“Why did they cut you?”

The shocking question came from a respected spine surgeon tracked down by Keith Swenson, who was still in severe pain after an earlier back operation.

He didn’t know what to believe. Two other surgeons had urged more operations, different ones.

And Swenson, who’s from Howard Lake, Minn., is far from alone. Even though only a fraction of people with back pain are good candidates for surgery, complicated spine operations are on the rise.

So is the hunt for any relief.

By one recent estimate, Americans are spending a staggering $86 billion a year in care for aching backs — from MRIs to pain pills to nerve blocks to acupuncture. That research found little evidence that the population got better as the bill soared over the past decade.

“The way medicine is so Star-Treky these days, they believe something can be done,” said Dr. Charles Rosen, a spine surgeon at the University of California, Irvine.

The reality is that time often is the best antidote. Most people will experience back pain at some point, but up to 90 percent will heal on their own within weeks. In fact, for run-of-the-mill cases, doctors aren’t even supposed to do an X-ray or MRI unless the pain lingers for a month to six weeks.

Yet a study last year found nearly one in three aching Medicare patients get some kind of back scan within that first month.

Why is that a problem? Those scans can be misleading. By middle age, most people who don’t even have pain nonetheless have degeneration of their disks, those doughnut-looking shock absorbers between vertebrae. So in someone who does have pain, pinpointing that a particular black spot or bulge on a scan is the true cause is tricky.

The bigger problem: When the misery lingers, there’s no one-size-fits-most treatment.

“There are a lot of procedures going on for patients in whom we don’t have good scientific evidence that it’s going to help,” said Dr. Richard Deyo of Oregon Health and Science University in Portland, who long has studied how people fare with different options for this tough ailment.

For example, there’s a wide variety of spinal injections that aim to numb back pain, using different drugs and targeting different spots. Which one works depends on what study you read.

When the Institute of Medicine recently listed the 100 how-to-treat questions that doctors most need answered, back pain neared the top of the list.

Lots of things can cause chronic back pain, from arthritis to bone-thinning osteoporosis, which has its own controversy over whether cementing cracks in the spine really helps.

But those cushiony disks are a big reason. They naturally thin and shrink with age. Sometimes they herniate, or rupture, so the gel-like center leaks and pressures a nerve. Sometimes a vertebra slips out of alignment. Sometimes the spinal canal painfully narrows, a condition called stenosis.

The right operation can help, but specialists say only about 10 percent of people with lasting pain are candidates. More than 333,000 of the simpler decompression operations — laminectomies and diskectomies that cut away part of a bone or disk to relieve nerve pressure — were performed in 2007, the latest data compiled by the American Academy of Orthopaedic Surgeons. There were nearly 381,000 spinal fusions — more complex, riskier surgeries that bind vertebrae together with a bone graft and sometimes metal hardware.

There is some hopeful news — increasing evidence that more people should try pushing past the pain in aggressive exercise programs. Deyo calls them boot camps for back pain.

That’s what ended Swenson’s five-year pain odyssey. After a volleyball injury, scans showed he had degeneration in seven disks but one bulged in a way that doctors thought explained the pain radiating down both legs. They cut away part of that spot; it didn’t help. Neither did multiple pain-blocking options.

“Exercise is medicine, but it has to be the right exercise,” said Dave Carpenter, president of Physicians Neck & Back Clinics in Minneapolis, where Swenson finally turned.

The clinic’s rehabilitation program focuses on strengthening muscles that support the spine, and published a study showing that only three of 38 patients prescribed surgery still needed it in the 13 months after completing tailored rehab.

Swenson, now 51, said he was so debilitated that it took several months to improve, plus two years of “maintenance” conditioning. Today, he’s running a thriving gardening business near Minneapolis that ships peonies nationwide. It’s a job that requires tremendous manual labor.

“Do I have flare-ups? Yes. But now that my back is strengthened, instead of flare-ups lasting one to two months … the flare-ups last one to two days,” he said. “This form of treatment is a lifetime change.”

In New York City, Nicia Cortez wishes someone had told her of other options before her 2003 operation on a herniated disk.

“I was naive, and in severe pain. I didn’t think properly at the time,” said Cortez, who felt worse after surgery. It took her six years to work up the nerve to try again, this time a fusion that mostly relieved the pain: “I have my life back.”

Her new doctor cautions that scar tissue and altered anatomy mean each subsequent back surgery has less chance of success than the one before.

“It’s like trying to pave your driveway, layer upon layer, but at some point you replace the whole driveway. We don’t have that ability with the spine,” said Dr. Alok Sharan, spinal chief at New York’s Montefiore Medical Center.

He makes patients exhaust nonsurgical options first, knowing that about one in five who has one back operation will have another in a decade.

“Sometimes people jump to this and think it will be a cure-all, and then five years later you need another procedure. If you’re only 40, that’s a big deal,” Sharan said.

What’s the best advice? First, some types of back pain are accompanied by red flags that need immediate attention — such as numb or weak legs or urinary problems. But for most people:

_Don’t expect an X-ray, MRI or CT until a month to six weeks has passed, unless the doctor suspects a more serious problem. Following that guideline is becoming a quality-of-care measure in many organizations.

_Get back to normal activity as quickly as possible; the days of prescribed bed rest are over.

_Patients with sciatica, pain radiating down the leg, have the best outcomes from those nerve-easing decompression surgeries, Deyo stressed. California’s Rosen said three criteria determine chances of success: a scan that correlates with the pain site; the patient has some weakness; and specific pain occurs when the doctor raises and straightens the legs.

Herniated disks heal on their own over about two years, but surgery for a faster fix is reasonable in good candidates, he said.

Fusions are appropriate for far fewer patients, those with fractures, unstable or slipping spines, curvature of the spine and rare other reasons, Rosen said.

Deyo recently studied surgeries for stenosis, that painful narrowing, and found decompression surgery as effective and less risky than fusions, which are more complicated and costly.

A formal exercise program is especially effective if coupled with cognitive behavioral therapy that teaches patients to manage and function with pain, Deyo said.

What if surgery fails? Usually, it was the wrong operation or the wrong candidate, said Rosen, who sees one or two patients a week classified as having “failed back syndrome” because of multiple failed surgeries.

Always get a second opinion. Rosen, who founded the Association for Medical Ethics, also recommends asking about a doctor’s ties to companies that make spine-surgery products. That way you’ll feel assured that a recommendation to cut doesn’t come from a too-cozy relationship.

Not a good candidate? A primary care physician can be a neutral adviser in helping navigate next steps. Patients with more challenging back problems may fare better at a multidisciplinary spine center with numerous specialists — in rehab and pain management — under one roof.

“You don’t want to leave them hanging,” said Rosen.

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A study of Medicare patients shows that costlier, more complex spinal fusion surgeries are on the rise — and sometimes done unnecessarily — for a common lower back condition caused by aging and arthritis.

What’s more alarming is that the findings suggest these more challenging operations are riskier, leading to more complications and even deaths.

“This is exactly what the health care debate has been dancing around,” said Dr. Eugene Carragee of Stanford University Medical Center.

“You have one kind of operation that could cost $20,000 and another that could cost $80,000 and there’s not good evidence the expensive one is being used appropriately in the majority of cases,” Carragee said.

Add to that the expense for patients whose problems after surgery send them back to the hospital or to a nursing home and “that’s not a trivial amount of money” for Medicare, said Carragee. He wrote an accompanying editorial in the Journal of the American Medical Association where the federally funded study appears Wednesday.

The cost to Medicare, just for the hospital charges for the three types of back surgery reviewed is about $1.65 billion a year, according to the researchers.

All the patients in the study had stenosis in their lower backs, a painful squeezing in the spine that’s most common in people over 50. The researchers compared the risks for three different types of surgery for the condition: decompression, simple fusion and complex fusion.

“All operations aren’t the same and some seem to be associated with higher complication rates than others,” said lead author Dr. Richard Deyo of Oregon Health and Science University in Portland. “It’s not necessarily true that the more aggressive surgery is better, at least in terms of safety.”

There’s little agreement about the best way to treat chronic lower back pain, and much depends on what’s causing the pain.

Patients should ask their doctors about alternatives to complicated operations, Deyo said. Could steroid injections and physical therapy be tried? Would a simple decompression procedure be as helpful as a spinal fusion and with less risk?

In a decompression procedure, the simplest method in the Medicare study, a surgeon cuts away part of the bone that’s painfully pressing on nerves. It can cost about $30,000 in hospital and surgeon fees.

For a fusion, a surgeon binds two or more vertebrae together using a bone graft, with or without plates and screws. The researchers defined a complex fusion as one involving three or more vertebrae or more than one side of the spine. Fusions cost $60,000 to $90,000.

The researchers analyzed data on more than 32,000 Medicare patients who had one of the three types of surgeries in 2007.

About 5 in 100 patients who had simple or complex fusions suffered major complications such as stroke compared to 2 in 100 with decompressions. The risk of death within 30 days after surgery was different too: 6 in 1,000 for complex fusions compared with 5 in 1,000 for simple fusions and 3 in 1,000 for decompressions.

The study didn’t address how successful the various types of surgeries were at relieving pain.

More than half the patients who had complex fusions had a simple stenosis, which usually calls for decompression alone. They did not have the curvature of the spine or a slipped vertebra — additional conditions that might suggest a fusion is needed. There’s not much evidence for doing a complex fusion for a person with simple stenosis, Carragee and other experts said.

“It certainly looks like there’s more complex surgery being done than we have very good evidence to support,” Carragee said.

Rates of complex fusions in Medicare patients rose 15-fold from 2002 to 2007, while decompressions and simple fusions declined, the study found. Although the overall procedure rate fell, hospital charges grew 40 percent.

Aggressive marketing of devices used in complex fusions is likely playing a role in the increase, Deyo said. The marketing includes ads in medical journals and lectures by surgeons on the payroll of device manufacturers.

Allegations of kickbacks to spine surgeons for using products and questionable financial arrangements to doctors as consultants have plagued the multibillion-dollar industry. One company, Medtronic Inc., reached a $40 million settlement with the U.S. Justice Department in a whistleblower case that included allegations the company paid doctors to use its spine surgery products. The company denied any wrongdoing.

Dr. Charles Rosen, a spine surgeon at the University of California, Irvine, founded the Association for Medical Ethics to nudge doctors toward scientific evidence over vested interests. Forty-nine spine surgeons have joined, pledging to refuse any type of compensation or earnings from companies for using a product.

Rosen applauded a provision in the new health care law that requires device makers and others to file annual reports to the government on their financial ties to doctors. Patients will be able to look up possible conflicts in a government database.

“Too much fusion surgery is done in this country and often for inappropriate reasons,” Rosen said. While complex fusions are needed for some conditions, he said, patients “should not hesitate to get a second opinion.”

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