Spine surgery is out of control. I am not against surgery and I was a complex spinal surgeon for 32 years. From the beginning of my career, I felt that too much surgery was being performed. But for my first eight years of practice, I was a part of this aggressive approach. When a research paper came out in 1993 showing the return-to-work rate was only 22% after a low back fusion for pain, I immediately stopped performing that operation. (1)

But he rate of spine surgery has continued to rise in spite of evidence that much of it is ineffective. It rose rapidly in the mid-1990’s with the introduction of new techniques that did improve the fusion rate. However, outcomes haven’t improved, and disability keeps rising. Why?

“Let’s try spine surgery”

Spine surgery works wonderfully well when there is a distinct identifiable anatomical abnormality, and the symptoms are in the expected region of the body. However, it works poorly if surgery is done for “pain” and the source of it is unclear. There is a widespread belief among patients and many physicians that if everything else has been tried and failed, then surgery is the next logical step. Nothing could be further from the truth.

Defining the correct anatomical problem to surgically treat would seem to be the first logical step. However, this step is often not done well. One of the most glaring examples of blindly proceeding with surgery in spite of the evidence stacked against it, is performing a fusion for low back pain. There was one paper in 2001 that hinted it might be effective, but it was sponsored by a spinal instrumentation company, and the non-operative care was not defined. (2) One well-known paper compared lumbar fusions for pain to a solid rehab protocol and the non-operative care resulted in better outcomes. The final comment in the paper was that “this type of care wasn’t widely available.” (3)

• It is well-documented that disc degeneration, bone spurs, arthritis, bulging discs, etc. are rarely the cause of back pain. So, when a fusion is performed for LBP, we really don’t know from where it might be arising. (4)
• The success rate of performing a fusion for LBP is less than 30%. (5) Most people expect a much better outcome and the resultant disappointment is also problematic.
• If any procedure is performed in a person with untreated chronic pain in any part of the body, he or she may experience chronic pain at the new surgical site up to 40-60% of the time. Five to ten percent of the time it is permanent. (6)

Trip to the dentist

Consider going to the dentist with a painful cavity that may require a root canal, crown or extraction. There is a defined problem, and the pain will predictably disappear once the problem is solved. But what about the situation where you might be having severe mouth or jaw pain, and there isn’t a tooth that seems to be the source. Would you expect your dentist to randomly try working on different teeth to see how it might work? After all, these are minor interventions compared to undergoing spine surgery. What if the problem is gum disease, a sinus infection, TMJ, or even a tumor in your oral cavity? Making an accurate diagnosis of the problem is always the first step in solving it.

The treatment grid

My intention is to educate you and anyone on your health care team about all of the issues that factor into deciding whether to undergo spine surgery. There are two sets of variables: 1) the type of anatomy – can you see it on a diagnostic test? 2) The status of your nervous system and resultant body chemistry. Are you calm? Or are you stressed and hyper-vigilant? If your nervous system is on “high alert” for any reason, the outcomes of surgery are predictably poor, especially if you can’t identify the anatomical problem. The combinations result in four possible scenarios. The book is based around this treatment grid:

• IA—Structural lesion, calm nervous system
• IB—Structural lesion, stressed
• IIA—Non-structural lesion, calm
• IIB—Non-structural lesion, stressed

The Treatment Grid

You will be able to place yourself in the correct quadrant with the help of your providers. Each one has a distinct treatment approach, which will allow you to make better treatment choices. The most basic decision is that if there isn’t a clearly identifiable source of pain, then surgery isn’t an option, regardless of how much pain you are experiencing. Low-odds surgery in the presence of untreated chronic pain has a high chance of making you worse – much worse. Especially if the surgery doesn’t go well.

Mike

Mike was in his mid-40’s and had just moved to Seattle about six months earlier. He was undergoing some physical testing to qualify for a government job. During the process, he tripped and twisted his back. His back pain was severe with a lot of muscle spasms. About four months after the fall, a surgeon elected to perform a fusion at his lowest level of his spine (Lumbar 5-Sacral 1). He had a small bony defect called a spondylolisthesis that had been there his whole life and was unlikely to be the source of his acute back pain. There was no reason to consider surgery.

During the operation, one of the screws used to stabilize his spine was misplaced and impaled the 5^th lumbar nerve root. It was removed a couple of days later, but the damage had been done. When he saw me for another opinion about a year later, he was still experiencing severe pain down the side of his right leg. He had no leg pain before the surgery. He was on high-dose narcotics without relief. He had already figured out that the surgery was unnecessary and was really angry about it. His life as he had known it was gone – permanently. There was nothing that I could do, I heard a couple of years later that he had undergone yet more surgery without any relief.

This book will enable you to understand the difference between a spine problem that is amenable to surgery versus one that is not. It covers the whole spine from your neck to your pelvis. You will also be able to assess the state of your nervous system and resultant body chemistry. If you are stressed, there are simple, consistently effective measures that can calm your nervous system. The goal of the comprehensive treatment process is to help you become pain free with or without surgery.

Whatever you decide to do or what resources you might use, don’t jump into spine surgery until you understand the whole picture. It may be the most major decision of your life.

1. Franklin GM, et al. “Outcomes of lumbar fusion in Washington state workers’ compensation.” Spine (2994); 19: 1897–1903; discussion 1904.
2. Fritzell P, et al. “Swedish Lumbar Spine Study Group. Lumbar fusion versus non-surgical treatment for LBP.” Spine (2001); 26: 2521-2532.
3. Brox J, et al. Randomized Clinical Trial of Lumbar Instrumented Fusion Cognitive Intervention and Exercises in Patients with Chronic Low Back Pain and Disc Degeneration. Spine2003; 17: 1913-1921.
4. Boden SD, et al. “Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation.” J Bone Joint Surg (1990); 72:403– 8.
5. Carragee EJ, et al. “A Gold Standard Evaluation of the ‘Discogenic Pain’ Diag­nosis as Determined by Provocative Discography.” Spine (2006) 31:2115-2123.
6. Ballantyne J, et al. Chronic pain after surgery or injury. IASP (2011); 19: 1-5.

Video: Get it Right the First Time

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Prehab

We decided that if the surgical results were so much better, we would have all of our patients engage in at least 8 to 12 weeks of “prehab” before any surgery, regardless of the magnitude. Our protocol included:

• Learning about chronic pain through my book, Back in Control: A Spine Surgeon’s Roadmap Out of Chronic Pain.
• They were sleeping at least six hours a night (often required meds).
• Addressing their stress.
• Engaging in the expressive writing exercises.
• Learning and using active meditation.
• Noting some improvement in their mood and pain.
• Narcotic medications were defined and stabilized.

We encouraged them to return, but we weren’t going to perform surgery without them engaging in a prehab process.. The data shows that not addressing these issues significantly compromises surgical outcomes. (1)

What Happened?

I am enjoying my practice at a level that I could not have imagined. Our patients are doing well and excited about their progress. What I didn’t expect was that so many patients would become pain-free without undergoing surgery I thought they needed. We presented a research paper reporting on a group of patients who’d come in for their final preoperative visit, and their pain was gone. Of course, we canceled the surgery.

What was even more surprising was the severity of the problems. Normally, the diameter of the spinal canal is about 15 mm. I don’t schedule surgery unless the canal is less than 8 mm, and the patient has leg pain. I have one patient who avoided surgery with a four mm canal.

Janet’s Story

The following letter is from a woman whom I saw last summer with a large synovial cyst. This is a problem where a sac of fluid is formed off a facet joint off the back of the spine. It was not only pinching her sciatic nerve, but it was calcified, which means it couldn’t shrink. I immediately offered her a small operation to remove it. The outcome of removing the cyst is predictably positive with few complications. It is one of my favorite procedures. I offered her the prehab process through my book and website. I also thought the pain center would help. I was surprised that she did not immediately take me up on surgery. She never returned to see me, and I received this letter from her about eight months later.

Dear Doctors,

Last summer, an MRI scan revealed a synovial cyst in my back. I had severe pain from cramps in my butt and calf muscles. My family doctor referred me to your office.

I am writing to update you on my status, which is greatly improved. On my initial visit at the Pain Center, the doctor asked me to keep a journal of what I couldn’t do.

What I cannot do because of pain

I cannot get up in the morning in a flash. I need to exercise and stretch my right leg in bed, roll carefully out of bed to ice my butt and calf, do stair-step exercises, and then finally do a 20 to 30 minute “working with pain” meditation. I can’t sit in any chair I want because my butt muscle will spasm. Car seats are hard to sit in. I have to get out at least every 45 minutes to stretch. I was on Gabapentin, Cyclobenzaprine, and Ibuprofen. I followed the Back-in-Control program, writing down my thoughts and beginning to focus on what I wanted to do, including returning to dance class. In early October, I began sleeping in a semi-upright position, with a pillow under my legs, and the cramping began to subside. I also had biofeedback training. By mid-November, I was able to get off all pain medications and start lifting weights again.

I have very occasional twinges in my right butt when sitting or walking, but I am basically pain-free. I am so grateful for the chronic pain management program and extremely grateful that you offered the program rather than immediate surgery on the synovial cyst.

Many, many thanks.

Sincerely,

Janet

Do Surgery Now??

I had forgotten about her case, so I reviewed her MRI scans and was shocked to see the size of the cyst. However, I have been surprised at the severity of the pathology with every surgical patient I have witnessed becoming pain-free without an operation. In fact, in the first edition of my book, I comment that if a patient has a significant structural problem with matching symptoms, surgery should be performed quickly so as to move forward with the comprehensive rehab program. I thought the pain would be too distracting to be able to participate. The opposite scenario occurred in that when I performed surgery in the face of a fired-up nervous system, the pain would frequently be worse. I eventually discovered this problem has been well-documented in the medical literature. (1) Chronic pain can actually be induced or worsened as a complication of any surgical procedure, including painless ones such as a hernia repair. One of the risk factors is pre-existing chronic pain in any part of the body.

I now have dozens of stories similar to Janet’s. There are many times that I do perform urgent surgery for compelling problems. But if there’s any room to have my patient participate in the prehab, that is what we have them do.

Video: Get it Right the First Time

Ask for This Approach!

I’m excited about this turn of events, although it is becoming a little challenging maintaining a surgical practice. The medical literature has clearly documented that this process is effective. Ask your doctor to help you out with setting up your own program. You don’t need a major pain center, as the necessary resources are readily available.

Every surgery has risks, and no one thinks a complication will happen to him or her. I have seen them all. They are unpredictable, and the outcomes can be catastrophic. Also, why would you not want to maximise your odds of success. Do you really need surgery? Be careful!!

Are You Kidding Me?

Perkins FM and Henrik Kehlet. “Chronic Pain as an Outcome of Surgery.” Anesthesiology (2000); 93: 1123-1133.

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Health care professionals want to provide healing. When we don’t have the tools to help you, all parties become incredibly frustrated. Additionally, the most basic healing modality is feeling safe with your provider because it creates a shift in your physiology to one of safety or “rest and digest. This is where healing occurs, and we are limited by the business of medicine that won’t let us spend time with our patients. How can we know you? What is your life like? Are you feeling stressed? How can we methodically understand your care up to this point, and make thoughtful decisions about what to do next? What has been done to optimize your chances of a good outcome of surgery?

Modern medicine is evolving in a dangerous direction with regards to your care. The major factor in deciding to offer a procedure or treatment is often whether it’s covered by insurance and how well it is reimbursed. The effectiveness of the intervention is a lesser consideration. In fact, we are sometimes encouraged to perform surgeries that have been documented to be ineffective. Additionally, there is little accountability for the outcomes unless there is severe negligence.

Profits over quality

The business of medicine, like any other business, is focused on making a profit. There are computer programs that monitor physicians’ contribution to the profit margin. The most revenue comes from performing procedures, many of which have been documented to be ineffective.¹ The downside risks include unnecessary costs, significant risks and patients are often worse off than before the intervention.² It has also been documented that only about 10% of spine surgeons are addressing the known risk factors for poor surgical outcomes.³

Dr. Ian Harris, who is an orthopedic spine surgeon from Australia, has done extensive research on the utilization of ineffective procedures. He wrote a book, Surgery: The Ultimate Placebo, where he extensively documents the data behind many procedures for pain that have been proven to be of no benefit and it hasn’t stopped their use.⁴

We want to provide relief, it is what we are trained to do, but we are not aware of the alternatives. It is like trying to hit a major league baseball pitch with a golf club. I would have no insights either unless I hadn’t suffered with chronic pain for over 15 years.

What works?

There are many ways to cause your body to change from threat physiology to safety. A term for this is, “dynamic healing.” Input (your stresses) are processed in a manner that has less impact on your nervous system, the nervous system can be calmed down, and there are ways to directly stimulate the powerful anti-inflammatory effects of the vagus nerve.

Effective treatments are often not covered or don’t generate enough revenue. For example, expressive writing has be shown to been helpful in multiple medical conditions in over 1,000 research papers.(5) Yet, I had never heard of it until I accidentally ran across it in 2003. It costs nothing, has minimal risk, and is rarely presented as a treatment option. It has proven to decrease symptoms of asthma, depression, and rheumatoid arthritis, improve student’s athletic and academic performance, speed up wound healing, and diminish many other symptoms. I had dinner with one of the pioneers of the technique, James Pennebaker, who is a psychologist from Austin, TX. The methods may differ, but it has only been reinforced as an effective tool. There is a lot of debate of why it works, but not about whether it works.

Mindfulness-based stress reduction has also been demonstrated to decrease pain in many papers and is usually not covered by insurance. I watched several excellent pain programs in the Puget Sound shut down because they could not afford to keep them open.

Listening is a proven healing modality in addition to being a basic requirement to understand a given patient’s whole situation. Dr. Francis Peabody, a famous Boston physician, was concerned about the intrusion of technology into the patient-physician relationship. One of his more notable quotes was, “The secret of care is caring for the patient.” He wrote this in 1927 when he was concerned about the intrusion of technology into the patient doctor relationship.(6)

What about the patient?

A person suffering from chronic pain is trapped beyond words. My term for it is, “The Abyss.” These are just a few of the ways.

• You have told that there is nothing wrong and you have to live with your pain the best you can. The reality is that there is a physiological explanation for all of it.
• There does not seem to be way out. Most people lose hope. The solutions are there but not being offered. The patients who break out of it feel the healing process is “disturbingly simple.”
• You are labeled by almost everyone, including the medical profession. They include, drug seeker, malingerer, lazy, not motivated, making things up, not tough enough, and the list is endless.

When you are trapped by pain, your frustration and anger is deep and powerful. This scenario creates a more intense flight or fight response, the blood supply to your brain shifts from the thinking center to the survival midbrain, and your behaviors are not rational.

Another problem that is not often acknowledged is that of inducing a depression from repeatedly dashing people’s hopes. This was powerfully demonstrated by Harry Harlow.⁶

Inducing depression–“The Pit of Despair”

Harry Harlow was an internationally renowned psychologist who pioneered research in human maternal-infant bonding using primates. During the first half of the 20^thcentury, it was felt that mothers should touch their children as little as possible. Leading mental health professionals aggressively discouraged mother-child interaction in research papers, lectures, books, and the media. Interestingly, or tragically enough, their recommendations were based on rodent research.  Dr. Harlow was the leading force in changing the tide of opinion using various species of monkeys. His story is well-presented in an entertaining book, Love at Goon Park by Deborah Blum. (

In the 1960s, he turned his attention, also based on primate research, to some of the smaller details of human interaction.  He wanted to understand how to induce depression. He used isolation methods and ways of simulating parental neglect or even abuse. He was able to create seriously disturbed monkeys, but not depressed ones.

He finally found a consistent methodology by devising an apparatus that resembled an upside-down pyramid. The sides were steep, but still allowed the monkey to climb to the top to peek outside the mesh-covered top. For the first couple of days, the monkeys would repeatedly climb up to look out and quickly slide back down. Within a couple of days, they would give up, sit in the middle of the device, and not move. They became almost unresponsive, and when they returned to their families, they wouldn’t revert back to normal social behavior. It didn’t matter what problems the monkey had prior to the experiment. The abnormal monkeys became worse and normal monkeys suffered the same fate. Even the “best” monkeys from stimulating and interactive families would succumb. The researchers were upset and called the apparatus, “The Pit of Despair”. It was felt that this “learned helplessness” was from a combination of feeling the loss of a good life reinforced by occasional glimpses of the outside world and feeling trapped. Within a half a week, every monkey spiraled down.

Tulsa

The surgeon was doing what he was trained to do with the best of intentions. I would feel badly during the first eight years of my career if I could not find a way to relieve my patients’ pain with surgery. The patient was trapped at a level that is indescribable and surgery is often viewed as the definitive answer. It also requires enduring more pain and a lot of anxiety about the whole process. So, the level of disappointment is even higher when it fails.

The literature also shows that pain is often worsened when surgery is performed in the presence of untreated chronic pain.² I was also not aware of that data until after I had quit my surgical practice. For him to act out the way he did is unacceptable but understandable. BTW, suicide is problematic in patients suffering from relentless pain. I was also at that point towards the end.

Recap

Physical therapy, chiropractic adjustments, injections, acupuncture, vocational retraining, medications, traction, inversion tables, and finally surgery. How many times can your expectations be dashed before you lose hope? You cannot blame a person for actions taken in this state of mind.

All the parties were victims of the business of medicine and I put the blame squarely on its shoulders. There are many variables, but the energy is all directed the same direction–money.

The business of medicine has trapped both the providers and patients and with computerized medical records, it is getting steadily worse. There are real solutions, but both the medical profession and patients are going to have to demand it.

References

1. Jonas, JB, et al. Are invasive procedures effective for chronic pain? A systematic review. Pain Medicine (2019); 20: 1281-1293.
2. Perkins, FM, and Henrik Kehlet. Chronic pain as an outcome of surgery. Anesthesiology (2000); 93: 1123-1133.
3. Young AK, et al. Assessment of presurgical psychological screening in patients undergoing spine surgery. Journal Spinal Disorders Tech (2014); 27: 76-79.
4. Harris, Ian. Surgery, The Ultimate Placebo. New South Publishing, Sydney, Australia, 2016.
5. Pennebaker JW and JM Smyth. Opening up by Writing it Down. 3^rd edition. Guilford Press, New York, NY, 2016.
6. Peabody, FW. The Care of the Patient. NEJM (1927); 88:877-882.
7. Blum, Deborah. Love at Goon Park. Perseus Publishing, New York, NY, 2002.

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A patient’s story – spine surgery gone bad

I had anterior/posterior surgery on election day 2008. I was taken directly to the furthest room from the nurse’s station with no monitors. My husband came in to visit me and I was not breathing. As he called out…I had an out of body experience watching the doctor enter the room and watched him yelling for nurses. They put me into ICU for 4 days.

A number of things happened including the doctor ignoring me when I told him of things I felt were wrong. When they sent me to rehab, they sent me sitting up in a wheelchair van. PAINFUL. I was an inpatient for three days. The 2nd day home I was sent to ER with MRSA, sepsis and three blood clots. In total, I was in hospitals for 2 months.

The end results were that I couldn’t sit for any length of time without pain forcing me to retire on disability….sex was and still is impossible. Even a slight jolt shoots pain through my back. Cannot motorcycle any longer. Can’t walk on uneven surfaces like beaches. Can’t walk long distances. And am permanently on 2 pain meds to be functional without pain. My whole life changed in many ways as a result of this surgery directly and indirectly. At one point they dropped me…hitting the NG tube and knocking it out. That damaged the interior of my nose, and it has never been the same.

I wish I’d never had it. But because I couldn’t walk for more than 3 days before I was in bed with debilitating pain, I didn’t feel I had a choice. I was fused from L2 to S1 (bottom four levels of the lumbar spine).

My perspective

I am going simply list the issues in this situation.

• This surgery was probably performed for degenerative disc disease and back pain. Disc degeneration is not a disease, is part of the normal aging process, and has been well documented to NOT be a source of pain.¹
• The success rate of a spine fusion (welding vertebrae together with metal and bone) for back pain is < 30%.² There is not one research paper that has ever shown that a lumbar fusion for chronic LBP is effective compared with thoughtfully implemented rehab.
• The data also shows that when you have an operation in the presence of untreated chronic pain, you can induce chronic pain at the surgical site (or make it worse) between 40-60% of the time.³ In other words, there is almost double the chance of making a patient worse than solving the problem.
• There is little attention paid to optimizing the chances of success of an elective spine surgery. One paper showed that only 10% of surgeons addressed the known risk factors for poor outcomes prior to surgery.⁴
  • For example, lack of sleep has been shown to CAUSE chronic low back pain. How many surgeons are attending to just that one detail prior to recommending surgery?⁵
• The more levels of the spine that are fused, the higher the complication rate. This person had four levels fused and was fused both through the front and back of the spine. This is a big operation.
• People will undergo surgery because “everything else has been done.” That is simply not true. By systematically addressing all of the factors that affect the complexity of chronic pain, it is a consistently solvable problem.
• 90% of all chronic mental and physical symptoms in your body are physiological and created by sustained exposure to flight or fight stress chemistry. When your body stays revved up, it will predictably break down. The solution lies in learning ways to regulate your threat physiology to that of safety.
• Many surgical decisions are made quickly on the first visit and sometimes you may not even meet the surgeon. This makes no sense. Chronic pain is complex, you are unique, it impossible to deeply understand a situation in any domain of life on one visit.
• We put all of our patients through a minimum of 12 weeks rehab before any elective surgery, and longer if the variables affecting pain weren’t successfully addressed. The process was called, “prehab.”

Do You Really Need Spine Surgery?

I could write a book on this situation, and I did. It is Do You Really Need Spine Surgery? Take Control with a Surgeon’s Advice.⁶ It breaks down the decision-making around spine surgery into two factors.

• The nature of the anatomy
• The state of the nervous system

You’ll fall into one of four quadrants and the choices are clear. If you have a specific anatomical problem with matching symptoms and your nervous system is calm, surgical outcomes are much more predictable. Every other situation is problematic but still solvable.

I am not just trying to sell a book today. My mission is to do what I can do to slow down the juggernaut of aggressive spine surgery.

I was a surgeon who was called a “salvage surgeon.” I would see patients that had many surgeries over their lifetime, and their lives were destroyed. I was able to help many of them out, but it was more with the rehab than with the additional surgeries. At the same time, I was seeing so many patients break free from the grip chronic mental and physical pain with the concepts presented in The DOC Journey, that I could no longer just sit on the sidelines. There were minimal costs, no risks, and patients would thrive. All of the treatments are based on effective and deeply documented modalities.

Be careful

Please do not jump into any spine surgery without really understanding the issues and maximizing your chances of success. Certainly, do not allow any decisions of this magnitude to be made on the first visit. This person had better choices, but they were not presented or implemented.

Chronic pain is a solvable problem, with or without surgery. Surgery is only an option if there is a surgical lesion. A normally aging spine is not in this category. Do not become one of the patients in this blog who has had their life destroyed. As bad as your chronic pain is at the moment, it can be made a lot worse with an ill-advised operation. It is even more tragic in that the solution, as many of my patients have said is, “disturbingly simple.” Do not just trust a physician you barely know. The basic step is to develop a relationship with him or her. Then take control of your decision, pain, and life.

There is still hope

I don’t want this article to end on a down note. As bad as this situation looks, it is still a solvable issue. Your brain is incredibly adaptable, and you can reprogram it in any direction you choose. I have seen many patients in this bad of shape eventually become free of pain. One gentleman had undergone 28 surgeries in 22 years and has now been free of pain for over six years. In fact, he says that “I have never felt better in my life.” Another woman had been in pain for 50 years and has done well for over seven years.

The main factor that determines success is simply your willingness to engage or as one my successful patients has said, “suspend your disbelief.”

Please share your story of a failed spine surgery. I am more than aware that there are many successes, even for chronic low back pain. It is just that the success rate is not high enough to justify the risks of surgery and there are alternatives that are so much better. The world needs to know the downside of a failed spine operation in order to make more informed decision.

Questions for your surgeon

References

1. Jensen MC, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. NEJM (1994); 331:69-73
2. Carragee EJ et al. A Gold Standard Evaluation of the ‘Discogenic Pain’ Diagnosis as Determined by Provocative Discography. Spine (2006) 31: 2115 – 2123.
3. Perkins FM and H Kehlet. Chronic pain as an outcome of surgery: A Review of Predictive Factors. Anesthesiology (2000); 93:1123–1133.
4. Young AK, et al. “Assessment of presurgical psychological screening in patients undergoing spine surgery.” Journal Spinal Disorders Tech (2014); 27: 76-79.
5. Agmon M and Galit Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 9: 1-7.
6. Hanscom David. Do You Really Need Spine Surgery? Take Control with a Spine Surgeon’s Advice. Vertus Press, Oakland, CA, 2019.

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• Her pain originally arose from severe arthritis of her hip. Historically, I have approached this is a simple structural problem that is best treated with an artificial hip replacement. What else can be done? Turns out there is plenty.
• She healed herself in spite of medical advice. Taking charge and being persistence are important aspects of healing.
• She recognized that pain is the result of sensory input and that the final signal arises in your brain. Her story is remarkable in how quickly she figured this out and re-routed around her pain circuits.

Here is her letter.

Dear Dr. Hanscom,

I’m really grateful to have a substantial, extended break from my relentless routine of the last few years. I am, finally, getting more than 5-6 hours of sleep…more like 7-8 every night. I do not have the physical demands of my job navigating a huge high school campus. I do not have the weekly organizational demands of coordinating work, shopping, laundry, family, household management, paying bills, home and car maintenance, concern for a parent living alone in another state, as well as concern for grown children and grandchildren…and on and on. Many of us experience the unrelenting demands of daily modern life and its effects can be exhausting.

Her childhood experiences

Reflecting on my life back to my earliest remembered childhood, I realized that I do have the type of personality that wrestles with the double bind of being a perfectionist, people pleaser, fixer, peacemaker, problem solver, responsible “adult” (among other adults who readily relinquish responsibility). I have always set a very high bar for myself. Even the thought of failing sparked a cascade of anxiety and panic. As I child, I was repeatedly reminded that “a job worth doing is a job worth doing well.” Also, “Smile and the world smiles with you, weep and you weep alone,” along with “You’ll get more with honey than you get with vinegar” and “If you can’t say something nice, don’t say anything at all.” (many of those from my Irish Grandmother who drummed them into my mother….sincerely well meaning, who, in turn, reinforced those messages for me.)

Emotions will be expressed–either physically, mentally, or both

Thanks to Dr. Hanscom’s work, I can see relationships between chronic physical conditions such as (Irritable bowel Syndrome) IBS, fainting, panic attacks, acute anxiety… that plagued me throughout childhood and into adulthood, and the messages and beliefs I internalized that were also combined with my innate temperament and personality traits.

My dad suffered from clinical depression and my mother intellectualized her emotions, suppressed negative feelings, and managed the overflow with relentless activity. The more I reflect on the elements of my life and continue to do expressive writing, the more patterns and clues gradually emerge.

Hip arthritis pain resolved

I had been diagnosed with “severe bone on bone osteoarthritis” in my left hip 10 months ago. I had such severe pain starting last May, that I had an ultrasound on my hip and then after seeing a series of doctors (having to wait 2-3 months between appts) had a hip xray which definitely showed the damage in my hip. I was told, by my Doctor, that the hip could send pain down the thigh to the knee but that pain below the knee was probably due to the L4L5 nerve compression that was revealed by my MRI. These diagnostic tests confirmed my condition was much worse than I had believed. After 16 weeks of various treatments and physical therapy I was advised to get a hip replacement. I was 61 and was really not keen on that idea and decided to wait a bit and see if it improved. By December, after doing stretches and mild strengthening exercises, my hip stopped hurting. It has been pain free for more than 4 months. I don’t think I miraculously grew new cartilage! It just does not hurt.

Pain from her brain

Now, fast forward to the past 3 weeks when, intermittently, I started to experience severe throbbing, aching, and burning pain in my left leg. The pain I was experiencing would migrate from the top of my left foot, hover around the ankle, sometimes jump to the side of the leg just below the knee….occasionally jump to the thigh and then zip back down to the ankle. The pain was a 10/10 and it woke me at night for hours. I was quite frustrated, angry really because I know that my foot, ankle and knee are fine. There is no structural damage or deterioration in those parts and I’ve had no prior issues. I completely committed to the belief that these symptoms were coming from somewhere in my brain that was generating pain due to some unconscious impulses to which I had no access with my rational prefrontal cortex.

She healed herself

I followed Dr. Hanscom’s prescription of expressive writing, reminding myself often that I am fine and safe, continuing to move, stretch, and maintain a mild exercise regimen, along with meditation. One night I woke with severe pain and my immediate impulse was to get up and take Aleve for the pain, but instead, I practiced breathing, relaxation, and focused attention instead, on the right leg which was completely pain free. Within 15 minutes the pain began to decrease and I was able to doze off. When I woke I was pain free. The following day the pain returned….I repeated the same routine and continued the writing. by the fifth day, I experienced no pain in the left leg. I found this experience very illuminating because the pain commands attention, but the more attention it gets, the greater the intensity.

Classic symptoms

This is a phenomenal insight and it allows a whole new way to frame this kind of migratory, fluctuating, recurring pain. I realized, as well, that I was repressing feelings of anger, frustration, overwhelm, and chronic stress over the need to excel constantly, without granting myself rest and reward time. I felt frustration and hopelessness as I had spent way too much time and effort in the past years pursuing various “therapies” without appreciable results. I would be encouraged by very temporary relief and then disappointed when symptoms soon returned and the cycle would repeat.

I now react to pain in my body without anxiety and fear but rather with understanding that I have, inadvertently, reinforced neural circuits for years by focusing on the pain. I can now practice responding rather than reacting when existing neural circuits are triggered. This has reduced my fear and anxiety from the sensation of pain. I am able to move my focus elsewhere, calm my nervous system with breathing or active meditation, and reduce my chemical stress response. This immediately reduces the pain sensation, sometimes eliminating it.

As I explore more of Dr. Hanscom’s website and began the DOC program, I feel empowered rather than vulnerable. I finally feel like I am regaining control over my outcomes and can work towards reclaiming my autonomy without depending on others to “fix me.” The result is I no longer feel resigned to pain. I am hopeful again.

My perspective

I originally thought that an obvious source of pain, such as her severe hip arthritis, just had to be fixed. The research shows that there is little correlation between the severity of hip, knee, or shoulder arthritis and pain. (1) Often people with severe arthritis have no pain, and patients with a lot of pain have minimal or no arthritis. The pain was more correlated with stress. How can this be? Under threat, mental or physical, your body is full of hormones that fire up your nervous system, which increases nerve conduction. You will feel more pain. Pain is also a significant source of stress.

I have now seen over 100 patients who I felt needed spinal surgery because there nerves were pinched so tightly. They cancelled the operation when their pain resolved from structured rehab before surgery. I had few resources to help, so I helped them through the DOC process they implemented from the book and website. I also had some of them see excellent pain physicians that used a similar approach. My team was wonderful in providing skilled and compassionate guidance and support. It was mostly self-directed process. We became disciplined in following established medical recommendations to address all the factors that portend a poor outcomes for at least eight weeks prior to surgery and that is when patients began to cancel their operations. If surgery was performed, the outcomes were more predictably positive.

Before you make any elective surgical decisions to relieve pain, please take the time to understand chronic pain. A failed surgery of any kind can destroy your life.

1. Bedson, J and Peter Croft. The discordance between clinical and radiographic knee osteoarthritis: A systematic search and summary of the literature.BMC Musculoskeletal Disorders (2008);  9:116.

The post Never Too Late for Hope first appeared on Back in Control.

The post Never Too Late for Hope appeared first on Back in Control.

After my fourth L3-L4 surgery the neurosurgeon sat me down and said “…you are not going to get better but rather worse as you grow older. You have a life sentence of pain.” I’ve had 6 spinal surgeries and 20 additional surgeries. I know chronic pain intimately. After 25 years of debilitating chronic back pain with daily migraines my anxiety level was extreme. My C-reactive test was exceptionally high. I could barely endure another day of pain. It seemed hopeless. I gave up and attempted suicide 3 years ago.

Letting go of anger

Since that time I discovered that Dr. Hanscom’s program works. I faced my anger and resentment and rid myself of all of my negative thoughts towards others and towards my losses brought on by the pain. I forgave everyone who had ever hurt or slighted me. I consciously resolved to face new anger  issues as they came up. I’m now quick to forgive and forget. I carried a lot of anger from my childhood and through my painful journey as an adult. I finally discovered that holding on to anger is toxic to my health. I discovered that I could not get better until I rid myself of anger and resentment.

Getting centered

This program works for me if I will just follow the steps in the book. I’ve lost track of the number of times I’ve read Back in Control. I have found that daily meditation is my best avenue for continued healing and peace of mind. Meditation helps me stay centered, stay in the moment and greatly reduces my stress level. I’m a living example of why you must never give up hope. If I can cleanse myself and open new pathways to a life without chronic pain you can too.

The post Life Sentence first appeared on Back in Control.

The post Life Sentence appeared first on Back in Control.

No one thinks that a surgical complication will happen to them. During my spine fellowship, I witnessed a large number of major complications and I was sure that I was going to be better than them – even though they were considered some of the top spine surgeons in the world. I set out on a quest to go without any complications for a year. I did not give up easily, but of course I failed. There is an inherent risk of any surgery with it rising with the complexity of the case. For example, there is a trend in the United States to perform multiple-level fusions, sometimes the length of the spine. The complication rate in adults is high and a significant percent of them are devastating – catastrophic. (1) Over 32 years of performing complex spine surgery, I watched hundreds of patients, including my own, have poor outcomes – sometimes from a direct technical problem in surgery and often from medical problems that can occur from prolonged operative time and blood loss. Even without a complication the pain may persist or worsen. (2)

Do You Really Need Spine Surgery?

The purpose of this article is to admonish you to consider if you really need the surgery and will the benefits outweigh the risks?  Every day in clinic I had several patients tell me that if they had just understood how much worse off they could be after surgery, they never would have undergone the procedure. Most of the time the surgery went well but their pain was worse. Add in a complication and the resulting situation was often intolerable.

What is making the current surgical environment harder for me to deal with is that we witnessed hundreds of patients go to pain free by systematically implementing medically treatments with minimal risks. Back in Control,  provided a framework that organized the patients thinking and most of it was implemented on their own. We now have The DOC Journey, which reflects the successes of many patients. The key is you taking charge of your own care once you understand the nature of chronic pain. One of he worst parts of this scenario is that many of the patients who got stuck in this hole of a failed back surgery, had a normal spine for their age. Surgery should not have ever been offered to them since you can’t fix what isn’t broken.

A life changing complication

I remember the moment my surgical life changed many years ago. I was in clinic about 11 o’clock in the morning when the ICU nurse called me and told me that my patient I had done surgery on yesterday couldn’t see. I had seen him earlier on rounds and he seemed fine. I rushed over to the unit and he was completely blind. He told me that he thought someone had placed a cloth over his eyes as part of his post-operative care. We had done an eight-level fusion on him for what we call, “flatback.” He had lost the curvature of his lower back from degeneration of his discs and he was tilted forward. He was experiencing a lot of pain.

The surgery had gone well and my colleague and I complemented each other on how well it went. However, one of the risks of any spine surgery in the face- down position is the blood supply to the eyes. For reasons that are unclear the flow was compromised and the nerves to his eyes were damaged. He never regained any of his vision. Needless to say, everyone was devastated. The only inspiring part of the situation was his attitude. He walked into my office about three months later and said, “This is the deck of cards life has dealt me and I am going to play it.”

He returned to see me about ten years later to have some of the hardware removed that was prominent. I was learning more about chronic pain and the effect that stress has on the body’s chemistry and perception of pain. I talked to him for a while and found out that just prior to his surgery, he was under extreme marital and family stress that eventually culminated in a divorce. I was so convinced that surgery was the answer that I did not pick up on it. I was not aware at the time how stress translates into changes in the body’s chemistry, which creates many different symptoms. what a critical factor

Didn’t need it

Today, in my practice, he wouldn’t have been a candidate for surgery. His flatback was not as severe as many I have seen rehab successfully without surgery. I would have had physical therapy stretch out his hips and get him into the gym. His sleep and stress would have been addressed and he would have done well. As I didn’t know how successful a structured approach could be, I did not offer these options to him. I would have certainly waited until his life stresses calmed down. He is blind from an operation that could and should have been avoided.

“If I Were Your Spine Surgeon”

Please read this book, Do You Really Need Spine Surgery? Take Control with a Surgeon’s Advice. Within a couple of hours you will understand the reasoning behind the decision to undergo a spine operation or not. There are two factors to consider; 1) Is there a structural abnormality that is amenable to surgery? 2) Is your nervous system in a calm or hypervigilant state? You will be able to place yourself into one of four quadrants with each one have a specific treatment approach. Watching many patients having their normally aging spines destroyed by ill-advised surgery is what caused me to quit my practice to pursue bringing proven effective treatments into the public domain. There are thousands of research papers documenting what should be done to treat chronic mental and physical pain that is not being widely implemented. Sustained levels of inflammatory markers are the hallmark of chronic disease. Surgery for inflammation cannot and does not work. There is not one paper in the last 60 years that shows that fusing someone’s spine for pain works.

It appears to me that many people put more effort in buying a car than they do making a decision about undergoing spine surgery. Although they are informed of the potential complications, there is no way to comprehend how bad life can be trying to live with a failed spine surgery. You are the one with the pain. No one else can accurately make the final decision whether the pain you are experiencing is worth the risk. Video: Get it Right the First Time

Anxiety

BTW, is the pain you are trying to solve your mental or physical pain? Please read this post I wrote, “Am I operating on your pain or your anxiety?” Anxiety does respond to the treatments outlined in The DOC Journey. As the anxiety drops, nerve conduction slows down and your pain drops. (3) Surgery will not solve anxiety even if the operation relieves your physical pain.

Don’t play roulette with your life. There is no turning back on this decision and there is no need to gamble. Once you understand the issues, you can make the correct choice for you.

1. Cho SK, Bridwell KH, Lenke LG, Yi JS, Pahys JM, Zebala LP, Kang MM, Cho W, Baldus CR. Major complications in revision adult deformity surgery: risk factors and clinical outcomes with 2- to 7-year follow-up. Spine (Phila Pa 1976). 2012 ;37(6):489–500
2. Perkins FM and Henrik Kehlet. “Chronic Pain as an Outcome of Surgery.” Anesthesiology (2000); 93: 1123-1133.
3. Chen X, et al. “Stress enhances muscle nociceptor activity in the rat.” Neuroscience (2011); 185: 166-173.

The post Comprehending the Downside of Spine Surgery first appeared on Back in Control.

The post Comprehending the Downside of Spine Surgery appeared first on Back in Control.

Asking for a referral

In late March this year I received this email from an educator in the South. I don’t recall how he found me.

Dear Dr. Hanscom,

Is there a doctor or clinic in the Nashville, TN area that you would recommend? I have ordered your book, Back in Control, and look forward to the journey!

Peace, Steve

My response:

Hi Steve,

I do not. However, what I have my patients do, who live a long ways from Seattle is to use my book as a foundation to begin the healing process and the website, www.backincontrol.com as the action plan. I suggest working with your primary care physician regarding sleep and medication management. If you can find a local counselor or biofeedback provider to help with the stress management, it is helpful. Most people that have gotten better have done it on their own by applying these concepts to their own specific situation. Eventually you may join a gym and consider working with a physical therapist. I am working hard on getting these concepts into the public domain and it is gaining traction. Let me know if you have specific questions.

Best regards, David Hanscom

He quickly wrote back:

Thank you for responding Dr. Hanscom. I should receive your book Monday. The surgeon I have seen believes I need neck surgery. The C5-6 & C6-7 levels have very little space from degenerative loss. I currently have neck pain radiating into the left upper extremity to the wrist with numbness in my left thumb. I have muscle spasms in my left arm as well. I’ve been doing PT off and on for about three years with some benefit. But recently the symptoms have gotten worse. I’m 63 years-old,  6′ ‘6″in height and weigh 225 pounds. I played intercollegiate basketball and continued until age 40…took up racquetball until age 55. I am now active hiking and biking. Obviously, I would rather not have surgery!! Looking forward to reading and applying the concepts in your book.

Thank you again! Steve

My reply:

Hi Steve, Great. Feel free to contact me in a few weeks to talk all of this over. Best of luck. David Hanscom

His recent email:

Dr. Hanscom, I finished your book. I have already recommended it to several friends who deal with back pain. I was scheduled to have neck surgery May 12 but canceled. After applying your recommended DOC process (especially the writing and discovering my anger) within a few days the pain went from “cut me open now” to “I can live with this”. If I had to rate my pain, it was a 7-9 and now is a 0-3.  It is mainly a discomfort rather than a deep pain. It’s funny…our NHL team is playing for the Stanly Cup. The past several months I would pound on the glass during a game with only my right hand because of the neck and arm pain…I noticed Tuesday night that I was pounding on the glass using both arms… I laughed…maybe because we were winning…but also, “Wow I’m using my left arm now and it doesn’t hurt!”

My wife deals with trigeminal neuralgia. She is reading your book now. It sounds like the principles can be applied to most/all chronic pain.

I am so thankful for what you have shared in your book. Your honesty, vulnerability, and life journey has I’m sure helped those you love and those you treat and now thru your book, those who read it and apply it.

Thank you! Grace & peace, Steve

This sequence transpired over a two-month span. I have heard similar stories from people all over the country, and witnessed many surgical patients in my own practice heal without undergoing the proposed surgery.

Surgical patients cancelling surgery

I have watched dozens of patients with surgical pathology that I had on the surgical schedule cancel the procedure because their pain dropped to such a low level or disappeared. Examples include:

• An active sportsman who I urgently added to the surgical schedule because he had only a 4 mm spinal canal. (normal canal diameter is 15 mm and we start considering surgery when the diameter becomes less than 8 or 9 mm) He had been using a wheelchair for several months. We had to postpone his surgery because he developed a respiratory infection. He had not engaged with the DOC program. I insisted that he at least begin using the expressive writing while we were waiting. It was during this 3-week delay that he improved. His leg pain disappeared and he came out of the the wheelchair. He has remained healthy over three years later and he is back in the hills hunting elk.
• An 80-year-old gentleman with a 4 mm spinal canal began the writing and relaxation techniques about 6 months ago. He had enough of a language barrier that I assumed that he would go on to surgery. He came in with a big smile on his face and told me he had only a low level of leg pain, could walk as far as he wanted and was back dancing two nights a week.
• A university professor who I had followed for over a year for leg pain caused by severe spinal stenosis was not buying the DOC program. Finally, he decided to undergo surgery but I told him that our protocol was that we won’t perform elective surgery unless the patient engages in 8 to 12 weeks of rehab, including the expressive writing. Many people do choose to have their surgery done elsewhere and I assumed that was going to be his decision. He returned three weeks later and just began to laugh. His pain was gone and he cancelled surgery. He has been fine for over three years.
• I have had two additional patients cancel surgery over the span of two weeks. It became unclear who really needed elective spine surgery.

Optimizing surgical outcomes

In the first edition of my book, Back in Control, I recommended that surgery be performed more aggressively for an identifiable structural problem with matching symptoms. I felt that a person in chronic pain could not tolerate the additional pain of a structural problem. The rehab could be done later. I was fairly busy performing surgery with this mind set but many patients were not doing that well in spite of a well-done procedure. Then someone pointed out the data to me that if you operate on any part of the body in the presence of pre-existing chronic pain, you can induce chronic pain at the new surgical site up to 40% of the time. Five to ten percent of the time it can become permanent. (1) Most patients are not informed that chronic pain is a potential complication of surgery. It is also extremely well-documented that anxiety, depression, substance abuse, high-dose narcotics, fear avoidance, catastrophizing, insomnia, poor physical conditioning, younger age, and being female are some of the risk factors predicting a poor outcome of surgery. (2) Yet, another paper shows that only 10% of surgeons are assessing these issues before surgery. (3)

I think that some of these patients with surgical problems improving without an operation will eventually go on to have the surgery. But there is no data. Remember, in light of the Hippocratic Oath of “First do no harm”, it is our duty to ensure that the potential benefits outweigh the risks of surgery. If someone is having no symptoms, the risk is there, and there is no benefit. If surgery is required at a later date, then the risk factors for a poor outcome have already been addressed.

“Simple surgery”

There is nothing more rewarding than watching a patient become pain free without taking any risk and there is minimal cost. And make no mistake about it, every surgery has risks – even the “simple” ones. My life changed when I had a patient die from a one-hour laminotomy many years ago.  It is operation that is done under the microscope with a dental-type burr used to remove the excess bone that is pinching the nerves. I had performed it thousands of time. The procedure was almost done when my instrument disrupted the dural sac. This sac contains the cerebrospinal fluid that the nerves float in. It is generally a solvable problem. I repaired it but he had some slight bladder numbness on one side and was having difficulty completely emptying his bladder. The residual urine became an ideal spot for an infection to brew. He would have resolved it over three to six months. However, about three weeks after surgery he developed an E. Coli bladder infection that quickly spread to his kidneys and then throughout his body. He died of septic shock.

I could tell you hundreds of stories about surgeries resulting in complications and the bigger the surgery the higher the chance of developing a problem. I still perform many major spine surgeries, but it is always the patient who makes the final decision if I offer them the option. You are the one with the pain and only you can decide if the benefits outweigh the risks.

I also wrote a second book, Do You Really Need Spine Surgery?, which defines the issues in deciding whether to undergo surgery based on a grid. I am not against surgery for a clearly defined pathology with matching symptoms. However, most people who read it find ways to avoid surgery and go on to heal.

Video: Get it right the first time

1. Perkins FM and Henrik Kehlet. Chronic Pain as an Outcome of Surgery. Anesthesiology (2000); 93: 1123-1133.
2. Nguyen TH, et al. Long-term outcomes of lumbar fusion among Workers’ Compensation Subjects. Spine (2011); 36:320-331.
3. Young AK, et al. Assessment of presurgical psychological screening in patients undergoing spine surgery. Journal Spinal Disorders Tech (2014); 27: 76-79.

The post It is Becoming Harder to Make a Living as a Surgeon……… first appeared on Back in Control.

The post It is Becoming Harder to Make a Living as a Surgeon……… appeared first on Back in Control.

After attempting many different approaches that failed, our team finally dug in our heels and wouldn’t consider elective surgery unless a patient would take responsibility for learning about pain and taking charge of his or her own care using a DOC-type structured approach. We wanted them to be engaged for at least eight weeks and preferably longer. My goal was to optimize the outcomes and avoid creating chronic pain. My surgical outcomes were better and my practice became more enjoyable and rewarding. What I didn’t expect was that dozens of patients with surgical problems began to cancel their scheduled operation because the pain had disappeared, even in the presence of bone spurs pinching nerves and causing severe sciatica. Here is one of those stories. This occurred about seven years ago. He still intermittently emails me and he never required surgery.

A pinched 5th lumbar nerve?

One afternoon, I received an anxious phone call from Jack, a 65 y/o retired businessman, asking me if I could see him urgently. His leg pain, which began two months earlier, was quite severe. As his pain pattern was so classic for a pattern for the 5^th lumbar nerve root (L5), and he was traveling, I put him on the surgical schedule. His MRI scan showed several bone spurs next to the L5 nerve, but none that were new. Although surgery was an option, I was a little uncomfortable, and wanted to give him a little time to calm down his nervous system. Much to my surprise, his pain quickly disappeared and I cancelled his surgery.

He experienced a second major flare-up about four months later. We both agreed that this time we would just get the problem definitively solved with surgery, and I put him back on the surgical schedule. By the time he saw me a week later for his pre-operative appointment, his pain again disappeared. This time we both felt that flared up pain circuits were were the cause. He wrote up his story, and we wanted to share it with you.

Jack’s story

When severe sciatic pain left me almost disabled 9 months ago, I knew it was time for back surgery…but the surgeon suggested I investigate an alternative to surgery; that my pain could be caused by a stressed nervous system. I was skeptical, but my research/practice of techniques eliminated my chronic pain…I am pain-free now. Details follow.

POSTPONE YOUR BACK SURGERY!

Yes, that’s correct…I’m humbly suggesting that you delay or postpone your back surgery until you’ve tried this alternative. I am grateful every day that I postponed my surgery…”dodged a bullet” as I think of it! Of course, I’m NOT a medical expert and I can’t adequately explain what happened to me; and your results may vary. But read my story, and see if you can benefit from this alternative to surgery.

Spontaneous onset

Here’s the background:  I’m a 65+ male, and have enjoyed excellent health my entire life; have jogged 3x per week since 1966 when Cooper first wrote Aerobics. About 18 months ago, I began noticing some mild sciatic pain…so I tried stretching…didn’t help. The pain level slowly increased, so my next “solution” was deep-tissue massage…maybe helped a little, but soon I was taking Tramadol, a mid-level pain reliever. Helped, but didn’t “fix” the problem. You know what comes next; right, I began Oxycodone. So in about 6 months, I had gone from healthy to being almost completely incapacitated with sciatic pain in my right leg. I could no longer jog. I realized it was time to consider back surgery!

Wait a minute

My primary care physician ccv referred me to Dr. David Hanscom, I now realized that the sciatic pain was caused by something seriously wrong with my lower back (a pinched or impinged nerve was my guess), and it seemed like surgery was necessary. By the time of the appointment, walking even with “help” from Oxycodone was painful. Dr. Hanscom and his team reviewed the imaging they had ordered (MRI and myelogram) and informed me that, yes, I had a “complicated” back! (Scoliosis, stenosis, pars defects, thin disks between the lower vertebrae, bone spurs, severe age degeneration). The surgery to correct this would be an L5-S1 fusion. But Dr. Hanscom also explained that none of these defects looked quite severe enough to be the convincing cause of my pain. So, while he would do the surgery if I insisted, he suggested I first look into other sources of my chronic pain. He gave me a copy of a book he wrote, Back in Control, and the link to his website, www.backincontrol.com.

I began reading the book when I returned to the hotel, and finished it that same evening! What a revelation! Chronic pain can be caused by mental stresses? Of course I was skeptical…I KNEW my pain couldn’t be caused by stress; I was retired, so what did I have to stress about? As the book explained, excessive stress and the chronic pain that results, are often not caused by external forces, but by internally generated issues. Could my sciatic pain be explained this way? It appears that this was the case.

Pain free

Over the following weeks, and now months  (8 months since my initial appointment with Dr. Hanscom), I’ve read and tried to follow the therapies prescribed by several additional books that have helped understand the cause of my pain…and the pain has been in total remission for about two months now. I’m even jogging again! Of course, there have been ebbs and flows of increased and decreased pain, but the trend is definitely decreasing. (I’m keeping a “pain journal” where I record a daily pain level, and activities that might impact the pain.)

Resources

Here are the other books I’ve found valuable:

1)     Unlearn Your Pain, by Howard Schubiner, MD

2)     Forgive For Good, by Fred Luskin, PhD

3)     The Hoffman Process, by Tim Laurence

4)     Healing Back Pain, by John Sarno, MD

5)     The Mindfulness Solution to Pain by Dr. Jackie Gardner-Nix

My hope is that this short history of my struggles with chronic pain will motivate potential back surgery patients to at least consider a self-directed structured approach as an alternative to surgery.

Jack

P.S. Why am I opposed to back/spine surgery?  As I understand it (a “civilian”, NOT a medical professional!) the complexity of the spinal area, the bone, muscle, and nerves, makes the outcome of spine surgery “iffy”. For many patients, the first surgery is “1 of __”.  In my case, I thought that simply decompressing the spur impinging the L5 nerve was the easy answer. But Dr. Hanscom explained that such a “simple” surgery could cause instability in other portions of the spine.

My initial position was,” I’m in pain, YOU fix it!”—a passive approach. The effective concept is that I CAN FIX THIS MYSELF!

Modern neuroscience 

We now know that although “stress” is linked to pain, the more accurate description would be that any mental or physical threat simulates the body to secrete hormones that increase your chances of survival and your whole body goes into a hyper-vigilant state. It is a necessary survival response. When these levels of stress chemical sustained, they wreak havoc with your body. There are many illnesses, symptoms and diseases that result, including early death. One of the effects is markedly increasing the speed of nerve conduction, so you will feel more pain. (2) As you learn the techniques to regulate your body’s chemistry, many symptoms resolve, including pain – even in the presence of “surgical” lesions.

Making your final decision about spine surgery will be outlined in my book, Do Really Need Spine Surgery? Take Control with Advice from a Surgeon.  All the factors affecting your choice are organized around a “Treatment Grid” to help you heal, with or without surgery. Make the correct choice.

1. Perkins, FM and H Kehlet. Chronic pain as an outcome of surgery. Anesthesiology (2000); 93: 1123-1133.
2. Chen X, et al. Stress enhances muscle nociceptor activity in the rat. Neuroscience (2011); 185: 166-173.

The post Structural Sciatica Resolved Without Surgery first appeared on Back in Control.

The post Structural Sciatica Resolved Without Surgery appeared first on Back in Control.

What next?

He elected to go ahead with surgery. He improved for a couple of months and the pain returned except that it was worse. He then underwent a second operation about six months later that did not help and in fact worsened his pain. He asked me again what I thought he should do next. About six weeks before I talked to him he had fired everyone and stopped everything. No more doctors, medications, or surgery. Within a week of making that decision his pain disappeared. He had taken complete charge of his care.

What makes his story more interesting was that when I looked at the MRI scan done after his second operation the bone spur was still there. The surgeon had missed it. He had worked on the middle part of his spine freeing up the 1^st sacral nerve root, not the L5 nerve root. He had needed to remove the bone spur out to the side of the spinal canal, not the middle. He should still have been in pain.

Both L5 nerves pinched

I treated another woman a couple of years ago who had pain down both of her legs in the pattern of the L5 nerve root. She had resisted the DOC project for a long time. She decided to undergo surgery to free up both of the L5 nerve roots. She did have significant spurring touching both of the nerves. When she made the decision to have the operation she also finally engaged in the DOC project. When she came in for her pre-operative visit her leg symptoms disappeared. I cancelled her surgery.

They Both Had Structural Problems

In both of these cases there were structural problems with matching symptoms. In the first case, if the L5 nerve root had been correctly freed up his pain would have disappeared after the first operation or the second operation. As the bone spur was never removed it now was clear that he could have gotten the same improvement without any surgery. With the second case she would have also done well with surgery. Both of them solved their own problem with engagement and taking charge. That is why my book is titled, “Back in Control.” Every patient I have seen get better has taken full responsibility for their pain and care.

Raising the Pain Threshold

When your nervous system calms down utilizing Neurophysiologic Disorder principles the threshold for sensing pain is raised. I am sure that the structural lesions in their spines are still firing pain impulses to the brain. It is just that they are now below the elevated pain threshold and are not interpreted as pain.

What did they do? They both took charge of their problem. They took control, which instantly decreases anxiety. That, in and of itself, is a major step in calming down the nervous system. Their pain did not just decrease; it disappeared. In the future there is a chance that the symptoms will re-appear under a certain level of outside stress. I am now used to having my patients go through the steps that originally calmed them down and the symptoms will reliably disappear. Remember that pain circuits are permanent. I also reassured them that if the symptoms don’t diminish I could always perform an operation.

Why Not Just Do the Surgery?

You might be asking, “Why not do the operation and then they would not have to worry about it in the future?” There are a several reasons. First, even with a successful operation it is common for pain pathways to get fired up under stress, even if there is not a recurrence of the structural problem. Second, even the simplest operation has risks. I could write a book of simple operations going bad. Third, with spine surgery you always cause the formation of scar tissue that can be permanently irritating. You are just better off avoiding surgery if at all possible. Video: “Get it Right the First Time”

The Change in My Thinking

I witnessed over one hundred cases similar to these two. It has caused me to change my thinking about the timing and role of surgery. I use to think that surgery was always required in the presence of a structural problem. My conversation with my patients would be, “Let’s get the surgery done and we’ll work through the rehab later. You cannot rehab a structural problem.” Now my discussion is, “I am happy to perform your surgery but I have seen patients go to pain free even in the presence of a structural problem. If we can calm down your nervous system your post-operative pain will be less and easier to control.” We now have decided that we will not perform elective surgery until a given patient has been involved in addressing his or pain in a structured manner for at least 8 to 12 weeks. Our outcomes have been much more consistent.

I am a surgeon. My thinking around the DOC project is continually evolving. The idea that a person could raise their pain threshold enough to avoid surgery simply by taking complete charge of their decision-making has been surprising to me.

“My Son Just Died”

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