopathy caused by disc herniation or spondylotic changes may require surgical decompression. Anterior cervical discectomy and fusion remains the standard for single or multilevel disease when symptoms correlate with imaging, radicular symptoms fail conservative therapy or myelopathy is present. Posterior decompression, such as laminectomy or laminoplasty, is reserved for multilevel stenosis or cases in which anterior approaches are unsuitable. These procedures aim not only to relieve neural compression and often stabilize the spine.
Thoracic spine pathology is less common as the rib cage gives inherent stability. Disc herniations or extrinsic compression from tumors or trauma can result in myelopathy This can present as gait disturbances, sensory changes, or bowel and bladder dysfunction. Surgical intervention is indicated when imaging confirms cord compression accompanied by corresponding neurological deficits. Thoracic decompression, with or without instrumentation is a consideration.
Lumbar spine disease accounts for the majority of operative cases. Symptomatic disc herniations producing radiculopathy are typically treated with microdiscectomy, which provides durable relief of leg pain and improved function. Degenerative spinal stenosis can cause neurogenic claudication and functional impairment. Laminectomy, with or without fusion, provides decompression while addressing stability. In cases of spondylolisthesis, deformity or recurrent disc disease, fusion techniques can restore spinal alignment and decompress neural elements. Minimally invasive approaches for decompression and/or fusion are increasingly used, offering reduced tissue disruption, shorter hospital stays, and faster recovery without compromising outcomes.
Pediatric and adolescent patients present distinct challenges, as back and neck pain in this population is often under recognized and may arise from congenital, developmental, or early degenerative conditions. Scheuermann’s kyphosis, spondylolysis, spondylolisthesis, and idiopathic scoliosis are the most common causes, with trauma or inflammatory disorders less frequent. Degenerative disc disease is rare, and neurological deficits may be subtle, sometimes appearing only as changes in gait, posture, or activity tolerance. Conservative management is the first line of treatment and typically includes bracing, targeted physical therapy, and activity modification. Surgery is reserved for progressive deformity, instability, persistent pain despite conservative therapy, or neurological compromise, with techniques adapted to minimize effects on growth and preserve spinal mobility. Recognizing the psychosocial impact of chronic spinal conditions in adolescents is crucial, as persistent pain or deformity can affect school performance and quality of life.
The role of surgeons extends beyond performing surgery. Patient selection is critical, as operative intervention carries inherent risks and is not universally appropriate. Progressive neurological deficits, intractable pain despite comprehensive conservative therapy, structural instability, and certain pathologies, such as tumors or infections, are key indications for surgery. Clinical assessment, imaging correlation, comorbidities, and patient expectations all guide decision-making. Collaboration with primary care physicians, pain specialists, physical therapists, and rehabilitation teams ensures that operative and non-operative care are optimized. This multidisciplinary approach allows treatment to focus on functional recovery and quality of life.
Advances in technology and research continue to reshape management strategies. Minimally invasive surgery, improved imaging, intraoperative navigation, and robotics have expanded surgical options while reducing perioperative morbidity. Biologic therapies for disc regeneration and spinal cord repair are under heavy research, but not yet a standard of care. Neuromodulation of chronic pain pathways show promise for non-operative treatment. Further understanding central sensitization and neuroplasticity may refine rehabilitation and pharmacologic strategies, particularly in chronic pain syndromes.
Despite these advances, managing back and neck pain remains complex. Surgeons and interventionalists play a pivotal role in identifying patients who will benefit from surgery while integrating operative and non-operative approaches. Early recognition of red flags, accurate diagnosis, and structured treatment planning are essential for achieving optimal outcomes. The overarching goal is to restore function, relieve pain, and prevent neurological deterioration.
Back and neck pain, while common, are far from trivial. These conditions demand a careful, patient-centered approach that combines clinical judgment, surgical skill, and conservative care principles. The host of authors of the following articles offer a tremendous amount of knowledge and experience and will highlight a variety of relevant spinal conditions.
Joshua T. Wewel, MD FAANS
Dr. Joshua T. Wewel is a board certified neurosurgeon and member of the Atlanta Brain andSpine Care team at Piedmont Atlanta Hospital. He treats all spinal conditions with specialfocus on minimally invasive and complex spine pathologies. Dr. Wewel is actively involvedin regional and national neurosurgical organizations while authoring numerous peer-reviewed publications, book chapters and speaking at national meetings.
