Decision Making in Spinal Surgery is a critical process. An operation permanently alters the anatomy of the spine: therefore a patient needs to receive a recognizable benefit. Surgery is not about changing x-rays: it is about changing quality of life.The value of surgery can be measured simply by two equations:

Degree of disability = magnitude of treatment
What was the patient like before surgery = What is the patient like after surgery matures
Two question can be asked by the preoperative patient to implement the decision processes:
1. Are there general principles for decision-making in spinal surgery?
2. Are there specific decisions for individual conditions and specific diagnoses?

The Surgical Condition
Why have surgery? The classic reasons are: Deformity, Pain, Neurological Dysfunction, Functional Impairment.
These are the questions that apply to the surgical condition as a generalization. The specific answers to these questions can be obtained from your surgeon when a particular diagnosis is established. These questions are only the skeleton.
Surgery has timing factors: relief involves the present and prevention involves the future. Does a specific operation linked to a particular diagnosis accomplish either objective? What is the initial and long term success rate of a procedure?
What group or sub-group of a particular diagnosis does a particular patient belong to? What characteristics of the patient's condition make the patient an ideal member of a particular group with a specific surgical outcome and what features (if any) alter the individual's prognosis for that particular group in surgery?
How are patients grouped?
1. Each diagnosis involves clinical, physical and diagnostic test information. This collection of information forms the basis of grouping patients for a surgical outcome. In other words, what happens to patients with similar characteristics with the same diagnosis? How do different patient characteristics make a patient part of the group or different from the group with the same diagnosis and how does this effect results? (individual factors count)
2. What are the predictive factors for a particular group of patients with a specific diagnosis and what factors influence the probability of a particular outcome in a sub-group of patients with the same diagnosis? 
3. Can different operations be compared for a specific diagnosis? Are there sub-groups within a diagnosis influencing choice of anatomic approach and surgical technique?

The Surgeon
Background: Spinal Surgery is a distinct specialty. Surgeons performing spinal operations should be specifically trained by fellowship after the completion of residencies in orthopaedic surgery or neurosurgery. In the ideal circumstance, your surgeon should have a practice exclusively devoted to spinal surgery. 
Why does this make sense? 
1. Information Age Decisions: The amount of increasing information in spinal surgery demands specialization to control, digest and integrate this medical information into clinical practice. There is only so much time and as information quantity is rapidly exploding, controlling that information requires focus and concentration on that particular area. An informed surgeon enlarges the choices for patients. Surgeons rarely recommend something they do not do or do not understand. 
2. Experience: Operating on the same anatomical regions (cervical, thoracic, lumbar spine) breeds a familiarity that leads to enhanced surgical experience. Surgery is a mechanical act: repetition breeds experience, experience breeds judgment, and judgment and technical skill breed excellence. The surgeon viewing the same pathologies and variations on those pathologies gains experience that cannot be acquired by occasional exposure. Spinal surgery demands full time exclusive dedication. 

Order of Decisions
1. Indications and Timing of Surgery: Indications for spinal surgery require an analysis of the patient's specific clinical condition.
Indications are the factors of a patient's clinical problem which surgery addresses, either because of the consequences of not having surgery (eg. loss of control of bowel and bladder function, paralysis, etc.) or the symptoms being amenable to surgical correction in a circumstance where those symptoms impact the patient's life (leg pain, muscle weakness, etc.)
The surgical questions are simple: If a surgeon alters the anatomy what does the patient get out of it? (the patient trades one abnormal anatomical state before surgery for another abnormal state created by surgery, so the focus is on the value of that change for the patient's life) How does surgery measure up against nature (or conservative treatment) with a particular condition? Nature has been in the business 3 billion years, modern spinal surgery is 30 years old. (the last 15 years spinal surgery has undergone a revolution that makes the landscape of surgery so different than it was 15 years ago, that it seems like an entirely different specialty) Nature does some things extremely well, but doesn't always deliver the desired result: surgery does specific things in the breach of nature's failure. The surgical decision must be framed against the success and timing of nature. Certain surgical solutions are optimized to a particular time. In other words, the percentage success of certain operations are related to the duration of patient symptoms or a particular condition. Frequently, there is a crossover point between the time-value of nature (duration of conservative treatment) and the optimal timing for the best surgical results. Endless conservative treatment that moves a patient beyond the optimal time for surgical intervention is not helpful to the patient. The patient needs to understand the value of conservative treatment and its proper duration and the optimal timing for the best results in surgery. This allows the patient to make informed choices regarding the value of a particular treatment as it effects the duration of their symptoms, the intensity of their symptoms (minor to severe), and the direction of their symptoms (plateau, worsening, improving). Some conditions do not have a timing factor and the results are independent of the duration of the patient's symptoms. Therefore, surgery should not be viewed as the last resort but be placed in the proper perspective of the total treatment options of the patient. 

2. Choice of Operation
Spinal Surgery is like golf: the location of the ball influences the choice of the club. If you're ball is in the sand trap, you are not going to choose a driver. If you're ball is your particular anatomical problem, then you want to choose an operation that fits the location of your problem. In many instances, you have more than one choice. Many operations apply to the same diagnosis. The analysis of surgical choice involves examining the diagnostic studies (MRI, Myelogram, C.A.T., CT-discograms, etc.) and deciding the optimum surgical tactic that leads to addressing the anatomical problem. Some operations may be larger and some smaller applied to the same anatomical problem. Some operations may involve approaching the spine from different angles to achieve a similar benefit. Different operations and approaches have different complication potentials and their are nuances among procedures affecting the quality of result. In the end , you want an operation that optimizes your success, minimizes your time to recovery but at the same time is sufficient to address your problem. This is the conundrum of the surgical consultation. The pluses and minuses of options leading to choice. 

Pre-Operative Format of Thinking
What format should a patient expect for Pre-Operative Evaluation?
1. Review the indications for the proposed surgery? Do I still fit? Have my symptoms changed?
2. Discussion of the alternative surgical choices and non-operative choices.
3. Review the diagnostic studies with the physician and have the surgeon explain how the operation fits the anatomy.
4. Receive the guidelines from the surgeon for the pre-operative and post-operative instructions.
Risk and Benefit Analysis of Surgery Return to Menu
1. Potential benefits of surgery: what does surgery accomplish in terms of altering my symptoms, physical findings and quality of life?
2. Potential risks: what chance exists that surgery will not accomplish the goals, or lead to other consequences?

The surgery ladder asks the questions: is the amount of surgery and surgical results equal to the degree of disability and the quality of life problem of the patient? The larger the surgery, the bigger the question? Is the patient having current clinical symptoms addressed in surgery or is the operation to prevent a future set of symptoms?