A straightforward decision

I rarely make a surgical decision on the first visit, but his situation seemed so straightforward that I decided to make an exception. He also wanted to proceed quickly, as he was frustrated by his limitations. As I walked out the door to grab the pre-operative letter that describes the details of the fusion, he quietly said, “My son just died a few months ago.” I immediately turned around and sat down with him. His son had died from a massive heart attack. I let him know how sorry I was about his loss, and also told him that I was not comfortable with him making such a major decision in light of the situation. He agreed. I gave him the pre-op letter and asked him to return in a couple of weeks. I gave him a copy of my book, Back in Control, which is an excellent resource for dealing with stress, as well as chronic pain. A week later he called and told me that he really wasn’t into reading my book and just wanted to proceed with surgery. I asked him one more time just to glance through the book, as it does help with post-operative pain and rehab; and I signed him up for surgery.

The pre-op appointment

He came in with his wife for his pre-operative appointment to coordinate the final details around the operation. I wanted be sure that I was on the same page regarding the severity of the pain and his understanding of the procedure. He said, “I am feeling better. I have read some  of your book and think that maybe I should work through some of the issues around my son’s death.” We had a long conversation about the effect this degree of trauma can cause. He asked me if it was OK with me for him to delay his surgery for a while.

I saw him a month later and he had no pain in his back or down his leg. He was fully active and had just re-joined the gym. I asked him what seemed to be the most helpful strategy in resolving his pain. He had continued to read the book. However, I am well-aware that reading my book, or any book, is not going to take away pain. It requires some level of engagement. For him, it was awareness. Just understanding the links between anxiety, anger, trauma, and pain helped him make sense of the different emotions he was trying to process. He was also now talking to his friends about his loss, who were offering a lot of support. His whole demeanor had changed and he was now more concerned about how the situation was affecting his wife.

How do I decide who needs surgery?

It is becoming increasingly unclear to me what severity of pathology requires surgery to solve a given problem. His constriction around his 5^th lumbar nerve root was severe and he had a classic history that matched. Had I done the surgery, his leg pain would have resolved; but not his emotional pain. He now is moving forward, as his emotional pain is being addressed. His back and leg pain are gone. He did not have to undergo the trauma and risks of surgery. He will return to being a productive person and provide emotional support for his wife. Although, not the main reason, there was essentially no cost involved.

“I know when a patient is at risk for a poor outcome”

I have witnessed many stories that are similar to George’s; and I am more diligent in making sure that there not major life stresses occurring while making a final decision regarding surgery. There doesn’t need to be one specific event. More commonly people hit their breaking point from cumulative stress, and they don’t see a way out. Physicians almost uniformly feel that they can detect emotional distress in their patients. As I have been doing spine surgery for so many years, I feel like I am really able to detect patients with anxiety and depression in my clinic. However, research shows that physicians are correct in this regards only 25-43% of the time. It does not matter whether the doctor is a junior resident or senior staff physician. George’s story again reminded me that I cannot figure any of this out either. There is too much going on in the middle of a busy clinic – especially on an initial visit. (1)

Physical versus mental pain

The areas of the brain that interpret physical and emotional distress are located in close proximity to each other. (2) It also seems that there are abnormalities of a given person’s body that are not quite severe enough to cause pain. But when the pain threshold is lowered, in the presence of adversity, these specific areas can become symptomatic. As one of my workout buddies points out, “It is the weak area that lights up.” Prior pain circuits can also be activated.

There are hundreds of research papers documenting the link between anxiety and depression with pain, and poor outcomes with treatment. For many reasons, these factors are not being routinely addressed. The culture of medicine is geared towards performing procedures, and not on talking to you about other options or providing the necessary resources. It is critical that you have done everything possible to calm down your nervous system before you undergo a surgical procedure. In this medical environment, you will have to take on that responsibility.

1. Daubs, M, et al. Clinical impression versus standardized questionnaire: The spinal surgeon’s abilityto assess psychological distress. JBJS (2010); 92; 2878-2883.
2. Hashmi, JA et al. “Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits.” Brain(2013); 136: 2751 – 2768.

The post “My Son Just Died” first appeared on Back in Control.

The post “My Son Just Died” appeared first on Back in Control.

In 2003, a neurosurgeon performed a laminectomy of his neck. That’s an operation where the lamina or the bone over the back of the spinal cord is removed to relieve pressure. He seemed to improve for a little while. In 2005, his symptoms worsened, and in 2009, he underwent a fusion through the front of his neck between his 5^th and 6^th vertebrae. Again there was a slight improvement but two years later he was in my office with crippling pain throughout his whole body.

Normal studies

As I talked to him, I could see how desperate he was for relief. He also wasn’t sleeping and his anxiety and frustration were a 10/10 on my spine intake questionnaire. I couldn’t find any neurological problems on my physical exam. When I looked at his neck MRI, I could see where the two prior surgeries had been performed, but there were no pinched nerves. The alignment and stability of the vertebrae were also fine. He also had undergone several workups of his brain and the rest of his nervous system. Everything was normal.

When I explained to him that I did not see a structural problem that was amenable to surgery he became understandably upset.  He was stuck on the idea that the prior surgeries had helped and that I was missing something. It didn’t matter what I said or how I explained the situation to him. He wasn’t buying it.

What I didn’t tell him was that I had also looked at his scans he had prior to undergoing each surgery. Telling a patient that they did not really need a prior surgery is a very unproductive, unpleasant interaction; I didn’t see why this patient’s prior surgeries were performed. On the first MRI of his neck, there were no bone spurs and the spinal cord was completely free. There wasn’t a structural problem that could have been corrected by surgery. On the scan before the second operation, there also wasn’t a hint of anything that could be causing any symptoms of any type.

The power of placebo

What’s difficult for patients (and physicians) to realize is that the placebo rate for any medical or surgical treatment is between 25-30% or even higher. The response and improvement is not only real but is powerful. It is the result of your body’s own healing capacity. It is a desired response, and you feel less pain.

The pain-killing effects of a placebo are reversed with Narcan, which is the drug used to reverse the effect of narcotics. There is a part of the frontal lobe of your brain that shuts off pain pathways for short periods of time. Another example is the placebo effect of cardiac medications causes the heart rhythms to actually change. Just because a prior surgery or procedure on normal age-appropriate anatomy might have been temporarily effective is irrelevant. It should have nothing to do with current decision-making. I tell my patients “If I can see it, I can fix it” and  “If I can’t see it, I can’t surgically correct it.” It’s critical to have a specific structural problem with matching symptoms before surgery becomes an option. Surgery: The Ultimate Placebo

I suggested that he take a look at the DOC website and I would be happy to explain the whole program to him in as much detail as needed. He was so angry that I didn’t think I’d hear from him again.

Early engagement

Over the next couple of months, I received a couple of emails and had a telephone conversation that seemed to go pretty well.  He was willing to engage in the DOC protocol and began some of the writing exercises. I had a second phone conversation with him a couple of weeks later that seemed to go even better. He was able to recognize that his thought of me “missing something that needed to be fixed” was an obsessive thinking pattern. I was encouraged and thought that maybe I had been able to break through his “story.”

Time went by and our third and final conversation was dismal. He couldn’t let go of the thought that “something was being missed” and that his seventh cervical vertebra was “out of alignment.” I assured him it was OK. As a surgeon, I am also quite obsessive about not missing problems that I can fix. At this point, it didn’t matter. He’d found a surgeon who was going to fuse his neck.

Injury conviction

Physicians use the term “injury conviction” to describe this phenomenon. It is the relentless pursuit of a cause for your symptoms that is well beyond reason. My concept has changed in that I feel this pattern of thinking becomes its own irrational set of neurological circuits. It is similar to phantom limb pain and my term is “phantom brain pain.” Regardless of whether the original source of pain is there, the symptoms are the same. Rational arguments have absolutely no effect.

Hell

I wrote a post Anxiety and Anger: The Highway to Hell. Unfortunately, if you’re in this pattern, you’re in Hell, and the only way out is through you. The deep tragedy is that if you don’t realize you’re in Hell, you’ll remain there. I never give up, but I have learned to let go when I can’t penetrate that firewall of obsessive thinking. For those of you that have let yourself out this hole, I am open to suggestions as to what gave you the insight to move forward. Awareness is the basis of the entire DOC process and is always the first step.

I don’t know how many more tests and surgeries he’ll undergo over the next 30 years. The personal cost to him and society will be enormous.

What’s puzzling is that if any of the surgeons who’d chosen to operate on this man’s essentially normal anatomy were examined by a board examiner about their indications for his surgeries, they’d be failed immediately for giving a “dangerous answer.” It’s our medical responsibility to you to not offer risky procedures that have been documented to be ineffective.

Video: “Get it Right the First Time”

The post How Many More Neck Surgeries? first appeared on Back in Control.

The post How Many More Neck Surgeries? appeared first on Back in Control.

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

The post Do You Really Need Spine Surgery? first appeared on Back in Control.

The post Do You Really Need Spine Surgery? appeared first on Back in Control.

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.

The post Optimizing (Avoiding) Spine Surgery first appeared on Back in Control.

The post Optimizing (Avoiding) Spine Surgery appeared first on Back in Control.

I had joined a prominent orthopedic group in town and was the fourth spine surgeon. We were all determined to create a major spine center in Seattle. I worked long hours with a high level of energy.  It was also an era where we had just started placing screws directly into the vertebrae to immobilize them. This technique offered a higher chance of obtaining a solid fusion. I was enthusiastic about my ability to obtain a solid fusion. If someone had back pain for more than six months, I would order a discogram, which is a test where dye is injected into the disc under x-ray control. If the injection simulates the patient’s usual pain, it is considered a positive test. Based on that test, I would then offer them a fusion that would remove the pain generator.

I was also quite diligent trying all types of non-operative care during this time. One approach I used was aggressively immobilizing the spine with a semi-rigid brace for three or four months while simultaneously work on conditioning in the gym. The idea was that if a fusion was going to work, why not try something to immobilize the spine that is less invasive. I had a lot of success with the bracing. Nonetheless, I performed many spine fusions for low back pain and I thought that the success rate would be over 90%. It is a big operation. I felt bad if I couldn’t offer my patient a fusion. Some patients would do extremely well. However, many if not most, would have some improvement in pain but still remain disabled. It wasn’t clear to me what variables would predict a good outcome.

One evening in the fall of 1987, I heard a knock on my door. A gentleman by the name of Stan Herring introduced himself.  He said he was a physiatrist who specialized in spine care and would like to have me work with him as his surgeon. He had to explain to me that a physiatrist is a rehabilitation physician. The philosophy is to take whatever physical limitations that exist and maximize the patients’ function. I had not heard of this concept before and it sounded interesting.

I began to spend a half a day a week in his office. It quickly became clear that this was a different world of spine care than I had been exposed to. He knew which physical therapists he wanted to work with, and knew what they did and why. He worked with a pain psychologist. His office practiced a much more complete approach to the pain problem. When his patients required surgery, the results were consistently better. My role in this practice became that of talking many patients out of surgery until they had really engaged in the rehab process. Once I explained the magnitude of the surgery in detail, they would usually proceed with their rehab and most patients seemed to do well without the surgery.

I became better at selecting my patients for low back pain surgery but was still frustrated by the unpredictability of the outcomes. It was not until 1994, eight years into my practice, that I stopped performing fusions for low back pain. The data out of Washington Workers Comp showed that the return to work rate one year after surgery was only 15%. It was half the rate of those who had not undergone surgery. (1) Meanwhile, I descended into my own ordeal with chronic pain and I didn’t emerge from it for over 13 years. Slowly, the current DOC process evolved about ten years later. It took me a long time to figure out what was going on and now the last five years of neuroscience research has revealed the answers to solving chronic pain. Surgery is occasionally needed but is never the definitive answer in isolation. It is also never indicated for chronic LBP and degenerative disc disease.

I am one of the few spine surgeons who has aggressively been on both sides of this fence of using surgery as a solution for non-specific low back pain and now successfully helping patients heal without the risk of an operation. It has been quite a journey.

1. Franklin GM, et al. Outcome of lumbar fusion in Washington State Workers’ Compensation. Spine (1994); 19:1897–1903.

The post My Early Surgical Philosophy first appeared on Back in Control.

The post My Early Surgical Philosophy appeared first on Back in Control.

• Spine surgery is not an option if there is not a structural problem with matching symptoms.
• Back pain does not respond to surgery and it is often made much worse in the presence of untreated chronic pain.
• It is understandable why you might choose it as it seems definitive and you are desperate.
• Anger shifts your brain activity from the thinking to the survival regions. You cannot think clearly.
• Back pain is solvable with no risk and minimal resources. Don’t let your life be destroyed by a failed back surgery.

Imagine your life before the pain. Stop and visualize a day or period back then when you were just plain angry. What kind of a day was it? It wasn’t great. Now add the pain back into the picture and what you have – living hell.

One of the byproducts of anger is obsessing over negatives. With chronic pain, it is deadly. As the brain focuses on the pain, your nervous system becomes sensitized and the signal becomes stronger. (1) Then you’ll become even angrier. An endless cycle emerges, and you spiral downward. The other problem with anger is that your brain is producing inflammatory proteins called cytokines. This also creates a shift in the blood flow from the neocortex (thinking centers) to the lower levels of the brain (survival) and you simply cannot think clearly. It is critical to get your brain back “on-line” before making major surgical decisions.

I know you have pain, but what exactly are you looking for? When I ask that question in the clinic, the most common answer I hear is “ I just want to get rid of the pain.” I’m sure you want this too, but even if the pain disappears, will the rest of your life just come together and be great? Being pain free is just one of the things you need to live a stress fee, happy, and healthy life. It turns out that if you work on some of these other things, like learning to deal with stress, the intensity of your pain becomes reduced. (2)

Bonnie

Around 1990, I had a patient in her mid-thirties who had suffered a lifting injury at work. She was seeking another surgical opinion. She had a moderate curvature of her lower back that she had been born with. The term for the disorder is congenital scoliosis. Although there is a slightly higher chance of low back pain with lumbar scoliosis, I felt strongly that she should not have surgery. I reminded her that patients with straight spines have the same type of pain after a lifting injury. She was also under a lot of personal stress and extremely angry. She had not fully participated in a conditioning program. I talked to her for over an hour about why she should not have an operation. She wanted to have seven levels of her spine fused. This included her whole lower back and her thoracic spine. She was determined to go ahead with the surgery. I was unwilling to do it, so she proceeded to have another surgeon fuse her whole lower back.

Didn’t work

She returned to me two years later in a wheelchair because of ongoing severe low back pain. Although the fusion had not completely healed, it was stable. She had yet another recommendation to have the weak spot in her fusion surgically repaired. The success rate of making the fusion solid is high. We are able to remove the hardware, re-graft the area, replace the hardware, and obtain a solid fusion most of the time. However, the chances of relieving her pain were almost zero. Her pre-operative mental state had markedly deteriorated after two more years of pain. There was nothing that could be done to surgically relieve her suffering. The tragedy was that she could still have done well with a structured rehab approach.

This situation occurred before I knew much about comprehensive rehabilitation and the importance of calming down the nervous system. Her main reason for returning to see me was to undergo yet another operation. She could not let go of the idea that surgery was the definitive solution. The tragedy is that her pain was so solvable without surgery. I don’t know her final outcome, as she never returned. She was even less open to non-surgical options.

Surgery is a not definitive solution for chronic pain

This is a common scenario. A person has ongoing chronic mental and physical pain and is justifiably angry about the whole situation. A surgeon offers them an option, which seems like a way out a dark situation even though there is no data to support the procedure. (3) I don’t blame her since there doesn’t seem like a lot of other options and surgery seems to be a “definitive solution.” But an operation should have never been offered to her that has less than a 30% chance of success. With anger in full gear, no one thinks clearly and the downside of a failed surgery is not fully comprehended. Then when a given surgery fails they often pursue surgery again and again.

Her situation was one of the major reasons I quit my surgical practice. I could no longer watch people have their lives destroyed with surgeries that should not have been considered. The DOC Journey is a platform that presents proven medical treatments in a manner to optimize surgical outcomes or completely avoid surgery. My book, Do You Really Need Spine Surgery? Take Control with Surgeon’s Advice clarifies the issues around the surgical decision-making. It is a much bigger deal than you can imagine and people just can’t comprehend the downside of a failed spine surgery. It has the potential to destroy your life as you know it.

Don’t let anger alter your decisions about surgery – or about anything. I have a little mantra that I keep in the forefront of my mind, “No action in a reaction.”

1. Giesecke T, et al. “Evidence of augmented central pain processing in idiopathic chronic low back pain.” Arthritis and Rheumatism (2004); 50: 613-623.
2. Schiavon, CC et al. Optimism and hope in chronic disease: A systematic review. Frontiers in psychology (2017); 7: 1-10.
3. Carragee EJ, et al. “A Gold Standard Evaluation of the ‘Discogenic Pain’ Diag­nosis as Determined by Provocative Discography.” Spine (2006) 31:2115-2123.

The post Anger Altering a Surgical Decision first appeared on Back in Control.

The post Anger Altering a Surgical Decision appeared first on Back in Control.

She was a healthy physically active rancher. Her low back pain started in the summer of 2005 after a lifting injury. The pain had become constant and was located throughout most of her back. She was still functioning at a fairly high level, in spite of the pain.

Her prior care

Jean’s care so far had consisted of six visits to physical therapy, and two sets of cortisone injections in her back, none of which had been helpful. She had not been prescribed a ongoing organized treatment plan. On her second visit to a spine surgeon, it was recommended that she undergo a eight-level fusion of her lower back from her 10^ththoracic vertebra to the pelvis. It is a six to eight-hour operation that carries significant risks.

Jean’s x-rays showed that she had a mild curvature of her lower back. Other imaging tests did not reveal any identifiable, structural source of pain. From my perspective as a scoliosis surgeon, I felt her spine was essentially normal for her age.

Instead, I felt that her pain was probably from the muscles and ligaments around the spine. The medical term that we use is myofascial. When an operation geared towards the bones, such a fusion, is done in the presence of mostly soft tissue pain, it rarely works. In addition to the risks, the entire lower back becomes a solid piece of metal and bone. This surgery should only be done if there are no other options. The procedure comes with long-term lifestyle limitations and she was still so active.

At this point, I was perplexed as to why surgery had been recommended when she had done so little rehabilitation. I also didn’t understand why she was continuing to experience such severe ongoing back pain without any obvious cause.

What was missing?

I consulted her spine intake questionnaire to look for clues.

It revealed that she’d had some marital difficulties and had just reconciled with her husband six months earlier. That immediately caught my attention because marital troubles usually indicate significant stress. She then said her job had become much more difficult. Although she worked for the same employer, they had forced her to switch duties without adequate training. She was worried about not only her performance, but also her ability to keep her job – another major problem.

I turned the page. A month before her pain began, her twenty-six-year old son had drowned. I knew that outside stressors played a role in chronic pain, but this factor had never been so powerfully demonstrated. Her case really brought home for me how crucial it was to take a full view of the patient’s life and circumstances, instead of just looking at surgical solutions.

As I sat there stunned, I realized that I needed to do something different. In fact, the whole medical profession needed to do something different. How could a surgeon have recommended a fusion without taking the time to get to know Jean and to hear her circumstances? I have always wondered if she went through with the surgery, but I never heard from her again.

From that moment, some form of structured rehabilitation became my focus with every patient, without exception. I have not taken my eyes off of that vision since that day.

The post My Call to Action first appeared on Back in Control.

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The same process occurs with thought patterns, which are also embedded and permanent. It is how we navigate life. You don’t have to learn to touch a hot stove every time you pass it or purposely put yourself in an emotionally abusive situation.

Your body’s response to sustained stress is the root cause of chronic mental and physical diseases. Your body is flooded with inflammatory molecules called cytokines and your stress hormones including adrenaline, cortisol, and histamines keep your body on high alert. This “threat physiology” translates into multiple physical and mental symptoms.They resolve as you learn to regulate your own body’s chemistry. Many of them are physical. The most difficult concept for many patients to grasp is that since the symptoms are physically experienced then there must be some structural source. It does not matter how many different ways I explain it or how many negative tests that have been done. They just will not believe that physical symptoms can be generated from the brain and body’s stress chemistry. YOUR BRAIN IS CONNECTED TO EVERY ONE OF THE 30 TRILLION CELLS IN YOUR BODY either chemically or by nerves. The only way that physical sensations can be experienced is by being processed and interpreted in your brain. BTW, there is something terribly wrong. Your body’s physiology is way out of balance.

The “Pain Switch”

Then he or she proceeds to explain to me in detail that since they can push on a certain spot and feel the pain, then how can it be in their brain? How can it not be there? The fact that a simple push can elicit pain means that the threshold for stimulating those pain fibers has been lowered –  often dramatically. Your pain switch is either on or off. The only place these switches exist is in the brain.

Water Torture versus a Rock

Do you think that the pain felt during water torture is imaginary? It is a simple, painless drop of water. There is no reason it should ever cause pain. If water constantly drips on a rock does that cause pain? In fact over years, decades, or centuries the rock will be eroded by the simple repetition of dripping. Why is there not pain in that scenario? Obviously a rock has no nervous system. Repetition of any activity lays down circuits that are repeatable and become increasingly efficient? It is true for musicians, artists, and athletes, and also true for the perception of pain.

Obsessive Thought Patterns

Unfortunately, it is also true for the thought, “My doctor is missing something because I am in pain.” I am repeatedly told that I just don’t understand how they feel. That set of thoughts becomes it’s own set of repeatable circuits that will not shut down. Logic alone will not break them up. The reason why it is such an unfortunate situation is that it also limits treatment. The one variable that predicts success or failure in treating chronic diseases is your willingness to engage in the tools. The problem is that these endlessly repeating circuits also block opens to learning. It is the reason why that The DOC Journey app and course emphasise expressive writing so early in that is the one necessary exercise that begins to break up these endlessly repeating circuits.

My Weekly Battle

I was reminded of the problem several times every week. I had a middle-aged woman who had not really engaged in the DOC project. She had experienced anxiety (another stress symptom) since she was a teen along with chronic LBP. She had ruptured a disc in her back six months earlier and was experiencing screaming leg pain. She did have a large ruptured disc. When I explained the neurological nature of chronic pain, it was an ugly conversation. I asked her to come back when she calmed down. I was surprised that she returned the next week. On the second visit I told her that I seldom operate anymore unless the chronic pain is being actively addressed. That means that the patient is actively reading, writing, learning, and generally taking full responsibility for their care. However this disc was so large that I felt that I had to take it out first. She swore that she would engage.

Guess what? The simple disc excision that took away all of her leg pain, as expected, did not relieve any of her LBP. In spite of at least 10  direct conversations that the operation was only effective in relieving leg pain. I could not convince her that her LBP was coming from the soft tissues around her spine and that spine surgery rarely helps LBP. It is a rehab issue. She was convinced that there was something causing her pain that I was missing.

Doctors do not like to miss anything. We are extremely aware, even paranoid, of overlooking a problem that can and should be fixed. It is one of the reasons why health care costs are so high. We will often order testing when we know that the chance of it being positive is less than one in a thousand.

Another Failure

I did not get through. She thought if we could “fix it” her pain would disappear and her anxiety around it would diminish. I don’t think she will ever engage in any structured rehab program. The tragedy is that both are easily treatable with usual outcome to be pain free with minimal anxiety. The general wisdom in surgery is that if a patient has had the surgical risks explained to them then they must be in enough pain to undergo the operation. What the surgeons don’t understand (historically including me) is that the decision-making has become irrational.

The success of a spine fusion for LBP is less than 30%. (1,2) When the surgery has failed then the surgeon “has done their part” and sends them on their way – to where??

I never again performed elective surgery unless the patient would engage in his or her own care at some level. I felt in every elective case that surgery was only about a third of the solution. Physical conditioning and healing the nervous system are the other two thirds of the picture.

Personal and Societal Costs

I don’t regret performing her surgery, as it was necessary from a perspective of the need to relieve her severe leg discomfort. I am sad and frustrated that only a fraction of the benefit will be realized. Not only is the suffering of truly trapped patients not solved, they are also costing the rest of society untold billions dollars with the relentless pursuit of an answer that does not exist. Obsessive thought patterns, which is one of the symptoms created by stress physiology, both exacerbates pain and blocks effective treatment. It is truly phantom brain pain.

Are You Kidding Me?

1. Franklin, GM et al. “Outcome of lumbar fusion in Washington State Workers’ Compensation.” Spine(1994); 19: 1897 – 1903.
2. Nguyen, TH et al. “Long-term outcomes of lumbar fusion among worker’s compensation subjects.” Spine (2010); 20: 1– 11.

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Common links to all chronic illnesses

Chronic mental and physical diseases are caused by common problems occurring at the genomic (DNA) and mitochondrial level (energy generators in each cell). These are the most basic components of evolution and maintaining life. Basic science research has brought this to light in numerous papers. The problem is the lack of communication between these silos of knowledge and clinicians to bring these critical concepts into the clinical domain.

This is short list of symptoms, illnesses, and disease states caused by exposure to chronic stress (threat), which is catabolic (consuming fuel) and inflammatory (attacking tissues). It is the reason that “stress kills.”¹ The variables are the intensity and duration. The sources of threat come in an infinite number of forms and can be real or perceived.

Symptoms

• Anxiety
• Obsessive thought patterns
• Carpal tunnel syndrome
• Migraine headaches
• Tension headaches
• Facial, neck, thoracic, and low back pain
• Pelvic pain
• Irritable bladder syndrome (interstitial nephritis)
• Irritable bowel Syndrome (IBS)
• Migratory skin rashes
• Tingling/burning sensations
• Tinnitus
• Insomnia
• Chronic mental and physical pain

Illnesses

• Fibromyalgia
• Chronic fatigue
• POTS disease (postural orthostatic hypotension)
• Asthma
• Hypertension
• PTSD
• Eating disorders
• Reflex Sympathetic Dystrophy (RSD)
• Temporomandibular joint syndrome (TMJ)

Diseases

• Cardiovascular disease
• Dementia/ Alzheimer’s disease
• Parkinson’s Disease
• Renal failure
• Autoimmune disorders
  • Crohn’s disease, colitis, rheumatoid arthritis, SLE (systemic lupus erythematosus), dermatomyositis, psoriasis, and ankylosing spondylitis
• Early mortality
• AODM
• Metabolic Syndrome
• Obesity (core)
• Major depression/ deaths of despair (suicide)
• Peripheral vascular disease
• Osteoporosis
• Bipolar disorder
• Addiction
• Obsessive compulsive disorder (OCD)
• Schizophrenia
• Cancer – except colon cancer and melnoma

You may be wondering how so many different symptoms and disease states can be linked by a common cause. It is because under sustained heightened threat physiology, each cell and organ system responds in its own unique way and will eventually breakdown.

Each of us is unique

Chronic disease is a complex problem affected and defined by many individual variables. It is not going to be solved by information gained by prospective clinical trials on ill-defined groups of patient. There are several reasons for this problem.

• • Trauma of any sort is connected to a higher chance of experiencing chronic disease.² It is worse when it happens in childhood as it alters the structure of the brain as well as causing long-term elevations of inflammatory markers. However, chronic adult trauma, bullying, or living under societal threats also keeps one in an activated threat state.³

There are at least four patient scenarios that affect one’s capacity to heal.

• Willing to engage – Since the greatest factor predicting a successful outcome is willingness to engage and take responsibility, any clinical study has to begin here. If people can or will engage, will they heal? This seems to consistently play out and we have seen hundreds of patients heal as evidenced by many powerful testimonials. This group must be clearly defined, and then various clinical interventions can be evaluated and refined with ongoing research. The “stages of change” questionnaire is one validated tool to sort this out.⁴
• Emotional inability to engage – This group is one who has suffered so much trauma that they have incurred a significant mental illness and/ or have no capacity to face incredibly unpleasant emotions. They are in a mental survival state. 86% of people in chronic pain referred as an outpatient to a psychiatrist are so frail, they cannot engage.⁵ It is a major reason why traditional psychotherapy is not very effective for treating chronic pain. There are ways to bring this group into a better state.
  • Skilled somatic trauma therapy – training one to feel safe
  • ISTDP – Intermediate Short Term Dynamic Psychotherapy.⁶ This is a specific approach designed to teach people to tolerate unpleasant emotions and also feel safe.
  • Specifically stabilizing their mental health situation.
• Don’t want to engage – Angry/ frustrated – This group is maybe the most challenging in that they are so angry that they will not engage in anything. Anger is a hyper-inflammatory/ metabolic state that causes the neocortex (thinking centers) to be less active and the survival midbrain to become more active. In other words, they cannot think clearly and process new information. They also don’t want to in that anger is destructive, including self-destructive. So, the activated physiology also blocks willingness to engage.
  • There are many approaches to bring them back “online”, but it is unclear what is the best approach for a given person.
• Lack resources – There are other obstacles to learning new skills. They include illiteracy, low educational level, no access to computers or lack skills, low IQ, poor access to care, poverty, chaotic family situation, and anything that causes unrelenting threat (stress).

Treating the individual

• We are not going to be healed from data gleaned from randomized clinical trials on general populations. Each person is “programmed” by their entire past up to this moment and are infinitely unique. It is a little unclear how modern medicine has veered so far away from treating each person individually.
• The complexity of chronic disease, uniqueness of each person and circumstances, and the need to address multiple factors simultaneously makes it impossible to do randomized prospective studies on large ill-defined groups and obtain meaningful data. It simply cannot and will never be done. How can you compare a college professor with someone who is illiterate? The core basis for our “data” is deeply flawed.
• We must think differently, as current approaches are not only ineffective, but they are also making the problem of chronic disease much worse. “Data” has not helped us heal. In fact, physicians, by being more focused on the data (which they may not realize is so flawed) have become more detached from their patients as they continue to administer ineffective care. Many caregivers and patients alike are frustrated by the lack of success and have somewhat given up.
  • Research has shown us solutions for specific symptoms, but it has not helped us deal with the complexity of a person and his or her disease state.
• This quote from Dr. Francis Peabody in 1927⁷ is at the core of the problem.

Disease in man is never exactly the same as disease in an experimental animal, for in man the disease at once affects and is affected by what we call the emotional life. Thus, the physician who attempts to take care of a patient while he neglects this factor is as unscientific as the investigator who neglects to control all the conditions that may affect his experiment.

What we now know is that emotions reflect one’s physiological state and he was well ahead of this time. In 1927, he was concerned with the intrusion of technology into the patient/ physician relationship.

Summary

Big data is harming all of us because it is not granular enough. Not only is the burden of chronic disease continuing to rise, but it is also crippling our society both financially and emotionally. “Mainstream medicine” is not only actively promoting ineffective risky, expensive, and ineffective treatments, we are hurting people that trust us.

Chronic disease is solvable by applying a systematic approach that creates a healing alliance where both the patient and provider can heal. Humans are not data points. The “data-based” foundation of care is deeply flawed. Is it any wonder that the burden of chronic disease continues to crush us financially and emotionally?

It is more important to know what sort of person has a disease than to know what sort of disease a person has. 

              Hippocrates

References

1. Holmes TH, Rahe RH. The Social Readjustment Rating Scale.J Psychosom Res (1967); 11:213–8. doi:1016/0022-3999(67)90010-4
2. Felitti VJ, Anda Rf, Nordenberg D, et al. The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine (1998); 14:245-258.

3. Takizawa, R, et al. Bullying victimization in childhood predicts inflammation and obesity at mid-life: a five-decade birth cohort study. Psychological Medicine (2015); 45: 2705- 2715.
4. Carr JL, et al. Is the pain stages of change questionnaire (PSOCQ) a useful tool for predicting participation in a self-management programme? BMC Musculoskeletal Disorders (2006); 7:101-108. doi:10.1186/1471-2474-7-101.

5. Abbass Allan. ISTDP in the treatment of chronic pain. Lecture to the Dynamic Healing Discussion Group (4/6/22); from the Halifax ISDTP database. https://drive.google.com/drive/folders/1k9AXx1webG69mKlCGoCU8XeUtNwTTM3q?usp=sharing
6. Abbass Allan, et al. Intensive short-term dynamic psychotherapy to reduce rates of emergency department return visits for patients with medically unexplained symptoms: preliminary evidence from a pre-post intervention study. CJEM (2009); 11:529-34.
7. Peabody FW. The care of the patient. JAMA (1927); 88:877-882.

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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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