Q&A Time! When to Refer for Spinal Surgery? | Modern Manual Therapy Blog

Q&A Time! When to Refer for Spinal Surgery?

I received a question from one of my online mentees recently. He asked: Have you ever referred your patient for spine surgery and based on what criteria ? - referring to lumbar

This is a good question and I base this on several criteria

  • loss of bowel and bladder control that worsens with motion/position
  • zero improvement or worsening neurologic signs within 2-4 visits
  • suspected cauda equina syndrome
That's it really! In my 16 year career, I have only referred directly for surgery maybe once or twice for lumbar, maybe a bit more for cervical spine (suspected upper cervical instability). I rarely refer directly for surgery, but have referred some spinal patients to the radiologist when they had zero improvement within 4-6 visits, persistent severe pain, and no positions of relief or directional preference was found. 

An example was written a while back on the blog of a lumbar case that myself and a mentee DipMDT were co-treating. That can be found here.

In the end, it's about knowing your weaknesses and doing what's best for the patient. Other than the case for central sensitization, we should expect rapid change in at least the first two visits, and/or some change occurring within the first month. Treating someone with little to no change longer than that is probably doing them a disservice. I usually present referring them out as just another step in their care, and part of my Plan B. It also does not mean, I my patient relationship will stop, as I am usually in contact with the specialist I referred to, and also tell the patient we can try again if scans/tests are negative for anything that requires a more invasive intervention. Sometimes a negative scan with some Pain Science Education from my side can turn around a case that was not responding.

Keeping it Eclectic...


  1. I believe surgery should always be the very last option. Such as in cases where there is intractable leg pain that does not resolve with position changes, significant leg weakness with episodes of falling/loss of balance, bowel & bladder incontinence (possible Cauda Equina syndrome), major instability such as spinal fracture (primary reason surgery such as lumbar fusion should be warranted).
    That being said conservative management should be explored first; at least 6 months of PT, referral to another clinician who is better than you are at managing the spine (hard pill for some PTs to swallow), and pain management (work as a team with physicians).

  2. 6 months of PT is overkill for spinal complaints.

  3. Sure, I should have said 6 months of multidisciplinary management before surgery. Perhaps getting patients to buy into a good home program of stabilization and sensory motor control could also help. Of course, this is all case specific and there is no cookie cutter solution/quick fix.