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The Low Back Surgery Checklist

Selecting The Best Mattress For Your Back

The Low Back Surgery Checklist

This article should help you determine whether you are a good candidate for surgery.

Surgery should always be considered in the following scenarios:

Back pain that is constant and severe, persisting several months or longer.
Serious neurological damage. This includes loss of bowel or bladder control, pressure on the spinal cord causing sudden/severe numbness or loss of sensation in legs.
Injury via trauma. High energy traumatic injuries often occur with a fall from heights, violence, car accidents, etc. You may need immediate surgical intervention for instability that needs to be stabilized (vertebral fracture, severe sacroiliac joint damage, torn spinal ligaments, etc).

If you are not experiencing any of the signs and symptoms above, it is best not to rush into surgery. There is no turning back once you have undergone surgery. In the absence of trauma, you may experience radiating pain, numbness, and weakness in anywhere from the back to the toes. These symptoms are likely due to a single compressed or irritated nerve root. Fortunately, this type of injury is very manageable with conservative care from a good clinician.

While being treated for chronic low back pain, if your doctor decides that all conservative care options have been exhausted, a series of injections or other invasive procedures (e.g. ablation/rhizotomy) will likely follow. If pain management fails, surgery may become the recommended course of action. At this time, it should be noted that without proper self-care techniques after the surgery, chronic back pain may reemerge. Furthermore, patients are led to believe that surgery will rid their back of pain. All chronic back-pained individuals must learn proper self-care of their back, regardless of whether they have surgery or not. A good surgeon will not only discuss alternative options for care prior to surgery, but also best and worst case scenarios, pre-op/ post-op active care, and realistic expectations about living with back pain.

If you are unsure of how or why you have chronic back pain, proceed with caution. You should never get surgery unless your doctor clearly shows you what exactly is causing your pain. In many cases of chronic low back pain, the mechanism of injury is often unknown. For example, consider a procedure requiring removal of material in the L4 disc. Without a clear understanding of the disc injury’s cause, the likelihood of re-injury is greatly increased. In other words, unless you know what caused the disc injury in the first place, and subsequently remove the cause, you can expect the same problem to occur in the future.

It is important to exhaust all your options for conservative care. Be an informed consumer. Consider this: if your doctor did not do a thorough assessment (30 mins or more), gave you pain medication, and no active care plan, you did not see a spine specialist. Alternatively, a patient may perform several months of therapeutic exercise. If no results are achieved the doctor might now recommend injections or suggest surgery. Mistaking an incorrect rehabilitation program as proof that surgery or pain medication is required eliminates a wholly valid and safe course of pain mitigation. Just because this therapy did not work, it does not mean that you need surgery or other types of invasive care. The exercise may simply not have been appropriate for your particular injury.

In any case, if you decide that surgery is the best course of action, try this experiment. Known as “Virtual Surgery”, the patient mirrors post-surgical care by undergoing a period of forced rest, refraining from normal exercise routines, strenuous work, stretching, and other daily habits that may be triggering back pain. After a few days of keeping activities restricted to gentle movements like walking, the patient may be surprised by how good they feel.

Patients recovering from surgery undergoing a period of rest often experience the same positive change in their symptoms. However, what these patients may not realize is that they are misinterpreting reduced pain as proof of a successful surgical procedure and dismissing the impact of daily activities that increase back pain. Removing these triggers helps reduce pain sensitivity, and more importantly demonstrates to the patient that their body has the ability to heal. This can be very empowering for chronic back-pained individuals.

Other helpful information:

Make sure you’ve received a thorough assessment from your doctor, and that the surgery is not solely based on medical images (X-ray, MRI). If you are unsure of what is causing your pain that will need to be addressed by your doctor. Pictures do not show specific pain-causing mechanisms. If certain aggravating activities, movements, postures, and strains are not understood and avoided, this daily stress on the spine almost guarantees that your pain will return.
A hands-on approach is required for a thorough assessment of chronic low back pain (Did the doctor even touch you?).
A good surgeon will identify the pain generator, and determine whether the pain generator can be "cut out". For example, say you have sciatica with numbness in the big toe. The cause could be a stubborn L5 disc bulge, putting unrelenting pressure on the nerve root. Your surgeon performed a detailed history and thorough assessment and arrived at a precise diagnosis. In this situation, if the pain generator can be cut out (e.g. removal of disc material), your chance of having a successful surgery is higher. Of course, the pain-causing mechanism should be well understood, or unsurprisingly, the pain will reoccur.
If you have pain generators at several spinal levels (e.g. multiple disc issues at L3, L4, L5...), the chance of successful surgery is reduced considerably.
In the wake of one unsuccessful surgery, the likelihood of subsequent surgeries yielding successful results drops, usually indicating that you probably were not a good candidate for surgery to begin with.
Proceed with caution if you have been elected to have a disc replacement. This is an especially tricky procedure due to the difficulty of replicating the biomechanics of an intervertebral disc. Furthermore, besides the disc joint, there are two other joints that connect one vertebra to another, called facet joints. An artificial disc puts unnatural stress on the facet joints. In the long-term, this leads to arthritis, stiffness, and more pain.
90% of low back surgeries could be avoided with appropriate care. Some of the complications that can result from hasty surgery will be covered in a later entry. Just know that once you undergo surgery, the procedure cannot be undone, and the success rate for long-term results is marginal.

We have seen first hand how the combination of “Virtual Surgery” with quality conservative care can produce fantastic results. Take it easy while you eliminate pain triggers, implement pain-free movement tools, and begin exercise progressions.

Still feel surgery is right for you?

Surgery

selecting the best mattress for your back

Topics covered in this article:

Reasons for morning back pain, stiffness, or discomfort
How to select a mattress that’s right for your body
Alternative options (if a new mattress is not feasible)

Key Terms

Lumbar lordosis- the natural inward curve of the lower back, seen best from a standing profile view

Curvy/Increased Lumbar Lordosis- angular person with wider hips and/or shoulders (high hip/shoulder to waist ratio), this is usually accompanied by large spine curvatures (increased lumbar lordosis)

Less Defined Curves/ “Flat” Spine/ Decreased Lumbar Lordosis- from a standing side view, this person does not have large curvatures in their spine (decreased lumbar lordosis), more narrow hips and shoulders (low hip/shoulder to waist ratio)

Pillow Top- soft mattress covering, may or may not be built-in to the mattress

Note: This article focuses on back sleepers and/or side sleepers. A major guideline for stomach sleepers is to avoid really soft mattresses. Stomach sleepers will often do well with a medium-firm to firm mattress, with a thin pillow top, or no pillow top.

Memory Foam vs. InnerSpring

If you’re looking for a flat out recommendation on best mattress type (like memory foam), or best brand (like Serta)… I’m sorry to disappoint you. There is no best bed for everyone.

The "springiness" of an innerspring mattress might be more convenient for people who change positions often, or toss and turn. Memory foam creates an indentation, so having to climb up and out of your body's imprint can be bothersome and disrupt sleep. On the other hand, those who don’t move much at night, or have one favorite sleeping position, may prefer memory foam as it allows the body to sink in comfortably.

There are no definitive guidelines for choosing the best bed, as sleeping comfort can be highly subjective. But if you’re unsure where to start when selecting your next mattress, this article should offer some insight.

Is My Mattress Stressing My Spine?

Waking up with back pain warrants an investigation into your sleeping situation. But keep in mind, certain daily activities could cause morning back symptoms as well. Some common examples include heavy labor, a poorly chosen exercise routine, or spending hours on the couch in a slouched posture. Nonetheless, some people wake up with back symptoms regularly, regardless of whether they stressed their spine the day before. If you can’t associate your symptoms with a pattern or recent injury, this is a strong sign that your bed is an aggravating factor.

Vacation can be another opportunity to test your hypothesis. Here's a useful clinical question: “When staying at a hotel, do you notice less pain and stiffness upon waking?” If yes, then you might want to contact the hotel for details on mattress type, mattress topper, additional bedding, etc!

Other Variables- Body Type, Pain Triggers

Your mattress isn’t the only factor that causes symptoms when laying down for prolonged periods. This also depends upon body type (the third variable, pain triggers, will be discussed later). It’s important to match your body type to the appropriate mattress. Body type, for the purposes of mattress selection, can be split into two categories:

Weight (lightweight, average, heavyweight)
Body shape (hips, shoulders, and spine contour).

Consider these two extremes (in the context of back and/or side sleeping position):

Lightweight with flatter spine (some Asian female spines, for example). May prefer a medium-firm mattress with no pillow top, or a futon.
Heavy with large curves (think Serena Williams, MLB’s Rafael Devers or Yasiel Puig, NHL’s Evander Kane). They would do well with the combination of a firm mattress and a thick pillow top (4+ inches). Firm mattress to support the weight. Thick pillow top to allow large shoulders/hips/butt to sink in.

In other words, someone with a flat spine or fewer curves may not need pillow top support to maintain a neutral spine position.

Yet someone with a curvy spine, or large hip/shoulder to waist ratio, may need a soft pillow top to hug their figure. The goal is to preserve your natural curves and maintain a neutral spine position when sleeping. This is of particular importance to the lumbar spine for back-pained individuals.

The majority of people won’t fall into these extremes, and therefore may want to avoid mattress extremes such as really soft/really firm, or a really thick pillow top. For the average American (130-170 lbs, moderately curvy), a good parameter would be a mattress that’s medium or medium-firm, with a pillow top that’s 2-3 inches.

In other words, a somewhat curvy male, weighing about 170 pounds, may do well with a medium-firm to firm mattress and 3-inch pillow top.

A somewhat curvy female, weighing about 130 pounds, may do well with a medium-firm mattress and 2-inch pillow top.

These guidelines can be applied to any body type. A heavy person with a flatter spine and no curves, for example, may do well with a firm mattress and no pillow top.

Pain triggers are the third variable of stress on the spine while laying. This can get a little tricky, but let’s discuss how pain triggers can be associated with sleeping positions. By definition, pain triggers are aggravating activities, movements, postures, and strains. Consider the classic case of posterior discogenic back pain. This patient is usually flexion-intolerant, meaning they have trouble with activities that flatten or round-out the low back. Sitting, driving, and bending over/stooping cause increased pain. A gym routine that involves crunches, posterior pelvic tilts, lifting weights off the floor, and knee to chest stretches would also irritate their back.

Now let’s assume:

1. This person has a large lumbar lordosis

2. He/she is a back-sleeper
3. He/she owns a very firm mattress

Picture this person’s lower back when lying face-up on a firm mattress. Can you see the problem? The inward curve of their lower back is like a bridge, and a firm mattress will not support their lumbar lordosis. The result is a gradual flattening of the lower back during sleep, which mimics the pain trigger of lumbar flexion (recall this patient is flexion-intolerant). The addition of a soft, high-quality pillow top may be helpful in this situation. Their pelvis and mid-back would then sink in. This allows the cushioning to press against the lower back, providing gentle support.

Another patient might have back pain with prolonged standing, and also sleeps on their stomach. A potential problem here is that both postures (i.e. standing and stomach sleeping) may stress the spinal facet joints via lumbar extension. Although there are some modifications that could be made here, a solution to this scenario, as with many back-pained patients, will likely involve identifying and eliminating pain triggers. This is best done with guidance from a professional, but an introduction to the topic of pain triggers is helpful for our discussion.

Can’t Get A New Bed?

If a new mattress is not feasible, here are some modifications that help support your natural curves while sleeping:

Mattress Topper

If your bed is firm, consider purchasing a mattress topper. This especially applies to a side sleeper with wide shoulders, for example, or a back sleeper with a big butt and a firm bed.

Lumbar Support

Lumbar support can help decrease stress on the spine throughout the night. You could try a folded towel, but if that doesn’t work consider purchasing a lumbar support sleeper from a manufacturer. These are relatively cheap. We recommend the Propair Sleeper (click picture for link to website).

Managing Morning Pain and Stiffness

The spinal discs are highly pressurized first thing in the morning. Refrain from bending or lifting activities for the first 1-2 hours after waking. This includes doing laundry, emptying the dishwasher, strenuous exercise (neutral spine exercises are generally okay), bending stretches, etc. Sitting for the first 1-2 hours of the day could also be a problem.
More tolerable morning activities would include showering, going for a morning walk, or making breakfast.
The discs become more pressurized the longer you’re in bed, so regularly sleeping longer than the typical 7-9 hours could cause symptoms as well.
Side sleepers often find relief with a pillow between the legs. For back sleepers, placing a pillow under the knees may help.
Adopt a sleeping position that allows you to maintain a neutral spine. The common fetal position, for example, can flatten the lumbar curve (if the knee is up too high) and/or cause unwanted twisting of the spine.
Use the “log roll” technique when rolling over in bed, this will help you avoid painful twisting of the spine. Also, make sure you are getting out of bed properly. These techniques are covered in our Youtube video: “Tips For Morning Back Pain”.

Investing Wisely

If you do end up buying a new bed, use the trial period! When purchasing a bed, please be a smart consumer. Use the 60/90/120 day trial and see if your back feels better in the morning. Maybe that means keeping your old mattress in a spare room, but have a back-up option in place. In the next five years, you’ll be getting about 15,000 hours of quality rest on this bed. It’s worth getting it right.

Best Mattress

References:

McGill, S. (2015). Back Mechanic. Gravenhurst, Ontario: Backfitpro.

McGill, S. (2017). Ultimate back fitness and performance. Gravenhurst, Ontario: Backfitpro

McGill, S. (2016). Low back disorders: Evidence-based prevention and rehabilitation. Champaign, IL: Human Kinetics.

Articles

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The Low Back Surgery Checklist

Selecting The Best Mattress For Your Back

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