There are four groups of patients:

  • IA—Structural lesion, low risk for chronic pain
  • IB—Structural lesion, at risk for chronic pain (high stress)
  • IIA—Non-structural lesion, low risk for chronic pain
  • IIB—Non-structural lesion, at risk for chronic pain (high stress)
  • An overview of how this looks is presented in this grid:


Low Risk for Chronic PainA High Risk for Chronic PainB
Structural Lesion


Non-Structural Lesion




The implications of this grid are important in making your decisions. It will be the basis of the discussions regarding the role of surgery in your care. I am a busy surgeon and I have found out that if a patient is not under a lot of stress (Type A) then outcomes are consistently positive if a structural problem (Type I) is addressed and solved. However, if that same person is in the middle of a major personal or professional crisis, then the results are less predictable. Surgery may still be helpful but the other factors need to be addressed.

Patients who do not have a lot of extra stress and are experiencing pain without a positive imaging study (Type IIA)  simply do not want or request surgery. Why? It is just pain that will resolve and it usually does.

The biggest problem we have in spine surgery is performing surgery on people who are stressed and the source of pain can’t be identified. Since mental and physical pain are processed in a similar area of the brain with the same chemical response of adrenaline and cortisol, the pain is often intense and people become desperate. First of all, surgery is never indicated without identifying the cause (Type II – non-structural). So the chances of success are already low. Then you add in the other factors that have been shown to adversely affect surgical outcomes (poor sleep, anxiety, depression, fear avoidance, poor physical conditioning, smoking, duration of pain, younger age) and the chances of an operation being helpful are not only low, patients often get worse. It is surgery being performed in this group that is creating a lot of ongoing pain and disability. It is critical for you to become aware if you fall into this group.