What I Still Don’t Know About Pain

We often stare at MRI images searching for answers. Yet the image reveals only anatomy. It shows the shape of bones, ligaments, and nerves, but not necessarily how they function. It cannot fully explain why one patient suffers intensely while another with a nearly identical image walks comfortably. Some of the most challenging patients are those whose pain far exceeds what the imaging appears to justify. Even today, there remains a gap between what we can see and what we can truly understand.

There is a truth that surgeons must admit with humility. Despite extraordinary advances in medicine, what remains unknown still far exceeds what we understand. The causes of pain are countless, and in many patients they cannot be fully explained by any single image, laboratory result, or diagnosis. A herniated disc fragment can be removed with a scalpel or an endoscope. Yet surgery cannot instantly reverse the biological consequences of prolonged nerve compression, nor can it erase the complex ways in which pain becomes embedded within the nervous system.

The course of recovery varies remarkably from one patient to another. What a surgeon can address in the operating room is ultimately a structural problem. To assume that correcting anatomy automatically restores function is a form of surgical arrogance. Once physical compression has been relieved, the process by which an injured nerve heals and regains function unfolds through biological mechanisms that remain, to a significant degree, beyond the surgeon’s control.

These limitations of surgery create an equally important responsibility outside the operating room: honest communication. Thoroughly discussing the goals of surgery, its limitations, and the time required for recovery is not secondary to the procedure itself. Patients deserve to understand that surgery is not a magic intervention capable of instantly eliminating every symptom. The conversation before and after an operation may be as important as the operation itself.

The longer I practice, the less I believe that spine surgery is about eliminating pain completely. More often, it is about creating an opportunity for recovery. Surgery opens a structural window through which healing may occur, but the journey that follows belongs not only to the surgeon, but also to the patient’s biology, resilience, and time.

Maintaining humility before the extraordinary complexity of the human body — and recognizing how much about pain remains unknown — may be among the most important responsibilities of a surgeon. It is a responsibility that continues long after the incision has healed.